Restoring sight: how cataract surgery improves
the lives of older adults

Sarah
Polack

(25.09.2013)

(http://www.cehjournal.org/article/restoring-sight-how-cataract-surgery-improves-the-lives-of-older-adults/)

           
               
               
        (www.karmayog.org)

Research Fellow, International Centre for Eye
Health, London School of Hygiene and Tropical Medicine, Keppel Street, London
WC1 7HT, UK. Email: sarah.polack@Lshtm.ac.uk

Related
content

The fundamental aim of most
ophthalmic interventions in later life is to improve the quality of patients’
lives, whether through sight-restoring cataract surgery or the provision of
visual aids. Amidst the pressures of targets, outputs, and backlogs, this may
be all too easily forgotten. It is therefore important to step back and
remember just how important good vision is in the lives of older adults.

Vision loss has a major negative
impact on the quality of older people’s lives. Sight remains as valued and
important in later life as at any other age and its loss is one of the things
older people fear most. Improving access to eye care services for this age
group, as well as older people’s uptake of such services, is therefore very
important.

This article takes a closer look at
some of the ways in which vision loss and blindness can affect the lives of
older adults; it also highlights the positive impact sight-restoring cataract
surgery has on older people’s lives.

Cataract
surgery has restored this man’s vision. PAKISTAN. © Jamshyd Masud/Sightsavers

The
impact of vision loss

It is usual to describe vision loss
in clinical terms (such as visual acuity, for example) or in epidemiological
terms (such as the prevalence of severe visual impairment or blindness in a
population). But what does low vision or blindness really mean for an older
person?

In order to find out, in-depth
interviews were conducted in Kenya and Bangladesh with adults over the age of
50 who had recently undergone cataract surgery. This formed part of a wider
study by the International Centre for Eye Health on the impact of cataract
surgery on quality of life and poverty. Some of the findings are presented in
this article.

These findings support previous
research using patient-reported outcome measures (PROMs) in both high- and
low-income settings.^1,2
PROMs are questionnaires which aim to discover the impact of health conditions
or treatment as perceived by the patient, rather than from clinical measures
alone.

Difficulties
with daily activities

Our research showed, unsurprisingly,
that older adults with visual impairment had greater difficulties with their
daily activities than those without impairment. These difficulties varied
considerably according to older adults’ lifestyle, environment, and social
support, as well as the severity of their vision loss.

“Before the operation I felt as if I
was put into a jail that I couldn’t escape. Many times I would take tea and
burn myself as I couldn’t see the handle. It was horrible.” (Kenya)

“[Before surgery] I never used to go
to meetings, bazaars, and weddings. I could not light fire for myself and I
never used to know the difference between crops and weeds. I couldn’t even
bathe myself. I could not differentiate money given to me and used to be given
less change often because I couldn’t see.” (Kenya)

Reduced
earning capacity

Older people with visual impairment
are less able to earn a living or contribute to the household. These
restrictions have obvious economic implications. Amongst the people we
interviewed in Bangladesh, a 70-year-old man told us that because of his poor
eyesight (from cataract) he was rejected as a day labourer and lost his job as
an imam. A 58-year-old woman from the same district reported that she used to
make handicrafts to sell, but because of her eyesight “they were no longer of
good quality.”

Limited
participation and social isolation

Older people with visual impairment
are less likely to engage in social and family life. Participation in activities,
relating to both work and leisure, is well established as an important factor
in the wellbeing and happiness of older adults.³ Restrictions
on participation not only have economic implications, but they can also impact
on many social and psychological aspects of a person’s life. Reduced
opportunities for interaction and involvement with social networks, for
example, could lead to feelings of isolation and lack of social support.

“Before [surgery] my friends didn’t
often come to visit; they were not interested because they knew I couldn’t
see.” (Kenya)

“I was gradually transforming into a
neglected person by my family members.” (Bangladesh)

“…when I used to ask for help they
used to get annoyed and tell me to do it on my own. I used to sit helpless in
the corner because I could not see.” (Bangladesh)

To further compound this impact,
there tends to be a disproportionately large number of older people among the
more neglected and marginalised members of society. It is likely that visual
impairment exaggerates this situation.

Anxiety
and depression

There is some indication of a
relationship between age-related vision loss and depression in later life.⁴ For example,
older adults in Kenya with visual impairment due to cataract were three times
more likely to report anxiety and depression compared to people of the same age
with normal vision.³

“I couldn’t do anything. Even if I
wanted to go to the road, someone had to hold my hand and take me. I didn’t
appreciate anything and felt really sad.” (Kenya)

In addition, research shows that
restricted capacity to contribute to the household or community can lead to
feelings of loss of independence, feelings of being a burden on others, and
reduced social status and self-esteem.⁶

“I was finished without my sight as
I was the breadwinner and I was not able to give my family anything. I felt
embarrassed about my eyes.” (Kenya)

The
impact on others

The significant contribution of
older people to the wellbeing of others and to wider society is well
documented, but it is under valued and all too often forgotten.

In low-income countries there is
evidence that, in poor households, all members – regardless of age – contribute
to the basic needs of the household.⁸ Taking care of
children is just one example of how older people contribute: the benefits of
this are likely to be multiple and include enabling a parent to continue in
paid employment. In countries heavily affected by HIV and AIDS, older people
often have to care both for their sick children and for their grandchildren.

When older adults become visually
impaired or blind, their ability to contribute economically, and to social and
family life, is greatly reduced (as some of the above quotes show); this loss
can be felt quite keenly by other members of the household.

The
positive impact of eye surgery

There is a misconception (seemingly
also present among older people themselves) that sight is less important in
older age. Some also believe that vision loss and its restrictive impact should
be expected – and accepted – as part of the ageing process. This is clearly not
the case. Research has shown that cataract surgery has a far-reaching impact on
the quality of older people’s lives.

Studies in various countries using
PROMs have shown a marked improvement in the physical functioning and
psychological well-being of older people.⁹ It has also
been shown that cataract surgery continues to be beneficial even amongst the
very old.¹⁰In our study in
Kenya and Bangladesh, the very old or those suffering from other health
problems or diseases expressed that their improved vision was of huge value.

“I had not seen two of my children,
who were born when I was blind. I couldn’t read reports of my children from
teachers at school. I could not raise money to educate my children. After
surgery I felt like a small child born again. I really celebrated; so did my
family. The first thing I wanted to see was my two grandchildren. It was
amazing! They were young and very beautiful.” (Kenya)

The following are some of the other
benefits that older people in our study experienced after receiving
sight-restoring cataract surgery.

Greater
social inclusion and participation

Patients reported an increase in
their participation in social activities.

“After surgery I was very happy because
I could visit my friends and attend village meetings, bazaars, and functions
like weddings.” (Bangladesh)

“I feel happy because even though
I’m old, at least I can see people.” (Kenya)

This renewed capacity to participate
in social events was considered a major beneft; it was also linked to feelings
of happiness and confidence.

“Now I have a very good relationship
with my family members and others. Before the operation I used to feel shy to
socialise. Now I do not feel that.” (Bangladesh)

Engagement
in productive activities

Following cataract surgery, many
interviewees were able to once again engage in productive activities, be that
driving a taxi, working on their farmland, or contributing to the upkeep of the
household.

“After surgery I completely got back
my eyesight, but because of my old age I cannot do heavy work. But I can help
with the household chores so my family can concentrate on earning money.”
(Bangladesh)

“I was able to do my business again
making locks and knives to sell. This helped me to get money for my family.”
(Kenya)

Increased
self-esteem

In addition to, and perhaps as a
result of, increased participation in social and work activities, a new level
of independence was commonly reported by older people after surgery. Associated
with this was a feeling of increased self-esteem and respect from others.

“Earlier [before surgery] I used to
feel helpless, but I am not feeling like that anymore. I am confident now. I
can earn my living by housekeeping.” (Bangladesh)

“I do not need to depend on anyone.
I can do my own work. Besides, people used to neglect me earlier, but now they
respect me very much.” (Bangladesh)

Improved
communication and relationships

Other, perhaps less obvious,
benefits from cataract surgery included improved communication with others,
stronger social relationships, and being more trusting of others:

“Now when I meet someone in the
community, I can say hello and genuinely feel I have communicated and I can
tell whether people are truly saying hello with a good heart. Before [surgery]
I didn’t want to talk to people because I didn’t know whether to trust if they
were being true. It’s easier to talk to people now.” (Kenya)

“My family is more harmonised and
able to work together better. We can discuss issues better now as I can see
them [his family] clearly.” (Kenya)

Wider
impact of surgery on other members of the community

It should also be remembered that
the benefits of sight-restoring cataract surgery extend beyond the individual
to the wider household; surgery has positive social and financial consequences.
Restoring one person’s sight may free up time and alleviate the anxiety of
others, for example those who previously needed to remain at home to look after
or assist an older blind relative.

“We used to worry when we used to
leave him alone at home. Now it is not happening. We can go to the workplace
without worrying. Besides, he needed help with eating, travelling, sleeping,
bathing … now it is not necessary. So we are very happy.” (Bangladesh)

“The family is happy because we are
able to attend other duties now that she is independent. We are able to go
about our duties without worry or hurrying back to the house to attend to her.”
(Kenya)

Conclusion

In the absence of appropriate
intervention (whether spectacles, surgery, low vision care, or rehabilitation),
visual impairment has a substantial negative impact on many factors that
contribute to the quality of life of older adults. These range from perhaps the
more obvious effects of a reduced capacity to undertake day-to-day activities,
through to a more subtle influence over psychological wellbeing.

The significant physical and
psychological benefits of cataract surgery, in terms of the quality of a
person’s life, should serve as a powerful reminder of the value of ophthalmic
interventions for the older adult.

References

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