Question:
My brother is 57 years old and other than Alzheimer’s, is in good health. He is going to need cataract surgery, but we are also concerned about his strabismus and how that will contribute to confusion and potentially hallucinations as his Alzheimer’s progresses. I’m concerned about anesthesia if he has surgery to correct the strabismus. We have an appointment with a specialist on Friday. What would be some good questions for me to ask or things to consider as we decide whether or not to have this surgery.
Answer:
Cataracts are clouding of the lens of the eye. The lens is usually clear, and when it becomes clouded, vision is impaired. Cataracts are treated with surgery to remove the clouded lens. Strabismus is the condition in which the eyes do not align (“eye crossing”). Surgery is one option to correct strabismus. Deciding on surgery for an older person with Down syndrome (DS) is often not an easy decision. The benefits and risks have to be weighed carefully.
Potential Benefits
In your brother’s case, improved vision is a potential benefit. The loss of vision can be very challenging for any of us. We find that it affects people with DS even more because they have fewer cognitive and other skills to compensate for the loss of vision. The first questions to consider are “How much are the cataract and strabismus affecting his vision? If there is a correction, how much vision will be restored”? The website for the American Academy of Pediatric Ophthalmology and Strabismus gives some good information that may help you think about the potential vision benefit of the strabismus surgery. Depending on the density of the cataract, the vision improvement can be substantial. We have a general article on vision that can be found at this link.
For a person with DS, improved vision can be a VERY significant benefit. For a person with DS and Alzheimer’s disease (AD), we have also seen benefit from improving vision. However, for a person with DS and AD, we factor in how rapidly the person’s cognitive skills are declining due to AD. If the person has vision improvement, will their cognitive level allow them to benefit from the improved vision? On the other hand, we have seen apparent cognitive improvement in some individuals with AD after cataract surgery. The impaired vision was limiting the use of the cognitive skills they still had. The answer to these questions is usually not definite going into the surgery.
Potential Risks
Anesthesia is always a potential risk during surgery. The article from the Adult Down Syndrome Center linked here and the article from the National Down Syndrome Society linked here describe some of the potential issues associated with anesthesia. In a person with DS who has developed AD, some of the risks are even greater. People with AD tend to have more swallowing issues and tend to have more behavioral and psychological issues that can complicate anesthesia and recovery from anesthesia. In addition, we have seen some individuals with DS and AD who seemed to develop a sudden further loss of cognitive skills that was noted some time after they awoke from anesthesia. For some, over time this resolved back to their pre-anesthesia level of cognition but for others there seemed to be a permanent loss of that cognitive function. They had a new (lower) level of cognition from which they continued to have gradual cognitive loss from AD.
Making a Decision
As I noted above, these are not easy decisions to make. I encourage individuals with Down syndrome and their families to weigh the potential benefits and risks and discuss them with their healthcare provider to help them reach a decision that is right for them.
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