Dr Anna Palagyi
PhD MPH BOptom
The George Institute for Global Health, UNSW
Associate Professor Lisa Keay
PhD MPH BOptom
The George Institute for Global Health, UNSW
Cataract is a primary cause of vision impairment in older Australians.1 An estimated one-third of the population aged 65 years and older has cataract-related vision loss, representing approximately 1.2 million people.2
Cataract surgery is one of the most cost-effective health interventions3 but patients with age-related cataract can wait up to three years for first eye surgery, comprising two years waiting for outpatient ophthalmology assessment and a further 12 months on the surgical waiting list.4
The consequences of waiting for surgery encompass physical, mental and social domains, compromising an older person’s quality of life and limiting active ageing. Studies from the United Kingdom and Canada show that those who undergo cataract surgery sooner (six weeks to six months after referral) experience better vision5 and quality of life,6,7 improved physical activity levels,6 and reduced levels of anxiety and depression6,8 than patients who wait longer than six months.
Patients receiving expedited first eye cataract surgery also experience fewer falls and fractures in the 12 months after surgery than those facing a routine waiting period of about 12 months.6 However, data describing the impact of protracted waiting for surgery on older Australians with cataract have until now been scarce, hindering policy change to support timely care.
The FOCUS study
The FOCUS study9 (Falls in Older People with Cataract: A Longitudinal Evaluation of Impact and Risk) investigated fall risk in older adults undergoing cataract surgery in eight Australian public hospitals across Sydney, Melbourne and Perth. It is the first longitudinal evaluation of fall risk in older Australians with bilateral cataract, and it followed more than 320 adults aged 65 years and older for up to two years after recommendation for first eye surgery.
By examining falls in a real-world clinical setting, the FOCUS study makes an important contribution to understanding cataract-associated fall risk and injury. In addition, the study highlights the personal costs of cataract-related vision impairment, exploring the impact of cataract on psychological well being, physical function, mobility and quality of life.
Fall risk and cataract
We found that one in three older adults with cataract experienced a fall while waiting for first eye cataract surgery.10 Almost one half of these falls resulted in an injury, including 15 head injuries and two fractures (Figures 1 and 2). Over a median pre-surgical observation time of 176 days (about five and a half months), the annual incidence of falls in our cohort was 1.2. This is two to three times higher than fall rates arising from studies of the general older community-dwelling population. An annual incidence of 0.4–0.6 falls per person in those aged equal to or greater than 65 years in the United States has been recently reported.11
Compared to non-fallers, those who fell while waiting for surgery had a greater number of comorbidities, took more medications, had a lower quality of life and a higher fear of falling. Adults who experienced a fall also demonstrated poorer lower limb function on entry into the study than those who did not fall.
Figure 1. Injuries sustained in falls (n = 267) experienced by 329 patients 65 years and older with bilateral cataract while waiting for first eye cataract surgery (median time of observation = 176 days [range 2-730 days])
Figure 2. Treatment received for injuries sustained in falls in Figure 1, (n = 267) experienced by 329 patients 65 years and older with bilateral cataract while waiting for first eye cataract surgery (median time of observation = 176 days [range 2-730 days])
More frequent falls were evident in those who undertook greater walking activity while waiting for cataract surgery, and in those who had a history of falling in the previous 12 months. Interestingly, we found no link between vision status (including high contrast visual acuity and contrast sensitivity) and fall risk. However, more than 70 per cent of adults had no to mild vision impairment (Snellen visual acuity better than 6/18 in the better eye) and it is feasible that a floor effect in visual acuity may explain its lack of association with falls in this patient group.
Cataract and psychological well-being
Older people with vision loss are susceptible to depression;12,13 however, few studies have evaluated rates and predictors of depression in those with age-related cataract. The FOCUS study demonstrated a high (28.6 per cent) prevalence of depressive symptoms in older Australians with cataract on surgical waiting lists.14 This is about three times greater than rates of depressive symptoms found in recent studies of general community-dwelling older people.15 We found a significant association between increasing patient-reported visual disability (assessed by the Catquest-9SF instrument) and depressive symptoms, and a 10 per cent greater likelihood of depressive symptoms for each additional comorbidity.
Our data predicted the onset of depressive symptoms at a Snellen visual acuity of 6/12 among older adults awaiting cataract surgery in Australia (Figure 3 and 4). Previous studies exploring associations between ophthalmic disorders and depression have focused on the permanently vision impaired or blind. We have uniquely illustrated the presence of depressive symptoms at even modest levels of vision loss, suggesting that the psychological impact of cataract may manifest in its earliest stages.
Figure 3. Thirty-four per cent of participants with binocular visual acuity of 6/12 or worse had depressive symptoms, compared to 25 per cent of those with visual acuity better than 6/12
Figure 4. ROC curve analysis illustrates an optimal visual acuity cut-point of 40 ETDRS letters (6/12 Snellen acuity) for the onset of depressive symptoms (sensitivity 0.65, specificity 0.52)
Recommendations for policy and practice
Waiting time for public patients requiring first eye cataract surgery in Australia remains significant for many, and the contribution of surgical delays to fall risk and psychological well-being should not be overlooked. With a projected 3.5 per cent annual increase to the older Australian population anticipated in the coming decade,16 the burden of age-related eye disease will continue to grow, bringing key challenges to the health system in terms of increased demand for health services and rising health costs.17 In this context, a new policy direction is required to improve the efficiency of cataract surgery pathways and avert the costly impact of visual disability both for the health system and for older adults with cataract.
Understanding who is more likely to fall while waiting for cataract surgery, and why they are likely to fall, will facilitate early recognition and management of those at highest risk and may reduce the negative physical and psychological outcomes associated with falls and fall injury. Our findings reinforce the need for clinicians to consider non-visual factors, including walking activity and falls history, when assessing fall risk during the surgical waiting period.
Recognition of the susceptibility of older people with cataract to depression, even in the earliest stages of vision impairment, is important. Efficient referral processes, more rapid surgical management and increased awareness of depressive signs while waiting for surgery may minimise the negative psychological effects of cataract-related vision loss in this already vulnerable population.
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