Cataract Surgery and Pre-Op Testing
Cataract surgery is one of the safest surgeries performed today. So, if your eye doctor suggests undergoing medical tests such as blood work or an electrocardiogram before your procedure, what could be the harm? Doesn’t additional testing ensure an even safer surgery?
Not always. Preoperative testing for cataract surgery may sound like a prudent idea, but besides being costly, it may lead to testing with only marginal benefits. According to a 2015 study in The New England Journal of Medicine (NEJM), routine preoperative testing neither reduces complications nor improves surgical outcomes.
“Routine preoperative tests like an electrocardiogram, a complete blood count, or a urinalysis themselves are safe, and patients may agree to them because they’re generally harmless and noninvasive,” says Ravi D. Goel, M.D., a cataract surgeon with Wills Eye Hospital in Philadelphia and a clinical spokesperson for the American Academy of Ophthalmology (AAO). There are exceptions, says Goel. Your ophthalmologist may advise you to visit your primary care physician for evaluation if you have a concerning systemic condition, such as chronic obstructive pulmonary disease; a recent heart attack; unstable angina; or poorly controlled diabetes, congestive heart failure, or high blood pressure. Your primary care physician may choose to perform some tests to ensure that you’ll be able to tolerate the surgery without complications.
“In the past dozen years, preoperative testing has helped a number of my patients,” says Goel. “For example, one patient saw his primary care physician for a preoperative visit and learned he had undiagnosed diabetes. His surgery was canceled until his newly diagnosed diabetes could be stabilized. In this instance, preoperative evaluation and testing worked, and the healthcare system will ultimately save thousands on a judicious preoperative evaluation.”
More isn’t always better
Cataract surgery is one of the most common procedures performed in America. The operation takes about 18 minutes per eye. Typically, only one eye is operated on at a time, though some health plans are experimenting with same-day surgery on both eyes. Surgery is usually performed in an outpatient setting with local anesthesia administered in the form of eye drops. You may be given a mild sedative.
The AAO has long recommended against routine preoperative testing before cataract surgery. However, the NEJM study suggests that, despite clinical guidelines to the contrary, too many patients continue to undergo needless tests. After gathering data from more than 440,000 Medicare patient records, the researchers estimated that up to 53 percent of cataract surgery patients were given one or more tests they didn’t need in 2011. Preoperative tests included lab tests such as blood work and urinalysis, as well as tests such as electrocardiography, echocardiography, cardiac stress tests, chest radiography and pulmonary-function tests. Patients were given 798,150 tests in the month leading up to their cataract surgery, at a cost of more than $16 million, according to the study.
Making it about you
On the surface, these findings should be cause for alarm. However, a closer look at the study reveals several limitations that might have resulted in overstated numbers. Most notably, the Medicare data that the researchers analyzed didn’t reveal who ordered the tests and whether they were ordered specifically for presurgical screening or for an unrelated condition.
The AAO took issue with some findings while reinforcing its position advising against routine testing before surgery. The study “cannot identify who ordered the services,” said Randall J. Olson, M.D., chair of the Academy’s cataract preferred practice patterns panel, in a statement. “This could have been anyone on the care team—anesthesiologists, internists, primary care physicians, nurse practitioners, or physician assistants, not just ophthalmologists. In addition, the tests could have been ordered as a requirement of the healthcare system or due to a patient’s specific health status.”
Yet, despite its limitations, the study serves as an important reminder that you need to be a savvy healthcare consumer who should understand the reasons for any tests your doctor wants to order, especially those involving cataract surgery. Speak with your ophthalmologist about preoperative cataract surgery testing to determine what’s right for you. And keep in mind that Medicare or your insurance plan may not cover such tests if they’re not deemed necessary. At $25 to $50 a test, costs could add up quickly.
“The key message,” says Goel, “is that medical testing before any surgical procedure is generally the purview of the primary care physician and not the ophthalmologist. Testing should be individually tailored to the patient. Routine medical tests before cataract surgery may not increase the procedure’s safety itself and may still be beneficial to assess a patient’s overall health.”
Exams you need
About a week to a month before cataract surgery, your eye surgeon will perform an A-scan or a noncontact optical biometry to measure the length of your eye. He or she will also measure the curvature of your cornea, using a technique called keratometry. Both measurements help determine the appropriate power of the artificial lens implant that will replace your clouded lens.
If the surgeon can’t see the retina in the back of the eye because the cataract is too opaque, he or she will perform another test, called B-scan ultrasonography. The test uses reflected sound waves to look at structures in the back of the eye.