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Appendix I. Literature Review: Preoperative Medical Evaluation
Appendix I. Literature Review: Preoperative Medical Evaluation Purpose The purpose of this literature review was to examine the preoperative medical and general evaluation of the patient with functional impairment due to cataract. The questions specifically identified by the panel for this topic are detailed in the Results section.
Method A computerized literature search was performed by the National Library of Medicine for abstracts of articles published from January 1, 1975, through December 31, 1990. (Chapter 2 and Appendix A give a detailed description of the search strategy.) A printout of four abstracts was produced. Additional articles were identified by reviewers and other interested parties. After the abstracts and additional articles were screened, articles were selected for further review if they appeared relevant to the topic covered. The review was supplemented with selected publications addressing the questions under consideration from the perspective of patients undergoing surgery for other reasons. The formal literature review was also augmented with literature addressing the issue of functional assessment in the elderly and preventive health care screening. Thus, a total of 34 articles were reviewed.
Results Question 1: Is there evidence to support or refute a specific association between short-term medical outcome in the postoperative period and the preoperative medical evaluation of the patient (physical examination, electrocardiogram, chest xray, complete blood count, other)? Comprehensive recommendations about preventive health screening have been made by the U.S. Preventive Services Task Force (Task Force Staff, 1989), the American College of Physicians (American College of Physicians, 1981; American College of Physicians Staff, 1987), the American Cancer Society (1988), the American Geriatrics Society (1989), the National Institutes of Health (National Cholesterol Education Program, 1988; Prepared by Ernest L. Mazzaferri, MD, and Denis M. O'Day, MD, FACS, Panel Chair, who comprised the literature review group.
National Institutes of Health, 1988; 1988 Joint National Committee, 1988), and the Canadian Task Force on the Periodic Health Examination (1989 and 1991). These preventive care guidelines have been recently summarized in a comprehensive paper by Hayward and associates (Hayward, Steinberg, Ford et al., 1991). There appears to be substantial variability among different institutions in the preoperative medical evaluation of cataract patients. The author of one textbook (Hardesty, 1991) recommended that a full battery of screening tests be obtained (e.g., complete blood count, electrolytes, renal function test, urinalysis, electrocardiogram, and chest x ray) because of the advanced age and multiple medical problems of these patients. Others (Blery, Charpak, Szatan et al., 1986; Kaplan, Boeckmann, and Roizen, 1982; Kaplan, Sheiner, Boeckmann et al., 1985; Lawrence, Gafni, and Gross, 1989; Roizen, 1988) advocated reducing the routine preoperative testing and reported no significant harm in making such reductions in patients undergoing a variety of surgical procedures, all of which have a greater risk of complications than cataract surgery. In particular, the usefulness of a routine preoperative urinalysis (Lawrence, Gafni, and Gross, 1989) and chest xray (Charpak, Biery, Chastang et al., 1988; Roberts, Fowkes, Ennis et al., 1983; Rucker, Frye, and Staten, 1983) was questioned, and it appeared that the benefit of preoperative pulmonary function testing is restricted to a very small group of surgical patients that does not include cataract surgery patients (American College of Physicians, 1990; Zibrak, O'Donnell, and Marton, 1990). Concurrent medical problems are especially common in patients undergoing cataract surgery. A retrospective study (Maltzman, Cinotti, and Calderone, 1981) of 200 patients who underwent cataract surgery found that only 51 patients (25.5 percent) had no disorders other than cataracts. Previously known chronic ailments were present in 137 (68.5 percent), whereas 44 (22 percent) had 58 newly discovered disorders. The medical ailments present in the patients included: cardiac disorders (7 percent); diabetes mellitus (4 percent); hypertension (3.5 percent); pulmonary disease (3.5 percent); anemia (2.5 percent); inguinal hernia (2 percent); hepatomegaly (2 percent); and other abnormalities, including venous insufficiency, urinary tract infection, electrolyte imbalance (4.5 percent).
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Each of the five preoperative tests (chemistry profile, complete blood count, urinalysis, x ray, electrocardiogram) performed on this group of patients appeared equally important in uncovering new disease. The authors believed that none of the preoperative medical tests could have been eliminated to reduce the cost of testing without missing some of the medical disorders. In addition to being retrospective, the study has several methodologic flaws that weaken its scientific strength. A number of patients were excluded from the study because threatening preadmission findings caused their surgery to be canceled, thus biasing the study toward making preadmission testing appear less important than it actually was in detecting unknown disease. The importance of preoperative testing is actually understated by the data in this study. The age of the patients in this study was not mentioned. In another retrospective study (Fisher and Cunningham, 1985), 100 consecutive patients who averaged 75 years of age and who had undergone cataract extraction in the hospital were reviewed. Laboratory investigation included a complete blood count, chemistry profile, urinalysis, chest x ray, electrocardiogram, and other tests as indicated by the history and physical examination. One or more significant preexisting medical conditions were found in 84 percent of the patients. Patients had hypertension (47 percent); diabetes mellitus (16 percent); congestive heart failure (10 percent); and significant pulmonary disease, including chronic obstructive pulmonary disease, chronic bronchitis, and interstitial fibrosis (7 percent). Significant atherosclerosis or arteriosclerotic heart disease, defined as previous myocardial infarction, angina, peripheral vascular insufficiency, occlusive carotid disease, atherosclerotic valvular disease, or a history of transient ischemic attacks or strokes, was found in 38 percent of the patients. The authors of this study believed that all patients undergoing cataract extraction should have a thorough preoperative medical evaluation. Many patients (78 percent) were taking one or more medications, including coumadin (4 percent). In addition to being retrospective, the study has several methodologic flaws that weaken its scientific strength. Patients whose preadmission findings caused their surgery to be canceled were excluded from the study, thus biasing the study toward making preadmission testing appear less important than it actually was in detecting unknown disease. The importance of preoperative testing is thus also understated by the data in this study. A study (Biery, Charpak, and Szatan, 1986) from a teaching hospital in France is informative in this
1965
regard. Selective ordering of 13 preoperative tests (blood typing, antibody screen, hemoglobin, prothrombin time, partial thromboplastin time, bleeding time, platelet count, electrolytes, creatinine, blood-urea-nitrogen [BUN], glucose, chest x rays, and electrocardiogram) was studied in 3,866 consecutive patients undergoing surgery under general or regional (but not local) anesthesia over a 1-year period during 1983 and 1984. Almost one-half the patients underwent minor surgical procedures defined as potentially bloodless operations, most of which were done on an elective basis. Although cataract surgery would fall into this category, the study did not specifically address cataract extraction. Preoperative testing was done according to a protocol that accounted for the patient's clinical status and type of surgery. Routine testing was not done in patients undergoing minor surgery unless they were age 40 and over, had associated conditions, or were taking medications. For instance, an electrocardiogram was done routinely in those age 40 and over, and electrolytes, creatinine, and BUN determinations were routinely done in those age 70 and over. Patients with cardiovascular or pulmonary disease had chest x rays and electrocardiograms, regardless of their age, and patients with diabetes mellitus all had renal function, electrolytes, and glucose determinations. This strategy resulted in an average of about four tests for each patient in the entire group. A total of 140 patients (8 percent) in the minor surgery group experienced preoperative or postoperative morbidity, and 2 died after surgery. The possible value of tests that were omitted was assessed in light of events that occurred during and after surgery. The authors concluded that 0.4 percent of nonordered tests would have been potentially useful according to predetermined computerized criteria, and only 0.2 percent would actually have predicted an adverse outcome according to the opinion of the anesthesiologists participating in the study. This study has several methodologic flaws, and its generalization to cataract patients is also questionable. The study actually comprised a series of judgments resulting in very different testing of a broad variety of patients with disparate diseases. Despite the large number of patients in this study, its statistical power is uncertain, since a number of patient populations with very different characteristics were studied. For example, the level of illness was not systematically addressed. In addition, the study's design may have biased the results to favor the conclusions that were reached by the authors; the idea that computerized criteria can be established to identify laboratory tests that will predict an adverse
Cataract Management Guideline Panel • Management of Functional Impairment Due to Cataract in Adults outcome is a unique idea that itself requires validation. The anesthesiologists were not blinded to the patient's adverse outcome when they made a judgment about the laboratory testing, which may also have biased the results. Perioperative management of selected common medical problems. The majority of patients undergoing cataract surgery are elderly persons, a patient population with a high prevalence of concurrent multiple medical problems such as coronary artery disease, hypertension, diabetes mellitus, dementia, cerebrovascular disease, arrhythmias, chronic obstructive pulmonary disease, alcoholism, thromboembolic disease requiring anticoagulant therapy, and nutrition problems. In addition, elderly patients often take one or more potent medicines. Despite these concurrent problems, the risk of this short, very limited surgical procedure is low. The perioperative mortality of ophthalmic surgery patients overall is only 0.16 percent and for cataract patients, 0.1-0.2 percent (Quigley, 1974). The incidence of serious medical complications such as myocardial infarction associated with ophthalmologic surgery under local anesthesia is less than 1 percent, even in patients with a past history of myocardial infarction. Although the risk of serious medical complications is quite low in cataract surgery patients, concurrent medical problems frequently cause concern among ophthalmologists, anesthesiologists, internists, and other physicians involved in the management of these patients. Such concerns may lead to additional pre-, intra-, and postoperative interventions that may be associated with considerable cost and uncertain benefit. To date, optimal perioperative management of medical problems has not been defined for cataract patients specifically. Therefore, it is likely that a great deal of variation exists in current practice patterns regarding the perioperative medical management of cataract patients. Anticoagulant drugs being taken for thromboembolic, cardiovascular, or neurologic disorders pose a special problem. The literature reflects conflicting practices during cataract surgery on patients taking anticoagulant drugs. A recent survey (Stone, Kline, and Sklar, 1985) of 135 cataract surgeons indicated that 75 percent of the respondents withheld anticoagulation during the perioperative period, which resulted in two deaths from strokes, two additional strokes, one transient ischemic attack, a cerebral embolism in a patient with an artificial valve, a pulmonary embolus, and an episode of deep-vein thrombosis. This retrospective survey does not provide enough data about the patients, their level of disease, or how the decision
was made to discontinue anticoagulant drugs to permit a critical analysis of the conclusion. Another study (McMahan, 1988) prospectively compared the outcome of 22 patients undergoing intraocular lens implantation who were receiving anticoagulants with that of age-matched patients (controls) who were not receiving these drugs. After continuing anticoagulation through the surgical and postoperative period, no patient experienced clinically significant bleeding that interfered with vision. There were no retrobulbar, vitreous, or retinal hemorrhages and no elevated pressures in any anticoagulated or control patient. On the basis of these limited data, it appears that anticoagulation does not pose a substantial risk for seriously complicating ophthalmic surgery, whereas discontinuing these drugs may impart some increased risk for new thrombotic events in the patient with preexisting cardiovascular, cerebrovascular, or thromboembolic disease. The selection of controls in this study was weak, since they were matched with patients only for age and not for other characteristics, such as underlying major illnesses. In addition, the study is flawed by the very small number of patients, which makes the likelihood of a type 2 error very high. Myocardial reinfarction in the course of cataract surgery is of particular concern in the elderly patient with a past history of myocardial infarction. A retrospective study (Backer, Tinker, Robertson et al., 1980) of myocardial reinfarction following local anesthesia for ophthalmic surgery found no postoperative reinfarctions or death in 195 patients who underwent 288 separate operations. The 0 percent reinfarction rate was significantly lower than the 6.1 percent reinfarction rate previously reported from the same institution for 587 operations on patients with documented preoperative myocardial infarction who had general or major regional anesthesia for non ophthalmic surgery. Thus, on the basis of these limited data, it appears that ophthalmic surgery under local anesthesia and/or retrobulbar block does not pose special risks for reinfarction in the patient with a preoperative myocardial infarction. This study's major weakness is that it selectively reports only on patients on whom surgery was done, omitting those who might have been rejected for surgery because of serious cardiac symptoms or signs or because of ominous laboratory tests. For instance, if patients with congestive heart failure or severe angina undergo surgery, the results might be different than if they had been rejected as unsuitable surgical candidates. Preoperative evaluation of the elderly patient. The majority of patients undergoing cataract surgery are 1975
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elderly persons who not only have a high prevalence of multiple medical problems but also have unique and commonly dysfunctional problems of aging. Functional problems, defined as difficulties that interfere with daily routines, are often unappreciated when conventional histories and physical examinations are done. Functional assessment, therefore, is an integral part of geriatric care (American College of Physicians, 1988; Williams, 1990). Its importance was underscored by the Consensus Development Conference at the National Institutes of Health (1988), which stated that comprehensive geriatric assessment is effective in improving the quality of ongoing care. Although most elderly noninstitutionalized adults are functionally competent, the percentage who need help doing everyday activities doubles with each successive decade up to age 84 and triples between age 85 and 94 (Feller, 1983). In addition to visual dysfunction, elderly persons often have other equally severe and unrecognized functional problems resulting from hearing disorders, difficulty with arm and leg function, urinary incontinence, depression, dementia, environmental hazards, and inadequate financial and social support systems. Although there is general agreement that functional assessment is most useful when a standard, systematic approach is used to measure and record observations, there is a general lack of consensus on the best way to perform these evaluations (Williams, 1990). Applegate, Miller, Elam et al. (1987) prospectively examined the impact of cataract surgery on the functional status of 293 elderly patients undergoing cataract surgery. Patient function was evaluated by both subjective measures (everyday activities and self-report of vision-dependent activities) and objective measures (timed manual performance tests and mental status tests). With marked improvement in visual acuity, modest positive changes occurred in self-reported everyday activities and vision-dependent activities; the most marked changes occurred in objective measures of function. Mental status improved significantly 1 year after surgery, and timed manual performance improved dramatically at 4 months and 1 year. This study is sound methodologically but does not address the issue of preoperative medical testing of cataract patients. Cataract surgery was associated with better vision and improved functional status in most patients by 4 months after surgery and was maintained 1 year later. The patient's perception of disability and selfassessment of impairment are extremely important in evaluating the impact of therapy. A new approach to assessing functional disability was described by
1985
Tugwell and associates (Tugwell, Bombardier, Buchanan et al., 1987), who devised an instrument that has the potential to detect small, clinically important changes in function. These authors developed a new patient preference questionnaire for assessing disability that focuses only on those activities directly affected by the disability and judged to be important by the patient. This study is sound methodologically but does not address the issue of preoperative medical testing of cataract patients. The American College of Physicians (1988) recently advocated incorporating functional status measurement into routine clinical practice. The College commissioned a group of investigators to identify the important areas in which elderly persons who are not acutely ill should be screened for functional disabilities and to develop a simple, practical, and sensible approach to the screening assessment. Lachs and associates (Lachs, Feinstein, Cooney et al., 1990) devised such an instrument. After a careful literature review, Lachs and coworkers concluded that most published instruments were impractical because they are too lengthy, require special equipment, or are not targeted to older populations. With the assistance of a panel of expert geriatricians and general internists, they developed a short, simple approach that can be used by primary health care providers to screen the functional status of elderly patients routinely. The instrument focuses on a limited number of target areas that are commonly dysfunctional but often unappreciated in the elderly when conventional histories and physical examinations are done. The instrument uses carefully selected tests of vision, hearing, arm and leg function, urinary incontinence, nutrition, mental status, depression, basic everyday .activities (a term that refers to the abilities needed for independent self-maintenance in the basic functions of bathing, eating, dressing, toileting, transferring, and walking), and instrumental everyday activities (a term often used for higher levels of independent function such as cooking, shopping, and light housework). It also explores potential environmental hazards and social support systems. Brief questions and easily observed tasks are used to obtain information in a short time. One of its targets is the home environment. It explores the most troublesome obstacle to mobility for elderly patients living at home: the stairs, both inside and outside. Patients are asked about potential hazards inside the home with rugs, bathtubs, and lighting. It also asks about the social support network in which the patient functions and examines the availability of care to be anticipated during a transient illness such as the
Cataract Management Guideline Panel • Management of Functional Impairment Due to Cataract in Adults postoperative period. The home environment and anticipated support network are especially important issues for patients undergoing cataract surgery. This instrument requires no special equipment and can be used by a nurse, physician, or other trained health care provider. It also suggests appropriate interventions. Cultural, ethnic, and spiritual values should be noted, along with the individual's own assessment of the quality of life (Maltzman, Cinotti, and Calderone, 1981). The clinician should evaluate the economic resources of the elderly person, since this often determines access to medical and personal care, and influences options for living arrangements.
Question 2: Is there evidence to support or refute an association between nonmedical evaluation and preparation of the patient and outcomes? (Issues researched include psychosocial issues, patient education, patient preparation, family preparation, and home environment.) Question 3: Is there information on cost and/or cost-benefit issues? No articles were found addressing these questions.
Conclusions All the publications concerning the medical preoperative evaluation of the patient prior to cataract surgery suffered from methodologic flaws. Most are retrospective studies of patient cohorts who had undergone cataract surgery and thus were sufficiently healthy to have tolerated it. None mentioned the findings or health status of patients who had not undergone surgery. Other studies had design problems that may have biased the results or did not specifically address the issue of comprehensive preoperative medical testing. Thus, there is scant explicit published information from which indisputable conclusions can be drawn and upon which irrefutable recommendations about the preoperative medical evaluation can be based. There is, nonetheless, abundant information to indicate that many patients undergoing cataract surgery are elderly persons with multiple medical problems whose general health cannot be taken for granted. There is sufficient evidence to support the notion that all patients should have an initial medical evaluation prior to undergoing elective cataract surgery; it is the extent of the evaluation that is uncertain from the literature. Some data indicate that preoperative laboratory testing will detect unrecognized and clinically important disease in elderly patients. Retrospective observations suggest that discontinuing anticoagulant drugs may pose a threat to the patient who has been taking them preoperatively, whereas
performing cataract surgery in a patient taking these drugs appears to confer little risk of bleeding. There is weak direct evidence that cataract surgery done under local anesthesia does not pose a major risk for reinfarction in patients with a history of preoperative myocardial infarction.
Literature Review Lists Literature Included This list comprises the 34 articles that were found to be relevant and were further reviewed for content and methodologic rigor. American Cancer Society. Summary of current guidelines for the cancer-related checkup: recommendations. Atlanta: American Cancer Society; 1988. American College of Physicians. Preoperative pulmonary function testing: position paper [comment]. Ann Intern Med 1990 May 15;112(10):793-4. American College of Physicians, Health and Public Policy Committee. Comprehensive functional assessment for elderly patients. Ann Intern Med 1988 Jul 1; 109(1):70-2. American College of Physicians, Medical Practice Committee. Periodic health examination: a guide for designing individualized preventive health care in the asymptomatic patient. Ann Intern Med 1981 Dec;95(6):729-32. American College of Physicians Staff. Clinical efficacy reports. Philadelphia: American College of Physicians; 1987. American Geriatrics Society. Screening for cervical carcinoma in elderly women. Developed by the Clinical Practice Committee and approved by the American Geriatric Society Board of Directors. J Am Geriatr Soc 1989 Sep;37(9):885-7. Applegate WB, Miller ST, Elam JT, Freeman JM, Wood TO, Gettelfinger TC. Impact of cataract surgery with lens implantation on vision and physical function in elderly patients. JAMA 1987 Feb 27;257(8):1064-6. Backer CL, Tinker JH, Robertson DM, Vliestra RE. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth Analg 1980 Apr;59(4):257-62. Biery C, Charpak Y, Szatan M, Dame B, Fourgeaux B, Chastang C, Gaudy JH. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986 Jan 18; 1(8473): 139-41. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1989 update 2. Can Med Assoc J 1989 Dec 1;141(11):1136-40. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1991 update: 1. Screening for cognitive impairment in the elderly. Can Med Assoc J 1991 Feb 15;144(4):425-31. Charpak Y, Biery C, Chastang CG, Szatan M, Fourgeaux B. Prospective assessment of a protocol for selective
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ordering of preoperative chest x-rays. Can J Anaesth 1988 May;35(3 Pt 1):259-64. Feller BA. Americans needing help to function at home. Hyattsville (MD): National Center for Health Statistics; 1983. Advance Data No. 92. Fisher SJ, Cunningham RD. The medical profile of cataract patients. Clin Geriatr Med 1985 May;1(2):339-44. Hardesty DC. The ophthalmic surgical patient. In: Wolfsthal SD, editor. Medical perioperative management '89-'90. Norwalk (CT): Appleton & Lang; 1991. p. 41726. Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991 [Erratum. In: Ann Intern Med 1991 Aug 15;115(4):332]. Ann Intern Med 1991 May 1;114(9):758-83. Kaplan EB, Boeckmann AJ, Roizen MF, Sheiner LB. Elimination of unnecessary preoperative laboratory tests. Anesthesiology 1982 Sep;57(3 Suppl):A445. Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN; Nicoll CD. The usefulness of preoperative laboratory screening. JAMA 1985 Jun 28;253(24):3576-81. Lachs MS, Feinstein AR, Cooney LM Jr, Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med 1990 May 1;112(9):699-706. Lawrence VA, Gafni A, Gross M. The unproven utility of the preoperative urinalysis: economic evaluation. J Clin Epidemiol 1989;42(12): 1185-92. Maltzman BA, Cinotti AA, Calderone JP Jr. Preadmission evaluation and elective cataract surgery. J Med Soc NJ 1981 Jul;78(7):519-20. McMahan LB. Anticoagulants and cataract surgery. J Cataract Refract Surg 1988 Sep;l4(5):569-71. National Cholesterol Education Program. Report of the Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults. Washington: Department of Health and Human Services (US); 1988. National Institutes of Health. Consensus Development Conference Statement: geriatric assessment methods for clinical decision-making. JAm Geriatr Soc 1988 Apr;36(4):342-7. 1988 Joint National Committee. The 1988 Report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1988 May;l48(5):1023-38. Quigley HA. Mortality associated with ophthalmic surgery: a 20-year experience at the Wilmer Institute. Am J Ophthalmol 1974 Apr;77(4):517-24.
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Roberts CJ, Fowkes FG, Ennis WP, Mitchell M. Possible impact of audit on chest x-ray requests from surgical wards. Lancet 1983 Aug 20;2(8347):446-8. Roizen MF. The compelling rationale for less preoperative testing [editorial]. Can J Anaesth 1988;35(3 Pt 1):214-8. Rucker L, Frye EB, Staten MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA 1983 Dec 16;250(23):3209-11. Stone LS, Kline OR Jr, Sklar CA. Intraocular lenses and anticoagulation and antiplatelet therapy. J Am Intraocul Implant Soc 1985 Mar;11(2):165-8. Task Force Staff (US). Guide to preventive clinical services: report of the U.S. Preventive Services Task Force. Baltimore: Williams and Wilkins; 1989. Chapter 32, Screening for glaucoma. p. 187-92. Tugwell P, Bombardier C, Buchanan WW, Goldsmith CH, Grace E, Hanna B. The MACTAR patient preference disability questionnaire-an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol 1987 Jun;l4(3):446-51. Williams ME. Why screen for functional disability in elderly persons [editorial]? Ann Intern Med 1990 May; 112(9):639-40. Zibrak JD, O'Donnell CR, Marton K. Indications for pulmonary function testing. Ann Intern Med 1990 May 15; 112(10):763-71.
Literature Excluded This list comprises the four articles rejected because they did not meet the inclusion criteria. Adams DF, Shock JP. Prediction of postoperative visual acuity in cataract patients using the Flying Corpuscle Viewer. Ophthalmic Surg 1986 Aug;17(8):509-12. Andrews CL. Nursing care of the cataract patient in an ambulatory surgery center. Ophthalmic Nurs Forum 1987;3(3):1-8. Brodie SE. Evaluation of cataractous eyes with opaque media. Int Ophthalmol Clin 1987 Fall;27(3):153-62. Shepherd B. Bilateral senile cataracts. NATNEWS 1976 Sep;13(7):25,27-9.
Method A computerized literature search was performed by the National Library of Medicine for abstracts of articles published from January 1, 1975, through December 31, 1990. (Chapter 2 and Appendix A give a detailed description of the search strategy.) A printout of four abstracts was produced. Additional articles were identified by reviewers and other interested parties. After the abstracts and additional articles were screened, articles were selected for further review if they appeared relevant to the topic covered. The review was supplemented with selected publications addressing the questions under consideration from the perspective of patients undergoing surgery for other reasons. The formal literature review was also augmented with literature addressing the issue of functional assessment in the elderly and preventive health care screening. Thus, a total of 34 articles were reviewed.
Results Question 1: Is there evidence to support or refute a specific association between short-term medical outcome in the postoperative period and the preoperative medical evaluation of the patient (physical examination, electrocardiogram, chest xray, complete blood count, other)? Comprehensive recommendations about preventive health screening have been made by the U.S. Preventive Services Task Force (Task Force Staff, 1989), the American College of Physicians (American College of Physicians, 1981; American College of Physicians Staff, 1987), the American Cancer Society (1988), the American Geriatrics Society (1989), the National Institutes of Health (National Cholesterol Education Program, 1988; Prepared by Ernest L. Mazzaferri, MD, and Denis M. O'Day, MD, FACS, Panel Chair, who comprised the literature review group.
National Institutes of Health, 1988; 1988 Joint National Committee, 1988), and the Canadian Task Force on the Periodic Health Examination (1989 and 1991). These preventive care guidelines have been recently summarized in a comprehensive paper by Hayward and associates (Hayward, Steinberg, Ford et al., 1991). There appears to be substantial variability among different institutions in the preoperative medical evaluation of cataract patients. The author of one textbook (Hardesty, 1991) recommended that a full battery of screening tests be obtained (e.g., complete blood count, electrolytes, renal function test, urinalysis, electrocardiogram, and chest x ray) because of the advanced age and multiple medical problems of these patients. Others (Blery, Charpak, Szatan et al., 1986; Kaplan, Boeckmann, and Roizen, 1982; Kaplan, Sheiner, Boeckmann et al., 1985; Lawrence, Gafni, and Gross, 1989; Roizen, 1988) advocated reducing the routine preoperative testing and reported no significant harm in making such reductions in patients undergoing a variety of surgical procedures, all of which have a greater risk of complications than cataract surgery. In particular, the usefulness of a routine preoperative urinalysis (Lawrence, Gafni, and Gross, 1989) and chest xray (Charpak, Biery, Chastang et al., 1988; Roberts, Fowkes, Ennis et al., 1983; Rucker, Frye, and Staten, 1983) was questioned, and it appeared that the benefit of preoperative pulmonary function testing is restricted to a very small group of surgical patients that does not include cataract surgery patients (American College of Physicians, 1990; Zibrak, O'Donnell, and Marton, 1990). Concurrent medical problems are especially common in patients undergoing cataract surgery. A retrospective study (Maltzman, Cinotti, and Calderone, 1981) of 200 patients who underwent cataract surgery found that only 51 patients (25.5 percent) had no disorders other than cataracts. Previously known chronic ailments were present in 137 (68.5 percent), whereas 44 (22 percent) had 58 newly discovered disorders. The medical ailments present in the patients included: cardiac disorders (7 percent); diabetes mellitus (4 percent); hypertension (3.5 percent); pulmonary disease (3.5 percent); anemia (2.5 percent); inguinal hernia (2 percent); hepatomegaly (2 percent); and other abnormalities, including venous insufficiency, urinary tract infection, electrolyte imbalance (4.5 percent).
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Each of the five preoperative tests (chemistry profile, complete blood count, urinalysis, x ray, electrocardiogram) performed on this group of patients appeared equally important in uncovering new disease. The authors believed that none of the preoperative medical tests could have been eliminated to reduce the cost of testing without missing some of the medical disorders. In addition to being retrospective, the study has several methodologic flaws that weaken its scientific strength. A number of patients were excluded from the study because threatening preadmission findings caused their surgery to be canceled, thus biasing the study toward making preadmission testing appear less important than it actually was in detecting unknown disease. The importance of preoperative testing is actually understated by the data in this study. The age of the patients in this study was not mentioned. In another retrospective study (Fisher and Cunningham, 1985), 100 consecutive patients who averaged 75 years of age and who had undergone cataract extraction in the hospital were reviewed. Laboratory investigation included a complete blood count, chemistry profile, urinalysis, chest x ray, electrocardiogram, and other tests as indicated by the history and physical examination. One or more significant preexisting medical conditions were found in 84 percent of the patients. Patients had hypertension (47 percent); diabetes mellitus (16 percent); congestive heart failure (10 percent); and significant pulmonary disease, including chronic obstructive pulmonary disease, chronic bronchitis, and interstitial fibrosis (7 percent). Significant atherosclerosis or arteriosclerotic heart disease, defined as previous myocardial infarction, angina, peripheral vascular insufficiency, occlusive carotid disease, atherosclerotic valvular disease, or a history of transient ischemic attacks or strokes, was found in 38 percent of the patients. The authors of this study believed that all patients undergoing cataract extraction should have a thorough preoperative medical evaluation. Many patients (78 percent) were taking one or more medications, including coumadin (4 percent). In addition to being retrospective, the study has several methodologic flaws that weaken its scientific strength. Patients whose preadmission findings caused their surgery to be canceled were excluded from the study, thus biasing the study toward making preadmission testing appear less important than it actually was in detecting unknown disease. The importance of preoperative testing is thus also understated by the data in this study. A study (Biery, Charpak, and Szatan, 1986) from a teaching hospital in France is informative in this
1965
regard. Selective ordering of 13 preoperative tests (blood typing, antibody screen, hemoglobin, prothrombin time, partial thromboplastin time, bleeding time, platelet count, electrolytes, creatinine, blood-urea-nitrogen [BUN], glucose, chest x rays, and electrocardiogram) was studied in 3,866 consecutive patients undergoing surgery under general or regional (but not local) anesthesia over a 1-year period during 1983 and 1984. Almost one-half the patients underwent minor surgical procedures defined as potentially bloodless operations, most of which were done on an elective basis. Although cataract surgery would fall into this category, the study did not specifically address cataract extraction. Preoperative testing was done according to a protocol that accounted for the patient's clinical status and type of surgery. Routine testing was not done in patients undergoing minor surgery unless they were age 40 and over, had associated conditions, or were taking medications. For instance, an electrocardiogram was done routinely in those age 40 and over, and electrolytes, creatinine, and BUN determinations were routinely done in those age 70 and over. Patients with cardiovascular or pulmonary disease had chest x rays and electrocardiograms, regardless of their age, and patients with diabetes mellitus all had renal function, electrolytes, and glucose determinations. This strategy resulted in an average of about four tests for each patient in the entire group. A total of 140 patients (8 percent) in the minor surgery group experienced preoperative or postoperative morbidity, and 2 died after surgery. The possible value of tests that were omitted was assessed in light of events that occurred during and after surgery. The authors concluded that 0.4 percent of nonordered tests would have been potentially useful according to predetermined computerized criteria, and only 0.2 percent would actually have predicted an adverse outcome according to the opinion of the anesthesiologists participating in the study. This study has several methodologic flaws, and its generalization to cataract patients is also questionable. The study actually comprised a series of judgments resulting in very different testing of a broad variety of patients with disparate diseases. Despite the large number of patients in this study, its statistical power is uncertain, since a number of patient populations with very different characteristics were studied. For example, the level of illness was not systematically addressed. In addition, the study's design may have biased the results to favor the conclusions that were reached by the authors; the idea that computerized criteria can be established to identify laboratory tests that will predict an adverse
Cataract Management Guideline Panel • Management of Functional Impairment Due to Cataract in Adults outcome is a unique idea that itself requires validation. The anesthesiologists were not blinded to the patient's adverse outcome when they made a judgment about the laboratory testing, which may also have biased the results. Perioperative management of selected common medical problems. The majority of patients undergoing cataract surgery are elderly persons, a patient population with a high prevalence of concurrent multiple medical problems such as coronary artery disease, hypertension, diabetes mellitus, dementia, cerebrovascular disease, arrhythmias, chronic obstructive pulmonary disease, alcoholism, thromboembolic disease requiring anticoagulant therapy, and nutrition problems. In addition, elderly patients often take one or more potent medicines. Despite these concurrent problems, the risk of this short, very limited surgical procedure is low. The perioperative mortality of ophthalmic surgery patients overall is only 0.16 percent and for cataract patients, 0.1-0.2 percent (Quigley, 1974). The incidence of serious medical complications such as myocardial infarction associated with ophthalmologic surgery under local anesthesia is less than 1 percent, even in patients with a past history of myocardial infarction. Although the risk of serious medical complications is quite low in cataract surgery patients, concurrent medical problems frequently cause concern among ophthalmologists, anesthesiologists, internists, and other physicians involved in the management of these patients. Such concerns may lead to additional pre-, intra-, and postoperative interventions that may be associated with considerable cost and uncertain benefit. To date, optimal perioperative management of medical problems has not been defined for cataract patients specifically. Therefore, it is likely that a great deal of variation exists in current practice patterns regarding the perioperative medical management of cataract patients. Anticoagulant drugs being taken for thromboembolic, cardiovascular, or neurologic disorders pose a special problem. The literature reflects conflicting practices during cataract surgery on patients taking anticoagulant drugs. A recent survey (Stone, Kline, and Sklar, 1985) of 135 cataract surgeons indicated that 75 percent of the respondents withheld anticoagulation during the perioperative period, which resulted in two deaths from strokes, two additional strokes, one transient ischemic attack, a cerebral embolism in a patient with an artificial valve, a pulmonary embolus, and an episode of deep-vein thrombosis. This retrospective survey does not provide enough data about the patients, their level of disease, or how the decision
was made to discontinue anticoagulant drugs to permit a critical analysis of the conclusion. Another study (McMahan, 1988) prospectively compared the outcome of 22 patients undergoing intraocular lens implantation who were receiving anticoagulants with that of age-matched patients (controls) who were not receiving these drugs. After continuing anticoagulation through the surgical and postoperative period, no patient experienced clinically significant bleeding that interfered with vision. There were no retrobulbar, vitreous, or retinal hemorrhages and no elevated pressures in any anticoagulated or control patient. On the basis of these limited data, it appears that anticoagulation does not pose a substantial risk for seriously complicating ophthalmic surgery, whereas discontinuing these drugs may impart some increased risk for new thrombotic events in the patient with preexisting cardiovascular, cerebrovascular, or thromboembolic disease. The selection of controls in this study was weak, since they were matched with patients only for age and not for other characteristics, such as underlying major illnesses. In addition, the study is flawed by the very small number of patients, which makes the likelihood of a type 2 error very high. Myocardial reinfarction in the course of cataract surgery is of particular concern in the elderly patient with a past history of myocardial infarction. A retrospective study (Backer, Tinker, Robertson et al., 1980) of myocardial reinfarction following local anesthesia for ophthalmic surgery found no postoperative reinfarctions or death in 195 patients who underwent 288 separate operations. The 0 percent reinfarction rate was significantly lower than the 6.1 percent reinfarction rate previously reported from the same institution for 587 operations on patients with documented preoperative myocardial infarction who had general or major regional anesthesia for non ophthalmic surgery. Thus, on the basis of these limited data, it appears that ophthalmic surgery under local anesthesia and/or retrobulbar block does not pose special risks for reinfarction in the patient with a preoperative myocardial infarction. This study's major weakness is that it selectively reports only on patients on whom surgery was done, omitting those who might have been rejected for surgery because of serious cardiac symptoms or signs or because of ominous laboratory tests. For instance, if patients with congestive heart failure or severe angina undergo surgery, the results might be different than if they had been rejected as unsuitable surgical candidates. Preoperative evaluation of the elderly patient. The majority of patients undergoing cataract surgery are 1975
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elderly persons who not only have a high prevalence of multiple medical problems but also have unique and commonly dysfunctional problems of aging. Functional problems, defined as difficulties that interfere with daily routines, are often unappreciated when conventional histories and physical examinations are done. Functional assessment, therefore, is an integral part of geriatric care (American College of Physicians, 1988; Williams, 1990). Its importance was underscored by the Consensus Development Conference at the National Institutes of Health (1988), which stated that comprehensive geriatric assessment is effective in improving the quality of ongoing care. Although most elderly noninstitutionalized adults are functionally competent, the percentage who need help doing everyday activities doubles with each successive decade up to age 84 and triples between age 85 and 94 (Feller, 1983). In addition to visual dysfunction, elderly persons often have other equally severe and unrecognized functional problems resulting from hearing disorders, difficulty with arm and leg function, urinary incontinence, depression, dementia, environmental hazards, and inadequate financial and social support systems. Although there is general agreement that functional assessment is most useful when a standard, systematic approach is used to measure and record observations, there is a general lack of consensus on the best way to perform these evaluations (Williams, 1990). Applegate, Miller, Elam et al. (1987) prospectively examined the impact of cataract surgery on the functional status of 293 elderly patients undergoing cataract surgery. Patient function was evaluated by both subjective measures (everyday activities and self-report of vision-dependent activities) and objective measures (timed manual performance tests and mental status tests). With marked improvement in visual acuity, modest positive changes occurred in self-reported everyday activities and vision-dependent activities; the most marked changes occurred in objective measures of function. Mental status improved significantly 1 year after surgery, and timed manual performance improved dramatically at 4 months and 1 year. This study is sound methodologically but does not address the issue of preoperative medical testing of cataract patients. Cataract surgery was associated with better vision and improved functional status in most patients by 4 months after surgery and was maintained 1 year later. The patient's perception of disability and selfassessment of impairment are extremely important in evaluating the impact of therapy. A new approach to assessing functional disability was described by
1985
Tugwell and associates (Tugwell, Bombardier, Buchanan et al., 1987), who devised an instrument that has the potential to detect small, clinically important changes in function. These authors developed a new patient preference questionnaire for assessing disability that focuses only on those activities directly affected by the disability and judged to be important by the patient. This study is sound methodologically but does not address the issue of preoperative medical testing of cataract patients. The American College of Physicians (1988) recently advocated incorporating functional status measurement into routine clinical practice. The College commissioned a group of investigators to identify the important areas in which elderly persons who are not acutely ill should be screened for functional disabilities and to develop a simple, practical, and sensible approach to the screening assessment. Lachs and associates (Lachs, Feinstein, Cooney et al., 1990) devised such an instrument. After a careful literature review, Lachs and coworkers concluded that most published instruments were impractical because they are too lengthy, require special equipment, or are not targeted to older populations. With the assistance of a panel of expert geriatricians and general internists, they developed a short, simple approach that can be used by primary health care providers to screen the functional status of elderly patients routinely. The instrument focuses on a limited number of target areas that are commonly dysfunctional but often unappreciated in the elderly when conventional histories and physical examinations are done. The instrument uses carefully selected tests of vision, hearing, arm and leg function, urinary incontinence, nutrition, mental status, depression, basic everyday .activities (a term that refers to the abilities needed for independent self-maintenance in the basic functions of bathing, eating, dressing, toileting, transferring, and walking), and instrumental everyday activities (a term often used for higher levels of independent function such as cooking, shopping, and light housework). It also explores potential environmental hazards and social support systems. Brief questions and easily observed tasks are used to obtain information in a short time. One of its targets is the home environment. It explores the most troublesome obstacle to mobility for elderly patients living at home: the stairs, both inside and outside. Patients are asked about potential hazards inside the home with rugs, bathtubs, and lighting. It also asks about the social support network in which the patient functions and examines the availability of care to be anticipated during a transient illness such as the
Cataract Management Guideline Panel • Management of Functional Impairment Due to Cataract in Adults postoperative period. The home environment and anticipated support network are especially important issues for patients undergoing cataract surgery. This instrument requires no special equipment and can be used by a nurse, physician, or other trained health care provider. It also suggests appropriate interventions. Cultural, ethnic, and spiritual values should be noted, along with the individual's own assessment of the quality of life (Maltzman, Cinotti, and Calderone, 1981). The clinician should evaluate the economic resources of the elderly person, since this often determines access to medical and personal care, and influences options for living arrangements.
Question 2: Is there evidence to support or refute an association between nonmedical evaluation and preparation of the patient and outcomes? (Issues researched include psychosocial issues, patient education, patient preparation, family preparation, and home environment.) Question 3: Is there information on cost and/or cost-benefit issues? No articles were found addressing these questions.
Conclusions All the publications concerning the medical preoperative evaluation of the patient prior to cataract surgery suffered from methodologic flaws. Most are retrospective studies of patient cohorts who had undergone cataract surgery and thus were sufficiently healthy to have tolerated it. None mentioned the findings or health status of patients who had not undergone surgery. Other studies had design problems that may have biased the results or did not specifically address the issue of comprehensive preoperative medical testing. Thus, there is scant explicit published information from which indisputable conclusions can be drawn and upon which irrefutable recommendations about the preoperative medical evaluation can be based. There is, nonetheless, abundant information to indicate that many patients undergoing cataract surgery are elderly persons with multiple medical problems whose general health cannot be taken for granted. There is sufficient evidence to support the notion that all patients should have an initial medical evaluation prior to undergoing elective cataract surgery; it is the extent of the evaluation that is uncertain from the literature. Some data indicate that preoperative laboratory testing will detect unrecognized and clinically important disease in elderly patients. Retrospective observations suggest that discontinuing anticoagulant drugs may pose a threat to the patient who has been taking them preoperatively, whereas
performing cataract surgery in a patient taking these drugs appears to confer little risk of bleeding. There is weak direct evidence that cataract surgery done under local anesthesia does not pose a major risk for reinfarction in patients with a history of preoperative myocardial infarction.
Literature Review Lists Literature Included This list comprises the 34 articles that were found to be relevant and were further reviewed for content and methodologic rigor. American Cancer Society. Summary of current guidelines for the cancer-related checkup: recommendations. Atlanta: American Cancer Society; 1988. American College of Physicians. Preoperative pulmonary function testing: position paper [comment]. Ann Intern Med 1990 May 15;112(10):793-4. American College of Physicians, Health and Public Policy Committee. Comprehensive functional assessment for elderly patients. Ann Intern Med 1988 Jul 1; 109(1):70-2. American College of Physicians, Medical Practice Committee. Periodic health examination: a guide for designing individualized preventive health care in the asymptomatic patient. Ann Intern Med 1981 Dec;95(6):729-32. American College of Physicians Staff. Clinical efficacy reports. Philadelphia: American College of Physicians; 1987. American Geriatrics Society. Screening for cervical carcinoma in elderly women. Developed by the Clinical Practice Committee and approved by the American Geriatric Society Board of Directors. J Am Geriatr Soc 1989 Sep;37(9):885-7. Applegate WB, Miller ST, Elam JT, Freeman JM, Wood TO, Gettelfinger TC. Impact of cataract surgery with lens implantation on vision and physical function in elderly patients. JAMA 1987 Feb 27;257(8):1064-6. Backer CL, Tinker JH, Robertson DM, Vliestra RE. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth Analg 1980 Apr;59(4):257-62. Biery C, Charpak Y, Szatan M, Dame B, Fourgeaux B, Chastang C, Gaudy JH. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986 Jan 18; 1(8473): 139-41. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1989 update 2. Can Med Assoc J 1989 Dec 1;141(11):1136-40. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1991 update: 1. Screening for cognitive impairment in the elderly. Can Med Assoc J 1991 Feb 15;144(4):425-31. Charpak Y, Biery C, Chastang CG, Szatan M, Fourgeaux B. Prospective assessment of a protocol for selective
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ordering of preoperative chest x-rays. Can J Anaesth 1988 May;35(3 Pt 1):259-64. Feller BA. Americans needing help to function at home. Hyattsville (MD): National Center for Health Statistics; 1983. Advance Data No. 92. Fisher SJ, Cunningham RD. The medical profile of cataract patients. Clin Geriatr Med 1985 May;1(2):339-44. Hardesty DC. The ophthalmic surgical patient. In: Wolfsthal SD, editor. Medical perioperative management '89-'90. Norwalk (CT): Appleton & Lang; 1991. p. 41726. Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991 [Erratum. In: Ann Intern Med 1991 Aug 15;115(4):332]. Ann Intern Med 1991 May 1;114(9):758-83. Kaplan EB, Boeckmann AJ, Roizen MF, Sheiner LB. Elimination of unnecessary preoperative laboratory tests. Anesthesiology 1982 Sep;57(3 Suppl):A445. Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN; Nicoll CD. The usefulness of preoperative laboratory screening. JAMA 1985 Jun 28;253(24):3576-81. Lachs MS, Feinstein AR, Cooney LM Jr, Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med 1990 May 1;112(9):699-706. Lawrence VA, Gafni A, Gross M. The unproven utility of the preoperative urinalysis: economic evaluation. J Clin Epidemiol 1989;42(12): 1185-92. Maltzman BA, Cinotti AA, Calderone JP Jr. Preadmission evaluation and elective cataract surgery. J Med Soc NJ 1981 Jul;78(7):519-20. McMahan LB. Anticoagulants and cataract surgery. J Cataract Refract Surg 1988 Sep;l4(5):569-71. National Cholesterol Education Program. Report of the Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults. Washington: Department of Health and Human Services (US); 1988. National Institutes of Health. Consensus Development Conference Statement: geriatric assessment methods for clinical decision-making. JAm Geriatr Soc 1988 Apr;36(4):342-7. 1988 Joint National Committee. The 1988 Report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1988 May;l48(5):1023-38. Quigley HA. Mortality associated with ophthalmic surgery: a 20-year experience at the Wilmer Institute. Am J Ophthalmol 1974 Apr;77(4):517-24.
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Roberts CJ, Fowkes FG, Ennis WP, Mitchell M. Possible impact of audit on chest x-ray requests from surgical wards. Lancet 1983 Aug 20;2(8347):446-8. Roizen MF. The compelling rationale for less preoperative testing [editorial]. Can J Anaesth 1988;35(3 Pt 1):214-8. Rucker L, Frye EB, Staten MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA 1983 Dec 16;250(23):3209-11. Stone LS, Kline OR Jr, Sklar CA. Intraocular lenses and anticoagulation and antiplatelet therapy. J Am Intraocul Implant Soc 1985 Mar;11(2):165-8. Task Force Staff (US). Guide to preventive clinical services: report of the U.S. Preventive Services Task Force. Baltimore: Williams and Wilkins; 1989. Chapter 32, Screening for glaucoma. p. 187-92. Tugwell P, Bombardier C, Buchanan WW, Goldsmith CH, Grace E, Hanna B. The MACTAR patient preference disability questionnaire-an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol 1987 Jun;l4(3):446-51. Williams ME. Why screen for functional disability in elderly persons [editorial]? Ann Intern Med 1990 May; 112(9):639-40. Zibrak JD, O'Donnell CR, Marton K. Indications for pulmonary function testing. Ann Intern Med 1990 May 15; 112(10):763-71.
Literature Excluded This list comprises the four articles rejected because they did not meet the inclusion criteria. Adams DF, Shock JP. Prediction of postoperative visual acuity in cataract patients using the Flying Corpuscle Viewer. Ophthalmic Surg 1986 Aug;17(8):509-12. Andrews CL. Nursing care of the cataract patient in an ambulatory surgery center. Ophthalmic Nurs Forum 1987;3(3):1-8. Brodie SE. Evaluation of cataractous eyes with opaque media. Int Ophthalmol Clin 1987 Fall;27(3):153-62. Shepherd B. Bilateral senile cataracts. NATNEWS 1976 Sep;13(7):25,27-9.