Eyeworld

93 EW FEATURE October 2017 • Challenging cataract cases The risks that need to be ex- plained as much as possible to the patient and the caregiver are those that go hand-in-hand with the possibility of general anesthesia, the possible neurologic risk of anesthe- sia making dementia worse, and sight-threatening risks if the patient, not under general anesthesia, is unable to control himself or herself, Dr. Hart said. Considering anesthesia Dr. Matossian said she is generally able to judge in the preoperative vis- its whether patients will be suitable for topical anesthesia, if they will need a block, or if they'll require general anesthesia. Dr. Matossian uses laryngeal mask airway gener- al anesthesia, finding it to be less invasive. In patients who are marginal when it comes to their level of de- mentia, Dr. Matossian plans for the possibility of having to switch from topical to general anesthesia. "Sometimes patients are mar- ginal, meaning they appear OK, but under an unfamiliar setting of an operating room, they may become confused, especially once the drape is placed over them," she said. "Anesthesia works very differ- ently with these folks," Dr. Matos- sian continued later. "Often less and caregiver to make appropriate surgical decisions, including type of anesthesia, refractive aim, and more. Susan MacDonald, MD, as- sociate professor, Tufts University School of Medicine, Boston, said early dementia can be hard to detect in patients, especially if they or their family members are being protective and private. Dr. MacDonald said she'll direct her staff to alert her to anything in the patient's history or behavior that might cause them to question the patient's mental status, but she'll also be watching for red flags herself. "When you're talking with patients about lens choices, risks, and benefits … ask some open-end- ed questions and make sure they understand what you're talking about. There are some patients who, when they have early dementia, will be clever by changing the subject or joking about things," Dr. MacDon- ald said. "If a patient is redirecting the discussion or if they're unable to remember something, it's criti- cal to probe a little bit more. It is important to be gentle with these patients and their families, but it's also important not to miss this diagnosis. Another sign to look for is if the patient's family members are answering questions for the patient, being overprotective, or helping the patient save face." Decision making in the preoperative stage Because cataract surgery can im- prove these patients' quality of life quite a bit, John Hart, MD, Associ- ates in Ophthalmology, Farmington Hills, Michigan, and clinical assis- tant professor of biomedical scienc- es, Oakland University, Rochester, Michigan, said his threshold for offering cataract surgery to patients with dementia is low. Dr. MacDon- ald also stressed the importance of early cataract surgery for dementia patients. Not only are mature cat- aracts more difficult to operate on, but dementia patients have a greater fall risk; having a more confused mental state might make it more difficult for them to feel physically oriented. "Confusion and decreased vision are a dangerous combination, so we want to make sure we are equipping them with all the tools we can for them to stay oriented and safe," Dr. MacDonald said. A study published in the American Journal of Ophthalmology found vision-related quality of life, cognitive impairment, and depres- sion were strongly related and that cataract surgery could improve all three. 1 Dr. Matossian said sometimes children or caregivers might think a patient's cognitive ability has de- clined—for example, because they're no longer reading magazines or showing interest in other hobbies— when in fact, it is the cataract that's inhibiting the activity. "In those circumstances, when I have done cataract surgery and helped them see again, their level of interest … is back up because now we've eliminated the visual hin- drance," Dr. Matossian said. First and foremost, it's "criti- cal" for dementia patients to have someone present who is legally allowed to make decisions for them, when needed, at appointments, Dr. Matossian said. Having that second set of ears to absorb all the informa- tion about the options, the surgery, and postop care is important and is something she recommends for all her patients. Dr. Hart pointed out that some parts of the exam might not be possible with a dementia patient, such as subjective refraction testing. As such, asking questions of the caregiver, at times, can help identify what the patient is and is not seeing and what his or her visual needs might be postop. "They're likely not driving a car. They need to be able to watch tele- vision, see the food on their plate and the people who are across from them, and typically you're gearing the surgical result to reflect that. Usually a low amount of myopia is an appropriate end point to be look- ing for," Dr. Hart said. Poll size: 160 continued on page 94 For the diabetic patient with or without retinopathy: I use NSAID drops for 4 weeks postoperatively I use NSAID drops for longer postoperative- ly due to patient risk I do not believe in using NSAIDs at all For patients with dementia, I: Target them a little bit myopic Target them plano Offer them a multifocal IOL

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