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Meta-Analysis
. 2009 Apr 15:(2):CD007293.
doi: 10.1002/14651858.CD007293.pub2.

Routine preoperative medical testing for cataract surgery

Lisa Keay  1 , Kristina Lindsley, James Tielsch, Joanne Katz, Oliver Schein
Affiliations
Meta-Analysis

Routine preoperative medical testing for cataract surgery

Lisa Keay et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Cataract surgery is practiced widely and substantial resources are committed to an increasing cataract surgical rate in developing countries. With the current volume of cataract surgery and the increases in the future, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management.

Objectives: (1) To investigate the evidence for reductions in adverse events through preoperative medical testing, and (2) to estimate the average cost of performing routine medical testing.

Search strategy: We searched CENTRAL, MEDLINE, EMBASE and LILACS using no date or language restrictions. We used reference lists and the Science Citation Index to search for additional studies.

Selection criteria: We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery.

Data collection and analysis: Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed methodological quality.

Main results: The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and 354 occurred in the no testing group. Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24) when compared to selective or no testing. Cost savings were evaluated in one study which estimated the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. There was no difference in cancellation of surgery between those with preoperative medical testing and those with no or limited preoperative testing, reported by two studies.

Authors' conclusions: This review has shown that routine pre-operative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self-administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in developed settings. Unfortunately, in developing country settings, medical history questionnaires would be useless to screen for risk since few people have ever been to a physician, let alone been diagnosed with any chronic disease.

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Conflict of interest statement

DECLARATIONS OF INTEREST

Oliver Schein, James Tielsch, and Joanne Katz were co-investigators in a trial examining preoperative medical testing and cataract surgery funded by a grant from the Agency for Health Care Policy and Research (RO1-HSO-8331).

Figures

Analysis 1.1
Analysis 1.1
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 1 Total intraoperative medical adverse events.
Analysis 1.2
Analysis 1.2
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 2 Total intraoperative hospitalizations.
Analysis 1.3
Analysis 1.3
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 3 Total postoperative medical adverse events.
Analysis 1.4
Analysis 1.4
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 4 Total postoperative deaths.
Analysis 1.5
Analysis 1.5
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 5 Total postoperative hospitalizations.
Analysis 1.6
Analysis 1.6
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 6 Cancellation of cataract surgery.
Analysis 1.7
Analysis 1.7
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 7 Total intraoperative ocular adverse events.
Analysis 1.8
Analysis 1.8
Comparison 1 Preoperative testing vs. selective or no preoperative testing, Outcome 8 Total postoperative ocular adverse events.
Figure 1
Figure 1
Funnel plot of comparison: 1 Preoperative testing vs. selective or no preoperative testing, outcome: 1.1 Total intraoperative medical adverse events.
Figure 2
Figure 2
Methodological quality summary: review authors’ judgements about each methodological quality item for each included study.
See this image and copyright information in PMC

References

References to studies included in this review

    1. Cavallini GM, Saccarola P, D’Amico R, Gasparin A, Campi L. Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery. European Journal of Ophthalmology. 2004;14(5):369–74. - PubMed
    1. Arieta CE, Nascimento MA, Lira RPC, Kara-Jose N. Waste o medical tests in preoperative evaluation for cataract surgery [Desperdício de exames complementares na avaliação pré–operatória em cirurgias de catarata] Cadernos de Saude Publica. 2004;20(1):303–10. - PubMed
    1. Lira RPC. Tese de Doutorado (Doctoral Thesis) Campinas: Faculdade de Ciências Médicas da UNICAMP; 2002. Preoperative tests in ambulatory cataract surgery in adults: Is a routine necessary?[Testes pré–operatórios na cirurgia de cataracta ambulatorial em adultos: É necessária uma rotina?]
    1. Lira RPC, Nascimento MA, Moreira-Filho DC, Kara-Jose N, Arieta CE. Are routine preoperative medical tests needed with cataract surgery? Pan American Journal of Public Health. 2001;10(1):13–7. - PubMed
    1. Nascimento MA, Lira RPC, Kara-Jose N, Arieta CE. Predictive value of preoperative fasting glucose test of diabetic patients regarding surgical outcome in cataract surgery [Valor preditivo da glicemia de jejum pré–operatória de pacientes diabéticos quanto ao resultado cirúrgico da cirurgia de catarata] Arquivos Brasileiros de Oftalmologia. 2005;68(2):213–7. - PubMed

References to studies excluded from this review

    1. Blery C, Szatan M, Fourgeaux B, Charpak Y, Darne B, Chastang CL, et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet. 1986;1(8473):139–41. - PubMed
    1. Brown MM. The value of routine preoperative medical testing before cataract surgery. Evidence-Based Eye Care. 2001;2(3):186–7.
    1. Bruns DE. Laboratory-related outcomes in healthcare. Clinical Chemistry. 2001;47(8):1547–52. - PubMed
    1. Coleman AL. Applying evidence-based medicine in ophthalmic practice. American Journal of Ophthalmology. 2002;134(4):599–601. - PubMed
    1. Francis JG, Barker JP. Postoperative morbidity following cataract surgery. Anaesthesia. 1996;51(9):888–9. - PubMed

Additional references

    1. American Academy of Ophthalmology. Cataract in the Adult Eye, Preferred Practice Pattern. 2006 www.aao.org/ppp. - PubMed
    1. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery: a report of the American College of Cardiology/American Heart Association ask Force on practice guidelines (Committee to update the 1996 Guidelines on perioperative cardiovascular evaluation for noncardiac surgery) American College of Cardiology. 2002 http://www.acc.org/clinical/guidelines/perio/dirIndex.htm. - PubMed
    1. Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, et al. Practice Advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on preanesthesia evaluation. Anesthesiology. 2002;96(2):485–96. - PubMed
    1. Bass EB, Steinberg EP, Luthra R, Schein OD, Tielsch JM, Javitt JC, et al. Do ophthalmologists, anesthesiologists, and internists agree about preoperative testing in healthy patients undergoing cataract surgery? Archives of Ophthalmology. 1995;113(10):1248–56. - PubMed
    1. Bellan L. Preoperative testing for cataract surgery. Canadian Journal of Ophthalmology. 1994;29(3):111–4. - PubMed

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