Cataract post-op Care Brian Wright, MD - PowerPoint Presentation

1. Cataract post-op CareBrian Wright, MDMann Eye Institute

2. POD1 uncomplicated surgeryCheck VaCheck IOPSee following flow chartSLEAssess for cell / flareIf hypopyon or > 3+ cell contact surgeonAssess wound for any leakageIf seidel + contact surgeonAssess IOL positionIf any signs of malposition contact surgeonAssess cornea for excess swelling or microcystic edemaCould be indicative of TASS or high IOPIf patient has marked swelling only, consider adding 5% NaCl drop or ointmentIf there is blood in the AC, see if patient had MIGS procedure as this is likely causeIf any nuclear fragments in the AC send the patient for next available appointment with the surgeon so it can be determined if surgery is required to remove

3. SymptomsHeadacheMicrocystic edemaNausea / vomiting

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5. Additional concerns with complicated surgerySame concerns as previously statedIrregular peaked pupilConcern for iris to the woundIf there is iris tissue outside the wound this is essentially an open globe and needs immediate notification to the surgeonPeaked pupil can be due to vitreous to the woundIf vitreous is outside the wound this is an emergent referral back to the surgeon as the patient is at high risk for endopthalmitisIf vitreous is inside the wound only and not on the surface then contact the surgeon to see patient next available for possible intraocular sweep or YAG vitreolysisShallow AC , corneal striae with flourosceneLikelihood of wound leak (low IOP) so double check seidelFlat ACPossible wound gape or malignant glaucoma, urgent referral to surgeon

6. EndophthalmitisRare complication following cataract surgery occurs in approximately 0.02-0.50 percent of cataract patients as a result of direct microbial invasion of the anterior chamber at the time of surgery or shortly after if patient has a wound leakIn those microorganisms which are extremely virulent, clinical signs and symptoms generally occur within 72 hours. The patient presents with severe pain, loss of vision, lid and corneal edema, and conjunctival injection. A severe anterior chamber reaction may occur, possibly with hypopyon formation, and the pupillary area may be bridged by a fibrinous membrane as well as cells and protein in the vitreousAlthough the onset of endophthalmitis generally occurs within the first week following surgery, it may occur as early as 1 day or as late as many months after surgeryIf any suspicion of endophthalmitis immediate referral back to surgeon or retina colleague

7. POW1Check VaCheck IOPIf new increase likely steroid responseSLEAssess for cell / flareShould be decreasing from POD1If unchanged or increased consider upping steroid frequencyEndophthalmitis typically happens a few days after surgery so be wary of increased pain, decreased vision, or increasing inflammationAssess IOL positionIf any signs of malposition contact surgeonCheck MRxIf large refractive miss inform surgeon for possible adjustment on second eye

8. POM1Check VaCheck IOPSLEAssess for cell / flareShould be resolvedIf still present then possible rebound and restart taper Assess IOL positionIf any signs of malposition contact surgeonCheck MRxIf expectation is for better vision by patient due to AMP or ERP then have patient seen by surgeon without promising any possible procedure as surgeon will determine next stepIf standard case then Rx glassesIf BCVa has 20/20 potential but patient cannot achieve despite MRx, then consider OCT macula to look for CME & assess surface for dryness/ irregularities as common cause of decreased BCVa

9. Various other concernsVarious studies have shown approximately a 1.0 percent risk for retinal detachment following planned extracapsular or phacoemulsification cataract surgery. The incidence increases with intraoperative capsular bag rupture or vitreous prolapse and loss. Any iatrogenic retinal detachment usually occurs within 6 months of surgery. Ptosis is commonly observed within a few weeks of surgery. In the early postoperative period (1-14 days), the patient should be reassured that most cases of early postoperative ptosis resolve in days to months. Occasionally, the ptosis does not improve and surgical correction may be needed. Choroidal detachment is more common in high hyperopes or low IOP from prolonged surgery or wound leak. It can present with decreased visual acuity or mild discomfort, and the IOP is usually below 8 mm Hg. The characteristic clinical signs are smooth elevations of the peripheral choroid and retina.

10. UGH syndrome (uveitis-glaucoma-hyphem)Ocular hypertension or glaucoma induced by irritation from the IOL if the optic or haptic of an IOL is in contact with vascularized tissueThis occurs more commonly with iris-fixated and anterior chamber IOLs; however, it can also occur with posterior chamber IOLs that are fixated in the ciliary sulcus, especially a one-piece IOL in the sulcusIn this condition, hyphema and anterior chamber inflammation result in IOP elevation from obstruction of the trabecular meshwork with inflammatory and hemorrhagic debris. The iris should be carefully inspected for signs of transillumination defects.Send to surgeon as IOL may need to repositioned or exchanged

11. Questions?When in doubt contact the surgeon and ask