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The purpose of this abstract is to examine the incidence of falls, visual acuity, and refractive status before and after first and second cataract surgeries.
Design and setting: Prospective observational study at eight public hospitals in Sydney, Melbourne, and Perth that serve as tertiary referral centres for ophthalmology.
Participants: Patients 65 years of age or older who underwent bilateral age-related cataract surgery between 2013 and 2016 were included in the study and were monitored for a maximum of 24 months following enrollment, or until six months after the second eye surgery, whichever was shorter.
Principal outcome metrics The main result is the adjusted incidence of falls for age and sex. Visual acuity and refractive error are secondary outcomes.
Results: 220 women made up the majority of the 409 participants, with a mean age of 75.4 years (SD, 5.4 years) (54 percent ). Prior to surgery, the age- and sex-adjusted fall incidence was 1.17 (95% CI: 0.95-1.43) per year; following the first eye surgery, it was 0.81 (95% CI: 0.63-1.04) per year; and following the second eye surgery, it was 0.41 (95% CI: 0.29-0.57) per year. The age- and sex-adjusted incidence of falls was similar before and after first eye surgery (0.81 [95 percent CI, 0.57-1.15] falls per year) for the 118 participants who underwent second eye surgery and took part in all follow-up visits, but it was lower after second eye surgery (0.32 [95 percent CI, 0.21-0.50] falls per year). Before surgery, the mean habitual binocular visual acuity (logMAR) was 0.32 (SD, 0.21), and 0.15 after (SD, 0.17)
following a second eye surgery.
Conclusions: The first eye surgery significantly improves vision in older cataract patients, but a second eye surgery is necessary to reduce the likelihood of falls. In addition to improving vision in older adults with cataracts, timely treatment for both eyes lowers their chance of damage from falls.
The known: Cataract surgery on the first eye lowers the risk of falls among seniors, but the impact on the second eye is less certain.
The new: After the initial eye operation, which restored binocular vision, the age- and sex-adjusted incidence of falls among older persons who had been referred for cataract surgery was 31% lower.
The implications: Providing timely and equal access to cataract surgery can reduce the risk of accidents caused by falls and promote healthy ageing.
In Australia, cataracts are the most common cause of vision impairment, despite the effectiveness and accessibility of cataract surgery.
2 A total of 2.7 percent (95 percent confidence interval [CI], 2.0-3.5 percent) of non-Indigenous Australians aged 50 or older had cataract-related vision impairment (logMAR, 0.3 [Snellen, 6/12] or worse). 3 In Australia and other high-income nations, significant discrepancies in access to cataract surgery have been documented. 4
The frequency of falls among older people is reduced by 32% following cataract surgery, according to a meta-analysis of six quasi-experimental studies5 (relative risk [RR], 0.68; 95 percent confidence interval [CI], 0.48-0.96). However, the authors did not make a distinction between first- and second-time cataract surgery. The only expedited cataract surgery randomised controlled trial (RCT) (conducted in the UK) discovered that first eye cataract surgery reduced the fall rate by 34% (RR, 0.66; 95 percent CI, 0.45-0.96);6 the authors' subsequent second eye surgery RCT did not discover a statistically significant reduction (RR, 0.68; 95 percent CI, 0.39-1.19). The effects of first and second eye surgery on the frequency of falls resulting in hospitalisation have been studied using data linkage, but the results have been inconsistent, and not all potentially confounding factors have been taken into account.
account.8,9
Falls in Older People with Cataract: a Longitudinal Evaluation of Impact and Risk (FOCUS)10, a recent cohort study of fall risk, distinguished between the preventive effects of first eye surgery (incidence rate ratio [IRR], 0.67; 95 percent confidence interval [CI], 0.49-0.92) and the influence of other factors, such as poor pre-surgery vision in the dominant eye (IRR, 2.20; 95 percent CI, 1.02-4.74) and significant
11 In this paper, we examine fall risk, as well as secondary outcomes such as visual acuity and refractive error, before and after first and second cataract surgeries.
Methods
The FOCUS study examined the effects of cataract surgery on falls, vision, and refractive status by prospective surveillance.
At eight Australian public hospitals, including the Sydney Eye, Westmead, Bankstown, and Royal North Shore Hospitals in Sydney, the Royal Victorian Eye and Ear Hospital in Melbourne, the Fremantle, Royal Perth, and Sir Charles Gairdner Hospitals, 10 patients 65 years of age or older were found on surgery waiting lists (1 October 2013 - 31 July 2016). (Perth). After receiving a letter inviting them to participate, potential participants were called by phone a week later to gauge their interest and check their eligibility. We rejected candidates from pre-recruitment evaluations if they made more than two errors on the Short Portable Mental Status Questionnaire12, reported dementia, Parkinson's
Questionnaire,12 reported having dementia, Parkinson's disease, or a stroke, being unable to walk (either with assistance or without assistance), living in a residential care facility, having other serious eye conditions (such as glaucoma, diabetic retinopathy, age-related macular degeneration), planning a combined operation (such as trabeculectomy and cataract surgery), or not being able to complete study assessments in English. Following second eye surgery, participants were monitored for either six months or two years, whichever came first. Data collection was completed on June 30, 2018.
Assessments
Utilizing standardised methods, trained research assistants conducted baseline and follow-up assessments. About three months following surgery, follow-up exams were carried out; if the interval between the first and second surgeries was less than three months, they were skipped. Data on birthdate, gender, height, and weight
Data on height, weight, and sex were gathered from the beginning. At each study visit, a medical history was obtained along with physical and vision-related evaluations, including checks on self-reported medication use and doctor-diagnosed medical conditions (combined as a summary measure, the Functional Comorbidities Index, FCI13), physical activity (Incidental and Planned Exercise Questionnaire14), and physical function (Short Physical Performance Battery, SPPB15). The SPPB score (0–12; 0 = poorest, 12 = highest physical performance) was calculated by adding the component scores for a timed 4 m walk (m/s), standing balance for ten seconds in six stances (range, 0–60 s), and five sit–to–stand repeats (stands per second).
The participant's typical eyewear was noted, and the Early Treatment Diabetic Retinopathy Study chart16 was used to test the participant's binocular and monocular high contrast visual acuity at 3 metres under standard room lighting with habitual distance correction (minimum, 480 lux). Using the Mars letter contrast sensitivity test17 at 50 cm, monocular and binocular contrast sensitivity were assessed. By applying the vector length equation |P| = [(S + C/2)2 + (-C/2cos2)2 + (-C/2sin2)2]—where S denotes spherical power, C denotes cylindrical power, and denotes the axis for sphero-cylindrical power stated in negative cylinder form—refractive error was calculated. 18 We present the percentage of participants who had at least moderate stereopsis (140 seconds of arc) on the Wirt circles, as determined by the Titmus Fly stereo test19.
Fall data
As "an unanticipated event in which the individual comes to rest on the ground, floor, or lower level," falls were the main effect. 20 From the start of the study until 24 months from the start date or six months after the second eye surgery, whichever came first, falls data were prospectively collected in monthly self-report calendars. If participants' monthly falls calendars were not returned, interviewers phoned them to ask about the details of any falls. Although they were not aware of our study premise, the interviewers confirmed the participants' scheduled surgeries.samples taken
The McNemar test power analysis, conducted in PASS 11 [NCSS], did not meet the FOCUS research recruitment target of 652 participants, which would have had a 90% chance of detecting a difference in proportions of 0.05.
10 The goal was determined using data from a pilot research, the fall prevalence in a previous study of cataract patients, a six-month observation period, and the proportions of discordant pairings (falls before and after surgery). The first 329 participants' data were used to evaluate the primary result (falls before21 and after first eye surgery11) as well as the secondary outcomes (depressive symptoms, physical activity, and fear of falling23). A sample size of 329 participants supplied 80% of the information because the drop in the number of falls was greater than expected.
a mean pre-surgery exposure length of 0.88 years and an overdispersion parameter of 1.5, and power to detect a reduction in fall incidence of 32%. Phase 2 recruitment ended in July 2016, and due to resource limitations, it was only possible to evaluate the key outcomes (falls and vision; Supporting Information); all gathered data were available for our analysis.
Statistic evaluation
There were three time periods established: before the first eye surgery (pre-surgery), between the first and second eye surgeries, and after the second eye surgeries. Data were classified as missing and not imputed if assessments were not completed. Descriptive statistics provide a summary of information on age, sex, health, and physical and visual abilities. We present baseline variations in baseline characteristics between participants who did not participate in the study and those who did.
not had surgery, have only had the first eye operated on, or have had both eyes operated on; and changes in vision characteristics over time. We calculated the incidence of falls and incident rate ratios for the three time periods using a negative binomial regression model, which was confirmed to be appropriate by examining the dispersion parameter. To account for the three time periods' various lengths, we used the number of observation days as the offset. Based on our prior research11,21, we selected a minimally adjusted model that took into account the collinearity of vision-related factors and surgical status. Repeated measures in individuals were accounted for using an exchangeable correlation structure by participant. To account for the innate correlation of repeated measurements, generic linear models (in SAS Enterprise Guide 7.1) were utilised in all analyses.
To account for the intrinsic correlation of repeated measurements ( = 0.05), use Guide 7.1. The STROBE recommendation is followed in our study report. 24
ethical endorsement
The NSW Population and Health Services Research Ethics Committee (HREC/13/CIPHS/25), Curtin University's HR 123/2013, and the Royal Victorian Eye and Ear Hospital's 13/1124H all approved the study's ethical conduct. Everyone who took part gave their signed, informed consent.
Results
416 out of 1664 invited participants accepted our invitation to take part in the study (25 percent ). Six were later eliminated because prospective falls data were unavailable, and one was eliminated because the dates of operation were noted in their hospital records.
and one because their hospital records' dates of surgery showed they did not initially have bilateral age-related cataracts. The average age of the 409 participants was 75.4, with an SD of 5.4 years, and 220 of them were female (54 percent ). During the study period, 63 patients (15%) did not get cataract surgery. For 346 participants, the median period from enrollment to the first eye operation was 176 days (interquartile range [IQR], 89-321 days). The median duration between the first and second eye surgeries was 265 days (IQR, 119-493 days), while the median time following the second eye operation was 211 days (IQR, 189-225 days). A total of 188 participants (46%) underwent second eye cataract surgery (Box 1).
Box 1 shows how the study's 416 enrolled participants progressed.
a visual display
When individuals were first included, their habitual vision was worse than that of those who later underwent second eye surgery (mean difference [logMAR], 0.09; 95 percent confidence interval [CI], 0.04-0.15) or underwent no surgery (mean difference, 0.11; CI, 0.04-0.18). In comparison to participants who underwent first eye surgery only (mean difference in SPPB scores, 1.11 points; 95 percent confidence interval, 0.17-2.05 points) or both first and second eye surgery (mean difference, 0.99 points; 95 percent confidence interval, 0.07-1.91 points), people who did not have cataract surgery had worse baseline physical function. The three groups' initial features were comparable overall (Box 2).
Box 2 lists the 409 study participants' initial characteristics (at the time of enrollment)
The 118 patients who underwent first and second eye cataract surgery and took part in all follow-ups saw improvements in their bilateral log contrast sensitivity and binocular habitual visual acuity following each procedure. 58 participants (52%) had anisometropia of 1.00 dioptre or more at baseline, 85 after the first operation (79%) and 36 after the second operation. The mean anisometropia was 1.38 (SD, 1.71) dioptres at baseline, 2.68 (SD, 2.94) dioptres after first eye surgery, and 1.12 (SD, 1.72) dioptres after second eye surgery (33 percent ). After surgery, the average refractive error was lower than it was before (first operated eye: 1.08 [SD, 1.86] v 2.62 [SD, 1.23] dioptres; second operated eye: 1.31 [SD, 1.65] v 2.52 [SD, 1.87] dioptres) (Box 3).
Box 3 shows the visual features of 118 participants who underwent both first and second cataract surgery and took part in all follow-ups before and after both procedures.
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Falls frequency
Surpassing expectations by 66%, participants submitted 5139 completed falls calendars by mail. During follow-up phone conversations, interviewers also obtained additional falls information from 379 participants. Falls incidence adjusted for age and gender occurred at a rate of 1.17 (95% confidence interval [CI], 0.95–1.43) per year before to surgery, 0.81 (95% CI, 0.63–1.04) per year following first eye surgery, and 0.41 (95% CI, 0.29–0.57) per year following second eye surgery (Box 4).
Box 4 shows the annual incidence of falls and the state of eye cataract surgery.
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The age- and sex-adjusted incidence was 0.80 (95 percent CI, 0.55-1.15) falls per year before surgery, 0.81 (95 percent CI, 0.57-1.15) falls per year after first eye surgery, and 0.32 falls per year (95 percent CI, 0.21-0.50) after second eye surgery. This analysis was restricted to the 118 participants who underwent second eye surgery and participated in all follow-ups (Box 5).
Box 5 displays the incidence of falls by eye cataract surgery status for 118 participants who underwent both first and second eye surgeries and participated in all follow-ups.
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Discussion
Around the world, cataract is a leading cause of vision impairment, but whether cataract surgery is fairly funded is up for contention in Australia26 and other countries.
4 We present data demonstrating the critical role that prompt access to both first and second eye cataract surgery plays in enhancing mobility and visual function in older patients with bilateral cataract. About 250 000 cataract procedures are conducted annually in Australia, with a third taking place in public facilities. 2 An earlier Australian study discovered that elderly patients with bilateral cataracts on public hospital waiting lists experience unusually high rates of falls, with 50% of these falls resulting in injury. 21 When binocular vision function is fully recovered after second eye surgery, we discovered that the fall rate decrease is larger.
Some apparent discrepancies between past publications are resolved by our findings. In order to determine the effect of cataract surgery on the frequency of falls resulting in hospitalisation, some writers have used administrative data. 8,9 Cataract surgery was linked to a lower rate of falls in a study of matched Medicare beneficiaries in the United States who had cataracts but had not undergone the procedure (adjusted odds ratio, 0.84; 95 percent confidence interval, 0.81-0.87). 9 In contrast, a study conducted in Western Australia discovered that both first and second cataract surgeries increased the risk of falls. 8 The effect of first eye surgery on fall risk was found to be statistically significant by the only relevant RCTs, but not by the effect of second eye cataract surgery. 7 Our discovery showed a second eye operation had a bigger effect on the incidence of falls
The results of a smaller Australian cohort study are consistent with the finding that second eye surgery had a bigger effect on fall incidence (55 participants). 27
Less than half of the study participants had both their first and second eye surgeries within the 24 months that were being looked at. Participants' profiles who received surgery on either eye, both eyes, or neither eye were identical. However, the disparities in physical function by surgical status show that external factors, such as competing health objectives and capacities, may influence the scheduling of surgery. People with worse vision may be expected to undergo surgery sooner.
As anticipated, measures of visual performance increased after cataract surgery, but vector analysis revealed anisometropia (i.e., a difference in refractive power between the eyes) in 79 percent of participants who had surgery on both eyes. This difference in refractive power was at least 1.0 dioptre. Only 102 out of 196 patients who had their first eye surgery had their prescription for eyeglasses alter within three months after the procedure, and the 63 patients who had significant changes (0.75 dioptre or more) were most at risk for falling. 11 According to these results, the interval between the first and second cataract operations should be kept to a minimum in order to allow for timely and adequate spectacle updates following the second procedure, which lowers between-eye disparities in refractive error.
Limitations
Our observational study cannot infer any causal relationships. Even though not all subjects underwent first and second cataract surgeries, our analyses were nonetheless modified to account for the various exposure times. To characterise our sample and investigate potential sources of selection bias, we gathered extensive data on visual status, physical function, and health-related risk factors for falls. However, certain tests could not be performed due to the timing of surgery. Prospective monthly falls reporting is advised for measuring the key outcome, fall incidence, as it was based on self-report and prone to reporting bias. 20 They were presumably not typical of all candidates for cataract surgery or of the general population because only 25% of possible participants volunteered to participate in our study.
people who were waiting for cataract surgery at a public hospital but may have been more mobile candidates who might travel for study evaluations. Residents of senior living communities were not included. Comparatively to individuals who have cataract surgery from private sector providers, our participants most likely come from lower socioeconomic status backgrounds. Many of these restrictions could be avoided in the planned randomised control study.
Conclusion
Our work adds to the body of research that shows older adults should be given prompt access to cataract surgery because it is a low-cost method of enhancing eyesight and reducing falls.
28 In Australia, older patients with cataracts may have to wait a long time for both first and second eye cataract surgery in the public hospital system. The issue has grown worse as a result of postponing elective
in the public hospital system for both first and second eye cataract surgery. Delaying elective surgery during the coronavirus disease 2019 (COVID-19) pandemic has made the issue worse and is especially detrimental to those who depend on public hospital services. According to our research, timely and equitable access to cataract surgery is essential for promoting healthy ageing and injury prevention.
24 November 2021: Received; 31 March 2022: Accepted
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