pre and post-operative management of cataract surgery

pre and post operative management of cataract surgery

1. *Pre and Post
Operative
Management of
Cataract Surgery
03/01/151
Pabita Dhungel
B.Optometry

2. 1.American Academy of Ophthalmology
(section - 11 Lens & Cataract)
2.Clinical Ophthalmology (Kanski fouth edition)
3.Clinical Ophthalmology (Myron Yanoff)
4.Oxford hand book of ophthalmology (second
edition)
5.Cataract surgery and its complications (6
th

edition, N.JAFFE, M. JAFFE, G.JAFFE)
03/01/152
References

3. *Introduction to cataract
*Introduction to cataract surgery
*Preoperative management
*Post- operative management
*Summary
03/01/153
Presentation Layout

4. *Cataract derives from the Latin word
‘cataracta’ meaning "waterfall“
*Any opacity in the human crystalline lens that causes
it to loose it’s transparency and /or scatter light
compromising the visual acuity
*Any opacification of IOL after cataract surgery is
known as after cataract
03/01/154
Introduction

5. *It is estimated around 20 million people are
blind due to this disease
*Estimated 50 million people blind due to
cataract by 2020
*By the year 2020, the final target should be 32
million cataract surgeries annually
03/01/155
Global Cataract Blindness:

6. According to Nepal Blindness Survey(1980-1981):
•A. Cataract and its sequelae(72%)
•B. Trachoma
•C. Ocular infections
•D. Xerophthalmia
•E. Glaucoma
• According to study “Prevalence of blindness and cataract
surgery in Gandaki Zone, Nepal” cause of blindness due to
cataract was found to be 60.5%
03/01/156
Cataract Blindness in Nepal:

7. *Common indication
* Loss of stereopsis
* Decrease of peripheral vision
* Bothersome glare
* Symptomatic anisometropia
03/01/157
INDICATION FOR CATARACT SURGERY

8. *Medical indication
* Phacolytic glaucoma (mature,hypermature cataract)
* Phacoantigenic uveitis (traumatic cataract)
* Phacomorphic glaucoma (intumescent cataractous
lens)
* Dislocation of lens into AC
* Lenticular tumor: Epithelioma, epitheliocarcinoma.
* Dense cataracts
03/01/158
Contd…

9. *Patients with significant cataracts
*Patients decide to seek of visual function through
cataract surgery.
*Cosmetic indication: Mature cataract in the blind
eye (for restore the black pupil only)
*May require cataract surgery:
* Posterior subcapsular cataracts (near VA < N8
even though far VA still 6/12).
* Nuclear cataracts that far VA 6/18 even though
near VA still N5.
03/01/159
Contd…

10. *GENERAL HEALTH
* Diabetes mellitus
* Ischemic heart disease
* Smoking
* HTN
* Chronic obstructive pulmonary disease
* Bleeding disorder
* Drug sensitivities & medications: immunosuppressant
or anticoagulant…
03/01/1510
Pre operative evaluation

11. PERTINENT OCULAR HISTORY
* H/o of trauma
* Inflammation
* Amblyopia
* Glaucoma
* H/o has already had cataract extraction
(compl: vitreous loss….)
03/01/1511

12. * Look for abnormalities of external eyes and adnexa:
. Blepharitis
. Entropion, ectropion
. Decrease of corneal sensation
. Abnormal tear function, Exposure keratitis
. Dacryocystitis
. Other condition: head tremor…
* Motility: EOM, Cover test, Strabismus + Amblyopia..
* Pupil: Reacting to light…RAPD (+/-)

03/01/1512
EXTERNAL EXAMINATION

13. a)- Conjunctiva:
. Scarring
. Symblepharon
. Conjunctivitis
03/01/1513
SLIT-LAMP EXAMINATION

14. b)- Cornea:
. Specular reflection with slit-lamp can estimate
the endothelium cell count and morphology.
. If abnormal or C- thickness > 600 µm is poor
prognosis for corneal clarity.
. Corneal dystrophy
. Keratoconjunctivitis sicca
03/01/1514
Contd…

15. c)- Anterior chamber:
. Shallow (intumescent of lens or forward
displacement by posterior pathology)
. Gonioscopy to rule out the angle abnormalities
(synechia, neovasculization).
d)- Iris:
. Pupil size after dilation is noted
. Posterior or anterior synechia (+/-)
03/01/1515

16. e)- Crystalline lens:
. The visual significance of oil droplet nuclear
cataracts & small posterior subcapsular cataracts are
the best appropriated before dilation.
. Exfoliation syndrome is the best seen follow
dilation.
. Small posterior subcapsular cataracts can cause
severe visual loss
03/01/1516
Contd…

17. b)- In DM patient,we should look for: Macular edema,
retinal ischemia, vitreous retinal traction, lattice
degeneration, macular hole.
c)- Mature cataracts, evaluated by B- Scan
Ultrasonography that helpful in RD & posterior
segment tumor
03/01/1517
FUNDUS…….

18. *a)-Visual acuity testing ( N & D)
*b)- Brightness acuity
* Pts complain of glare (should check distance & near
acuity in well lighted room with non projected or
projected eye chart.
* Pts with significant cataracts show decrease VA of
three or more lines under this condition
03/01/1518
Measurement of visual function

19. *c)- Contrast sensitivity
*d)- Visual field testing (Goldmann & Automated)
*e)- Color vision
03/01/1519
Contd…

20. *SPECIAL TESTS
a)- Potential acuity estimation
•Clinical Interferometers & Potential Acuity Meter are able to
measure macular acuity directly by projecting grating patterns or
Snellen letter on the retina.
•This test can be misleading in present of: Age related macular
degeneration, amblyopia, macular edema, glaucoma, small macular
scar & serous RD.
03/01/1520
PREOPERATIVE EVALUATION (Cont)

21. b)- Testing for macular function
* Maddox Rod: large scotoma (macular disease)
* Purkinje’s entoptic phenomenon ( Retina)
(light shone through close eyelid…shadow).
* Two light discrimination indicates normal
macular function, if two point light sources can be
distinguished when held 2 inches apart & 2 feet from
the eye
03/01/1521
Special tests

22. *REFRACTION
*BIOMETRY (keratometry & A-Scan)
Performed to calculate the approximate IOL power implantation.
Use SRK formula (Sanders, Retlaff & Kraff)
P = A – 2.5L – 0.9K
P : Lens implant power for emmetropia (D)
L : Axial length (mm)
K : Average keratometric reading (D)
A : Constant specific to the lens implant to be used
That A = 113 for AC lenses & 119 for PC lenses.
03/01/1522
Pre operative measurement

23. *Check that biometry does indeed belong to your
patient
*Check for intraocular consistency in axial length and
K values (i.e that they are similar and the standard
deviation is low)
03/01/1523
IOL selection

24. *Check for interocular consistency in axial length and
K values
*If axial length difference >0.3mm confirm by B-scan
and if the difference in K readings >1D then consider
corneal topography
03/01/1524
Contd…

25. *CORNEAL PACHYMETRY
* Ultrasonic pachymeters can accurately & reliably
measure endothelial cell function.
* If thickness > 600 µm maybe consistent with corneal
edema & endothelium dysfunction that increase the
likelihood postoperative clinical corneal edema.
03/01/1525

26. *SPECULAR MICROSCOPY: (endothelium cells)
* A normal cell count > 2400 cells/mm
2
* If a cell count fewer than 1000 cells/mm
2
is risk of
postoperative corneal decompensation.
03/01/1526
Contd…

27. *B-Scan ultrasonography
Useful whenever it is impossible to view the retina & can
determine of posterior segment with regard to the
potential for:
* RD
* Vitreous opacity
* Posterior pole tumor
*Complete blood counts, Hb…
*Blood sugar
*Urinalysis
*Chest X-ray
03/01/1527
Laboratory investigations

28. *Syringing
*Conjuctival swab
03/01/1528
Contd…

29. *Pediatric IOL: size, design and power
*1. Size of IOL above the age of 2 years may be
standard 12 to 12.75mm diameter for the bag
implantation
*2. Design of IOL recommended is one- piece PMMA
with modified C- shaped haptics (preferably heparin
coated)
03/01/1529
Pre operative management in
pediatric age groups

30. *Power of IOL in children between 2-8 years of age 10%
undercorrection from the calculated biometric power
is recommended to counter the myopic shift
*Below 2 years on undercorrection by 20% is
recommended
03/01/1530
Contd…

31. *Topical antibiotics : tobramycin, gentamycin or
ciprofloxacin QID for 3 days
*Preparation of eye to be operated : eyelashes of
upper lid should be trimmed at night
*An informed and detail consent should be obtained
03/01/1531
Preoperative medications

32. *IOP should be lowered by acetazolamide 500mg stat
2 hours before surgery and glycerol 60ml mixed with
equal amount of water or lemon juice 1 hour before
Sx or, IV mannitol 1gm/kg body weight half hour
before Sx
03/01/1532

33. *To sustain dilated pupil
*antiprostaglandin eye drops such as indomethacin or
flurbiprofen TID 1 day prior to surgery
*Adequate dilation also by 1% tropicamide
03/01/1533

34. *Patient is asked to lie quietly upon the back for 3/ 4
hours
*For mild to moderate post-operative pain injection
diclofenac sodium may be given
*Next morning bandage is removed & inspected for
post-op complication
*Antibiotic-steroid eye drops are used two hourly 1
week,QID 4 week then tapering, TID, BD and OD for
each week
03/01/1534
Post- operative management

35. *Tear supplements are given for at least one month or
more depending upon the patients complain to
prevent post cataract surgery dry eyes
03/01/1535
Contd…

36. *Cornea: wounds sealed (Seidel test negative), clarity
*AC: formed, activity
*Pupil: round, regular and reacting
* PCIOL: centred and in the bag
*Consider : IOP checking
03/01/1536
Post -op examination

37. *Give clear instructions re postoperative drops
*Use of clear shield
*What to expect (discomfort, watering)
*What to worry about (increasing pain/ redness,
worsening vision)
*Where to get help (including telephone number)
03/01/1537

38. *Examination
*VA: unaided/aided
*Cornea: wounds sealed (Seidel test
negative), clarity
*AC: depth and clarity
*Pupil: round, regular and reacting
03/01/1538
Final review (2-4wks later)

39. *IOP
*Fundus : no cystoid macular oedema, flat retina
*If good result then either list for second eye (in
bilateral cases) or discharge to optometrist for
refraction as appropriate
03/01/1539
Contd…

40. *If disappointing VA (unaided) perform
refraction/autorefraction to look for ‘refractive error’
and dilated fundoscopy to check for the subtle CMO
(specially if VA (pinhole) < VA (unaided)) and if in
doubt, consider OCT
03/01/1540
Contd…

41. *In patients where the refractive outcome is harder to
predict (high ametropia, previous corneal refractive
surgery), review patients early (1 week) with
refraction to permit the option of an early IOL
exchange if a large discrepancy noticed
03/01/1541
Refractive surprises

42. *After 6-8 weeks of operation corneoscleral sutures
are removed (when applied)
*Final spectacles are prescribed after about 8 weeks of
operation
03/01/1542
Contd…

43. *Correction of paediatric aphakia
*Children above the age of 2 years corrected by PC-IOL
during surgery
*Children below the age of 2 years should be
preferably corrected by extended wear CL
*Spectacles can be prescribed in B/L cases
03/01/1543
Postoperative management of
pediatric age group

44. *Later on secondary IOL implantation may be
considered
*Primary implantation at earliest possible (2-3 months)
specially in unilateral cases
*Management of amblyopia in long term follow up
03/01/1544
Contd…

45. *Every 6 months follow up for first five years and then
followed by yearly follow up
*Correction of refractive error as far as possible to
prevent amblyopia
03/01/1545
Contd…

46. *Refractive error is assessed at 8
th
week of cataract
surgery
*Refractive correction is prescribed only if the error
persist even after three months of cataract surgery
03/01/1546
Management of refractive error in
adults

47. 03/01/1547
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