An OD's Guide to Postoperative Cataract Care: Practical advice for both routine and complex cases

Providing care for your patients during their recovery from cataract surgery can be exciting and gratifying. Few experiences will cement patients to your practice like regaining their vision; it will also help your clinic operate at the peak of its capacity. Most patients have a straightforward recovery, and only a few require more attention. If any serious problems present, your surgeon is standing by, ready to assist. (1)

Each month, our clinic and the community optometrists we serve see hundreds of cataract patients through their healing process. This article describes the sequence and elements of an uncomplicated recovery from cataract surgery and then discusses how to handle some of the more common complications.

The Uncompiicated Course

The vast majority of cataract cases undergo an uncomplicated and predictable path; in the United States today, more than 97% of all cataract cases unfold successfully. (2) Timeline, medications and care have all been standardized for decades.

Medications. All cataract patients will require medications postoperatively to protect them from infection, inflammation and pain, but a wide variation exists in the specific medications and dosages used by individual surgeons. All formulas include an antibiotic to protect against endophthalmitis and a steroid to control inflammation. A steroid used for less than a month can be stopped abruptly when the bottle is empty, although many clinics will ask for the more traditional taper.

Some clinics use a nonsteroidal anti-inflammatory drug (NSAID) to complement the steroid in controlling inflammation and pain, while others do well without them. Regardless, NSAIDs are frequently prescribed for patients whose eyes have a high risk of developing cystoid macular edema (CME) or inflammation: this includes cases of diabetic retinopathy, epiretinal membranes, a history of retinal vein occlusion or macular degeneration.

A growing movement urges doctors to skip some, or all, post-op drops in favor of an injection usually containing a steroid and an antibiotic. In these cases you must be familiar with your surgeon's mixture and its expected performance. This approach can produce some harmless but unusual visual effects immediately after surgery and has a rare but significant risk of a dangerous reaction to the medication. (3)

The one-day exam. Use the first postoperative exam to ensure that the surgery was carried out well, to verify that the patient understands their responsibilities and to answer their immediate post-op questions and concerns. The one-day exam must include a history, measurement of visual acuity (VA), an auto-refractor reading or pinhole acuity, an intraocular pressure (IOP) check and a slit-lamp exam.

For most patients, normal symptoms at the one-day exam include blur, foreign body sensation, ache and redness. Normal findings include reduced VA (typically around 20/25 to 20/60), a small ptosis (from the spring clamps used during surgery), residual dilation, mildly elevated IOP, injection and cells and flare in the anterior chamber.

There will be a primary incision, either in the temporal cornea or in the superior conjunctiva, along with one or two small corneal port incisions. Subconjunctival hemorrhages are common, especially following femtosecond-laser assisted surgery...