Routine Preoperative Testing Before Cataract Surgery
Routine Preoperative Testing Before Cataract Surgery
abstract & commentary
Synopsis: Routine preoperative testing before elective cataract surgery did not improve patient outcomes. Tests should be ordered only when the history or physical examination indicate a need for tests even without a planned surgery.
Source: Schein OD, et al. N Engl J Med 2000;342:168-175.
To determine if routine testing before cataract surgery was beneficial, Schein and colleagues studied more than 18,000 patients undergoing elective cataract surgery at nine clinical centers. Study centers included private, academic, and community-based hospitals. Each patient was randomized to either a routine testing group (12-lead electrocardiogram, complete blood count, electrolytes, blood urea nitrogen, creatinine, and glucose) or no testing. Patients with testing done one month before the surgery or those with a myocardial infarction (MI) within the previous three months were excluded.
After randomization, adverse medical events were recorded on the day of surgery and for one week after surgery. Primary adverse events were MI, angina, arrhythmia, congestive heart failure, hypertension, hypotension, stroke, transient ischemic attack, respiratory failure, bronchospasm, oxygen desaturation, hypoglycemia, hyperglycemia, or other adverse events identified by a study coordinator.
No significant differences in complications were found on the day of surgery in the routine testing (19.2 events/1000 operations) vs. the nontesting group (19.7 events/1000 operations). Likewise, the adverse event rate for the postoperative period was also virtually identical (12.6/1000 operations vs 12.1/1000 operations). Subgroup analysis showed no benefit according to the age, ethnicity, sex, or health status.
Comment by Martin Lipsky, MD
Cataract surgery is the most commonly performed operation in elderly people in the United States. As a primary care physician caring for older patients, I am frequently asked to clear individuals for cataract surgery. Often these requests are accompanied by routine orders for preoperative testing. This elegant, randomized, large-scale study indicates that routine testing does not improve patient outcomes. Schein et al recommend that only those patients whose clinical evaluation would have indicated a need for testing even without a planned surgery should undergo testing. Clearly, with approximately 1.5 million annual operations performed in the United States, the potential cost savings are enormous. Since some of these tests are undoubtedly ordered as "defensive medicine," it is reassuring to have defensive evidence that a careful history and physical examination is a sufficient preoperative evaluation. I would expect that once the results of this study are disseminated among ophthalmologists, primary care physicians will see few routine requests for preoperative testing for cataract surgery. Also, as Schein et al suggest and I agree, it is reasonable to think about applying the results of this study to other low-risk procedures.
Which of the following tests are helpful for evaluating an elderly patient with chronic stable hypertension before cataract surgery?
a. Electrolytes
b. Bun and creatinine
c. An electrocardiogram
d. None of the above
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.