Phacoemulsification In Nonagenarians: Visual Outcomes, Complication Profile And Predictive Factors In A Real-World Cohort

To comprehensively evaluate the safety profile and early visual outcomes of phacoemulsification in nonagenarians, a rapidly growing and underrepresented surgical population characterized by advanced cataract density, higher prevalence of alpha-antagonist (AA) exposure, zonular fragility, systemic frailty, and potentially limited visual retinal reserve. This real-world study quantifies early functional benefit at 1 month, defines the incidence and pattern of intra- and postoperative complications, and evaluates biometric and perioperative predictors of adverse events to refine risk stratification, optimize surgical planning, and improve preoperative counselling in very elderly candidates. 

Retrospective single-centre cohort study conducted at the tertiary referral Department of Ophthalmology, Hospital Clínic of Barcelona, Spain. Consecutive phacoemulsifications in patients aged ≥90 years were analyzed at eye level, including bilateral cases. Standardized optical biometry and a protocolized 1-month postoperative evaluation were performed. Ninety-six eyes from 68 patients were analyzed (53.1% female; mean age 91.8±1.8y); 14.6% were only functional eyes (blind fellow eye).

Comorbidities included glaucoma (21.9%) and AMD (35.4%, 20.6% with macular atrophy). Preoperative data included AA exposure (43.7%), baseline IOP (16.4±4.7 mmHg), and optical biometry parameters (AL 22.9±1.2 mm, ACD 2.8±0.4 mm, and LT 4.92±0.3 mm). Cataracts were graded using LOCS III (mean C:2.6, NC:3.9, P:1.7). Intraoperative variables comprised anesthesia type, total operating room (OR) time (patient entry to exit), adjuncts (blue dye, capsular tension ring CTR, pupil expanders) and IOL position. Outcomes were intraoperative, early (<1 month) and late (≥1 month) complications, plus 1-month BCVA (logMAR) and spherical equivalent (SE). Statistical analysis included chi-square, paired t-test/Wilcoxon, and multivariable logistic regression. 

Anesthesia was topical (69.8%), peribulbar (15.6%), sub-Tenon (13.5%) or retrobulbar (1%). IOLs were in-the-bag (95.8%), sulcus (2.1%) or aphakic (2.1%). Adjuncts included Malyugin ring (5.2%), CTR (10.4%), opposite incisions (7.3%) and blue dye (5.2%). BCVA improved from 0.78±0.6 to 0.31±0.2logMAR (Δ−0.45, p=.05); 98.9% remaned stable/improved, 1 patient declined (nAMD). SE decreased from +1.58D to +0.47D. Intraoperative events (12.5%), mainly zonular/capsular, correlated with longer OR time (36.5 vs 15.0 min, p=.0001), dye use (p=.01) and anesthesia (p=.02). On multivariable analysis, AA exposure (OR 1.3) and OR time (OR 1.108/min) were predictors. Postoperative events occurred in 9.4% (<1 mo; ocular hypertension) and 7.3% (≥1 mo; CME). 

Phacoemulsification in nonagenarians provides substantial early visual rehabilitation with high rates of in-the-bag IOL implantation despite advanced age, substantial ocular comorbidity burden and anatomical complexity. Intraoperative events were predominantly zonular or capsular and independently associated with alpha-antagonist exposure and longer operating room time, underscoring the impact of IFIS and tissue fragility. Postoperative complications were infrequent and mainly transient. These findings support cataract surgery as a safe and effective intervention in nonagenarians when guided by proactive IFIS risk assessment, anticipatory pupil/zonular support, and individualized surgical planning.