What to Look For in Co-Managing Cataract Patients
By: Paul M. Karpecki, OD, FAAO
Clinical Director – PECAA
The typical visits following cataract surgery are day 1, week 1, month 1 and month 3 following the surgery. Of course it’s important to do a thorough examination VA, pressures and examining the ocular surface, incision site, cornea, anterior chamber, intraocular lens (IOL) position and macula/retina at the appropriate visits and sometimes all visits, there are certain complications that are more likely to occur at each visit.
Day 1 post-op: IOP elevation or drop
Provided the patient does not have a diagnosis of glaucoma, a slightly elevated pressure is not a great concern. In fact some surgeons argue that slightly elevated pressures may even be a benefit to sealing the incisions. The primary cause is from the viscoelastic that is used during cataract surgery to maintain a formed anterior chamber. This thick material can clog the trabecular meshwork resulting in a temporary elevated pressure.
Low pressures (i.e. under 4mmHg) are a much greater concern for a leaking incision and the risk of choroidal effusion. A pressure above 30mmHg should generally be treated simply because a spike to a highly elevated pressure can lead to complications that may include retinal vascular occlusion, delayed healing and patient discomfort/nausea.
The best medications are likely topical beta blockers (provided there are no contraindications like breathing problems) and alpha-adrenergic drops like Iodine or bromonidine/alphagan. One might even consider a combination agent like Combigan. Highly elevated pressures (>40) may warrant a partial paracentesis to remove aqueous and/or oral medications like Diamox. Avoid prostaglandin analogues because of their slower onset of action and topical carbonic anhydrase inhibitors because of the potential to slow endothelial pump function.
Week 1 post-op: Endophthalmitis
Although extremely rare most cases of endophthalmitis are diagnosed around the first week after the surgery. It is postulated that the reason includes the time it takes to colonize bacteria in the eye (mainly in the vitreous), the better medications we have today and the type of bacteria often implicated etc. Either way if the patient’s pain is increasing, vision is dropping or the anterior chamber appears to have more cell and flare or a hypopyon, notifying the surgeon and the likely referral to a retina specialist is required.
Month 1 post-op:
CME Cystoid macular edema is more likely to occur around the one month post-op time fame. So if a patients VA is decreasing or not improving as expected, a close examination of the macular is required. It’s for this reason we typically dilate patients at the 1-month post-operative visit if vision is not correctable to 20/20 without a potential reason identified. An OCT is the definitive test. Patients with diabetes and a history of uveitis are more prone to this occurrence. Treatment in mild cases may involve increasing the steroid dosage and NSAID and even adding oral NSAIDS. more severe cases of CME or a significant drop in vision may warrant seeing the surgeon or retina specialist for a potential anti-VEGF injection.
Month 3 post-op:
PCO Posterior capsular opacification (PCO) is the more common finding at the 3 month post- operative period. Therefore a dilated examination is typically required at this visit and a thorough examination of the retina to ensure that there are no holes or tears should the patient have to proceed with a YAG capsulotomy procedure. Keep in mind that the exception to waiting 3 months is if noticeable PCO is noted sooner (e.g. younger patient with a posterior sub-capsular cataract or PSC), or someone who has had a premium IOL such as an accommodating lens (Crystalens) or multifocal IOL (Restore or Tennis MF). In the case of the premium IOL’s the capsule may be preventing the accommodating lens from it’s full movement and patients are not able to read even at intermediate distance. In the case of multifocal IOL’s it could be causing a contrast loss affecting vision which could make the contrast loss of the multifocal lens more exaggerated.
These are some nice guidelines to the successful co-management of your cataract surgery patients.
