In our previous entry we discussed systemic conditions that can have a significant influence on a patient’s postoperative outcome.
Much like when planning surgery in a patient with uncontrolled diabetes or one who is immunocompromised, a good practitioner will educate their patients with active infectious disease. If a patient is currently on antibiotics or being followed for an infection, it is often best to give time for complete resolution of the infection before exposing the patient to the trauma of a surgery.
Patients will rarely volunteer the fact that they are being treated for an infection on their leg, not imagining that it could be relevant during an eye exam; therefore, a thorough review of systems must be performed in order to get the most complete medical history from a patient. Additionally, if a patient is known to have a history of methicillin-resistant Staphylococcus aureus infection, they will likely be put on an alternate prophylactic antibiotic, for example moxifloxacin rather than ofloxacin with the addition of Polytrim (polymyxin B and trimethoprim, Allergan).
If a patient is suffering an active ocular herpes zoster infection, an elective eye surgery should be postponed until 6 to 12 months after resolution, with at least 3 of these months medication-free, in an effort to prevent reactivation. One may even consider waiting 3 months before proceeding with cataract extraction on the non-affected side. For those with a history of herpes simplex ocular conditions, prophylactic acyclovir can be started 1 week prior to surgery and continued 3 to 4 weeks postoperatively.
Moving beyond systemic or infectious disease, a practitioner also needs to consider their patient’s physical ability to lie through a surgery. Even with a short surgery time of 5 to 10 minutes on an average cataract extraction case, several factors could result in a patient’s inability to get through the procedure. One example would be attempting surgery with only local anesthesia on patients with impaired mental ability such as severe dementia or patients with Down’s syndrome. For these patients, general anesthesia with its total sedation can make for a safer procedure. In such cases the capabilities of a hospital-based surgery is likely more appropriate than the local anesthesia performed in many ambulatory surgery centers.
Other patients who may benefit from general anesthesia are those who may be unable to cooperate during surgery due to a severe head or body tremor or even very claustrophobic patients. Patients with back, neck or ambulatory issues can undergo a trial run with the surgical team to be sure a certain surgical set-up will be suitable for them prior to scheduling.
Medical chairs and equipment also have limitations of what they can safely accommodate. Even more importantly, a patient’s weight can obstruct a practitioner’s ability to provide care should the patient become nonresponsive. For this reason, patients are asked their weight prior to scheduling an outpatient surgery. In our clinic, those who are between 300 and 350 lbs. are individually assessed, and inpatient care is discussed. Again, this is a case-by-case basis, as certain morphologies, such as a very tall patient, may get approval from anesthesia or after a trial run in the surgical suite.
The eyeball is a small but complex organ, yet, as eye care providers our job does not stop there. Only when we consider the patient as a whole, taking such details as their systemic health, binocular or monocular status, immune status and physical abilities into account, are we able to provide the best care for them. In many ways, a thorough preoperative evaluation can spell the best success for your patients’ postoperative outcomes.