Cataracts, Cognition and Care at ESCRS 2025

How to navigate vision and cognition in patients where cataracts and dementia intersect.

A unique symposium on Day 3 of the 43rd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2025) brought together neurologists, geriatricians, cognitive psychologists and ophthalmologists to tackle a tricky duo: dementia and cataract surgery.

While visual impairment can amplify the challenges of dementia, dementia can complicate even the simplest ophthalmic interventions. In short, when the brain or the eyes decide to misbehave, nothing about patient care stays straightforward, making this cross-disciplinary conversation both fascinating and essential for eye care professionals navigating the increasingly complex needs of an aging population.

Blurry minds, blurry vision

Neurologist Prof. Giorgio Fumagalli (Italy) kicked off the symposium by untangling the knotted subject of dementia. Spoiler: it’s not a single disease, but rather a syndrome that wears many disguises.

“There is a presentation in which patients have problems with language, called logopenic aphasia, or behavior, which we call behavioral dysexecutive Alzheimer’s disease,” explained Prof. Fumagalli. “More relevant for you is the visual variant of Alzheimer’s disease, which is called posterior cortical atrophy.”

In other words, dementia doesn’t just meddle with memory. It can hijack vision too, sometimes masquerading as an ophthalmic problem. Enter Dr. Renate Claassen (United Kingdom), consultant geriatrician, who highlighted just how often the two conditions team up.

“[About 32%] of people living with dementia have visual impairment, and of people living with dementia in care homes, up to 50% have visual impairment,” she said, adding that cataract was behind nearly half of the impairment, despite corrective glasses being in the mix.¹

The key takeaway? Visual impairment is no longer viewed as just another symptom floating around dementia’s orbit. It’s now officially considered a potentially modifiable risk factor. As Dr. Claassen reminded the audience, the 2024 Lancet report gave vision its due recognition by naming it an individual factor worth addressing in dementia prevention strategies.²

Vision without recognition

Not all visual complaints can be fixed with new glasses or a sharper refraction. Sometimes the issue lies in the brain’s backstage crew, where perception and recognition quietly go off-script.

Assoc. Prof. Silvia Primativo (Italy), a cognitive psychologist, unpacked posterior cortical atrophy (PCA), a progressive neurodegenerative syndrome that meddles with visual perception and visual-spatial attention.

“PCA patients have a reduction in the gray matter volume in the posterior parietal, occipital and temporal cortical regions,” she explained. “The most common cause of PCA is typical Alzheimer’s disease, and the onset is quite young, usually between 50 and 65 years old.”

Here’s the twist: these patients can see just fine on standard acuity tests, but their visual processing circuits misfire. “If they look at an apple, they might struggle to say this is an apple,” Prof. Primativo said. “If they try and taste it, they have no problem in saying okay, this is an apple.”

Prof. Primativo stressed that such cases are frequently missed or mistaken for common ophthalmological conditions—a mix-up that can cause frustrating delays in diagnosis.

Hunting for dementia biomarkers

The eye may be the window to the brain, but researchers are still debating whether it’s a clear pane of glass or a slightly smudged one when it comes to dementia biomarkers.

Dr. Jurre den Haan (The Netherlands), a neurology resident and postdoctoral researcher, explored the promise (and pitfalls) of retinal biomarkers in Alzheimer’s disease. He explained how optical coherence tomography (OCT) can measure retinal layer thickness with micrometer precision, potentially shining a light on neurodegeneration.

“The hypothesis is that you see ganglion cell retinal nerve fiber loss in Alzheimer’s disease as a reflection of neurodegeneration,” he said. But as his data revealed, the reality isn’t quite that straightforward.

“I would say if you form an early diagnosis regardless of age of onset, I think the retina has not yet changed,” Dr. den Haan concluded.

Instead, he suggested the research spotlight should shift toward proteins. “One of my colleagues studied this in Alzheimer’s disease, FTD [frontotemporal dementia] and DLB [dementia with Lewy bodies], and you can see tau, alpha-synuclein and TDP [transactive response DNA-binding protein] in the retina,” he reported.

Managing eyes in dementia

When dementia enters the exam room, the clinical playbook needs a few extra chapters, especially when it comes to balancing autonomy, reassurance and realistic expectations.

Dr. Cathleen McCabe (United States) tackled these practical considerations for ophthalmologists treating patients with dementia. She emphasized the importance of gauging a patient’s ability to participate in decision-making and identifying whether a health care power of attorney is already in place.

“I like to reassure these patients who are very anxious. They don’t want to be challenged on how good their vision is. And so I like to reassure them that they are the boss of their eyeballs,” Dr. McCabe shared. “Nobody’s going to take away their independence and force them to have surgery, but you want to be able to lead them towards surgery if that’s in their best interest.”

She advised simplifying information according to the degree of cognitive impairment and framing conversations around improvements in vision and function rather than technical surgical detail. Just as importantly, she reminded the audience that caregivers must be part of the process.

“Educating the family with regard to the impact of progression of dementia is really key,” she noted. “If they have advanced cognitive impairment, they may not be able to communicate that loss of function at all. It may be even more important to rely on caregivers and family.”

Straightforward lenses for complicated minds

When it comes to IOL choice in patients with dementia, the safest bet may be keeping things simple, because the brain isn’t always up for fancy optical tricks.

Prof. Paul Ursell (United Kingdom) raised the hot question of whether simultaneous vision IOLs (multifocal lenses) should even be considered for these patients.

“Falls are a big issue,” Prof. Ursell emphasized. “Falls are bad because you’ve got dementia. Fractured neck or femur, you often don’t get out of hospital. It’s a terminal event.”

The problem, he explained, lies in neuroadaptation. Multifocal lenses demand that the brain learn new visual processing skills, and that takes cognitive horsepower. “If you put a multifocal into a patient, the brain is needed. We call it neuroadaptation,” he said. “Now if your brain is failing, that ain’t going to happen.”

His advice? Keep it practical. “We aim for plano in most of our patients,” Prof. Ursell recommended. “My parameter is if you’re not driving, you don’t need your distance vision. You can put some glasses on…You now need near vision. You need to be able to eat. You need to be able to see what’s going on.”

A few handy rules of thumb

The speakers laid out several practical pearls for ophthalmologists:

Early intervention. Prof. Ursell urged colleagues not to wait too long. “Fix the roof while the sun’s shining,” he quipped, pointing out that patients with cognitive decline are unlikely to return for follow-ups if things worsen.
Anesthesia considerations. Although general anesthesia often raises concerns about postoperative cognitive dysfunction (POCD), Prof. Ursell reassured the audience: “the incidence of POCD is the same for local anesthetic as general anesthetic” in cataract surgery.
Postoperative care. Simplicity wins, according to Dr. McCabe, who recommended streamlined regimens—or better yet, dropless approaches. “A standard drop regimen that’s complicated with three different drops and a tapering schedule might be difficult for these patients to follow,” she noted.
Multidisciplinary approach. The consensus was clear: collaboration with neurologists, geriatricians and caregivers is essential to successful outcomes.

Beyond these practical points, the symposium spotlighted an intriguing trend: cataract surgery may deliver benefits beyond sharper sight. Multiple studies suggest it could lower dementia risk. Prof. Ursell cited one University of Washington study where 3,038 out of 5,546 participants underwent cataract surgery, and those who did saw a lower risk of developing dementia.³

By the end of the session, the audience understood just how entangled vision and cognition really are. Spotting and managing dementia isn’t just about the eyes, it’s about the whole patient.

“Your work can have an impact not only on vision, but also on cognitive and behavioral symptoms,” Prof. Fumagalli concluded. “Improving vision can significantly enhance the quality of life in dementia patients and of caregiver life by improving mobility, reducing falls and potentially mitigating cognitive decline from sensory deprivation.”

As our population ages, the crossroads of ophthalmology and neurology will only become more important, calling for thoughtful, patient-centered care that looks beyond the eye chart.

Editor’s Note: The 43rd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2025) is being held from 12-16 September in Copenhagen, Denmark. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

References

Zhang W, Roberts TV, Poulos CJ, Stanaway FF. Prevalence of visual impairment in older people living with dementia and its impact: a scoping review. BMC Geriatr. 2023;23(1):63.
Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024;404(10452):572-628.
Lee CS, Gibbons LE, Lee AY, et al. Association Between Cataract Extraction and Development of Dementia. JAMA Intern Med. 2022;182(2):134-141.