Association of Cataract Surgery With Mortality in Older Women: Findings from the Women's Health Initiative

Depressive and generalized anxiety symptoms in adults awaiting cataract surgery in India

Background Systematic data on mental health issues among adults awaiting cataract treatment are not readily available in India. We explored the prevalence and predictors of depressive and generalized anxiety (GA) symptoms in a cohort of adults awaiting cataract surgery. Methods Our study is based on data from baseline assessments which were conducted as part of a multicentre prospective, longitudinal cohort study. Subjects were recruited from four eye hospitals to assess depression and GA and associated risk factors using standardized scales, i.e. Center for Epidemiologic Studies-Depression Scale (CES-D) and Generalised Anxiety Disorder (GAD-7). Variation in the intensity of depression and GA was assessed using multiple classification analysis (MCA). Results A total of 813 adults awaiting cataract surgery participated, of whom 456 (56.1%) were men. The mean (SD) CES-D and GAD-7 scores were 24.6 (7.8) and 6.3 (SD 4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively. The overall prevalence of depression score of >16 was 87.4% (95% confidence interval [CI] 84.7%- 89.6%), and GA score of >10 was 57.1% (95% CI 53.5%-60.7%). The prevalence of comorbid depressive and anxiety symptoms was 56.6% (95% CI 52.9%- 60.2%). MCA showed that being neglected and mistreated by family/friends because of vision condition and facing difficulty and requiring help with daily tasks had the highest effect on the intensity of both depression (beta=0.254 and 0.238, respectively) and GA (beta=0.219 and 0.211, respectively). Conclusion The majority of adults with untreated cataract had both depressive and GA symptoms. These findings could be used for planning mental health interventions for adults awaiting cataract surgery.

Beyond vision:Cataract and health status in old age, a narrative review

Cataract is a leading cause of visual impairment in old age. Lens opacification is notoriously associated with several geriatric conditions, including frailty, fall risk, depression and cognitive impairment. The association is largely attributable to visual impairment, while other mechanisms, associated with extraocular comorbidity and lifestyle, might partly explain this correlation. Available literature suggests that cataract surgery may be effective in decreasing fall risk, improving depressive symptoms and limiting the risk of cognitive impairment and dementia incidence, although intervention studies on these outcomes are still limited. In this review we also emphasize the need to move from the concept of visual acuity to functional vision, especially in the context of the geriatric patient. Research is needed regarding the effect on the cited outcomes of different cataract treatment strategies, such as systematic bilateral versus monolateral surgery and use of different intraocular lenses.

Resident involvement in cataract surgery at the Veterans Health Administration: complications, case complexity, and the role of experience

PURPOSE

To characterize intraoperative complications, case complexity, and changes in complication rates with surgical experience for cataract surgeries involving residents at the Veterans Health Administration (VHA).

SETTING

All VHA facilities where cataract surgery was performed.

DESIGN

Multicenter, retrospective cohort study.

METHODS

A retrospective review of all cataract surgeries within the VHA between July 2010 and June 2021 was conducted. Several parameters, including resident involvement, intraoperative complications, and case complexity as determined by Current Procedural Terminology codes, and use of pupil expansion or capsular support devices, were collected. Complication rates were compared between residents and attendings.

RESULTS

Of 392 428 cataract surgeries completed across 108 VHA facilities, 90 504 were performed by attendings alone, while 301 924 involved a resident. Of these, 10 244 (11.3%) of attending cases were complex compared with 32 446 (10.7%) of resident cases. Pupil expansion devices were required in 8191 of attending cases (9.05%) and 31 659 (10.5%) of cases involving residents ( P < .001). Similarly, cases involving residents were more likely than attending-only cases to require a capsular support device (0.835% vs 0.586%, P < .001). Cases involving residents were more likely to have posterior capsular rupture (4.75% vs 2.58%, P < .001) and dropped nucleus (0.338% vs 0.198%, P < .001). Higher resident case volumes were associated with significantly lower complication rates for posterior capsular rupture, dropped nucleus, zonular loss, and suprachoroidal hemorrhage.

CONCLUSIONS

Although residents had higher intraoperative complication rates than attendings, these rates were reduced with surgical experience. Residents were involved in a similar number of complex surgical cases as attendings.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Exploring Shared Effects of Multisensory Impairment, Physical Dysfunction, and Cognitive Impairment on Physical Activity: An Observational Study in a National Sample

Multisensory, physical, and cognitive dysfunction share age-related physiologic disturbances and may have common health effects. We determined whether the effect of multisensory impairment on physical activity (PA) is explained by physical (timed up and go) or cognitive (Short Portable Mental Status Questionnaire) dysfunction. A National Social Life, Health, and Aging Project participant subset (n = 507) underwent objective sensory testing in 2005-2006 and wrist accelerometry in 2010-2011. We related multisensory impairment to PA using multivariate mixed-effects linear regression and compared the effect magnitude after adjusting for physical then cognitive dysfunction. Worse multisensory impairment predicted lower PA across three scales (Global Sensory Impairment: β = -0.04, 95% confidence interval [-0.07, -0.02]; Total Sensory Burden: β = -0.01, 95% confidence interval [-0.03, -0.003]; and Number of Impaired Senses: β = -0.02, 95% confidence interval [-0.04, -0.004]). Effects were similar after accounting for physical and cognitive dysfunction. Findings suggest that sensory, physical, and cognitive dysfunction have unique mechanisms underlying their PA effects.

Relationship Between Tamsulosin Use and Surgical Complications of Cataract Surgery in Elderly Patients: Population-Based Cohort Study

Purpose

Although several previous studies have investigated the relationship between tamsulosin use and surgical complications of cataract surgery, no population-based cohort study has been conducted for the Asian population. We aimed to investigate the relationship between tamsulosin use and surgical complications of cataract surgery in the Korean elderly population.

Methods

This nationwide population-based retrospective cohort study included elderly patients (≥60 years) who had undergone cataract surgery in the period from 2003 to 2015. Baseline characteristics were age, sex, income, residence, and systemic, and ocular comorbidities (glaucoma, myopia, eye trauma, diabetes mellitus with ophthalmic manifestations, severe cataract, age-related macular degeneration). The exposure of interest was tamsulosin use within 1 year before cataract surgery. Logistic regression model was used to evaluate the relationship of tamsulosin use with surgical complications of cataract surgery.

Results

The rate of surgical complications of cataract surgery was 0.88% (375/42,539) in the non-tamsulosin group and 0.83% (71/8,510) in the tamsulosin group. The groups showed no significant difference in the risk of surgical complications of cataract surgery in the unadjusted model [odds ratio (OR) = 0.946; 95% confidence interval (CI):0.733–1.220; P = 0.669]. Additionally, tamsulosin use was not significantly associated with surgical complications of cataract surgery in the fully adjusted model accounting for age, income, residence, and systemic and ocular comorbidities (OR = 0.997; 95% CI: 0.749–1.325; P = 0.981).

Conclusions

The rate or risk of surgical complications of cataract surgery does not change with tamsulosin use. We suggest that better surgical techniques and surgeons' cognizance of the patient's tamsulosin use could improve surgical outcomes, without increasing surgical complications.

Vitrectomy and All-Cause and Cause-Specific Mortality in Elderly Patients With Vitreoretinal Diseases: A Nationwide Cohort Study

Purpose

To determine the all-cause and cause-specific mortality in elderly patients with vitreoretinal diseases based on vitrectomy status.

Methods

Elderly patients (aged ≥ 60 years) diagnosed with vitreoretinal diseases between 2003 and 2012 using the Korean National Health Insurance Service-Senior cohort (2002–2015) were included in this nationwide population-based retrospective cohort study. The exposure of interest was vitrectomy, and information on mortality from patient inclusion until December 2015 was obtained. Cox regression modeling was used to assess the association between vitrectomy and mortality. An additional subgroup analysis was performed to investigate the effects of the underlying retinal disease characteristics and comorbidities on mortality.

Results

The study cohort included 152,283 patients (3,313 and 148,970 in the vitrectomy and non-vitrectomy groups, respectively). The adjusted model showed vitrectomy was associated with a decreased risk of pulmonary-cause mortality [hazard ratio (HR), 0.51; P < 0.001]; however, no association was observed for all-cause mortality (HR, 0.93; P = 0.325). Vitrectomy was associated with increased mortality risk (all-cause: HR, 1.26; P < 0.001 and vascular causes: HR, 1.41; P = 0.003) among patients with retinal vascular diseases and decreased mortality risk (all-cause: HR, 0.64; P < 0.001 and pulmonary causes: HR, 0.35; P = 0.011) among patients with macular diseases. There were significant interactions between age and vitrectomy with respect to all-cause mortality among patients with either vitreoretinal disease.

Conclusions

In elderly patients with retinal diseases, the vitrectomy group showed the lower mortality from pulmonary causes with no association for all-cause mortality.

Relationship between Cataract Surgery and Mortality in Elderly Patients with Cataract: Nationwide Population-Based Cohort Study in South Korea

We aimed to investigate the relationship between cataract surgery and all-cause and cause-specific mortality in Korean elderly patients with cataract using the Korean National Health Insurance Service-Senior cohort database. Elderly patients (≥60 years) diagnosed with cataract from 2002 through 2012 were included. The baseline characteristics included demographics and systemic and ocular comorbidities. Adjusted Cox regression models with time-varying covariates for cataract surgery were used to assess the relationship between cataract surgery and mortality. The study cohort included 241,062 patients, of whom 127,941 were in the cataract surgery group and 113,121 were in the cataract diagnosis group. The incidence of all-cause mortality was 3.62 deaths/100 person-years and 3.19 deaths/100 person-years in the cataract surgery and cataract diagnosis groups, respectively. Cataract surgery was associated with a decreased hazard of all-cause mortality after adjusting for demographics as well as systemic and ocular comorbidities (hazard ratio (HR), 0.93; p < 0.001). A protective association was noted between cataract surgery and mortality from vascular (HR, 0.92; p < 0.001) or neurologic (HR, 0.64; p < 0.001) causes. Patients with cataract who were 85 years of age and older, women, those who had lower income, and a Charlson comorbidity index score of 5 or more, or those without glaucoma revealed the largest reductions in mortality hazards resulting from cataract surgery.

Association between glaucoma surgery and all-cause and cause-specific mortality among elderly patients with glaucoma: a nationwide population-based cohort study

This population-based, retrospective cohort study aimed to evaluate the association between glaucoma surgery and all-cause and cause-specific mortality among Korean elderly patients with glaucoma. A total of 16210 elderly patients (aged ≥ 60 years) diagnosed with glaucoma between 2003 and 2012 were included, and their insurance data were analyzed. The participants were categorized into a glaucoma surgery cohort (n = 487), which included individuals who had diagnostic codes for open angle glaucoma (OAG) or angle closure glaucoma (ACG) and codes for glaucoma surgery, and a glaucoma diagnosis cohort (n = 15,723), which included patients who had codes for OAG and ACG but not for glaucoma surgery. Sociodemographic factors, Charlson Comorbidity Index score, and ocular comorbidities were included as covariates. Cox regression models were used to assess the association between glaucoma surgery and mortality. The incidence of all-cause mortality was 34.76/1,000 person-years and 27.88/1,000 person-years in the glaucoma surgery and diagnosis groups, respectively. The adjusted hazard ratio (HR) for all-cause mortality associated with glaucoma surgery was 1.31 (95% confidence interval [CI], 1.05–1.62, P = 0.014). The adjusted HR for mortality due to a neurologic cause was significant (HR = 2.66, 95% CI 1.18–6.00, P = 0.018). The adjusted HRs for mortality due to cancer (HR = 2.03, 95% CI 1.07–3.83, P = 0.029) and accident or trauma (HR = 4.00, 95% CI 1.55–10.34, P = 0.004) associated with glaucoma surgery for ACG were significant as well. Glaucoma surgery was associated with an increase of mortality in elderly patients with glaucoma. In particular, the risk of mortality associated with glaucoma surgery due to neurologic causes was significant.

Aging With Vision Loss: A Framework for Assessing the Impact of Visual Impairment on Older Adults

There is limited research examining the impact of visual impairment (VI) on older adults while considering the complexities of aging, leaving gaps in our understanding of how health consequences of VI might be averted. We created a framework integrating concepts from disability, geriatrics, and ophthalmology that conceptualizes how VI challenges successful aging. Here, VI influences multiple functional domains, and increases the risk of negative health outcomes. This model acknowledges that common causes, such as risk factors that affect eyes and other systems simultaneously, may also drive the relationship between VI and health outcomes. Finally, the model highlights how the impact of VI on aging outcomes can be addressed at multiple intervention points.

Association between Age-related Cataract and Mortality in Sweden: A Long-term Population-based Follow-up Study

PURPOSE

To assess the relationship of age-related cataract with all-cause mortality in a Swedish population.

METHODS

Cox regression analyses were performed in a cohort of 746 residents 65-74 years of age, examined in a population survey in the rural district of Tierp, Sweden, 1984-86. To expand the sample size, 1,071 people were recruited by means of glaucoma case records established at the Eye Department in Tierp from 1978 to 2007. In this way, the cohort comprised 1,817 subjects, representing nearly 27,000 person-years at risk. The presence of cataract was determined based on retroillumination with lens opacities evident on slit-lamp examination. Information on deaths was obtained from the local population register.

RESULTS

By the conclusion of the study in April 2020, 1,633 deaths had been reported. Of these cases, 694 were affected by lens opacities or had history of cataract surgery at baseline. In multivariate analysis, including cataract, age, sex, smoking habits, cancer, diabetes, hypertension and ischemic heart disease, no association was found between cataract and mortality (hazard ratio 0.99; 95% confidence interval 0.90-1.10). Adjustment for participation in the population survey had no effect on the estimate.

CONCLUSION

In this long-term follow-up study of subjects 65-74-years-old in Sweden, cataract was not associated with all-cause mortality.

Validating Publicly Available Crosswalks for Translating ICD-9 to ICD-10 Diagnosis Codes for Cardiovascular Outcomes Research

Background On October 1, 2015, the Center for Medicare and Medicaid Services transitioned from the International Classification of Diseases, Ninth Revision ( ICD-9) to the ICD, Tenth Revision ( ICD-10) compendium of codes for diagnosis and billing in health care, but translation between the two is often inexact. Here we describe a validated crosswalk to translate ICD-9 codes into ICD-10 codes, with a focus on complications after carotid revascularization and endovascular aortic aneurysm repair. Methods and Results We devised an 8-step process to derive and validate ICD-10 codes from existing ICD-9 codes. We used publicly available sources, including the General Equivalence Mapping database, to translate ICD-9 codes used in prior work to ICD-10 codes. We defined ICD-10 codes as validated if they were concordant with the initial ICD-9 codes after manual comparison by two physicians. Our primary validation measure was the percent of valid ICD-10 codes out of the total ICD-10 codes obtained during translation. We began with 126 ICD-9 diagnosis codes used for complication identification after carotid revascularization procedures, and 97 ICD-9 codes for complications after endovascular aortic aneurysm procedures. Translation generated 143 ICD-10 codes for carotid revascularization, a 14% increase from the initial 126 codes. Manual comparison demonstrated 98% concordance, with 99% agreement between the reviewers. Similarly, we identified 108 ICD-10 codes for endovascular aortic aneurysm repair, an 11% increase from the initial 97 ICD-9 codes. We again noted excellent concordance and agreement (98% and 100%, respectively). Manual review identified 4 ICD-10 codes incorrectly translated from ICD-9 codes for carotid revascularization, and 3 codes incorrectly translated for endovascular aortic aneurysm repair. Conclusions Algorithms to crosswalk lists of ICD-9 codes to ICD-10 codes can leverage electronic resources to minimize the burden of code translation. However, manual review for code validation may be necessary, with collaboration across institutions for researchers to share their efforts.

Cataract Services are Leaving Widows Behind: Examples from National Cross-Sectional Surveys in Nigeria and Sri Lanka

The Sustainable Development Goals aim to leave no one behind. We explored the hypothesis that women without a living spouse—including those who are widowed, divorced, separated, and never married—are a vulnerable group being left behind by cataract services. Using national cross-sectional blindness surveys from Nigeria (2005–2007; n = 13,591) and Sri Lanka (2012–2014; n = 5779) we categorized women and men by marital status (married/not-married) and place of residence (urban/rural) concurrently. For each of the eight subgroups we calculated cataract blindness, cataract surgical coverage (CSC), and effective cataract surgical coverage (eCSC). Not-married women, who were predominantly widows, experienced disproportionate cataract blindness—in Nigeria they were 19% of the population yet represented 56% of those with cataract blindness; in Sri Lanka they were 18% of the population and accounted for 54% of those with cataract blindness. Not-married rural women fared worst in access to services—in Nigeria their CSC of 25.2% (95% confidence interval, CI 17.8–33.8%) was far lower than the best-off subgroup (married urban men, CSC 80.0% 95% CI 56.3–94.3); in Sri Lanka they also lagged behind (CSC 68.5% 95% CI 56.6–78.9 compared to 100% in the best-off subgroup). Service quality was also comparably poor for rural not-married women—eCSC was 8.9% (95% CI 4.5–15.4) in Nigeria and 37.0% (95% CI 26.0–49.1) in Sri Lanka. Women who are not married are a vulnerable group who experience poor access to cataract services and high cataract blindness. To “leave no one behind”, multi-faceted strategies are needed to address their needs.

Point: Immortal Time Bias-What Are the Determinants of Its Magnitude?

In cohort studies, "immortal time" bias refers to a portion of time during which events cannot occur for a particular group of participants. Typically, immortal time bias occurs when: 1) Exposure can be initiated after follow-up of cohort members has begun; and 2) analytically, the preexposure experience is combined with that which takes place following exposure, rather than (correctly) as part of the experience of nonexposed individuals. Using the example of a cohort study of mortality in relation to receipt of cataract surgery, we sought to describe those study design and population characteristics that influence the magnitude of immortal time bias, so as to aid readers in gauging its impact on published research findings. These characteristics include the mean interval between cohort entry and when exposure criteria are met, the proportion of exposed study participants, and the length of study follow-up.

Visual acuity after cataract surgery in patients with optic neuropathies

PURPOSE

To compare visual acuity outcomes of cataract surgery between patients with and without non-glaucomatous optic neuropathies.

METHODS

Retrospective case-control study of patients with and without optic neuropathies who underwent cataract surgery from 2010 to 2017. For all eyes, the last preoperative best corrected visual acuity (BCVA) and first BCVA greater than 1 month postoperatively (to ensure sustained refractive stabilization) were recorded in logarithm of the minimum angle of resolution (logMAR) units.

RESULTS

Thirty patients (42 eyes) with optic neuropathies and 30 control patients (42 eyes) underwent uncomplicated cataract surgery. The mean age at surgery was significantly younger in the optic neuropathy group (64 versus 71.2 years, p < 0.01). The mean improvement in visual acuity in the optic neuropathy group was 0.4 ± 0.6 logMAR units (roughly 4 Snellen lines) from 0.7 ± 0.8 units preoperatively to 0.3 ± 0.5 postoperatively. Between the cases and controls, there was no significant difference in preoperative BCVA (p = 0.48), postoperative BCVA (p = 0.42), or the mean improvement in BCVA (p = 0.82). When stratified by optic neuropathy subtype, patients with optic neuropathies secondary to multiple sclerosis (n = 12) or non-arteritic ischaemic optic neuropathy (n = 11) had significant improvement in BCVA postoperatively (p < 0.01 and p = 0.03, respectively).

CONCLUSION

Contrary to what may be expected from such a severe ocular comorbidity, our data suggest that the mean BCVA improvement after cataract surgery in patients with non-glaucomatous optic neuropathies was comparable to that of control patients. Cataract surgery may be performed in patients with both optic neuropathies and advanced cataracts with a reasonable preoperative expectation that visual acuity improvement can be significant.

Counterpoint: Keeping the Demons at Bay When Handling Time-Varying Exposures-Beyond Avoiding Immortal Person-Time

The potential for immortal time bias is pervasive in epidemiologic studies with left truncation or time-varying exposures. Unlike other biases in epidemiologic research (e.g., measurement bias, confounding due to unmeasured factors, and selection based on unmeasured predictors of the outcome), immortal time bias can and should be avoided by the correct assignment of person-time during follow up. However, even when handing person-time correctly, allowing late entry into a study or into an exposure group can open the door to more insidious sources of bias, some of which we explore here. Clear articulation of the study question, including the treatment plans of interest, can provide navigation around these sources of bias and elucidate the assumptions needed for inference given the available data. Here, we use simulated data to illustrate the assumptions required under various approaches to estimate the effect of a time-varying treatment and describe how these assumptions relate to the assumptions necessary to estimate single sample rates and risks in settings with censoring and truncation.