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DOI: 10.1155/2021/2169571

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Journal of Ophthalmology
Volume 2021, Article ID 2169571, 7 pages
https://doi.org/10.1155/2021/2169571

Research Article
Effect of Cataract Surgery on Frequency of Falls among Older
Persons: A Systematic Review and Meta-Analysis

Luis Miguel Gutiérrez-Robledo ,1 Miguel Angel Villası́s-Keever ,2

Arturo Avila-Avila ,3 Raúl Hernán Medina-Campos ,4
Roberto Carlos Castrejón-Pérez ,5 and Carmen Garcı́a-Peña 6
1
Instituto Nacional de Geriatrı́a, Mexico City, Mexico
2
Head of Analysis and Synthesis of Evidence Research Unit, Instituto Mexicano del Seguro Social, Mexico City, Mexico
3
Director of Education, Instituto Nacional de Geriatrı́a, Mexico City, Mexico
4
Head of Epidemiologic and Geriatric Research, Instituto Nacional de Geriatrı́a, Mexico City, Mexico
5
Health Researcher, Instituto Nacional de Geriatrı́a, Mexico City, Mexico
6
Director of Research, Instituto Nacional de Geriatrı́a, Mexico City, Mexico

Correspondence should be addressed to Carmen Garcı́a-Peña; [email protected]

Received 26 June 2020; Revised 4 March 2021; Accepted 6 March 2021; Published 16 March 2021

Academic Editor: Dirk Sandner

Copyright © 2021 Luis Miguel Gutiérrez-Robledo et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. Falls are a significant public health problem among older people worldwide. The aim was to perform a new systematic
review and meta-analysis to assess whether cataract surgery is effective in reducing the rate of falls in older persons. Methods. The
systematic review was performed following the recommendations by the Cochrane Collaboration. Original papers were included
with RCT or quasi-experimental design, which described the effect on uni- or bilateral cataract surgery on the rate of falls among
people aged 60 or older. Titles and abstracts were reviewed, full-text versions were retrieved, and two independent examiners
reviewed them to assess inclusion criteria. All relevant variables were synthesised in an evidence table. Random-effects meta-
analyses were performed pooling the trials, and results were expressed as relative risk (RR) and 95% confidence intervals. Results.
The initial search reported 99 potential abstracts, and 41 full-text versions were examined. In the end, eight studies were included.
Five included patients 65 years of age and older, two patients 55 years and older, and one included patients 50 years or older.
Phacoemulsification and intraocular lens implant were performed in all studies. Two were RCT, and six were quasi-experimental.
Falls was the main outcome. The six quasi-experimental studies reported that a reduction in the frequency of falls was observed
(RR 0.68, 95% CI 0.48–0.96), although heterogeneity was significant (I2 = 74%). Only one RCT reported risk reduction of 34% (RR
0.66, 95% CI 0.45–0.96). Conclusions. This meta-analysis provides evidence that the first cataract surgery reduces the frequency of
falls in older people with bilateral cataracts, but a second surgery does not have significant impact.

1. Background Factors that increase the incidence of injuries derived

from falls include older age, visual impairment, cataracts
Falls are a significant public health problem among older (uni- or bilateral), history of falls in the two previous years,
people worldwide. They represent the second cause of death disorders of gait and balance, neurological disorders, limited
by nonintentional injuries, with 646,000 deaths by falls mobility, back pain, limited neck rotation, cognitive im-
occurring annually. Most of these deaths occur among pairment, dementia, and any compromise in overall capacity
persons 60 years and older. Moreover, 37.3 million nonfatal [3–5].
falls occur every year, producing 17 million disability-ad- It has been suggested that visual impairment compro-
justed life years, mostly among older persons. [1, 2]. mises the ability to avoid obstacles, being cataracts and
2 Journal of Ophthalmology

refractive error the most frequent cause of visual impairment whether studies met inclusion criteria. Studies were included
among older people [6–8]. Age-associated cataracts remain only when the two examiners agreed. In case of discordance,
the leading cause of visual impairment and blindness in low- a consensus decision was made to include or exclude the
and middle-income countries, including Latin America studies.
[8, 9]. Full-text versions were retrieved for all selected studies.
Treatment for cataracts consists of the surgical extraction Two independent examiners reviewed them to assess the
of the opacified crystalline and its replacement with an inclusion criteria. Studies were included when both exam-
intraocular lens. With different surgical techniques de- iners agreed, and a consensus was made in case of dis-
scribed and different types of intraocular lenses available, agreement. After this selection, relevant data were extracted
cataract surgery over all is effective in improving vision and from the studies, and each independent examiner performed
is quick, cost-effective, and safe [10]. an individual assessment of the quality of the studies.
Visual impairment has been recognised as a risk factor
for falls among older people since the 1950s [11]. Never-
theless, it is not clear whether cataract surgery decreases the 2.2. Statistical Analysis. For each study included in the
incidence of falls. In 2003, a prospective study by Brannan systematic review, all relevant variables were collected and
et al. showed that cataract surgery efficaciously reduced the synthesised in an evidence table. Random-effect meta-an-
risk of falls in older people with visual impairment [12]. alyses were performed pooling the trials that assessed par-
Several studies have followed after that which have evaluated ticipants in a similar fashion, and results were expressed as
the impact of cataract surgery on falls in older people, in- relative risk (RR) and 95% confidence intervals. All analyses
cluding some randomised controlled trials (RCT) and even were performed using the RevMan 5.3 software.
two meta-analyses. The most recent meta-analysis by
Desapriya et al. included only two clinical trials and they did 3. Results
not find evidence that cataract surgery reduced incident
3.1. Study Selection Process. Figure 1 illustrates the process of
falling (OR 0.81, 95% CI 0.55–1.17) [13]. The lack of asso-
study selection. The initial search rendered 99 potential
ciation can be explained because these two clinical trials
abstracts, of which 58 were excluded for not fulfilling in-
reported a different intervention; one corresponds to the first
clusion criteria. Further on, 41 full-text versions were ex-
surgery and the other to the second cataract surgery. More
amined and 33 of them excluded because the design was not
clinical trials evaluating the impact of cataract surgery on
RCT or quasi-experimental or because they did not include
falls have been published since 2010.
falls as an outcome. In the end, eight studies were included in
Considering the growing accessibility to cataract surgery
the systematic review [12, 14–20].
and the critical consequences of falls in older people and the
possibility that new clinical trials may modify the results
previously reported, we decided to perform a new systematic 3.2. Study Characteristics. The eight included studies were
review and meta-analysis to assess whether cataract surgery published between 2003 and 2018. Four of them were
is effective in reducing the rate of falls in older people. performed in the United Kingdom [12, 15, 16, 19], two in
Australia [14, 18], one in the United States [17], and one in
2. Methods Vietnam [20].

This systematic review was performed following the rec-

ommendations by the Cochrane Collaboration. Relevant 3.2.1. Patient Characteristics. Five studies included patients
studies were retrieved from Medline, EMBASE, and 65 years of age or older [12, 15, 16, 18, 19], two included
Cochrane Library, using the following search terms: cata- patients 55 years or older [14, 17], and one included patients
ract, cataract extraction, falls, accidental falls, aged, elderly, 50 years or older [20]. Two studies were performed exclu-
clinical controlled trial, and clinical trial. The date of the last sively in women [15, 16], while the rest included patients of
search was March 2019. both sexes.
The following inclusion criteria were used: original
papers with RCT (participants were randomly allocated to 3.2.2. Type of Surgery. In all studies, cataract surgery was
intervention or comparator) or quasi-experimental design performed by phacoemulsification and intraocular lens
(randomization process was not used for the allocation of implant. The study [15] by Foss et al. included patients
the intervention, such as before-and-after studies: partici- undergoing surgery in the second eye. Two studies included
pants were their own controls; that is, the incidence of falls participants undergoing two surgeries (first and second eyes,
were compared before and after the intervention) which with no specified time between surgeries) [14, 20]. All others
described the effect on uni- or bilateral cataract surgery on included patients undergoing their first cataract surgery.
the rate of falls among people aged 60 or older. The language
was restricted to English and Spanish.
3.2.3. Design. Only two studies were RCT’s comparing
expedite cataract surgery with the usual waiting time
2.1. Study Selection Process. Titles and abstracts were [15, 16]. The other six studies were quasi-experimental,
assessed by two independent examiners, who determined comparing the incidence of falls before and after surgery.
Journal of Ophthalmology 3

Mediline EMBASE Cochrane Library

1980–2019 1980–2019 1980–2019
24 Citation (s) 90 Citation (s) 4 Citation (s)

99 nonduplicate
citations screened

Inclusion/exclusion 58 articles excluded

criteria applied after title/abstract screen

58 articles retrieved

Inclusion/exclusion 33 articles excluded 0 articles excluded

criteria applied after full-text screen during data extraction

8 articles included

Figure 1: Study selection process.

3.2.4. Falls Assessment. All studies provided a definition of that underwent expedite surgery versus the rate of falls in a
the occurrence of falls. In general, a fall was defined as an control group with usual waiting time to surgery (Supple-
unexpected or accidental event in which the participant had mentary Table 3). However, one of the studies included
reached a ground level from an upper position. Four studies patients undergoing their first cataract surgery [16], and the
used the same definition as that by Lamb et al. in 2005 [21]. other one included patients undergoing surgery in their
The specific method for assessing falls varied across the second eye [15].
studies. Four studies used daily logs and direct interviews at The study by Harwoodet al. [16] compared 154 patients
the end of follow-up [12, 14, 18, 19]. The other four studies undergoing cataract surgery to 152 patients with surgery
used direct interviews at the end of the follow-up period, delayed up to 13 months. After 12 months, 49.3% of patients
which ranged from 6 to 12 months [15–17, 20]. in the surgery group had fallen at least once, compared to
45.3% in the control group. However, patients having two or
more falls were less in the surgery group (28 frequent fallers,
3.3. Quality Assessment of the Studies. For the six quasi-
18%) than in the control group (38 frequent fallers, 25%).
experimental studies, the quality was assessed using the
According to the authors, the total risk reduction was 34%
ROBINS-1 tool for risk of bias assessment (Supplementary
(RR 0.66, 95% CI 0.45–0.96).
Table 1). No risk of bias was found regarding the inter-
In the study by Foss et al. [15], they compared 120
vention. As for participant selection, two studies had no risk
patients who had cataract surgery with 119 who had no
of bias [14, 18], but the rest did not provide sufficient detail
surgery. No statistical difference was found between the two
of the selection procedure. None of the studies considered
groups after 12 months (RR 0.68, 95% CI 0.39–1.19).
the possibility that falls could have been due to factors other
McGwin et al. [17] studied 122 patients who had cataract
than visual impairment. In the studies where two cataract
surgery on one or two eyes and compared them to 92 pa-
surgeries were performed, it was not specified whether a fall
tients who chose not to have surgery. After 12 months, no
assessment was performed in between surgeries [14, 20].
difference was found between both groups (RR 0.96, 95% CI
Regarding the two RCT’s included in this systematic review
0.64–1.42).
[15, 16], no risk of bias was detected after applying the
Cochrane risk of bias tool (Supplementary Table 2).
3.5. Frequency of Falls before Vs. after the First Cataract
Surgery. Table 1 presents the synthesis of six quasi-exper-
3.4. Falls after Surgery vs. No Surgery. The two RCT's in- imental studies comparing [12, 14, 16, 17, 19, 20] the fre-
cluded in this systematic review had a similar design quency of falls before and after cataract surgery. A meta-
comparing the rate of falls after cataract surgery in a group analysis was performed pooling 1014 patients before surgery
4 Journal of Ophthalmology

Table 1: Characteristics of included studies of the relationship between the frequencies of falls after the first cataract surgery in older people.
Follow-up Falls before
Author Design Patients Age Sex Falls after surgery
time surgery
Female
54
Brannan Before and after (64.2%)
N � 84 79.8 ± 5.8 6 months 31 (36.9%) 6 (7.1%)
et al., [12] surgery Male
30
(35.7%)
N � 154 (before
Controlled clinical Median Female
Harwood surgery)
trial: expedited 78.8Range: 154 12 months 79 (51.3%) 76 (49.3%)
et al., [16] N � 154 (after
surgery group 79–95 (100%)
surgery)
Female
71
McGwin Before and after (58.2%)
N � 122 70.9 ± 6.8 12 months 46 (37.8%) 42 (34.4%)
et al., [17] surgery Male
51
(41.8%)
Female
N � 413 (before 268
Before and after surgery) (64.9%)
To et al., [20] 66.6 ± 7.9 12 months 53 (12.8%) 13 (10.9%)
surgery N � 119 (after Male
surgery) 145
(35.1%)
Female
N � 287 (before 158
Supuk et al., Before and after surgery) (55.1%)
76.5 ± 6.3 6 months 66 (22.9%) 56 (19.8%)
[19] surgery N � 283 (after Male
surgery) 129
(44.9%)
Female
N � 228(before 182
1.17 (IC95% 0.88 (IC 95%
Palagyi et al., Before and after surgery) (55.3%)
75.7 ± 5.3 12 months 0.93–1.46) year- 0.66–1.17) year-
[18] surgery N � 196(after Male
person falls person falls
surgery) 147
(44.7%)
Female
30
Feng et al., Before and after (54.6%) 99.6 ± 73.7
N � 55 73.3 ± 7.7 14 (25.5%) 5 (9.1%)
[14] surgery Male days
25
(45.4%)

and 817 patients after surgery. A reduction in the frequency 0.66–1.17). They reported an annual reduction of 33% in the
of falls was observed after surgery (RR 0.68, 95% CI rate of falls after adjusting for age, sex, physical activity, and
0.48–0.96), although heterogeneity was significant (I2 = 74%) medication use (p � 0.001).
(Figure2).
Because the authors of the study (Palagy et al.) [18] did 3.6. Frequency of Falls before vs. after the Second Cataract
not report specific data on the incidence of falls, we could not Surgery. Three studies assessed falls after cataract surgery in
integrate the results in the meta-analysis. However, the the second eye [14, 15, 20]. It should be noted that in two of
results have a similar trend. This study recruited 329 patients these studies, analysis of the incidence of falls was performed
and followed a total of 228 for 12 months after cataract after the first and second surgeries. However, Feng et al. [14]
surgery. Before surgery, the observed rate of falls was 1.17 managed to follow-up all 55 patients in both periods, while
falls per year-person (95% CI 0.93–1.46). After surgery, the To et al. [20] only evaluated 193, out of a total of 413, who
rate dropped to 0.88 falls per year-person (95% CI had initially been recruited.
Journal of Ophthalmology 5

Post-surgery Pre-surgery Risk ratio Risk ratio

Study or subgroup Events Total Events Total Weight M-H, random, 95% Cl Year M-H, random, 95% Cl
Brannan et al, 2003 6 84 31 84 10.4% 0.19 (0.09, 0.44) 2003
Harwood et al, 2005 76 154 79 154 23.5% 0.96 (0.77, 1.20) 2005
Mc Gwin et al, 2006 42 122 46 122 20.9% 0.91 (0.65, 1.28) 2006
To et al, 2014 13 119 53 312 15.2% 0.64 (0.36, 1.14) 2014
Supuk et al, 2016 56 283 66 287 21.3% 0.86 (0.63, 1.18) 2016
Feng et al, 2018 5 55 14 55 8.7% 0.36 (0.14, 0.92) 2018

Total (95% Cl) 817 1014 100.0% 0.68 (0.48, 0.96)

Total events 198 289
Heterogeneity: tau2 = 0.12; chi2 = 19.08, df = 5 (P = 0.002); I2 = 74%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.22 (P = 0.03) After surgery before surgery

Figure 2: Meta-analysis of the frequency of falls after the first cataract surgery in older people.

The meta-analysis included these three studies, pooling merely comparing the frequency of falls between groups
368 patients before surgery and 487 patients after surgery might not be the best way to measure the effect of expediting
(Table 2). No statistically significant difference was observed surgery because the incidence of falls is time-dependent in
in the risk for falling (RR 0.66, 95% CI 0.37–1.20), but nature. The rate of falls per 1000 patient-days might be a
heterogeneity was detected (I2 � 66%) (Figure 3). more appropriate measurement of the effect.
The study by McGwin et al. [17] showed no difference
4. Discussion between surgery and no surgery in the frequency of falls.
However, the results of this study must be taken with caution
With the results of this systematic review and meta-analysis because the two groups might have had significant baseline
aimed to assess whether cataract surgery is effective in re- differences that were not accounted by the authors. Al-
ducing the rate of falls in older people, for the first time, it though it is stated that all patients in the study could walk
can be established that cataract surgery reduces the inci- independently and had no dementia, no further description
dence of falls in older patients with bilateral cataracts, by of their health status is provided. Patients who declined
approximately a third. However, when considering the surgery may have done so for a number of reasons, including
second cataract surgery, no significant difference in fall rates a worse self-perception of health status or worse socio-
was found. economic conditions.
Falls in older people are usually multifactorial in The possible beneficial effect of cataract surgery on re-
origin. It is not surprising that interventions that have ducing falls would have to be (in part) secondary to the
proven to be effective in reducing falls in older people are improvement in visual acuity. Although it was not the
also multicomponent (i.e., comprised of several combined present study’s aim, we considered the change in visual
interventions aimed at multiple risk factors). Vision, acuity after surgery. Supplementary Table 4 shows that
however, is usually regarded as one of the most critical contrasting visual acuity among the included studies is
factors regarding falls. Age-associated visual impairment challenging since each study used a different measurement
in stereopsis and contrast perception may compromise methodology, and only a subsample of each study was
older persons' ability to avoid obstacles successfully. As evaluated. However, overall, there was a significant clinical
such, it is reasonable to assume that the correction of improvement.
visual impairment derived from cataracts might reduce Although quasi-experimental studies provide weaker
the risk of falling. evidence than randomised controlled trials, our meta-
We found that the first cataract surgery reduces the analysis still makes a strong case for a reduction of the
frequency of falls by 34%, while surgery in the second eye frequency of falls after the first cataract surgery. Addi-
had no significant impact on falls according to our findings, tionally, our results make evident that cataract surgery is
which could explain why Foss et al. [15] did not find dif- becoming increasingly accessible since the studies included
ferences in the risk of falling after surgery since they in- in our analysis were performed in both developed
cluded women following one successful cataract surgery. The [12, 14–19] and developing [20] countries, highlighting the
available evidence does not support that the correction of relevance of cataract surgery from a public health per-
cataracts in the second eye adds any benefit reducing the risk spective, which can become an effective measure to avoid
of falls, although one could argue that stereopsis does require falls and their complications in appropriately selected pa-
input from both eyes. tients. A study by Tseng et al. [22] in Medicare beneficiaries
It is also noticeable that both Harwood’s and Foss’s trials aged 65 years and older with a diagnosis of cataracts showed
showed a significant reduction in the rate of falls per 1000 that cataract surgery was associated with lower odds of hip
patient-days in the expedite surgery group compared to the fracture within one year after surgery compared to patients
control group. This is relevant because, in both studies, the who did not have surgery. We did not assess hip fracture as
control group were patients who also underwent surgery but an outcome in our study because, although it is one of the
waited longer for it. Waiting times varied widely in the most severe consequences of falls in older people, it is not the
control group, from 133 to 485 days. Given this variation, only one.
6 Journal of Ophthalmology

Table 2: Characteristics of included studies of the relationship the frequency of falls after the second cataract surgery in the older people.
Follow-up Falls before Falls after
Author Design Patients Age Sex
time surgery surgery
Female
Foss et al., Controlled clinical trial: Range:
N � 120 120 12 months 57 (47.5%) 48 (40.0%)
[15] expedited surgery 70–90 y
(100%)
Female
268
To et al., N � 413 (pre-surgery) (64.9%)
Before and after surgery 66.6 ± 7.9 12 months 53 (12.8%) 13 (6.7%)
[20] N � 193 (post-surgery) Male
145
(35.1%)
Female
30
Feng et al., (54.6%) 283 ± 52.2
Before and after surgery N � 55 73.3 ± 7.7 14 (25.5%) 5 (9.1%)
[14] Male days
25
(45.4%)

After surgery Pre-surgery Risk ratio Risk ratio

Study or subgroup Events Total Events Total Weight M-H, random, 95% Cl Year M-H, random, 95% Cl
Foss et al, 2006 48 120 57 120 47.4% 0.84 (0.63, 1.12) 2006
To et al, 2014 13 193 53 312 35.4% 0.40 (0.22, 0.71) 2014
Feng et al, 2018 5 55 5 55 17.2% 1.00 (0.31, 3.26) 2018

Total (95% Cl) 368 487 100.0% 0.66 (0.37, 1.20)

Total events 66 115
Heterogeneity: tau = 0.17; chi = 5.94, df = 2 (P = 0.05); I2 = 66%
2 2
0.01 0.1 1 10 100
Test for overall effect: Z = 1.35 (P = 0.18) After surgery before surgery

Figure 3: Meta-analysis of the frequency of falls after the second cataract surgery in older people.

We did not assess the cost-effectiveness of cataract Conflicts of Interest

surgery; however, it is crucial to include the costs derived
from falling when evaluating cataract surgery’s cost-effec- The authors declare that they have no conflicts of interest.
tiveness among older people. Still, our findings suggest that
there may be potentially significant savings in costs derived Acknowledgments
from falling that might be attained by cataract surgery. An
in-depth analysis of this matter is warranted. This project was supported by a grant from the Secretarı́a de
Although this meta-analysis provides evidence that the Educación, Ciencia, Tecnologı́a e Innovación de la Ciudad
first cataract surgery reduces the frequency of falls in older de México CM-SECTEI/041/2020 “Red colaborativa de
people, we recognise that it has limitations. The overall Investigación Traslacional para el Envejecimiento Saludable
quality of the studies was deficient due to methodological de la Ciudad de México (RECITES)”.
issues. One issue is how to evaluate falls, where there may be
recall bias since, in most studies, what happened the year Supplementary Materials
before is questioned; while after surgery, the evaluation is
Supplementary Table 1: quality analysis of quasi-experi-
prospective. The second is that among the studies, the
mental studies: risk of bias∗ . Supplementary Table 2: quality
number of patients is highly variable, as well as their follow-
analysis of controlled clinical trials: risk of bias∗∗ . Supple-
up. Finally, there are very few studies on the impact of
mentary Table 3: studies comparing the frequency of falls
second cataract surgery.
between those who perform and do not perform cataract
Further studies are needed that assess not only the ef-
surgery in older people. Supplementary Table 4: visual acuity
ficacy of cataract surgery but also its cost-effectiveness as a
evaluation before and after cataract surgery. (Supplementary
potential intervention for reducing the risk of falls and their
Materials)
complications, such as hip fracture, in older people.
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