Cataract surgery in patients with advanced cognitive impairment who cannot consent for surgery: an evaluation of surgical outcomes, review of the literature and recommendations for the cataract pathway

Background Patients with advanced cognitive impairment and cataract are an under-represented group with limited data on surgery outcomes and best practice. The burden of cataract in these groups is significant, and its functional impact can be severe and poorly recognised. We aimed to evaluate cataract surgery outcomes and optimise the surgical pathway for this group at our unit. Methods We conducted a retrospective observational study of adult patients with advanced dementia or learning disability and no capacity to consent to having cataract surgery between January 2021 and May 2023 at Moorfields Eye Hospital in London, UK. Data were collected on clinic assessment, consent, choice of anaesthetic, choice of immediate versus delayed sequential bilateral cataract surgery and intraoperative and postoperative findings. Results 51 patients (67 eyes), 40 (78%) with dementia and 17 (22%) with a learning disability, were included. 24 (36%) eyes had advanced cataract, and 15 (22%) of eyes had corrected distance visual acuity (CDVA) of counting fingers or worse. Surgery was performed under local anaesthetic (± sedation) in 37 (55%) cases. There were no intraoperative complications. Subjective visual improvement was recorded in 49 (73%) cases. There was a median improvement in CDVA of 0.55 LogMAR. The refractive outcome was within 1D of the target outcome in 31 (72%) eyes. 35 (81%) eyes had a hyperopic outcome. Conclusions These patients present late with advanced cataract. Multidisciplinary and family/carer input for assessment, consent and anaesthesia selection is necessary. Surgery was most often performed under local anaesthesia, and the complication rate and visual outcomes were acceptable.