Cataract surgery is one of the most successful surgeries performed in the United States. By 2020, it is estimated the number of people having cataract surgery will double, and by 2030 it will triple.1 The optometrist’s role in comanaging these patients will be of critical importance. Developing and maintaining your post-operative clinical care skills is imperative.
After surgery, most surgeons like to see the patient either same day or next day postop before returning the patient to your care for the remaining postoperative period. Patients seen at one day postop may have the following signs and symptoms:
• Reduced visual acuity
• Residual dilation
• Subconjunctival hemorrhage
• Significant corneal edema
• Cells and flare in the anterior chamber
• Corneal keratitis and/or abrasion
• Elevated intraocular pressure (IOP)
Rarely, patients may experience a retinal detachment, a tilted or decentered intraocular lens (IOL), or retained cortical material.
The patient may have symptoms of:
• Reduced vision
• Foreign body sensation
• Flashes and floaters
• Loss of peripheral vision
• Light sensitivity
As an optometrist, you are trained to diagnose and comfortably manage these postoperative signs and symptoms in order to successfully comanage cataract patients. This is a win-win situation for the surgeon, the patient, and your practice.
Immediate postop care
Visual acuity at one day post-op can range anywhere from 20/20 to hand motion. Do not let a wide acuity range be a cause for alarm for the patient or yourself—the next-day postop patient may still be dilated. I tell my patients they can expect to be dilated for at least 24 to 48 hours after the surgery.
Also remember that no two eyes heal the same. If a patient is diabetic, you can expect more corneal edema. I often preoperatively tell my diabetic patients to expect longer healing times than nondiabetics. If the patient has corneal dystrophy such as guttata or Fuch’s, you can expect more corneal edema as well. Patients with corneal guttata or Fuch’s dystrophy require a long discussion about what guttata is and what to expect postoperatively, including the need for a possible corneal transplant. I stress this pre-operatively so there are no surprises if I am not able to reduce their postop corneal edema with topical treatment.
Don’t forget to look at the posterior capsule because haze may also show itself early. If it is present, immediately inform the patient about capsular haze. Explain why it occurs and the possible need for a Nd: YAG (YAG) laser procedure once she is out of her postop period. Most insurances will not cover a YAG capsulotomy until the patient is outside the 90-day postoperative period.
Postoperatively, subconjunctival hemorrhages are very frightening for a patient to observe. I assure my patients that this is normal and will resolve with time. Look in the patient’s chart to see if he is taking aspirin, vitamin E, Plavix (clopidogrel, Bristol-Myers Squibb), Coumadin (warfarin sodium, Bristol-Myers Squibb), or any other blood thinning medications because they may contribute to the cause of the hemorrhage. Patient reassurance is very important because patients will mostly likely have a friend or family member who had cataract surgery and did not have hemorrhages like these and raise cause for worry. If the patient has laser-assisted cataract surgery, subconjunctival hemorrhages are often a given due to the docking device.
The anterior chamber (AC) will have a varying degree of cells and possibly flare. I find flare ranges from trace cells to grade 3. Again, this is to be expected because the eye just underwent major surgery. We were all taught to make a small square beam in order to view the cells in the AC; however, I find that using a narrow slit-lamp beam gives a better view and more light to grade the degree of cells. Because the patient is generally placed on prednisolone and a nonsteroidal anti-inflammatory drug (NSAID) such as Ilevro (nepafenac ophthalmic suspension, Alcon) or Prolensa (bromfenac ophthalmic suspension, Bausch + Lomb), these cells should be dramatically less prevalent by the one-week postop visit.
It is not uncommon for some patients to develop postop iritis several weeks after surgery. Signs and symptoms include circumlimbal injection, photophobia, tearing and pain. Upon examination, you will notice an increase in the number of cells in the AC. Explain to the patient that he is experiencing rebound inflammation and increase the prednisone back to TID or QID for one week. See the patient back in one week—if symptoms are resolving, taper the prednisone slowly over several weeks to prevent recurrence. If symptoms are not resolving, you may need to continue the prednisone at its current rate and possibly add atropine BID.
Patients may also display corneal keratitis and/or a small epithelial abrasion. Do not be alarmed if you see significant corneal staining. When I see significant staining, I ask the patient if she is experiencing discomfort, and if so to rate it from zero to 10. If she is experiencing significant discomfort, do not hesitate to apply a bandage lens for a couple of days.
I usually use Acuvue Oasys (senofilcon A, Johnson & Johnson Vision Care) plano bandage lens 8.4 mm or 8.8 mm base curve. I explain to the patient that corneal dryness is a common side effect after surgery. I find I usually do not have to bandage keratitis that is a grade 2+ or less. However, coalesced keratitis or actual abrasions may necessitate a bandage lens. I have seen small epithelial abrasions that I thought needed bandaging and was amazed by what little discomfort these patients experienced. Do not hesitate to add preservative-free artificial tears and a mild ointment at night as well. Keratitis and epithelial abrasions will be more common in patients who have map-dot-fingerprint dystrophy, loose or soft epithelium, or a history of recurrent corneal erosions. Again, the best thing to do is to immediately review these things with the patient. A patient will be more at ease during the postoperative period if everything is explained in detail.
Ask the patient if he is experiencing floaters because these may also be observed during the slit-lamp exam. At one day postop, most patients are still dilated enough to take a peek at the retina to make sure the retina is intact. If the patient is experiencing floaters, reassure him that they are normal and educate him on the symptoms of a retinal detachment. Explain to the patient that most of the time these floaters will reduce in size and quantity and that there also may be the need for a psychological adaptation to floaters.
Rarely, you may see a postop patient with retained cortical material in the anterior chamber. Retained cortical material that is adhering to the corneal endothelium and causing edema will need to be removed. In an otherwise quiet eye, a small fragment can be monitored.
Many times patients will have an elevated IOP at their one day post-op visit. This can be alleviated by simply tapping the anterior chamber with a 27 gauge TB needle and releasing the pressure. This is done by pressing the needle flat against the conjunctiva just posterior to the secondary incision. You will be amazed by how easily some chambers tap and how others can be quite demanding. Once you get the hang of it, it is not hard to do. We will instill one drop of Alphagan P (brimonidine tartrate ophthalmic solution, Allergan) or timolol during the initial visit as well if the IOP is greater than 20 mm Hg. We do not usually tap the chamber unless it is close to 35 mm Hg or greater. However, if the patient has glaucoma, we may tap at much lower IOPs.
If you see the patient at one week and the IOP is high, start the patient on Alphagan P or brimonidine BID and see him back in one week. It is common for IOPs to be in the high 20s and 30s at the one-week visit if the patient is a steroid responder. Again, explain to him that the IOP is elevated due to the necessity of the steroid for the eye to heal properly and to decrease inflammation. Additionally, inform him that you can reduce IOP with another drop. Sometimes the patient frowns at another drop being added, but reassure him this does happen frequently and it is only a temporary situation. Prostaglandin inhibitors do not lower the IOP postoperatively as well as timolol, Alphagan or Combigan (brimonidine tartrate/timolol maleate ophthalmic solution, Allergan).
You may see a patient who comes in for the next-day or one week postoperative appointment who says she is doing fine, but upon examination you notice the IOL is tilted or decentered. For monofocal IOLs, a certain degree of tilt and/or decentration is often clinically unnoticed. If the IOL is so tilted that part is anterior to the iris and part is posterior to the iris, you will need to contact the surgeon repositioning (usually the sooner the better).
If your patient received a toric IOL that is rotated or tilted, again you will need to get the patient back to the surgeon for realignment. Haste is of importance for toric IOLs because the implant becomes adhered to the posterior capsule after four weeks. Adherence makes the IOL difficult to realign without complications involving tearing the posterior capsule. Some surgeons prefer to wait until the patient is three weeks postop to realign because by then the capsule has started to adhere to the IOL haptics and thus makes the realignment more likely to stay in place. Remember that for every degree a toric IOL is misaligned, there is a three percent loss of cylinder lens power. If the IOL is more than 30 degrees off, it will increase the patient’s post-operative astigmatism.2
For multifocal IOLs, tilt and/or decentration can cause significant decrease in lens performance.
What happens in my office
Our current recovery drop therapy consists of Besivance (besifloxacin, Bausch + Lomb) TID for one week, Prolensa QD for three weeks, prednisolone TID for one week, BID for two weeks and QD for one week. The therapy can be adjusted as needed. For example, diabetic patients may need to follow a six-week schedule instead of the usual four-week schedule to reduce the incidence of macular edema. If you see a patient with reduced acuity at one or two weeks you need to explore all the possible reasons. Start by examining the cornea for edema, striae, or folds. Dilate the patient and check for posterior capsular haze, retinal detachment, and macular edema. If the corneal edema is not resolving, add Muro-128 QID and see the patient in two weeks. If you are not able to clear the edema topically, a corneal specialist referral may be indicated. If the reduced acuity is due to macular edema an OCT is needed to confirm the diagnosis. If so, increase the prednisolone to QID and continue the Prolensa QD and see the patient in two weeks to recheck the visual acuity and repeat the macular OCT. If the macular edema is resolving, continue with the therapy and taper as needed. If it is not resolving, a retinal referral may be needed and the eye may need to be injected. Some pharmacists may substitute the Prolensa with ketorolac. If you notice significant corneal keratitis at the one-week visit, it is most likely due to the ketorolac and you will need to switch the patient to Prolensa or Ilevro.
If the patient is having cataract surgery on the second eye, be sure to get an accurate one-week refraction on the operated eye to the surgeon as soon as possible. This gives the surgeon vital information needed for deciding on the IOL power for the second eye in order to balance the vision post-operatively.
Our visits consist of one a day post-operative visit for each eye as well as a one week and three week visit if the patient was not referred by an OD. We usually perform the final refraction when the second eye is at least three weeks post-op.
The latest in IOLs
Patients may benefit from several advances in IOLs coming to market. Acrysof IQ ReSTOR +2.50 D (Alcon) is available as a multifocal option. It is designed for patients with distance dominance lifestyles and offers a decrease in spectacle dependence. This IOL is designed with fewer diffractive zones and a larger central refractive zone. Its design directs a higher percentage of light energy to the distance focal point.3 Patient selection for this IOL is dependent upon pupil size, corneal coma, and angle kappa.
Sapphire Autofocal (Elenza) IOL is the first implantable lens with artificial intelligence. It has its own power cell and computer chip embedded inside. It is rechargeable and programmable. It is designed to mimic accommodation by detecting changes in pupil size.4
New advances in cataract surgery, including femtosecond laser (femto) assisted procedure, can greatly decrease many signs and symptoms that usually accompany cataract surgery. The femtosecond laser is an infrared laser with a wavelength of 1053 nm. Femto has been utilized in ophthalmology since 2001, mostly with LASIK refractive surgery. Patients with Fuch’s dystrophy or guttata will benefit from a femto procedure due to the reduced phacoemulsification needed and therefore reduced corneal edema. Patients with dense cataracts also benefit for the same reason.
Providing the best postop care
Regarding symptoms, patient reassurance is essential. Some patients require more encouragement than others. Take the time to reassure your patients that blurred vision, foreign body sensation, grittiness, itching, and burning are all normal and transient. In regards to flashes and floaters, be sure to examine the retina. Although the incidence of a retinal detachment is low, educate the patient on your findings. In cases when a patient complains of loss of peripheral vision and the retina is intact, the symptom is probably due to a temporal primary incision. Let your patient know this will pass as the incision heals.
Cataract surgery is one of the most successful surgeries performed in the United States, and the number of patients requiring exceptional post-operative care is rising. Optometrists need to be comfortable and confident in their abilities to provide the post-op care needed to ensure successful outcomes.
1. National Eye Institute. Cataracts. Available at: https://nei.nih.gov/eyedata/cataract#5. Accessed 3/22/16.
2. Kent C. Toric IOLs: Nailing the Alignment. Rev Ophthalmol. Available at: http://www.reviewofophthalmology.com/content/i/2251/c/38570/. Accessed 3/22/16.
3. Alcon Surgical for Professionals. Available at: www.alconsurgical.co.za/acrysof-iq-restor-2-5-d-iol.aspx. Accessed 3/22/16.
4. Hayden FA. Electronic IOLs: The Future of Cataract Surgery. Eyeworld. 2012 Feb 17(2):58-60.