Don’t be afraid to answer your phone

August 22, 2013

When you co-manage a patient for a surgical procedure, be prepared for some common post-op doctor-patient dialogues.

Co-managing a patient can be a complicated and often time-intensive endeavor. Don’t get me wrong; as optometrists, we are fully capable of managing all aspects of the visual system. However, when your smartphone rings with a number you don’t recognize, your first thought would probably be, “Is it a patient who just had surgery and has questions?”

Dr. BloomensteinOver time you can see (yes, pun intended) that there are common occurrences with surgeries that can place your mind at ease. A great example is when a patient says, “My eye is bleeding.” A newbie OD may panic and feel that he needs to put down the quarter he was about to bounce into that red Solo cup and rush in to examine this hemorrhaging patient. Yet, over time it becomes apparent that patients see red and think bleeding, as opposed to a confined red spot from a hard stool or vomiting too hard from watching the season finale of Real Housewives of OC.

I was recently reminded of two post-operative courses that, although common, are linked by the commonality of the treatment. As in most everything post-operative, inflammation is the key characteristic of the healing process. Although some surgeries may have a limited amount of inflammation, it is always present and needs to be managed. There has been some debate about the relative importance of using a steroid following cataract surgery, as well as the length of dosing.1,2 With LASIK surgery, it’s even more Robin Thicke “Blurred Lines” as to the significance this anti-inflammatory plays. However, steroids are the treatment du jour for light sensitivity and painful red eye.

Patients will call you with vague complaints of discomfort or light sensitivity. The questions you should ask every time you hear such a complaint is: “What type of surgery did you have?” immediately followed with: “How long ago was your procedure performed?”

Varying degrees of pain can follow a patient after surgery, but an immediate thought from a patient who is at least 1 month post-op can be traced back to inflammation. The cataract patient is prone to rebound iritis that will initiate a red and painful eye. A mild-to-moderate degree of discomfort and hyperemia can be treated by restarting prednisolone or loteprednol drops. This will get the patient going; however, I would have the patient come in to the office at the next appointment. FYI: A good rule of thumb is to have your patients keep all their drops from surgery.

Similar in complaint and yet different in appearance is the 1-month post LASIK patient. The exaggerated sense of light sensitivity that befalls some of our super-happy LASIK patients can be befuddling and disconcerting. The eye will look perfectly normal, yet the patient will look perfectly upset. This condition was originally coined GAPP-good acuity, poor photosensitivity; however, the nomenclature never stuck and the condition is now referred to as transient light sensitivity (TLS).3 TLS occurs almost like clockwork at the 1-month mark after a femtosecond excimer laser surgery. Several theories exist on what causes the condition. A popular theory involves the evacuation of gases instituted by the laser in the intrastromal space. These cavitation bubbles may spread to the peripheral cornea and episclera, secondarily irritating the ciliary body. Although this condition is one made by exclusion of any other signs and may be self limiting, the use of a steroid can expedite recovery. I restart the steroid for a 1 month slow taper, and see the patient back at the 2-week mark for some verbal Valium.

Don’t be afraid to answer the phone, unless you owe people money, and be prepared for some common post-operative scenarios.ODT

References

1.   Lane SS, Modi SS, Lehmann RP, Holland EJ. Nepafenac ophthalmic suspension 0.1% for the prevention and treatment of ocular inflammation associated with cataract surgery. J Cataract Refract Surg. 2007 33(1):53-58.

2.   Heier J, Cheetham JK, Degryse R, et al. Ketorolac tromethamine 0.5% ophthalmic solution in the treatment of moderate to severe ocular inflammation after cataract surgery: a randomized, vehicle-controlled clinical trial. Am J Ophthalmol. 1999;127(3):253-259.

3.   Nader N. Transient light sensitivity a minor complication of IntraLase use. Ocular Surgery News. October 1, 2004 http://www.healio.com/ophthalmology/refractive-surgery/news/print/ocular-surgery-news/%7B40fd7731-7015-46bc-8b72-626b4b6254f3%7D/transient-light-sensitivity-a-minor-complication-of-intralase-use. Accessed 8-8-2013.