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Is a day 1 postop review necessary after pars plana vitrectomy?
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Day 1 mandatory for IOP measurement, pain control, reassurance
In my opinion, the answer is a resounding, absolute yes. The first and most important data point necessary to reduce risk in any intraocular surgical procedure is an accurate IOP measurement within 24 ± 10 hours postoperative. Failure to detect and treat a high pressure could lead to permanent vision loss. Hypotony detection will likely lead to a very different series of instructions. Next, the patient’s pain is an important variable to actively manage and seems to peak during this interval. There are other issues that may be unexpected and best managed when recognized early in the course of events. Examples include choroidal detachments (serous or hemorrhagic), intraocular lens malposition, loose sutures or corneal defects.
Before surgery, patients tend to focus only on the surgery. Despite your best attempts to educate them about postoperative instructions, most do not listen. However, once the surgery is behind them (ie, postoperative day 1), they are completely focused on any suggestions or instructions and will listen to most suggestions from the surgeon. Reassurance in cases without incident is also extremely beneficial at this point in the surgical process. Most patients greatly appreciate the care and attention, the time for further education, or simply the opportunity to ask questions that have evolved since their surgery. In my own experience, I commonly modify my written instructions based on the findings from the exam on postoperative day 1.
Timothy W. Olsen, MD, is an OSN Retina/Vitreous Board Member. Disclosure: Olsen reports no relevant financial disclosures.
More to gain in safety and convenience by postponing to day 2
Why do we see our vitreoretinal surgery postop patients the next day? Because we have always done it that way. It is standard. Yet other surgical specialists see their postop patients a week or two after surgery. On postoperative day 1 (POD1), we check on basically three things. Wound leaks may manifest as hypotony and are virtually always managed conservatively with prompt resolution. Endophthalmitis, rare after pars plana vitrectomy, presents on average 3 days after surgery, meaning it will not yet be apparent on POD1. Elevated IOP, particularly if gas or oil is used, may manifest on POD1, but it is usually symptomatic, causing pain. It may also develop later in the following days.
We reviewed 134 patients undergoing vitreoretinal surgery who received a postoperative day 2 (POD2) exam rather than a POD1 exam. All patients received a technician phone call on POD1 to make sure the patient could see their hand moving and that their pain was not severe. Those both triggered a POD1 exam. Only one patient was seen on POD1 due to pain from elevated pressure, which was treated in office. Six patients had a pressure above 30 mm Hg on POD2, all treated medically. No cases of endophthalmitis or wound leak occurred.
Could the POD2 exam miss something significant on POD1? Possible but unlikely. Conversely, a POD1 exam would miss a pressure spike or endophthalmitis occurring on postoperative day 3. Self-reporting of symptoms by patients remains crucial in the postoperative period.
The main advantage of offering a POD2 exam is allowing patients to see their surgeon in a more convenient office location, particularly in large multi-office retina practices in which physicians travel between offices. This avoids a “handoff” to another surgeon with potential communication errors while enhancing convenience for patients and their caregivers.
- Reference:
- Zick J, et al. Retina. 2017;doi:10.1097/IAE.0000000000001544.
Brian C. Joondeph, MD, practices at Colorado Retina Associates, Denver. Disclosure: Joondeph reports no relevant financial disclosures.