Cataract Surgery Postoperative CareIntroduction Goals of Therapy Investigations Stan P. George, MD, FRCSC Date of Revision: July 2015 It is difficult ...
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Cataract Surgery Postoperative Care
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Cataract Surgery Postoperative Care Stan P. George, MD, FRCSC Date of Revision: July 2015
Introduction
It is difficult for a primary care practitioner to manage and diagnose the complications of a postoperative cataract patient without the benefit of a slit lamp or indirect ophthalmoscope; frequently even a Snellen acuity chart is unavailable. The goal of this chapter is to review symptoms and signs that would allow a primary care practitioner to identify cases that should be urgently referred to the ophthalmologist.
Goals of Therapy
Control inflammation Prevent infection
Maintain eye comfort
Promote early visual rehabilitation The goals of the postoperative assessment are to: Detect intraocular infection in its early stages
Detect postoperative uveitis or intraocular pressure (IOP) elevation
Detect other abnormalities in the postoperative course such as a retinal detachment, iris prolapse, wound leak, flat anterior chamber, excessive corneal edema or intraocular hemorrhage
Investigations
Figure 1 illustrates an assessment process for the postoperative cataract patient. Pain:
the postoperative eye should be comfortable. At worst, the patient may have a mild foreign-body sensation
more intense pain suggests increased IOP, increased inflammation and/or infection (not uncommon in the first 24 hours)
History of recent trauma:
any trauma to the eye in the early postoperative phase requires thorough reassessment with a slit lamp
Change in vision (worsening, darkening, loss of detail or peripheral visual loss):
any significant change could indicate infection, hemorrhage, retinal detachment or other acute intraocular pathology requiring immediate attention
Visual phenomena (flashing lights, dark shadows or floaters):
worsening of floaters requires thorough reassessment to rule out infection, retinal tear or detachment, or uveitis
in the first few days or weeks after implantation of an intraocular lens, many patients notice a glare or shadow in the peripheral vision (dysphotopsia); in this time frame it is usually not a cause for concern provided that confrontation visual field testing (finger counting using peripheral vision) is normal using a pinhole to test visual acuity will eliminate the effect of refractive error if the patient has apparent reduced acuity
Itching of the eye (as predominant symptom): suggests allergy to medications
Examination of eye:
swelling of lids and/or conjunctiva suggests drug allergy or infection
pupil(s) should react normally to light unless a mydriatic agent has been used. Photophobia (glare sensitivity and pain from light exposure) can indicate anterior uveitis or corneal haze (from infection, inflammation or increased IOP)
the cornea should be clear of any clouding or infiltrates (to rule out corneal or anterior segment infection, inflammation or intraocular pressure elevation); the cornea should reflect a clear, well-demarcated image when the direct ophthalmoscope or pupil light is shined on it
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use the ophthalmoscope to see if the disc is clearly viewed and a red reflex is present (to rule out vitreous clouding, inflammation or infection)
Review of ocular medications: reinforce proper use
clarify any confusion
discuss with family member
Verify follow-up visits with surgeon
Therapeutic Choices Pharmacologic Choices
Postoperative ophthalmic medications may include: Antibacterials (Table 1)
a broad-spectrum antibacterial is used perioperatively to reduce the risk of endophthalmitis. Although there is some evidence that prophylactic antibacterials are beneficial,1 the evidence is weak.2 Nonetheless, not using perioperative topical antibacterials could be problematic from a medical-legal point of view as they have become a standard of care. one study demonstrated the efficacy of preoperative topical povidone iodine in reducing the rate of endophthalmitis.3 The use of perioperative fourth-generation topical fluoroquinolones (besifloxacin, gatifloxacin, moxifloxacin)4,5 is very common; however, many surgeons still prefer a formulation that combines an antibacterial with a corticosteroid in the same bottle, e.g., tobramycin/dexamethasone (Tobradex), for ease of use and to improve adherence to therapy.
Glaucoma medications (Table 2)
used to lower the intraocular pressure after eye surgery. In patients with pre-existing glaucoma, medication regimen may be modified in postoperative period to protect against early postoperative rise in intraocular pressure.
Anti-inflammatory agents (Table 3)
used during the first few postoperative weeks to reduce inflammation and the risk of developing cystoid macular edema.
Dilators and cycloplegics (Table 4)
used to keep iris away from implant during early healing period and to improve comfort by decreasing ciliary muscle spasm.
A mild analgesic may be required (e.g., acetaminophen 500 mg every 4–6 hours). Sedation is rarely needed.
Other systemic medications should be continued.
Therapeutic Tips
Any changes to postoperative ophthalmic medications should be discussed with the treating ophthalmologist.
Initiate topical antibacterials immediately following surgery rather than waiting until the first postoperative day.6,7,8
Advise patients to separate the administration of different eye drops by a period of at least 5 minutes. Counsel them to close the eye and put pressure on the inner canthus after instilling drops in order to reduce the transfer of ophthalmic medication to the nasal and/or oral mucosa where it can be absorbed systemically. Any worsening of vision, floaters or eye redness, especially in the first postoperative week, should be considered endophthalmitis until proven otherwise and requires urgent assessment by an ophthalmologist.
Treatment with many medications in this setting is for a limited course, therefore any remaining ophthalmic medication should be disposed of properly. Patients having clear corneal cataract surgery should take all their usual medications, including anticoagulants and antiplatelet agents, on the day of surgery.
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Figure 1: Evaluation of the Postoperative Cataract Patient by the Primary Care Practitioner
Drug Tables Table 1: Antibacterials for Cataract Surgery Postoperative Care Class
Drug
Aminoglycosides
tobramycin, ophthalmic Tobrex, generics
Aminoglycoside Combinations
neomycin/dexamethasone /polymyxin B sulfate, ophthalmic Maxitrol
Duration
Adverse Effects
Comments
7–10 days
Extended use may cause conjunctivitis or epitheliopathy reactions to the eye.
High concentrations on and in the eye lead to broader bacterial coverage than traditional in vitro testing suggests.
7–10 days
Extended use may cause conjunctivitis or epitheliopathy reactions to the eye. Dexamethasone: Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
High concentrations on and in the eye lead to broader bacterial coverage than traditional in vitro testing suggests.
$
Costa $
Dexamethasone: commonly used after all types of eye surgery.
Antibiotic Combinations
bacitracin ± polymyxin B ± gramicidin, ophthalmic Polysporin, generics
7–10 days
Allergic/hypersensitivity reactions.
Good broadspectrum coverage but hypersensitivity reactions in some patients, especially with longer use.
$
Fluoroquinolones
besifloxacin, ophthalmic Besivance
7–10 days
Blurred vision, local irritation or discomfort.
4th generation fluoroquinolone; improved broadspectrum activity,
$$
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Class
Drug
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Adverse Effects
Comments especially against gram-positive organisms.
Costa
Fluoroquinolones
ciprofloxacin, ophthalmic Ciloxan, generics
7–10 days
Formation of white crystalline precipitate on a corneal defect after administration.
Excellent broadspectrum profile and minimal ocular surface toxicity; very commonly used; may be used orally if lens capsule ruptured during cataract surgery.
$
Fluoroquinolones
ciprofloxacin, oral Cipro, Ciprofloxacin, other generics
500 mg Q12H po × 7–10 days
Abdominal pain, headache, dizziness, photosensitivity, hepatitis, pseudomembranous colitis, cartilage toxicity.
Used orally if lens capsule ruptured during cataract surgery.
$$
Fluoroquinolones
gatifloxacin, ophthalmic Zymar
7–10 days
Well tolerated and minimal eye toxicity with topical administration. Allergic reactions uncommon.
4th generation fluoroquinolone; improved broadspectrum activity, especially against gram-positive organisms.
$$
Well tolerated and minimal eye toxicity with topical administration. Allergic reactions uncommon.
4th generation fluoroquinolone; improved broadspectrum activity, especially against gram-positive organisms.
$$
Well tolerated and minimal eye toxicity with topical administration. Allergic reactions uncommon.
Excellent broadspectrum profile and minimal ocular surface toxicity; very commonly used; may be used orally if lens capsule ruptured during cataract surgery.
$
Abdominal pain, headache, dizziness,
Used orally if lens capsule
$$$
Blurred vision, local irritation or discomfort. Fluoroquinolones
moxifloxacin, ophthalmic Vigamox
7–10 days
Blurred vision, local irritation or discomfort. Fluoroquinolones
ofloxacin, ophthalmic Ocuflox, generics
7–10 days
Blurred vision, local irritation or discomfort.
Fluoroquinolones
ofloxacin, oral generics
400 mg Q12H po
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Drug
Duration
× 7–10 days
a
Adverse Effects
Comments
photosensitivity, hepatitis, pseudomembranous colitis, cartilage toxicity.
ruptured during cataract surgery.
Costa
Cost of smallest available pack size or 10-day supply for oral treatment; includes drug cost only.
Dosage adjustment may be required in renal impairment; see Dosage Adjustment in Renal Impairment.
Legend:
$ < $10
$$ $10–20
$$$ $20–30
Table 2: Glaucoma Medications for Cataract Surgery Postoperative Care Class
Drug
Duration
Adverse Effects
Comments
Alpha2adrenergic Agonists
apraclonidine Iopidine
Used as long as intraocular pressure is elevated, or permanently in patients with pre-existing glaucoma
Common ocular reactions include hyperemia and a burning sensation.
Potent in controlling postoperative pressure spikes; avoid in patients with severe cardiovascular disease in light of alpha-adrenergic effects; use with caution in patients taking tricyclic antidepressants.
Alpha2adrenergic Agonists
brimonidine 0.2% Alphagan, generics
Used as long as intraocular pressure is elevated, or permanently in patients with pre-existing glaucoma
Common ocular reactions include hyperemia and a burning sensation.
Potent in controlling postoperative pressure spikes; avoid in patients with severe cardiovascular disease in light of alpha-adrenergic effects; use with caution in patients taking tricyclic antidepressants.
$
Alpha2adrenergic Agonists
brimonidine 0.15% Alphagan P, generics
Used as long as intraocular pressure is elevated, or permanently in patients with pre-existing glaucoma
Common ocular reactions include hyperemia and a burning sensation.
Potent in controlling postoperative pressure spikes; avoid in patients with severe cardiovascular disease in light of alpha-adrenergic effects; use with caution in patients taking tricyclic antidepressants.
$
Costa $$$
Contains purite as preservative rather than benzalkonium chloride; may have slightly lower incidence of ocular allergy than brimonidine 0.2%.
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Cost of smallest available pack size or 30-day supply of oral therapy; includes drug cost only.
Dosage adjustment may be required in renal impairment; see Dosage Adjustment in Renal Impairment.
Legend:
$ < $10
$$ $10–20
$$$ $20–30
$$$$ $30–40
Table 3: Ophthalmic Anti-inflammatories for Cataract Surgery Postoperative Care Class
Drug
Corticosteroids
dexamethasone Maxidex
Corticosteroids
Corticosteroids
Corticosteroids
Corticosteroids
Corticosteroids
Duration
Adverse Effects
Comments
3–4 wk; longer if evidence of cystoid macular edema
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Commonly used after all types of eye surgery.
difluprednate 0.05% Durezol
Start 24 h after surgery, continue × 2 wk then taper. 1 drop into conjunctival sac of affected eye QID
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Preservative is sorbic acid.
$$$
fluorometholone Flarex, FML, generics
3–4 wk; longer if evidence of cystoid macular edema
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Commonly used after all types of eye surgery.
$
loteprednol 0.5% Lotemax, , Lotemax Gel, , Lotemax Ointment
3–4 wk; longer if evidence of cystoid macular edema
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Commonly used after all types of eye surgery.
$$$
prednisolone Pred Mild, Pred Forte, Minims Prednisolone, generics
3–4 wk; longer if evidence of cystoid macular edema
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Commonly used after all types of eye surgery.
$
rimexolone Vexol
3–4 wk; longer if evidence of cystoid macular edema
Elevated intraocular pressure; anti-inflammatory effects can mask signs of infection.
Commonly used after all types of eye surgery.
$$
Costa $
Less elevation of intraocular pressure compared to dexamethasone or prednisolone, but less potent.
Less elevation of intraocular pressure compared to dexamethasone or prednisolone.
Minims prednisolone are preservative-free.
Less elevation of intraocular pressure compared to dexamethasone or prednisolone.
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Class
Drug
NSAIDs
bromfenac Prolensa
NSAIDs
https://www.e-therapeutics.ca/print/new/documents/CHAPTER/en/c0017 Duration
Adverse Effects
Comments
Start 1 day before surgery; continue on day of surgery then for 2 wk postoperatively, longer if evidence of cystoid macular edema 1 drop in affected eye once daily
Mild to moderate burning on instillation; epitheliopathy and possible ulceration with prolonged and frequent use. Specific to bromfenac: possible eye pain, anterior chamber inflammation.
Used as a substitute for corticosteroids, to decrease inflammation without the risk of elevating intraocular pressure; reduces risk of developing cystoid macular edema; should not be used in patients with asthma or allergies to ASA or NSAIDs. Bromfenac contains sodium sulfite, which may cause an allergic reaction.
diclofenac Voltaren Ophtha, generics
3–4 wk; longer if evidence of cystoid macular edema
Mild to moderate burning on instillation; epitheliopathy and possible ulceration with prolonged and frequent use.
Used as a substitute for corticosteroids, to decrease inflammation without the risk of elevating intraocular pressure; reduces risk of developing cystoid macular edema; should not be used in patients with asthma or allergies to ASA or NSAIDs.
$$
NSAIDs
ketorolac Acular, Acuvail, generics
3–4 wk; longer if evidence of cystoid macular edema
Mild to moderate burning on instillation; epitheliopathy and possible ulceration with prolonged and frequent use.
Used as a substitute for corticosteroids, to decrease inflammation without the risk of elevating intraocular pressure; reduces risk of developing cystoid macular edema; should not be used in patients with asthma or allergies to ASA or NSAIDs.
$
NSAIDs
nepafenac 0.1% Nevanac
Start 1 day before surgery; continue on day of surgery then
Mild to moderate burning on instillation; epitheliopathy and
Used as a substitute for corticosteroids, to decrease
$$$
Costa $$$
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Class
Drug
NSAIDs
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nepafenac 0.3% Ilevro
Duration
Adverse Effects
Comments
for 2 wk postoperatively, longer if evidence of cystoid macular edema 1 drop in affected eye TID
possible ulceration with prolonged and frequent use. Eyelid margin crusting, eye pain, punctate keratitis, blurred vision, dry eye, pruritis, headache.
inflammation without the risk of elevating intraocular pressure; reduces risk of developing cystoid macular edema; should not be used in patients with asthma or allergies to ASA or NSAIDs. Shake well before using.
Start 1 day before surgery; continue on day of surgery then for 2 wk postoperatively, longer if evidence of cystoid macular edema 1 drop in affected eye once daily
Mild to moderate burning on instillation; epitheliopathy and possible ulceration with prolonged and frequent use. Eyelid margin crusting, eye pain, punctate keratitis, blurred vision, dry eye, pruritis, headache.
Used as a substitute for corticosteroids, to decrease inflammation without the risk of elevating intraocular pressure; reduces risk of developing cystoid macular edema; should not be used in patients with asthma or allergies to ASA or NSAIDs. Shake well before using.
Costa
$$$
Cost of smallest available pack size; includes drug cost only.
Legend:
$ < $10
$$ $10–20
$$$ $20–30
Table 4: Ophthalmic Dilators and Cycloplegics for Cataract Surgery Postoperative Care Class
Drug
Duration
Adverse Effects
Comments
Dilators and Cycloplegics
cyclopentolate Cyclogyl, generics
First few weeks after surgery
Uncommonly, systemic anticholinergic side effects (e.g., flushing, tachycardia, urinary retention).
Less commonly used with modern cataract surgery in light of smaller incisions and less postoperative inflammation.
Dilators and Cycloplegics
phenylephrine Mydfrin, generics
First few weeks after surgery
Rarely, tachycardia and hypertension.
Less commonly used with modern cataract surgery in light of smaller incisions and less postoperative inflammation.
$
Dilators and Cycloplegics
tropicamide Mydriacil, generics
First few weeks after
Uncommonly, systemic anticholinergic side
Less commonly used with modern cataract surgery in light of
$$
Costa $$
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Class
Drug
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a
Adverse Effects
Comments
effects (e.g., flushing, tachycardia, urinary retention).
smaller incisions and less postoperative inflammation.
Costa
Cost of smallest available pack size; includes drug cost only.
Legend:
$ < $10
$$ $10–20
Suggested Readings
American Academy of Ophthalmology. Cataract and Anterior Segment Panel. Preferred practice pattern: cataract in the adult eye. San Francisco (CA): American Academy of Ophthalmology; 2011. Available from: one.aao.org/preferred-practice-pattern/cataractin-adult-eye-ppp--october-2011. Fintelmann RE, Naseri A. Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions. Drugs 2010;70(11):1395-409. Gerstenblith AT, Rabinowitz MP. The Wills eye manual: office and emergency room diagnosis and treatment of eye disease. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2012. Harper RA, ed. Basic ophthalmology. 9th ed. San Francisco (CA): American Academy of Ophthalmology; 2010. Tasman W, Jaeger EA, eds. Duane's ophthalmology on DVD-ROM. 2013 ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2012.
References 1. Allen HF, Mangiaracine AB. Bacterial endophthalmitis after cataract extraction. II. Incidence in 36,000 consecutive operations with special reference to preoperative topical antibiotics. Arch Ophthalmol 1974;91(1):3-7. 2. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002;109(1):13-24. 3. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98(12):1769-75. 4. Callegan MC, Ramirez R, Kane ST et al. Antibacterial activity of the fourth generation flouroquinolones gatifloxacin and moxifloxacin against ocular pathogens. Adv Ther 2003;20(5):246-52. 5. Deramo VA, Lai JC, Fastenberg DM et al. Acute endophthalmitis in eyes treated prophylactically with gatifloxacin and moxifloxacin. Am J Ophthmol 2006;142(5):721-5. 6. Jensen MK, Fiscella RG, Crandall AS et al. A retrospective study of endophthalmitis rates comparing fluoroquinolone antibiotics. Am J Ophthalmol 2005;139(1):141-8. 7. Jensen MK, Fiscella RG, Moshifar M et al. Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over ten years. J Cataract Refract Surg 2008;34(9):1460-7. 8. Lloyd JC, Braga-Mele R. Incidence of postoperative endophthalmitis in a high-volume cataract surgicentre in Canada. Can J Ophthalmol 2009;44(3):288-92. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-02-2016 11:17 AM] RxTx, Compendium of Therapeutic Choices © Canadian Pharmacists Association, 2016. All rights reserved
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