EYE TESTS

[caption id='attachment_5207' align='alignright' width='200'] Paul Ursell FRCOphth[/caption]

Surgeons should choose the most minimally invasive and pain free approach to removing cataracts in cognitively impaired patients, recommends Paul Ursell FRCOphth, Sutton Eye Unit, UK. Dr Ursell detailed his extensive experience of performing cataract surgery in patients with learning disabilities and dementia in a talk at the XXXVI UKISCRS Congress.

He noted that patients with learning difficulties have a much higher incidence of visual impairment, with approximately 60 per cent needing glasses. However, because of their cognitive impairment, many of these patients may not be able to communicate their vision issues, thus regular eye tests and screening are very important.

Dr Ursell advised early treatment for any patients with impaired cognitive function diagnosed with cataracts, as the impact of vision loss can be more difficult for them to deal with and they will have a better physical and psychological recovery when treated early. When considering cataract surgery for this cohort surgeons should consider that near vision is often more important than distance vision to patients with learning disabilities, he said.

If surgery is to be performed, Dr Ursell advised removing cataracts in the “easier†eye first. Local anaesthetic can be used for many dementia patients undergoing cataract surgery but general anaesthetic is also acceptable, and can be particularly useful in agitated patients, he said. “In the past people wouldn’t use general anaesthetic on these patients as they believed it would make their dementia worse, but modern cataract surgery is quite short and it is known now that anaesthetic does not have a detrimental effect on their dementia,†he explained.

If biometry cannot be performed before surgery, it is possible to do it when the patient is on the table under anaesthetic, Dr Ursell noted. He recommending contact immersion biometry for determining the axial length and hand held corneal keratometry readings, followed by Perkins tonometry to help determine the best implant choice for the patient.

Dr Ursell expressed a preference for a square-edged intraocular lens with a low posterior capsule opacification profile. “This is because you don’t want them to need YAG capsulotomy, because that is hard work in patients with dementia.†Additionally, surgeons should avoid sutures where possible and use nontoothed forceps, meaning the eye is as comfortable as possible post-surgery to minimise eye rubbing.

“Particularly in patients that can be difficult to handle, your surgical technique should be geared towards causing no postoperative pain,†he maintained. Postoperative care should be as straightforward as possible, and planned beforehand, Dr Ursell said. The patient should be involved in the decision on postoperative treatment care as much as possible and the plan should be fully discussed with their care group – carers, GP, nurse, etc. If the patient’s family/carers don’t think they will be able to put eye drops in the patient’s eye, Dr Ursell recommended using steroid injections or subconjunctival antibiotics while the patient is still under anaesthetic.

“Cataract surgery in patients with dementia or learning difficulties is a very important and rewarding surgical procedure and has a very big impact on the quality of people’s lives. Also remember if you can improve their vision, it can often help their cognitive function too,†he concluded.