Module 5: Postoperative Management

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Cynthia A. Matossian, MD, FACS

Founder, owner and chief medical officer of Matossian Eye Associates with offices in Doylestown, Pennsylvania, and in Hopewell and Hamilton, New Jersey; Adjunct clinical assistant professor of ophthalmology at Temple University School of Medicine; Clinical instructor, Department of Family Medicine, University of Medicine and Dentistry of New Jersey; and Clinical instructor, Robert Wood Johnson Medical School

Refractive cataract surgery requires an office-wide approach to help patients achieve their best potential vision with lens-based surgery. To deliver outstanding outcomes, surgeons and staff must proactively engage patients with education and tackle any postoperative problems that may arise. Learn from Cynthia A. Matossian, MD, FACS, as she describes several postoperative scenarios and how to handle them with confidence.

Q. Describe the current treatment landscape after refractive cataract surgery. How do you recommend surgeons approach postoperative management?

Cynthia A. Matossian, MD, FACS: Treatment options after refractive cataract surgery are continually evolving; no surgeon should be stuck with a postoperative protocol if better and more effective options become available. A good surgeon remains nimble to adapt with the times and stay current with changes in the field, and adjusts his or her techniques and perioperative regimens accordingly.

For years, I have been prescribing patients the typical postoperative triad: an antibiotic, a nonsteroidal anti-inflammatory drug and a steroid. This seemingly simple treatment plan, however, comes with its share of problems. Because I prefer branded medications, ensuring that patients receive only branded products from the pharmacy has become a dreaded, time-consuming task for my staff.

Q. How should surgeons handle medication cost concerns and patient compliance to postoperative care?

Matossian: Generic formulations may be slightly less expensive for patients than branded products, but they are not subject to FDA clinical trials. For the skeptical patient, I offer them words of encouragement:

“You only have two eyes; I will do the best I can. I would like your commitment, too, that we will do this together to achieve the best possible visual and surgical results, and branded products are integral to great outcomes.”

Even with branded medication, compliance remains a real issue in my experience. All surgeons know that many patients do not use drops as prescribed. Furthermore, when patients do take their drops, they may have trouble squeezing the bottle, their hands may shake, or the drop may land on the cheek instead of the cornea. Of equal concern is that, if the bottle tip becomes contaminated by touching the lid margin or lashes, it could introduce bacteria to the very surface surgeons are trying to keep infection free. Finally, patients who start with a compromised tear film from prior refractive surgery, a systemic autoimmune condition or ocular surface disease require special attention. The cornea may not be able to handle the impact of multiple drops per day, and patients may develop superficial punctate epitheliopathy with reduced vision. For these reasons, ophthalmology is experiencing a paradigm shift — researchers are working to develop alternative drug delivery routes to help patients with cost and compliance issues, as well as to help surgeons and their staff with the barrage of pharmacy and patient callbacks.

To decrease treatment burden and to manage costs, I recently switched to Omni (dexamethasone ophthalmic/moxifloxacin hydrochloride, Ocular Science), a combination anti-infective and anti-inflammatory steroidal agent injected into the anterior chamber under the capsulorrhexis edge at the end of surgery. Additionally, I look forward to implementing the dexamethasone insert (Dextenza, Ocular Therapeutix) into my practice once it receives FDA approval. This intracanalicular plug is placed into the inferior punctum after intraocular lens implantation, delivering a steady-state level of steroid for 30 days postoperatively. It will minimize the number of drops needed after surgery and simplify the treatment course, as no taper regimen will be required. However, a topical NSAID along with an antibiotic drop will still be necessary.

Top Physician Takeaways

POSTOPERATIVE MANAGEMENT: It comes down to confidence.

  • A surgeon must be dedicated to continually improve his or her skills.
  • Learning cannot come to a halt when the fellowship ends, so I suggest attending meetings, mastering new techniques through skill transfer courses and visiting colleagues during surgery to stay current.
  • When unsure about a particular case, ophthalmologists should be encouraged to call a mentor for advice. Surgeons have a wealth of information to share, and I do not know any physician who is unwilling to help a colleague.

Q. How soon after surgery — and how often — do you recommend surgeons schedule follow-up appointments?

Matossian: I usually see my patients 1 day postoperatively, then refer them back to the comanaging optometrist for subsequent care. If they are patients of Matossian Eye Associates, I see them at 1 week to evaluate the refraction in the operated eye to fine tune the IOL calculation for the upcoming second eye.

Q. Do you recommend manifest refraction or autorefraction after implanting premium IOLs?

Matossian: I recommend surgeons use manifest refraction rather than autorefraction, especially for more sophisticated IOLs such as multifocal, toric and extended depth of focus IOLs. The Symfony IOL (Johnson & Johnson Vision [formerly Abbott Medical Optics]), for example, features technology that corrects chromatic aberration.1 Because many autorefractors use infrared light that adjust for chromatic aberration, this may lead to false myopic readings. For example, a patient with an uncorrected distance visual acuity of 20/20 may end up with an autorefractor reading of –1.5 D, whereas with manifest refraction, the result may be close to plano using a fogging technique to avoid adding minus spherical power. Therefore, having well-trained staff members who perform refractions with great precision after premium IOL implantation is crucial for patient satisfaction and outcomes tracking.

Q. How do you handle outcomes that are slightly off-target yet noticeable to patients?

Matossian: The best way to handle off-target outcomes after refractive cataract surgery is to prevent them from happening in the first place. Starting with an optimized ocular surface to achieve more reliable and accurate keratometry and topography measurements will reduce the chance of postoperative refractive surprises.

Often, ophthalmologists neglect the ocular surface when, in fact, calculations should be postponed until the ocular surface is adequately treated. Surgeons must be proactive with diagnostic tools to detect ocular surface and lid disease, and then aggressively address these entities before performing surgical measurements. Educating patients about the role of the tear film to achieve desired refractive goals will help them understand the need to delay surgery. Surgeons who skip this step may end up with unwanted refractive surprises and unhappy patients who will undoubtedly share their negative comments online.

Q. How do you suggest surgeons address more disruptive postoperative symptoms?

Matossian: Some patients expect 20/20 vision as soon as they are wheeled out of the operating room; consequently, it is important to communicate that patience is a virtue. I do whatever I can to make my patients’ experience as positive as possible. I reinforce to my patients that, as with any other surgery, the eye needs time to heal and adjust to a new visual system. Reassurance goes a long way. I explain that slightly blurred vision is not uncommon in the immediate postoperative period because of a dilated pupil, disparity between the operated and cataractous eye or because of the impact of medication drops on the ocular surface.

Pain and inflammation
The additional intraocular manipulations required to insert a pupil-dilating device mid-case can lead to patient discomfort. Studies have shown that complications such as retained nuclear fragments, a break in the posterior capsule with vitreous presentation, haptic misplacement in the sulcus instead of in the bag and difficulty with toric IOL alignment are more prevalent in pupils smaller than 6.0 mm. Therefore, I recommend phenylephrine 1% and ketorolac 0.3% injection (Omidria, Omeros). The phenylephrine maintains pupil dilation to reduce unexpected miosis during surgery and, in addition to maintaining mydriasis during surgery, Omidria provides steady and continuous irrigation of ketorolac for pain control both intraoperatively and in the immediate postoperative period.2

In addition, pain, light sensitivity and discomfort are all results of inflammation and can influence the patient’s perception of his or her cataract surgery experience. I always attempt to aggressively suppress inflammation from the start by prescribing an NSAID, a steroid and an antibiotic beginning 3 days before surgery.

Elevated intraocular pressure
Elevated IOP can occur after cataract surgery. In the immediate postoperative period, increased IOP may result from retained viscoelastic material. An IOP rise later in the postoperative course may occur in a patient who is a steroid responder. In the latter case, I suggest switching the steroid to one that is associated with less IOP elevation, such as loteprednol etabonate ophthalmic gel 0.5% (Lotemax, Bausch + Lomb), or discontinue the steroid altogether while continuing the NSAID.

Reduced visual acuity
Reduced visual acuity in the postoperative period must be thoroughly evaluated to determine a proper course of action. It may be caused by mild or moderate symptoms such as macular edema, ocular surface decompensation, inflammation or posterior capsular opacification, all which are temporary and easily treated. More serious causes range from implanting an incorrect IOL power to new onset retinal pathology, and may likely need greater treatment intervention or additional surgery.

Corneal edema
In complex cases that involve rock-hard cataracts, surgeons must use greater phacoemulsification power and longer phaco time for nuclear disassembly. Setting proper patient expectations before surgery of possible corneal edema with a slight delay in visual recovery will allay their fears. Depending its severity, increasing steroid dose frequency and tapering more slowly will most often be all that is required.

Q. Surgeons, regardless of their experience with refractive cataract surgery, may encounter patients who are dissatisfied with their visual outcome. At what point would you recommend surgeons perform a corrective procedure such as LASIK, PRK or an IOL exchange?

Matossian: The decision depends on how off-target a patient is with his or her refractive outcome. Fortunately, when surgeons are meticulous with their preoperative measurements, refractive surprises become inordinately rare. Nonetheless, a vision solution must be crafted for the dissatisfied patient.

Especially after premium IOL implantation, surgeons need to take the time to listen to patient concerns and then proceed with a careful history, followed by a comprehensive examination of the cornea, tear film, IOL position and posterior pole. It is also important to consider the patient’s age and level of refractive surprise to devise a corrective solution, whether it be PRK, LASIK or IOL exchange. When in doubt, I recommend asking a colleague for advice.

I prefer performing an IOL exchange because I can enter the eye through the original incision to remove the IOL and implant the new one. If the patient refuses another intraocular surgery, or if the patient has a pre-existing condition that can make the procedure more challenging, such as zonulopathy, then a cornea-based procedure may be the best option.

Additional Insight

References

  1. TECNIS Symfony Extended Range of Vision IOLs Directions for Use. Johnson & Johnson Vision; Santa Ana, CA.
  2. Omidria [prescribing information]. Seattle, WA: Omeros Corporation; May 2016.

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