EyeWorld India December 2017 Issue

24 EWAP FEATURE December 2017 Special considerations – from page 23 are equipping them with all the tools we can to stay oriented and safe,” Dr. MacDonald said. A study published in the American Journal of Ophthalmol- ogy in 2008 found vision-related quality of life, cognitive im- pairment, and depression 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 declined—for example, be- cause 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 sur- gery and helped them see again, their level of interest … is back up because now we’ve eliminated the visual hindrance,” Dr. Matos- sian 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 ap- pointments, Dr. Matossian said. Having that second set of ears to absorb all the information 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 demen- tia patient, such as subjective refraction testing. As such, ask- ing 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 television, see the food on their plate and the people who are across from them, and typi- cally you’re gearing the surgical result to reflect that. Usually a low amount of myopia is an ap- propriate end point to be looking for,” Dr. Hart said. The risks that need to be explained as much as possible to the patient and the caregiver are those that go hand-in-hand with the possibility of general anes- thesia, the possible neurologic risk of anesthesia making demen- tia 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 gener- ally able to judge in the preoper- ative visits whether patients will be suitable for topical anesthesia, if they will need a block, or if they’ll require general anesthe- sia. Dr. Matossian went on to say she uses laryngeal mask airway general anesthesia, finding it to be less invasive. In patients who are marginal when it comes to their level of dementia, Dr. Matossian plans for the possibility of having to switch from topical to general anesthesia. “Sometimes patients are marginal, meaning they appear OK, but under an unfamiliar set- ting of an operating room, they may become confused, especially once the drape is placed over them,” she said. “Anesthesia works very differently with these folks,” Dr. Matossian continued later. “Often less medication is better than more. The more anesthesia we give them, the more confused they become.” Dr. Hart expressed a similar sentiment. “As much as possi- ble, less is more, but ultimately, you’re doing anesthesia so that you can have a safe surgery,” he said. On the vein of keeping the patient calm, Dr. Hart provided a couple of other simple tips for the OR. “Have a running commen- tary, calm demeanor, talk with the patient,” he said. “I also tend to like the CRNA to hold the patient’s hand. Before we drape the patient, she will explain that she’s going to be there holding their hand and if there is an issue, they should squeeze her hand and that will be our clue to try to respond right away. It’s something we try to do with everyone because it is very calm- ing.” Both Drs. Matossian and MacDonald said they will tape the head of dementia patients who they fear might get con- fused during the surgery and try to move. Reflecting on refraction Target refraction is of particular importance in this group. As Dr. Hart previously stated, he thinks these patients are less likely to need clear distance vision, mak- ing intermediate vision impor- tant. As such, Dr. Hart targets