December 03, 2025
5 min read
Age-related dementia, cataract, age-related macular degeneration, glaucoma, diabetic retinopathy and hearing loss are all more common in the elderly patient.
The average age of onset of a cataract in the U.S. is about 60 years and for cataract/IOL surgery, 74 years. The average age of onset for age-related dementia is 70 years, for glaucoma 55 years, for AMD 60 years, and for diabetic retinopathy in adult-onset diabetes 65 years. All of these age-related diseases tend to progress with increasing age.
A patient who presents for cataract/IOL surgery in their 70s has a 10% to 15% chance of having at least mild dementia. In 15% to 20%, glaucoma will be a comorbidity. Another 15% to 20% will have macular degeneration, and for the patient with diabetes, nearly 30% will have evidence of diabetic retinopathy. In addition, a surprising 55% will manifest a dry eye and another 50% hearing loss. Because these diseases and degenerations are all age related, it is no surprise that more than one of these diagnoses are present in most patients who present for cataract/IOL surgery.
We ophthalmologists are excellent at recognizing ocular comorbidities but less proficient at looking for hearing loss and dementia. In my experience, these two diagnoses are rarely recorded in our preoperative cataract/IOL surgery patients’ charts. Most of us can and should do better here, as cataract/IOL surgery and hearing aids can both have a positive impact on the onset and rate of progression of age-related dementia and significantly enhance the ability of a patient with dementia to perform daily activities and improve their quality of life.
The most common indication for cataract/IOL surgery with lens implantation in the U.S. patient is vision loss caused by cataract that results in difficulty driving or reading or has a negative impact on avocations such as sports or household activities such as sewing. Because the patient with dementia usually no longer drives, reads or sews, one might conclude that cataract/IOL surgery can be delayed to a later stage in the patient with dementia. However, the well-established fact that quality vision delays both the onset and rate of progression of age-related dementia while enhancing daily activity performance, including personal hygiene, independence in daily activities such as dressing and eating, and recognizing friends and family along with watching television, leads me to conclude that dementia is an indication for early cataract/IOL surgery. While the presence or treatment of dementia has no impact on the development of cataract, glaucoma, macular degeneration, diabetic retinopathy, dry eye or hearing loss, the opposite is not true. The treatment of age-related eye disease with preservation or restoration of vision and improved hearing has an additive and significant positive impact on dementia and a patient’s quality of life.
I tend to offer surgery to patients with cataract and glaucoma at an earlier stage of lens opacity because cataract surgery with or without a combined MIGS procedure can have a significant positive effect on the control of glaucoma and reduce the risk for progressive optic nerve damage. In my opinion, we should also be treating patients with dementia at an early stage because it will positively affect their cognitive decline and quality of life. In addition, patients with dementia with cataract have an increased incidence of falls, and cataract/IOL surgery reduces the likelihood of a fall eight times, positively affecting both longevity and quality of life.
A few personal thoughts from managing family members with cataract and dementia. I am the only physician in my or my wife’s family. My sister developed mild dementia at 78 years, my mother at 75 years and my mother-in-law at 80 years. In each case I recommended surgery, and in my sister and mother, I performed cataract/IOL surgery early at a Snellen acuity of 20/25 with a brightness acuity test of 20/40 to 20/50. Operating early before their cognitive decline was significant, allowing their surgery to be completed with topical anesthesia and mild IV sedation. Dementia has been shown to induce a loss of contrast sensitivity, constricted visual fields and reduced color vision. None of these three relatives were still driving or reading. All three of my family members with mild to moderate dementia enjoyed watching TV and looking at the view outside their windows. They needed to see well in the distance for these activities. They were all still ambulatory and enjoyed walks outside and needed to walk up or down one flight of stairs. They wanted to perform their own personal hygiene including some makeup, dress themselves and eat independently. They also engaged in face-to-face conversation daily with fellow residents, family and friends. None could manage spectacles, which were never worn and always lost immediately when prescribed.
I felt they all needed to see far and near without spectacle correction and required high-quality vision without color distortion or loss of contrast sensitivity to best retard the progression of their age-related dementia. I opted for so-called blended vision targeting very mild myopia in the dominant eye and –1.5 D in the nondominant eye. They all functioned well without the use of spectacles until death, with my mother passing at age 94 years, 20 years after her cataract/IOL surgery. None required a toric IOL, but astigmatism correction is also appropriate in a patient who must function at distance and near without correction. Reviewing the published literature, many experts recommend targeting myopia in the –1 D to –2 D range in both eyes of patients with dementia, but for my family and all my other patients with dementia, mild monovision/blended vision with a monofocal IOL has worked extremely well.
Operating at an early stage of age-related dementia with a well-informed anesthetist and mild IV sedation, I routinely used topical anesthesia supplemented with intracameral lidocaine. I also used compounded intracameral dexamethasone, moxifloxacin and ketorolac (ImprimisRx/Harrow) at the end of the case. In high-risk cases for cystoid macular edema in those with diabetes, I also injected subconjunctival triamcinolone. If the patient had access to a caregiver, I prescribed a compounded triple drop containing an antibiotic, steroid and NSAID as well as an artificial tear to rehabilitate the ocular surface, but I was never concerned with compliance because of my intraoperative treatment with an antibiotic, steroid and NSAID. Over the last decade, when a general anesthetic was required, I always performed bilateral same-day sequential cataract surgery, operating on both eyes on the same day to avoid subjecting the patient to the risk of two rounds of general anesthesia.
Age-related dementia and age-related eye diseases often present together in our senior patients. It is important to remember that cataract/IOL surgery with visual restoration is a positive treatment for all forms of dementia, delaying its onset and rate of progression. Earlier surgery provides the patient with dementia with several benefits including a better quality of life, a slower increase in cognitive decline and a reduction in falls. With milder dementia and early cataract, it is possible to perform cataract/IOL surgery under topical anesthesia. Like the patient with cataract and glaucoma, the patient with cataract and age-related dementia has much to gain from early cataract/IOL surgery.
In my practice, the patient with dementia did well with a monofocal or toric monofocal IOL targeting blended vision. Others recommend mild myopia in both eyes, but most avoid multifocal IOLs. We should all be on the lookout for cataract patients with early cognitive decline/age-related dementia because our surgery can meaningfully affect their disease, daily function and quality of life in a positive way.
For more information:
Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.
Sources/Disclosures
Source:
Expert Submission
Disclosures:
Lindstrom reports having financial disclosures for Alcon, Harrow, ImprimisRx, Minnesota Eye Consultants and Unifeye Vision Partners.
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