Fracture Risk After Cataract Surgery

Abstract

To the Editor: Dr Tseng and colleagues conducted a retrospective study of the association of fracture risk after cataract surgery in a random 5% sample of Medicare beneficiaries. The authors noted that patients with decreased visual acuity have a higher incidence of fractures. Therefore, it is reasonable to propose that fracture risk would decrease after cataract surgery. When corrected for demographic data and comorbidities based on the Charlson Comorbidity Index (CCI) score, this relationship was confirmed for patients with a propensity score decile subgroup of 4 or higher (Table 5 in article) for patients aged 70 years or older, and for those with a CCI score of 3 or higher (Table 6). However, this benefit did not extend to younger and healthier patients who underwent cataract surgery. With a significance level of P .05, the odds ratio (OR) for any fracture was actually higher for propensity score deciles 1 to 3 (ORs: 1.28 and 1.08; P .02; Table 5) and for patients with a CCI score of 2 or lower (OR, 1.03; P=.04; Table 6). For the youngest patients in the study (aged 65-69 years), cataract surgery was linked to a higher OR of hip fracture and any fracture (ORs: 1.16 and 1.09; P .02; Table 6). These subgroups comprised a significant percentage of pseudophakic Medicare beneficiaries; 19.5% were aged 65 to 69 years and 62.8% had a CCI of 2 or lower (Table 1). Why would cataract surgery result in a higher OR of hip fracture and any fracture in younger and healthier patients? Should these patients with visual impairment secondary to cataracts be counseled against cataract surgery? Ophthalmologists, other physicians, and patients with cataracts who are considering surgery would benefit from discussion of this paradoxical observation. The sequence of the diagnoses is important given the premise of the study: fracture risk after cataract surgery. The authors acknowledged their inability to distinguish whether the fracture or cataract diagnosis was noted first if both diagnoses occurred in the same calendar year. Severe cataracts, which the authors designated as “posterior subcapsular cataracts, total or mature cataract, hypermature cataract, and combined forms of cataract,” can progress rapidly, especially if the patient has diabetes mellitus or Cushing syndrome or is taking systemic corticosteroids. In these cases, the fracture diagnosis may have preceded the cataract diagnosis in the same year, which may confound the robust, reported link between extraction of severe cataracts and subsequent fracture risk.