EyeWorld India December 2017 Issue

EWAP FEATURE 23 by Liz Hillman EyeWorld Staff Writer AT A GLANCE • Cataract surgery in patients with dementia requires ophthalmologists to take extra considerations during the perioperative period. • Having a caregiver with the legal authority to make decisions for the patient, if applicable, is vital. • Know when patients are still suitable for topical anesthesia or if they’ll need general anesthesia. With anesthesia in dementia patients, sometimes less is more. • Try to simplify postop drop regimens as much as possible for patients who might have trouble remembering. Special considerations for cataract surgery in patients with dementia “ At the end of the day, the days of doctors telling patients what to do are long gone. We’re in a partnership with our patients and their families and we try to help them make good decisions and explain to them the options. ” - John Hart, MD continued on page 24 December 2017 From extra preop prep to anesthesia to target refraction, surgeons explain how they modify their care to best suit these patients W hile there are various ocular factors that can drive the course of cataract surgery, non-ophthal- mic factors, such as the patient’s mental state, can impact all aspects of the surgery as well as preop and postop care. Take dementia, the most common form of which is Alz- heimer’s disease. According to the latest data from the Alzhei- mer’s Association, there are more than 5 million Americans with Alzheimer’s. The association estimates that this number could reach 16 million by 2050. “With our aging popula- tion, the increased prevalence of dementia and cataracts, I am seeing a larger number of pa- tients who have the diagnosis of both dementia and cataract,” said Cynthia Matossian, MD , Matossian Eye Associates, Doyles- town, Pennsylvania, and adjunct clinical assistant professor of ophthalmology, Temple Univer- sity School of Medicine, Philadel- phia. But, Dr. Matossian continued, there is a spectrum of dementia diagnosis, ranging from those mildly forgetful to those who are extremely confused and unable to follow commands. Treatment and the surgeon’s approach should vary based on the level of dementia, Dr. Matossian said. While a physician might be informed that a patient has dementia before they even enter the exam room, the physician needs to make their own obser- vations and ask the right ques- tions of the patient and caregiver to make appropriate surgical de- cisions, including type of anes- thesia, refractive aim, and more. Susan MacDonald, MD , associate professor, Tufts Univer- sity 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 ques- tion 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- ended 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. MacDonald said. “If a patient is redirecting the discussion or if they’re un- able to remember something, it’s critical to probe a little bit more. It is important to be gentle with these patients and their fami- lies, but it’s also important not to miss this diagnosis. Another sign to look for is whether the patient’s family members are an- swering questions for the patient, being overprotective, or helping the patient save face.” Decision-making in the preoperative stage Because cataract surgery can improve these patients’ quality of life quite a bit, John Hart, MD , Associates in Ophthalmol- ogy, Farmington Hills, Michigan, and clinical assistant professor of biomedical sciences, Oakland University, Rochester, Michigan, said his threshold for offering cataract surgery to patients with dementia is low. Dr. MacDonald also stressed the importance of early cataract surgery for demen- tia patients. Not only are mature cataracts more difficult to oper- ate 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 combina- tion, so we want to make sure we