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Preventing falls in older people with cataract – it is not just about surgery

The risk of being injured through a fall increases dramatically as we age. Falls can result in hip fracture, head injuries or even death but also have indirect consequences such as fear of future falls, loss of confidence and activity avoidance. Being hospitalised after a fall increases the likelihood of long term nursing home admission and can precipitate a general decline in health. Reducing falls is of critical importance to health care systems, and to the safety and wellbeing of older people in our society. Vision impairment has long been recognised as a risk factor for falls and epidemiologic studies show a 2–3 fold increase risk of falls in older adults with cataract compared to those without. There has only been one randomised trial globally evaluating the benefits of expedited cataract surgery, conducted in the UK between 1999–2002. This study found that first eye cataract surgery within 1 month of referral reduced the rate of falls by 34% over a 12 month period (rate ratio 0.66, 95% CI 0.45–0.96). Since this time, there have been some valuable additions to the literature which reveal the complex relationships between surgery, refractive correction and falls risk. Many cataract patients will require an update to their spectacle correction prior to first eye surgery, most commonly due to index myopia and changes to astigmatism as the cataract develops. Additional, and often significant, refractive changes occurring after cataract surgery and necessitate further change to spectacle lenses. Synthesis of the body of research on blurred vision, spectacle correction and falls in older adults finds substantive effects of spectacle lens correction on gait and postural control, which correspond to findings of epidemiologic research and falls prevention trials. Older people are particularly vulnerable to these spectacle effects, as age-related declines in the ability of our proprioceptive and vestibular systems to respond to changes in balance greatly increases reliance on visual cues for stability and safe mobility. Our recent Australian study has quantified the magnitude of falls risk associated with changes in spectacle correction accompanying cataract surgery and found a twofold increase in risk associated with changes in spectacles of more than 0.75 dioptres spherical equivalent (Odds Ratio 2.17; 95% CI 1.23–3.85). In this study, 329 cataract surgery candidates prospectively reported falls each month in the period before and after first eye cataract surgery. Though incident falls reduced after surgery by around one-third, the changes to spectacle correction had an independent impact on falls risk. Almost half (48%) of cataract surgery patients in this study updated their spectacles and close to one-third (32%) had substantial post-surgical changes to the spherical equivalent power of their spectacles. Supuk investigated falls in 287 patients in a similar study design in the United Kingdom, documenting falls before and after cataract surgery. Changing into multifocal spectacles post-surgery was shown to increase falls risk (OR 3.56, 95% CI 1.34–9.43; p = 0.011). In this observational study, 30% of participants switched into multifocals after surgery, providing an opportunity to explore the relationship with fall risk not possible in the Australian study where only few (5%) were prescribed multifocals. In both studies, changes to spectacle prescription were shown to independently impact the occurrence of falls in older people receiving cataract surgery. Though cataract surgery is highly successful and can be transformative, caution is needed in managing changes to spectacle correction and optometrists and others involved in refractive management need to be aware of this issue. For an older person at risk of falls, 0.75 dioptres is the maximum recommended change in spectacle prescription. Achieving this may require ‘partial-prescribing’ rather than prescribing based entirely on subjective refraction results. Elliott has proposed extending ‘partial-prescribing’ to prescribing mid-range addition multifocals. This allows wearers sufficient near vision to spot read and has been shown to mitigate the negative impacts on gait safety found with full addition multifocals. In conclusion, recent research has shown that spectacle prescribing can have a measurable and substantial impact on the risk of falls in older adults with cataract. Together, these studies provide valuable direction for how spectacles should be prescribed to minimise risk of falls. The 2017 National Institute for Health and Care Excellence (NICE) guidelines on ‘Cataracts in adults: management’ refer to the risk of falls associated with cataract and describe processes to enhance refractive targeting but do not make recommendations for spectacle management. Further efforts are needed to better integrate surgical and refractive management of cataract to fully realise the benefits of cataract surgery.