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Risk for Fractures Following Cataract Surgery

Risk for Fractures Following Cataract Surgery Abstract Context:  Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk. Objective:  To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract. Design, Setting, and Participants:  Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009. Main Outcome Measures:  One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling. Results:  There were 1 113 640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410 809 (36.9%) received cataract surgery during the study period. There were 13 976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134 335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212 382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater. Conclusion:  In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery. Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries It certainly is the case that vision can be very important for safe ambulation. Cataracts have been found to be the most common cause of decreased vision leading to fracture—causing up to 49% of femoral neck fractures related to visual impairment.1 Of course, the central vision loss of age-related macular degeneration and visual field constriction associated with advanced glaucoma also present common risks. In patients with known cataracts who experience a fall, one might wonder whether the fall could have been prevented by earlier cataract surgery. We do know from previous studies that there is an increased fall risk if patients wait more than 6 months for cataract surgery.2 With falls and subsequent fractures being such costly and major health concerns in our aging population, it makes sense for health professionals to attempt to reduce the incidence of these events. Given the prevalence of cataracts and the ease with which they are treated, a logical study would be to see whether surgical treatment of cataracts would reduce the incidence of fractures related to falling. That is precisely what this study set out to do. The authors used a 5% Medicare database sample of more than 1 million patients with a diagnosis of cataract from 2002 through 2009 and categorized them based on severity and comorbid conditions. The primary outcome was hip fracture occurrence during that year, with a secondary outcome of any fracture occurrence. Hip fracture occurrence was also determined in the 1 year prior to cataract surgery in this group. With regard to fractures, they found a 5.4% incidence of fracture overall, with a 1.3% incidence of hip fracture and almost twice as many lower limb fractures. Patients who underwent cataract surgery reduced their odds of having a fall-related fracture when adjusted for demographics and comorbidities. Also, those patients who were older and sicker with more severe cataracts received even more benefit—up to an almost 30% reduction. The number needed to treat to avoid hip fracture was 507 patients.1 Although the power of the study was outstanding, the authors correctly identified many of the study's limitations including the data being retrospective and observational. If further studies were to be performed, a uniform method of data collection, such as lenticular photographs and the use of an established ophthalmic reading center, would help better stratify the cataracts. Using visual acuity data would further enhance the results. In this study, gross generalizations were made regarding different types of cataract and severity associated with those types. Additionally, in a prospective study, there would be increased ability to stratify based on individual disease. As this data would be collected, definitions of mild, moderate, and severe cases would be helpful because not every patient with early rheumatologic disease, peptic ulcer disease, or diabetes mellitus without complication should be getting a similar Charleston Comorbidity Index score as those with dementia, congestive heart failure, or metastatic malignancies. The authors did also mention this and appropriately commented that this was partly remedied owing to the very large sample size. Even with its limitations, it seems from this study that we, as cataract surgeons, are doing a good job of identifying some risk factors for falls, such as osteoporosis, and improving vision in these patients by cataract extraction. We also seem to be maximizing vision in patients with ocular comorbidities. We are correctly operating on patients with more severe forms of cataract. Based on these findings, we are helping patients avoid falls and subsequent hip fractures. However, it is not clear why the authors put such great emphasis on hip fracture, analyzing it separately, while clumping up the data for other types of fractures. A quick glance over Table 2 in that article reveals that pelvic and neck fractures were also among the fractures listed by the authors. Mortality in elderly individuals with hip fracture can be as high as 30%.3 The risk for mortality in patients with pelvic fracture is cited as 27% after 1 year, increasing to 50% after 3 years in one study.4 Fracture of the cervical spine also has a high mortality rate of up to 30%.5 Given the facts that the odds ratio for any fracture is 0.92 and that neck and pelvic fractures are as important as hip fractures in terms of mortality, the data presented in Table 4 may be misleading. In fact, there may be very little difference or no difference at all in the incidence of morbid fractures after cataract surgery. Another interesting question that might be asked would pertain to the immediate postoperative period. Certainly patients also fall after cataract surgery and one might wonder whether postoperative issues that can limit vision or depth perception, such as persistent corneal edema, cystoid macular degeneration, or anisometropia (especially in the period between both eye procedures), might have played a role. But on the contrary, it seems that many elderly patients will have relatives or friends visit them more often during their postoperative period. It would be interesting to determine factors increasing or decreasing postoperative fall risk and to carry the study further so that we are taking into account the times when the patient is living more independently. It is possible that if the authors looked at the data beyond 1 year, they would have seen an increase in the rate of fractures in the operated on group. One way to use the information garnered from this study in our practice would be to stratify our patients' risks and make sure we have a place in our operating room schedule for these patients who are otherwise at high risk for fracture. A long wait of several months might be the difference between having a healthy and active postoperative patient or having a physically limited patient who may even have had further fracture-related problems such as emboli or nosocomial infections. Another change we can make is that we might be more aggressive in our recommendation of surgery for patients at high risk such as those with osteoporosis. Many of us live by the “if it's not broken, don't fix it” rule. We have long been taught to assess the cataract on the patient's quality of life, and we tend to hold off on cataract surgery if the patient is performing activities of daily living without limitations. Potentially, we should be talking to patients about an actual medical indication for cataract surgery. We also often assess cataract based on visual acuity and possibly glare testing results, but not other examination findings such as contrast sensitivity that can be very important cues in such things as climbing or descending a staircase. Possibly, we should be examining more of these visual functions and piecing together a patient's risk based on more of these. How might this play into the evolutions rapidly happening in cataract surgery? If faster, femtosecond laser might debulk our surgery schedules, allowing more procedures to be done in a day and reducing wait time between diagnosis and surgery. Also, the ability to perform nuclear fracture prior to entering the eye with the phacoemulsification handpiece will likely decrease the amount of corneal edema and increase the rate of recovery in patients with severe cataract and Fuchs endothelial dystrophy. Lastly, any astigmatism correction that could be done at the time of surgery, whether using a toric lens or using the femtosecond laser to create limbal-relaxing incisions, would reduce visual impairment in the postoperative period before a glasses prescription is given. This study has done what it intended to do; it has made us all think about further studies that can be done and it has made us think about cataracts in a different way. It also has allowed us to step back and work with our primary care colleagues to focus on the whole patient. Back to top Article Information Correspondence: Dr Potter, Department of Ophthalmology and Visual Sciences, University of Wisconsin, 600 Highland Ave, Mail Code 3220, Madison, WI 53792 (hpotter@wisc.edu). Conflict of Interest Disclosures: None reported. References 1. Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in Medicare beneficiaries. JAMA. 2012;308(5):493-50122851116PubMedGoogle ScholarCrossref 2. Hodge W, Horsley T, Albiani D, et al. The consequences of waiting for cataract surgery: a systematic review. CMAJ. 2007;176(9):1285-129017452662PubMedGoogle Scholar 3. González-Rozas M, Pérez-Castrillón JL, González-Sagrado M, Ruiz-Mambrilla M, ,García-Alonso M. Risk of mortality and predisposing factors after osteoporotic hip fracture: a one-year follow-up study. Aging Clin Exp Res. 2012;24(2):181-18722842836PubMedGoogle Scholar 4. Morris RO, Sonibare A, Green DJ, Masud T. Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J. 2000;76(900):646-65011009580PubMedGoogle ScholarCrossref 5. Harris MB, Reichmann WM, Bono CM, et al. Mortality in elderly patients after cervical spine fractures. J Bone Joint Surg Am. 2010;92(3):567-57420194314PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Ophthalmology American Medical Association

Risk for Fractures Following Cataract Surgery

JAMA Ophthalmology , Volume 131 (2) – Feb 1, 2013

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6165
eISSN
2168-6173
DOI
10.1001/jamaophthalmol.2013.851
Publisher site
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Abstract

Abstract Context:  Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk. Objective:  To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract. Design, Setting, and Participants:  Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009. Main Outcome Measures:  One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling. Results:  There were 1 113 640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410 809 (36.9%) received cataract surgery during the study period. There were 13 976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134 335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212 382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater. Conclusion:  In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery. Risk of Fractures Following Cataract Surgery in Medicare Beneficiaries It certainly is the case that vision can be very important for safe ambulation. Cataracts have been found to be the most common cause of decreased vision leading to fracture—causing up to 49% of femoral neck fractures related to visual impairment.1 Of course, the central vision loss of age-related macular degeneration and visual field constriction associated with advanced glaucoma also present common risks. In patients with known cataracts who experience a fall, one might wonder whether the fall could have been prevented by earlier cataract surgery. We do know from previous studies that there is an increased fall risk if patients wait more than 6 months for cataract surgery.2 With falls and subsequent fractures being such costly and major health concerns in our aging population, it makes sense for health professionals to attempt to reduce the incidence of these events. Given the prevalence of cataracts and the ease with which they are treated, a logical study would be to see whether surgical treatment of cataracts would reduce the incidence of fractures related to falling. That is precisely what this study set out to do. The authors used a 5% Medicare database sample of more than 1 million patients with a diagnosis of cataract from 2002 through 2009 and categorized them based on severity and comorbid conditions. The primary outcome was hip fracture occurrence during that year, with a secondary outcome of any fracture occurrence. Hip fracture occurrence was also determined in the 1 year prior to cataract surgery in this group. With regard to fractures, they found a 5.4% incidence of fracture overall, with a 1.3% incidence of hip fracture and almost twice as many lower limb fractures. Patients who underwent cataract surgery reduced their odds of having a fall-related fracture when adjusted for demographics and comorbidities. Also, those patients who were older and sicker with more severe cataracts received even more benefit—up to an almost 30% reduction. The number needed to treat to avoid hip fracture was 507 patients.1 Although the power of the study was outstanding, the authors correctly identified many of the study's limitations including the data being retrospective and observational. If further studies were to be performed, a uniform method of data collection, such as lenticular photographs and the use of an established ophthalmic reading center, would help better stratify the cataracts. Using visual acuity data would further enhance the results. In this study, gross generalizations were made regarding different types of cataract and severity associated with those types. Additionally, in a prospective study, there would be increased ability to stratify based on individual disease. As this data would be collected, definitions of mild, moderate, and severe cases would be helpful because not every patient with early rheumatologic disease, peptic ulcer disease, or diabetes mellitus without complication should be getting a similar Charleston Comorbidity Index score as those with dementia, congestive heart failure, or metastatic malignancies. The authors did also mention this and appropriately commented that this was partly remedied owing to the very large sample size. Even with its limitations, it seems from this study that we, as cataract surgeons, are doing a good job of identifying some risk factors for falls, such as osteoporosis, and improving vision in these patients by cataract extraction. We also seem to be maximizing vision in patients with ocular comorbidities. We are correctly operating on patients with more severe forms of cataract. Based on these findings, we are helping patients avoid falls and subsequent hip fractures. However, it is not clear why the authors put such great emphasis on hip fracture, analyzing it separately, while clumping up the data for other types of fractures. A quick glance over Table 2 in that article reveals that pelvic and neck fractures were also among the fractures listed by the authors. Mortality in elderly individuals with hip fracture can be as high as 30%.3 The risk for mortality in patients with pelvic fracture is cited as 27% after 1 year, increasing to 50% after 3 years in one study.4 Fracture of the cervical spine also has a high mortality rate of up to 30%.5 Given the facts that the odds ratio for any fracture is 0.92 and that neck and pelvic fractures are as important as hip fractures in terms of mortality, the data presented in Table 4 may be misleading. In fact, there may be very little difference or no difference at all in the incidence of morbid fractures after cataract surgery. Another interesting question that might be asked would pertain to the immediate postoperative period. Certainly patients also fall after cataract surgery and one might wonder whether postoperative issues that can limit vision or depth perception, such as persistent corneal edema, cystoid macular degeneration, or anisometropia (especially in the period between both eye procedures), might have played a role. But on the contrary, it seems that many elderly patients will have relatives or friends visit them more often during their postoperative period. It would be interesting to determine factors increasing or decreasing postoperative fall risk and to carry the study further so that we are taking into account the times when the patient is living more independently. It is possible that if the authors looked at the data beyond 1 year, they would have seen an increase in the rate of fractures in the operated on group. One way to use the information garnered from this study in our practice would be to stratify our patients' risks and make sure we have a place in our operating room schedule for these patients who are otherwise at high risk for fracture. A long wait of several months might be the difference between having a healthy and active postoperative patient or having a physically limited patient who may even have had further fracture-related problems such as emboli or nosocomial infections. Another change we can make is that we might be more aggressive in our recommendation of surgery for patients at high risk such as those with osteoporosis. Many of us live by the “if it's not broken, don't fix it” rule. We have long been taught to assess the cataract on the patient's quality of life, and we tend to hold off on cataract surgery if the patient is performing activities of daily living without limitations. Potentially, we should be talking to patients about an actual medical indication for cataract surgery. We also often assess cataract based on visual acuity and possibly glare testing results, but not other examination findings such as contrast sensitivity that can be very important cues in such things as climbing or descending a staircase. Possibly, we should be examining more of these visual functions and piecing together a patient's risk based on more of these. How might this play into the evolutions rapidly happening in cataract surgery? If faster, femtosecond laser might debulk our surgery schedules, allowing more procedures to be done in a day and reducing wait time between diagnosis and surgery. Also, the ability to perform nuclear fracture prior to entering the eye with the phacoemulsification handpiece will likely decrease the amount of corneal edema and increase the rate of recovery in patients with severe cataract and Fuchs endothelial dystrophy. Lastly, any astigmatism correction that could be done at the time of surgery, whether using a toric lens or using the femtosecond laser to create limbal-relaxing incisions, would reduce visual impairment in the postoperative period before a glasses prescription is given. This study has done what it intended to do; it has made us all think about further studies that can be done and it has made us think about cataracts in a different way. It also has allowed us to step back and work with our primary care colleagues to focus on the whole patient. Back to top Article Information Correspondence: Dr Potter, Department of Ophthalmology and Visual Sciences, University of Wisconsin, 600 Highland Ave, Mail Code 3220, Madison, WI 53792 (hpotter@wisc.edu). Conflict of Interest Disclosures: None reported. References 1. Tseng VL, Yu F, Lum F, Coleman AL. Risk of fractures following cataract surgery in Medicare beneficiaries. JAMA. 2012;308(5):493-50122851116PubMedGoogle ScholarCrossref 2. Hodge W, Horsley T, Albiani D, et al. The consequences of waiting for cataract surgery: a systematic review. CMAJ. 2007;176(9):1285-129017452662PubMedGoogle Scholar 3. González-Rozas M, Pérez-Castrillón JL, González-Sagrado M, Ruiz-Mambrilla M, ,García-Alonso M. Risk of mortality and predisposing factors after osteoporotic hip fracture: a one-year follow-up study. Aging Clin Exp Res. 2012;24(2):181-18722842836PubMedGoogle Scholar 4. Morris RO, Sonibare A, Green DJ, Masud T. Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J. 2000;76(900):646-65011009580PubMedGoogle ScholarCrossref 5. Harris MB, Reichmann WM, Bono CM, et al. Mortality in elderly patients after cervical spine fractures. J Bone Joint Surg Am. 2010;92(3):567-57420194314PubMedGoogle ScholarCrossref

Journal

JAMA OphthalmologyAmerican Medical Association

Published: Feb 1, 2013

Keywords: fractures,cataract surgery,hip fractures,cataract,surgical procedures, operative,visual impairment,osteoporosis,glaucoma,absolute risk reduction

References

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