When comanaging cataract patients, optometrists should have an open line of communication with the surgeon; however, ODs should know what findings will dissipate over time.
Optometrists frequently provide 1-day and 1-week follow-up after cataract surgery, depending on the patient’s needs, the travel distance for the patient, the OD’s knowledge and experience, the type of surgery and the overall plan agreed upon in advance between the comanaging optometrist and the surgeon, Paul M. Karpecki, OD, FAAO, a Primary Care Optometry News Editorial Board member, told PCON in an interview.
Karpecki encouraged all comanaging ODs to take a confident approach in managing these patients.
“Know what to look for, what lenses the surgeon typically uses and the postoperative findings that are normal vs. those that require contacting the surgeon, and partner with your patients in all of their eye care needs,” Karpecki said.
Paul M. Karpecki
“Don’t hesitate to contact the surgeon directly with questions, even if you are not sure,” he said. “Spend a day with her or him in surgery. If the surgeon isn’t responsive or professional regarding your questions, there is probably another surgeon better fitted for your patients, so feel free to ask as many questions as necessary to continue to advance your knowledge and clinical care of these patients. You should have each other’s cell and office numbers.”
What patients can expect
In regard to the subjective patient report, most will experience discomfort or a scratchy feeling for the first day or two, but that will normally resolve quickly, John A. Hovanesian, MD,FACS, a PCON Editorial Board member, said in an interview.
Patients may also experience significant brightness, which is expected and common for the first few days, he said.
John A. Hovanesian
“Patients will often describe having a lot of glare, saying it’s as though they’ve been wearing sunglasses forever, and now everything seems too bright,” Hovanesian said. “I tell them that they have been wearing the equivalent of sunglasses because their cataract was filtering out a lot of light.”
Patients may also notice a dramatic difference in the perception of color in the eye that has undergone treatment, he said.
Anterior chamber cells and flare can be expected after cataract surgery.
Image: Karpecki PM
“Moreover, they may notice a purple hue to their vision for about 24 to 36 hours, which comes as a side effect of the after-image from the microscope light during surgery,” Hovanesian added.
If patients notice edge glare, Hovanesian said he would validate the complaint, then tell them to “wait it out, as it always seems to improve.”
According to Karpecki, “Edge glare requires education about the pupil being dilated, the time it normally takes to dissipate and the clarity of the IOL. Tell them many patients indeed notice this, and it will go away with time.”
What the OD can expect
Physicians should expect to see some cells and flare, grade 1 or 2, in the anterior chamber, and they should also expect to see some corneal edema for the first week, Hovanesian continued.
“In patients who have Fuchs’ endothelial dystrophy – or other abnormalities of the endothelium – corneal edema might be prolonged,” he said.
In these cases, the edema should clear within several weeks, he noted.
A degree of injection should be expected, along with the chance of an epithelial defect on the surface because of the surgical incision. This usually heals within a few days, Hovanesian said.
For patients with a healthy optic nerve and no history of glaucoma, Hovanesian said, “I will simply observe an IOP of less than 30 mm Hg at day 1, as it’s usually short-lived. If it is more than 30 mm Hg I will initiate a drop for a few days or perform a paracentesis at the slit lamp to release fluid.”
Karpecki added that if IOP remains high 30 minutes after the medication is administered, he would send the patient back to the surgeon for a modified paracentesis or burping of the wound to release aqueous.
“Pressures over 40 mm Hg should be sent back to the surgeon, but treated prior to making the trip,” he added.
“At day 7, pressures should be back to normal,” Karpecki said. “If they are still elevated, the patient could be a steroid responder and should receive additional ocular antihypertensive medications but remain on the steroids or consider switching to an ester-based steroid. Monitor pressures in a few days to a week to ensure they return to normal while on both medications.”
Karpecki also noted that the ocular surface should be investigated for signs of dry eye, which can affect vision, so patients will not blame the procedure or IOL if it is not the cause of blurred vision.
A retinal examination should be conducted to look for abnormalities such as epiretinal membrane or vitreomacular traction syndrome, which may be more evident once the cataract has been removed, Karpecki said.
Anterior chamber cells should gradually clear of inflammation over the first 2 weeks after surgery and leave behind a quiet anterior chamber as long as a patient is on an adequate steroid and nonsteroidal anti-inflammatory drug, Hovanesian said.
In the vitreous, occasional debris, such as fragments of the original lens, may appear, but otherwise it should remain clear, he said.
“This can happen even after well-done surgery,” he added.
The posterior capsule should remain intact with a well-centered lens implant, Hovanesian said.
“Visual acuity should approach expected level of visual potential by 1 month, although patients will typically be functional within the first few days after surgery,” Karpecki said. – by Daniel R. Morgan
- John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; (949) 951-2020; fax: (949) 380-7856; firstname.lastname@example.org.
- Paul M. Karpecki, OD, FAAO, can be reached at Koffler Vision Group, Eagle Creek Medical Plaza, 120 N. Eagle Creek Dr., Suite 431, Lexington, KY 40509; (859) 263-4631; email@example.com.