Impact of first eye cataract surgery on falls among patients of advanced age: a comparative study

Abstract

Objective

To compare the incidence of falls between patients with visually significant cataracts in both eyes and those who have undergone first-eye cataract surgery.

Methods

This retrospective case–control study involved patients with a history of cataracts in both eyes who had undergone first-eye cataract surgery within the past 9 to 12 months (pseudophakic group). The control group comprised patients with cataracts in both eyes (cataract group). We assessed best-corrected visual acuity (BCVA), systemic comorbidities and medications (using the Charlson comorbidity index), and independent daily activities (using the Lawton Instrumental Activities of Daily Living scale). The patients were questioned about experiencing two or more falls in the last 6 months.

Results

Each group comprised 50 patients. Binocular BCVA was significantly better in the pseudophakic group (0.05 ± 0.06 logMAR) than in the cataract group (0.77 ± 0.34 logMAR). Of all participants, 22% reported experiencing two or more falls in the last 6 months. Multivariate analysis demonstrated significantly better BCVA in participants with less than two falls.

Conclusions

Patients of advanced age with visually significant cataracts in both eyes are at a higher risk of falling. First-eye cataract surgery may mitigate the occurrence of falls by improving binocular BCVA.

Keywords

Fall cataract phacoemulsification advanced age visual acuity case–control study

Introduction

Falls among individuals of advanced age represent a significant health concern. The annual incidence of falls is 33% among individuals aged >65 years and 50% among those aged >80 years.¹ Although most falls have no substantial consequences and resolve without professional intervention, a substantial proportion lead to medical consultations, hospitalization, and prescribed periods of physical inactivity.^2–4 Notably, approximately 15% of falls culminate in fractures, with a minimum of 5% resulting in severe soft tissue injuries or head trauma.⁵ The aftermath of such falls can have far-reaching impacts on an individual’s lifestyle, encompassing reduced functional capacity, heightened dependency, social isolation, depression, anxiety, and a surge in medical service requests and referrals.^6,7

Although medical conditions such as dementia, osteoarthritis, cerebrovascular incidents, and movement disorders such as Parkinson’s disease undoubtedly heighten the susceptibility to falls, it is imperative to recognize that normal age-related physiological changes can also render otherwise healthy individuals more prone to falling.^1,8–10

Many studies have established a link between compromised visual function and an increased risk of falls.^11–13 Diminished visual acuity, a restricted visual field, reduced contrast sensitivity, and impaired stereopsis collectively predispose individuals to falls. Notably, various researchers have proposed that the presence of cataracts elevates the risk of falls and this risk can be mitigated through lens extraction.^14–17

Against this backdrop, the present study was performed to compare the incidence of falls between individuals with cataracts and those who have undergone cataract surgery. By evaluating the impact of cataract surgery on fall rates, we endeavor to contribute to the broader understanding of how visual interventions may mitigate the risk of falls in patients of advanced age.

Methods

Study Design and Participants

The reporting of this study conforms to the STROBE guidelines.¹⁸ This retrospective case–control study was conducted from January 2018 to June 2019 at the eye clinic of 5-Azar Hospital in Gorgan, Iran. The participants were selected using convenience sampling and enrolled consecutively based on specific criteria. The groups were matched by age and sex. The pseudophakic group comprised patients with a history of visually significant cataracts in both eyes who had undergone first-eye cataract surgery within the preceding 9 to 12 months. The surgical procedures were performed exclusively by a single surgeon (MAK) using a standard phacoemulsification technique accompanied by the implantation of a one-piece hydrophobic acrylic intraocular lens (enVista; Bausch & Lomb, Vaughan, Ontario, Canada). Patients in the cataract group, serving as controls, were selected based on the presence of binocular visually significant cataracts. The criterion for significant cataract was a Snellen best-corrected visual acuity (BCVA) of less than 20/40, attributable to lens opacity.¹⁹

Ethical Considerations

The study adhered to the principles outlined in the Declaration of Helsinki. Written consent was obtained from all participating patients. The Ethics Committee of The Golestan University of Medical Sciences approved the study (ethics code: IR.GOUMS.REC.1397.164). Furthermore, all participants’ data were de-identified.

Ophthalmic Assessments

A single examiner (MAK) conducted comprehensive ophthalmic examinations of all participants, including autorefractometer measurement of refractive errors, monocular and binocular BCVA assessments, slit-lamp biomicroscopy, Goldmann tonometry for intraocular pressure measurement, and dilated fundus examinations using a 90-diopter lens. Logarithm of the minimal angle of resolution (LogMAR) equivalents were assigned to BCVA values for statistical analysis. Participants below the age of 50 years; those with significant refractive errors (spherical equivalent of <−2.00 or >+2.00 diopters), visual field defects, any comorbid eye diseases (including diabetic retinopathy, glaucoma, or macular degeneration), a history of ocular surgeries in either eye, or cognitive impairment (assessed via the Mini-Mental State Examination); and individuals unable to walk independently were excluded from the study.²⁰

Data Collection and Analysis

Systemic comorbidities and medications were documented using the Charlson comorbidity index (CCI).²¹ The patients’ independent daily activities were assessed using the Lawton Instrumental Activities of Daily Living (IADL) scores.²² Participants were questioned about experiencing two or more falls during the last 6 months. A fall was defined as unintentionally coming to rest on the ground or at a lower level, with or without loss of consciousness.²³

Statistical analysis was performed using SPSS software version 24 (IBM Corp., Armonk, NY, USA). Descriptive statistics were employed for continuous and categorical variables. Between-groups comparisons were performed using the t-test (continuous variables) and the chi-square test (categorical variables). Multiple linear regression analysis was performed to evaluate the relationship and predictability of independent variables on the falling rate as the dependent variable. Furthermore, Pearson’s coefficient was used to calculate correlation coefficients between the variables. A P value of <0.05 was considered statistically significant.

Results

The pseudophakic and cataract groups comprised 50 patients each. The patients’ demographics are summarized in Table 1. The patients’ mean age was 66.50 ± 8.68 years in the pseudophakic group and 63.68 ± 8.29 years in the cataract group. No significant differences were observed in age, sex, CCI score, or IADL score between the two groups. Notably, binocular BCVA was markedly better in the pseudophakic group (0.05 ± 0.06 logMAR) than in the cataract group (0.77 ± 0.34 logMAR, P < 0.001).

Table 1.

Demographics and binocular BCVA in the pseudophakic and cataract groups.

Variable	Pseudophakic group (n = 50)	Cataract group (n = 50)	P (t-test or chi-square test)
Age, years	66.50 ± 8.68 (50–85)	63.68 ± 8.29 (52–88)	0.100
Sex	Female: 30 (60.0)	Female: 26 (52.0)	0.273
Sex	Male: 20 (40.0)	Male: 24 (48.0)	0.273
CCI score	1.62 ± 1.19 (0–5)	1.52 ± 1.54 (0–7)	0.718
IADL score	11.28 ± 3.23 (2–14)	11.88 ± 2.62 (0–14)	0.310
Binocular BCVA, logMAR	0.05 ± 0.06 (0.00–0.22)	0.77 ± 0.34 (0.30–1.30)	<0.001

Data are presented as mean ± standard deviation (range) or n (%).

CCI: Charlson comorbidity index, IADL: Lawton Instrumental Activities of Daily Living, BCVA: best-corrected visual acuity, logMAR: logarithm of the minimal angle of resolution.

Among all participants, 78% reported experiencing no or one fall within the preceding 6 months, while 22% indicated two or more falls in the same period. In the multivariate analysis using multiple linear regression, variables including age, sex, CCI score, IADL score, and history of cataract surgery showed no statistically significant associations with the occurrence of two or more self-recalled falls within the previous 6 months. Importantly, the sole variable that demonstrated a significant difference between the two fall frequency groups was binocular BCVA, which proved better among participants with fewer than two falls (P = 0.003) (Table 2).

Table 2.

Distribution of two or more falls during the last 6 months according to demographics, history of cataract surgery, and binocular BCVA

Variable	Two or more falls during the last 6 months		P (multiple linear regression test)
Variable	No (n = 78)	Yes (n = 22)	P (multiple linear regression test)
Age, years	64.51 ± 8.61 (50–88)	67.14 ± 8.24 (53–78)	0.327
Sex	Female: 43 (55.1)	Female: 13 (59.1)	0.621
Sex	Male: 35 (44.9)	Male: 9 (40.9)	0.621
CCI score	1.45 ± 1.40 (0–7)	2.00 ± 1.20 (0–5)	0.451
IADL score	11.91 ± 2.96 (0–14)	10.41 ± 2.59 (4–14)	0.311
History of cataract surgery	No: 34 (43.6)	No: 16 (72.7)	0.359
History of cataract surgery	Yes: 44 (56.4)	Yes: 6 (27.3)	0.359
Binocular BCVA, logMAR	0.33 ± 0.38 (0.00–1.30)	0.72 ± 0.49 (0.00–1.30)	0.003

Data are presented as mean ± standard deviation (range) or n (%).

CCI: Charlson comorbidity index, IADL: Lawton Instrumental Activities of Daily Living, BCVA: best-corrected visual acuity, logMAR: logarithm of the minimal angle of resolution.

A significant negative correlation emerged between binocular BCVA and the falling rate (P < 0.001, r = −0.375). Additionally, the CCI score showed a significant negative correlation with the IADL score (P < 0.001, r = −0.350).

Discussion

This study was performed to assess the fall rates among individuals with visually significant cataracts in both eyes versus those who had recently undergone first-eye cataract surgery. We found that individuals with better binocular BCVA exhibited a significantly lower incidence of two or more self-recalled falls within the previous 6 months. This corroborates existing literature, which has consistently demonstrated a notable correlation between visual acuity and the risk of falling.^24–26 Moreover, several researchers have suggested that surgical interventions aimed at improving visual acuity can effectively reduce the likelihood of future falls.^14,27–29 For instance, Feng et al.²⁸ reported a 54% decrease in the risk of falls after timely first-eye cataract surgery and a 73% reduction after second-eye surgery. Similarly, To et al.³⁰ documented a 78% fall reduction following the first eye surgery and an 83% decrease after the second eye surgery. Other studies have also revealed statistically significant postoperative reductions in the number of falls after lens extraction.^16,23 These findings collectively underscore the potential for interventions, including cataract surgery, to reduce the risk of falls in older individuals by enhancing their visual acuity.

Interestingly, our study also revealed that participants reporting fewer than two falls displayed higher independent daily activity levels (based on IADL scores) and a lower burden of systemic comorbidities (based on CCI scores). However, these differences failed to attain statistical significance in the multivariate analysis. Moreover, we identified a negative correlation between the CCI and IADL scores, a trend consistent with prior research.^11,31–33

It is important to acknowledge the limitations of our study, including its retrospective design, potential recall bias regarding self-reported falls, and relatively small sample size. Additionally, we did not assess other facets of visual function, such as contrast sensitivity or stereopsis.

In conclusion, our findings suggest that individuals of advanced age with visually significant cataracts in both eyes are at an elevated risk of falling. Notably, first-eye cataract surgery is a promising intervention that may reduce the occurrence of falls by improving binocular visual acuity.

Footnotes

Acknowledgements

The authors are grateful to the research participants and all the hospital staff who took interest in and assisted with the study.

Authors’ contributions

MAK designed the study, supervised the project, and performed the ophthalmic examinations and surgeries. HH, MN, AG, and FA collected the data. SC, SH, and AZ performed the statistical analysis. FA, SH, SSA, and MKF wrote and revised the main manuscript text. All the authors read and approved the final manuscript.

Data availability

The datasets used during the current study are available at the Department of Ophthalmology, 5-Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran. The data are not available publicly for confidentiality reasons. However, the data can be obtained from the corresponding author upon reasonable request

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iDs

Amin Zand

Fatemeh Abdi

References

Sharif

Al-Harbi

Al-Shihabi

, et al. Falls in the elderly: assessment of prevalence and risk factors. Pharm Pract (Granada) 2018; 16: 1206. doi:10.18549/PharmPract.2018.03.1206.

Dionyssiotis

Analyzing the problem of falls among older people. Int J Gen Med 2012; 5: 805–813. http://www.ncbi.nlm.nih.gov/pubmed/23055770.

Tornero-Quiñones

Sáez-Padilla

Espina Díaz

, et al. Functional ability, frailty and risk of falls in the elderly: relations with autonomy in daily living. Int J Environ Res Public Health 2020; 17: 1006. doi:10.3390/ijerph17031006.

Vaishnav

Joshi

, et al. The National Programme for Health Care of the Elderly: a review of its achievements and challenges in India. Ann Geriatr Med Res 2022; 26: 183–195. doi:10.4235/agmr.22.0062.

Lukaszyk

Harvey

Sherrington

, et al. Risk factors, incidence, consequences and prevention strategies for falls and fall‐injury within older indigenous populations: a systematic review. Aust N Z J Public Health 2016; 40: 564–568. doi:10.1111/1753-6405.12585.

Alshammari

Alhassan

Aldawsari

, et al. Falls among elderly and its relation with their health problems and surrounding environmental factors in Riyadh. J Fam Community Med 2018; 25: 29–34. doi:10.4103/jfcm.JFCM_48_17.

Salvà

Bolíbar

Pera

, et al. Incidence and consequences of falls among elderly people living in the community. Med Clin (Barc) 2004; 122: 172–176. doi:10.1016/S0025-7753(04)74184-6.

Arik

Soysal

Capar

, et al. The association between fear of falling and orthostatic hypotension in older adults. Aging Clin Exp Res 2021; 33: 3199–3204. doi:10.1007/s40520-020-01584-2.

Kario

Tobin

Wolfson

, et al. Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study. J Am Coll Cardiol 2001; 38: 246–252. doi:10.1016/S0735-1097(01)01327-4.

10.

Rubenstein

LZ.

Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35: II37–II41. doi:10.1093/ageing/afl084.

11.

Lamoureux

Gadgil

Pesudovs

, et al. The relationship between visual function, duration and main causes of vision loss and falls in older people with low vision. Graefe’s Arch Clin Exp Ophthalmol 2010; 248: 527–533. doi:10.1007/s00417-009-1260-x.

12.

Saftari

Kwon

OS.

Ageing vision and falls: a review. J Physiol Anthropol 2018; 37: 11. doi:10.1186/s40101-018-0170-1.

13.

Dhital

Pey

Stanford

MR.

Visual loss and falls: a review. Eye 2010; 24: 1437–1446. doi:10.1038/eye.2010.60.

14.

Keay

Palagyi

Preventing falls in older people with cataract – it is not just about surgery. Ophthalmic Physiol Opt 2018; 38: 117–118. doi:10.1111/opo.12445.

15.

Palagyi

McCluskey

White

, et al. While we waited: incidence and predictors of falls in older adults with cataract. Investig Opthalmology Vis Sci 2016; 57: 6003. doi:10.1167/iovs.16-20582.

16.

Brannan

A prospective study of the rate of falls before and after cataract surgery. Br J Ophthalmol 2003; 87: 560–562. doi:10.1136/bjo.87.5.560.

17.

Iroku-Malize

Kirsch

Eye conditions in older adults: cataracts. FP Essent 2016; 445: 17–23. http://www.ncbi.nlm.nih.gov/pubmed/27348528.

18.

Von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–349. doi:10.1016/j.jclinepi.2007.11.008.

19.

Richter

Chung

Azen

, et al. Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery. Ophthalmology 2009; 116: 2327–2335. doi:10.1016/j.ophtha.2009.05.040.

20.

Creavin

Wisniewski

Noel-Storr

, et al. Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations. Cochrane Database Syst Rev 2016; 2016: CD011145. doi:10.1002/14651858.CD011145.pub2.

21.

Charlson

Pompei

Ales

, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383. doi:10.1016/0021-9681(87)90171-8.

22.

Graf

The Lawton Instrumental Activities of Daily Living Scale. AJN, Am J Nurs 2008; 108: 52–62. doi:10.1097/01.NAJ.0000314810.46029.74.

23.

Harwood

Foss

Osborn

, et al. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol 2005; 89: 53–59. doi:10.1136/bjo.2004.049478.

24.

Kasuga

Aruga

Ono

, et al. Visual impairment as an independent risk factor for falls in hospitalized patients. Can J Ophthalmol 2017; 52: 559–563. doi:10.1016/j.jcjo.2017.04.010.

25.

Brundle

Waterman

Ballinger

, et al. The causes of falls: views of older people with visual impairment. Health Expect 2015; 18: 2021–2031. doi:10.1111/hex.12355.

26.

Kingston

JT.

Visual impairment and falls: outcomes of two fall risk assessments after a four-week fall prevention program. J Vis Impair Blind 2018; 112: 411–415. doi:10.1177/0145482X1811200408.

27.

Gutiérrez-Robledo

Villasís-Keever

Avila-Avila

, et al. Effect of cataract surgery on frequency of falls among older persons: a systematic review and meta-analysis. J Ophthalmol 2021; 2021: 2169571. doi:10.1155/2021/2169571.

28.

Feng

Meuleners

Fraser

, et al. The impact of first and second eye cataract surgeries on falls: a prospective cohort study. Clin Interv Aging 2018; 13: 1457–1464. doi:10.2147/CIA.S164419.

29.

Desapriya

Subzwari

Scime-Beltrano

, et al. Vision improvement and reduction in falls after expedited cataract surgery. J Cataract Refract Surg 2010; 36: 13–19. doi:10.1016/j.jcrs.2009.07.032.

30.

Meuleners

Bulsara

, et al. A longitudinal cohort study of the impact of first- and both-eye cataract surgery on falls and other injuries in Vietnam. Clin Interv Aging 2014; 9: 743–751. Published online April 2014. doi:10.2147/CIA.S61224.

31.

Canaslan

Ates Bulut

Kocyigit

, et al. Predictivity of the comorbidity indices for geriatric syndromes. BMC Geriatr 2022; 22: 440. doi:10.1186/s12877-022-03066-8.

32.

Gong

Wan

Zhang

, et al. Correlation between the Charlson comorbidity index and skeletal muscle mass/physical performance in hospitalized older people potentially suffering from sarcopenia. BMC Geriatr 2019; 19: 367. doi:10.1186/s12877-019-1395-5.

33.

Mohler

Wendel

Taylor-Piliae

, et al. Motor performance and physical activity as predictors of prospective falls in community-dwelling older adults by frailty level: application of wearable technology. Gerontology 2016; 62: 654–664. doi:10.1159/000445889.