Careful monitoring can determine expected, unexpected findings after no-stitch phaco

In the constantly changing patient care environment, optometrists are taking a more active role in the postoperative care of patients. Ophthalmologists and optometrists are working more closely and harmoniously than ever before.

Cataract extraction and IOL implantation are achieved with a variety of surgical techniques, extracapsular extraction and phacoemulsification. In a 1991 study, phacoemulsification was preferred by 66% of the members of the American Society of Cataract and Refractive Surgery. Since that time, the majority of highly skilled, high-volume cataract surgeons use no-stitch phacoemulsification under topical anesthesia. Although it has been shown that cataract extraction is a safe and effective way to restore good vision, it is not without complications.

Pre- and postop care

A discussion of cataract extraction and postoperative care can assist in the management of patients with and without complications. It is good practice to inform the patient about the day in surgery, step-by-step. A description of the surgical process helps the patient better understand the surgery. Moreover, an approximate time schedule will ease the patient and his or her family. Lastly, a discussion of common complications and their management is crucial in allowing a patient to make an intelligent decision about the procedure.

Day 1 postop

On the first day after surgery, the patient should be relatively comfortable. Any complaints of pain should be investigated further. Reports of mild discomfort, glare, mild tearing, photophobia, redness and itching are all expected symptoms.

Patients may also experience a reflection from the edge of the implant. This usually disappears as the dilation diminishes. On occasion, if the intraocular pressure (IOP) is elevated, a headache may occur on the operated side. On rare occasions, the patient may experience nausea from elevated IOP or anesthesia. This should resolve itself in a few days.

Visual acuity can vary depending on the surgeon's intentions, accurate IOL choice, creation of surgical astigmatism, successful reduction of preoperative astigmatism or the amount of inflammation. A pinhole or quick refraction will give you the most accurate result. If the vision is decreased but all other findings are normal, patient reassurance and follow-up in 1 week is all that is necessary.

A mild ptosis may be present, but this will usually resolve over a 2-week period. Surgical correction is optional if the ptosis is still present in 6 months.

Conjunctival, corneal edema expected

---Hyphema 3 days postop in a 52-year-old male. While this condition may obscure vision, it usually resolves over time.

Conjunctival injection is almost always present. A subconjunctival hemorrhage may occur with more severity over the incision. This will resolve in a few days to a few weeks, depending on the severity. If conjunctival edema is present, it will resolve within a few days.

Small amounts of corneal edema may be present. This will usually resolve in a few days. Stromal edema, Descemet's folds and striae are rare and usually resolve in a few weeks.

An anterior chamber reaction, including a cell response of up to 3+ and up to 1+ flare, is expected. Hyphema may also be present. Smaller hyphema will resolve in a few weeks; larger hyphema may take up to a month. Cortex may be observed in the inferior aspect of the anterior chamber. This will usually re-absorb within a few weeks.

The wound may appear to have a gap on the first day with no-stitch surgery. This is normal. A conjunctival injection over the wound and a negative Seidel's sign are also expected.

The IOL should be centered and stable, and the posterior capsule should be clear. Small decentrations of less than 1 mm are of little concern. Small wrinkles in the capsule are expected and may persist, but they usually do not affect vision.

The vitreous and retina are expected to be clear after surgery. Any variation from this, with the exception of a new vitreous detachment, requires a prompt referral. If a new posterior vitreous detachment is noted, a dilated fundus examination is crucial in ruling out a retinal detachment.

Intraocular pressures up to 30 mmHg are acceptable in the normal eye. Pressures of 30 or more require hypotensive therapy. Patients with preexisting glaucoma may not tolerate pressures over 20. Confrontation fields and motilities should be normal.

Review postop course, therapy

A review of the postoperative course and medications are crucial. In our office, we use TobraDex (tobramycin dexamethasone, Alcon) and Profenal (suprofen, Alcon) four times daily for 1 week, then taper to twice daily for 2 weeks. We ask the patient to keep the eye dry for 1 week and caution against rubbing it. We also request that the patient does not strain or lift heavy objects for a few days. Finally, we instruct the patient to call the office immediately if experiencing pain or loss of vision.

All of the above signs and symptoms are expected variations of normal day 1 postoperative recovery.

One-week visit

---Hypopyon secondary to endophthalmitis: This 62-year-old female demonstrated this condition 2 weeks postop. Endophthalmitis is treated with topical, subconjunctival and intravitreal antibiotics, and topical and oral steroids are often used.

At 1 week, the patient should be reasonably comfortable as the history is taken. There may be complaints of mild redness and discomfort. Uncorrected visual acuity should be good unless the surgeon was striving for a specific refractive error. The conjunctiva may still be injected, and a subconjunctival hemorrhage may persist. The cornea should be clear. On rare occasions, folds in Descemet's membrane may persist. The anterior chamber should demonstrate no more than 1+ to 2+ cell and no flare. If 2+ cell is noted, the patient should remain on the TobraDex four times daily for an extra week before titration. If more than 2+ cell is noted, endophthalmitis must be considered, and the patient should immediately be referred.

The wound site may still show moderate injection radiating from it. This should resolve with time. The IOL should be centered, and the posterior capsule should be clear. The vitreous and retina should be clear and quiet. The IOP should be in the normal range. If the patient is responding to the steroid (which should happen about 7 days after initial use), changing the steroid to a nonsteroidal anti-inflammatory agent may decrease the IOP. Pupils, confrontation fields and motilities should be normal.

A review of the patient's medications is necessary. Assuming the patient is healing on schedule, he or she may wet the eye and return to normal activities. Finally, the patient is instructed to call the office if experiencing a sudden loss or change in vision.

Three-week visit

The patient should be comfortable and asymptomatic with the exception of refractive needs. Uncorrected visual acuity should be good, depending on the surgical plan. Refraction should yield a good visual outcome depending on presurgical expectations and visual potential of the eye.

Motilities, confrontation fields, pupils and IOP should be normal. The clinical findings, including external observation, slit-lamp examination and dilated fundus examination, should be normal or as expected. The IOL should be centered and stable, and the posterior capsule should be clear.

Three-month/6-month visit

The patient's exam findings after 3 months should be normal or as expected with the possible exception of posterior capsule haze. If this is present, the patient may require a YAG posterior capsulotomy.

Most patients follow a variation of the described uncomplicated postoperative schedule. However, clinicians must be aware of the complications and the time frame in which they occur.

Diagnosing complications

If a patient suffers complications following cataract surgery, a dilated comprehensive evaluation of the eye is crucial. Upon inspection of the eye, the clinician should be aware of any preexisting conditions. Moreover, in the event of a complication, the patient should be educated and surgeon notified.

Diplopia/ptosis

---Retinal detachment: Three months postop, this 67-year-old female had visual acuity of 20/400 secondary to this condition.

Two late complications of cataract extraction are diplopia and ptosis. About 13% of patients have ptosis following cataract extraction. Most ptosis is transient in nature. Ptosis is usually caused by surgical stretching of the levator by the lid speculum or superior rectus bridle suture in older style surgery. If by 6 weeks the ptosis is still present, the patient should be informed that if it has not resolved by 6 months surgical repair may be necessary.

Diplopia is another late and rare complication of cataract surgery. The major causes of diplopia following cataract surgery are refractive errors following extraction and tissue damage caused by the surgery, or the diplopia can be secondary to preexisting conditions. Monocular diplopia can be caused by preexisting conditions, such as macular and corneal changes, uncorrected refractive error, spherical aberrations and decentration of the IOL.

All other causes of diplopia must be ruled out. Monocular diplopia is usually correctable by prescribing glasses for the impaired eye. If the causative agent is IOL decentration or spherical aberration, a mild miotic may be prescribed (0.5% pilocarpine three times daily is commonly used in our office). If this is not well tolerated, discussion with the surgeon is necessary to consider IOL replacement or repositioning.

In the case of binocular diplopia, prism neutralization can be considered. The amount of prism deviation can change over a 6-month period. Therefore, surgical correction of the strabismus should be deferred for at least 6 months. A Fresnel prism is commonly used to neutralize diplopia for the first 6 months. If the patient is happy with the amount of prism correction, a ground in prism is recommended. Surgery is only recommended if the patient absolutely cannot tolerate the ground in prism. This complication was rarely seen with retrobulbar block and was almost never seen with topical anesthesia.

Corneal edema

A small degree of corneal edema may be present after surgery. However, it is usually transient in nature. Diffuse epithelial edema may occur from acutely increased IOP greater than 35 mm Hg to 40 mm Hg in the normal cornea.

Postoperative corneal edema may be divided into chronic and acute. Acute corneal edema usually presents as either microcystic epithelial edema or folds in Descemet's membrane. Epithelial edema is usually caused by IOP spikes from retained viscoelastic and should disappear quickly with IOP control. Stromal edema evidenced by folds in Descemet's membrane is usually the result of surgical trauma or insult to an already compromised endothelium. Acute corneal edema usually resolves within the first few weeks after cataract surgery.

Chronic corneal edema or pseudophakic bullous keratopathy may lead to corneal decompensation and is the leading cause of penetrating keratoplasty.

Clinically, corneal edema may present as fluctuating or poor vision that is usually worse in the morning. A thickened cornea is almost always present, occasionally with folds in Descemet's membrane. Epithelial microcysts may be present; in more severe cases, epithelial bullae may be present. In advanced corneal edema, corneal erosions may present secondary to ruptured bullae. Small Descemet's detachment may lead to stromal edema at the site of the detachment. Large Descemet's detachment may require surgical repair.

Most corneal edema will resolve with time. If postoperative corneal edema persists at week 1 with normal IOP, exchange TobraDex for Pred Forte 1% (prednisolone acetate, Allergan) every 1 to 3 hours, and recheck in one week. If edema still persists, hyperosmotic agents, such as Muro 128 (sodium chloride hypertonicity agent, Bausch & Lomb), may be added. If edema is not gone by 1 month, the patient should be referred for surgical evaluation. If corneal edema becomes chronic, it is termed as pseudophakic bullous keratopathy and most likely will require surgery.

Wound leak

Although wound leaks are not common, they can be cumbersome to manage. They are caused by wound architecture, tissue contraction due to phaco burn or insufficiently or overly tight sutures in the incision.

Typically, patients will present with a positive Siedel sign, low IOP, wound gap and a shallow anterior chamber. Other signs of wound leak may be an against-the-rule shift on postoperative keratotomy, corneal stromal edema secondary to hypotony and occasionally anterior synechia. More rare complications include a flat anterior chamber; disc edema due to hypotony; a pupil pulled toward the wound incision, if the iris is incarcerated in the wound, and endophthalmitis.

To treat wound leaks, add a few drops of either Ciloxan (ciprofloxacin HCl, Alcon) or Ocuflox (ofloxacin, Allergan). Apply a pressure patch and shield at night. Recheck IOP in 24 hours. If the pressure has not increased, repatch another 24 hours; if IOP is still low, refer the patient for surgical evaluation. In the case of a flat anterior chamber, immediate referral is necessary.

Hemorrhage/hyphema

A hemorrhage or hyphema is one of the most unnecessarily alarming disorders following cataract surgery. Often, the patient is in a state of panic because vision may be obscured from the hyphema. Moreover, a subconjunctival hemorrhage may look dangerous to the patient. Both conditions resolve nicely with time.

Hyphema usually occurs 1 day after cataract surgery; however, it may occur 2 to 14 days later. It is characterized as red blood cells in the anterior chamber. Occasionally, the patient may present with blood staining on the iris. Blurred vision, which is worse upon waking, is commonly reported in the case of a large hyphema. Some patients may present with increased IOP and, in rare cases, cystoid macular edema. A subconjunctival hemorrhage commonly follows cataract surgery. This occurs when blood is trapped in the subconjunctival space.

If the IOP is not elevated, no treatment is required. Patient reassurance, instruction and clinical observation is appropriate. An eye shield should be worn until the hyphema resolves. The patient should be instructed to sleep with his or her head elevated at a 45° angle and restrict all activity. If the IOP is elevated, hypotensive therapy is indicated. A subconjunctival hemorrhage should be managed with patient reassurance and education.

Endophthalmitis

Endophthalmitis is one of the most visually disruptive postoperative complications. It is a massive intraocular infection or sterile immune response due to surgical trauma or retained lens debris. Occurrence has been reported to be as high as 0.5% after cataract surgery. The most common offending agent is Staphylococcus epidermidis followed by Staphylococcus aureus, Streptococcus species, gram-negative species, Propionibacterium Acnes, fungi and Corynebacterium.

Depending on the causative agent, the onset may be between 1 day and a few months following cataract surgery. However, most cases occur between 1 day and 2 weeks. Patients may present with decreased vision, pain in and around the eye, edema of the lid, conjunctiva and cornea, a severe anterior chamber reaction, hypopyon, inflammatory reaction in the vitreous, a dull red reflex or loss of red reflex, suppuration of the wound, increased IOP, retinal or optic nerve damage (afferent pupillary defect), cystoid macular edema and a cyclitic membrane formation.

Endophthalmitis may be difficult to diagnose, because patients may have between one and all of the above complications. It is better to assume endophthalmitis until proven otherwise.

Endophthalmitis is treated with topical, subconjunctival and intravitreal antibiotics. Moreover, topical and oral steroids are often used. If more inflammation than expected is present, endophthalmitis should be suspected. The patient should be referred for a culture, anterior chamber and vitreous tap immediately. Additionally, the surgeon should be contacted immediately.

Increased IOP

---Bullous keratopathy: Two years postop, this 79-year-old male had visual acuity of counting fingers at 3 feet. Bullous keratopathy usually requires surgery.

Increased IOP on day 1 is common following cataract surgery with any technique. The increase is usually caused by retained viscoelastic, residual inflammation, steroid response or pupillary block. Patients with glaucoma are more susceptible to pressure spikes following cataract surgery.

Commonly, patients will complain of an ipsilateral headache or pain. Corneal edema may be present in patients with significantly elevated IOP. Moreover, microcystic epithelial edema without stromal edema is common with increased IOP.

It is uncommon for patients with postoperative IOP spike to still have IOP elevation at 1 week. If patients have elevated IOP, the practitioner must consider a steroid response. If the eye is healing well, consider changing the steroid to a nonsteroidal anti-inflammatory agent four times daily for 1 week. Recheck the IOP in 2 to 3 days. If the pressure is still elevated, consider adding a beta-blocker as long as a history is taken for lung disease, asthma and cardiac disease prior to use.

Patients with pseudophakic pupillary block require a prompt referral for surgical intervention (laser iridotomy).

IOL dislocation

IOL dislocation is an unusual complication following cataract surgery. A dislocated lens is classified as a lens that has partially moved from its original position. A subluxated lens is one that is completely detached.

Patients with lens abnormalities may complain of distortion, blurred vision and glare from the edge of the lens. Patients may or may not have pain depending on location.

The clinician can usually see the displaced lens upon slit-lamp examination. If the lens is touching the cornea, corneal edema may be present. Vitreal inflammation or retinal involvement may occur if the lens subluxates and falls into the posterior chamber.

Mild lens decentrations may be well tolerated. In the symptomatic patient, pilocarpine 0.5% three times daily may relieve symptoms. If symptoms persist, a referral to the surgeon will allow him or her to reposition or replace the IOL.

Pupillary capture occurs when the lens is partially in front and behind the iris. Dilation with phenylephrine 2.5% and tropicamide 1.0% may allow the IOL to fall into the correct position. If the lens falls into the correct position, pilocarpine 2% four times daily should be used for 2 weeks. This will allow the IOL to firmly adhere and stay in place. If pupillary capture is left untreated, a chronic iritis may ensue.

Posterior capsule opacification

Posterior haze of the capsule occurs in about 20% to 50% of all cases. The younger the patient, the more posterior capsular haze will be seen. Frequently, there is little correlation between the amount of capsular haze and the patient's symptoms; therefore, history is crucial.

Posterior subcapsular haze is observable upon slit-lamp examination. Patients usually return with complaints that their cataract is growing back. They may have decreased vision, glare and photophobia.

YAG laser, posterior capsulotomy is a simple, effective and low-risk procedure for treating posterior capsule haze.

Retinal detachment

The incidence of retinal detachment and retinal breaks have been reported to be from 0.5% to 2% following cataract surgery. Appropriate patient counseling can save a patient from losing his or her vision.

Patients complain of a sudden onset of flashes and floaters. Moreover, they may have decreased vision if the macula is involved. Visual field loss and an afferent pupil are common signs of a retinal detachment. Pigment in the anterior vitreous, called Shafer's sign or tobacco dust, is also indicative of a retinal detachment. A retinal detachment or tear is observable with direct or indirect ophthalmoscopy.

The patient's visual outcome depends on a timely treatment of the detachment. The patient should be educated and prepared for surgery. He or she should be told not to eat or drink and to limit activity. The longer the span from detachment to repair, the greater the chance of macular involvement and irreversible visual damage.

Cystoid macular edema

Cystoid macular edema (CME): Two months postop, this 70-year-old male had a best-corrected visual acuity of 20/40 secondary to CME, one of the most common postop complications leading to visual acuity loss.

Cystoid macular edema (CME) is one of the most common complications leading to visual acuity loss with and without complications. It is caused by leakage from perifoveal capillaries leading to cystic swelling of the fovea. CME is most commonly caused by intraoperative trauma or postoperative inflammation. It is clinically significant in fewer than 1% of all patients following cataract surgery.

CME usually occurs 4 to 36 weeks following cataract surgery. Patients' vision usually fluctuates between 20/50 and 20/200. Patients often complain of metamorphopsia and blurred vision. Posterior segment evaluation will reveal retinal bullae surrounding the fovea. Moreover, wrinkling of the internal limiting membrane is usually present.

Most cases will resolve with time and observation. Many advocate the use of steroids and prostaglandin inhibitors. We use Pred Forte every 3 hours, Acular (ketorolac tromethamine, Allergan) or Ocufen (flurbiprofen sodium, Allergan) four times daily and Indocin (indomethacin, Merck) 250 mg three times daily for 1 month and then reevaluate.

Less common complications

Anterior ischemic optic neuropathy has been reported to be associated with cataract surgery. Because it is a visually devastating disorder, early recognition and prompt referral is essential.

Expulsive choroidal hemorrhage is another visually devastating complication. This occurs when blood accumulates in the subarachnoid space causing the ciliary body and choroid to detach from the sclera. The clinician will observe a large dark mound pushing the retina forward. If this is detected, a prompt referral is indicated. Iris prolapse and vitreous to the wound are extremely rare complications with the advanced surgical techniques.

For Your Information:

• Bruce A. Levinson, OD, FAAO, and George O. Temnycky, MD, can be contacted at 5100 West Taft Rd., Suite 31, Liverpool, NY 13088; (315) 458-2020, fax: (315) 695-7020. Neither Dr. Levinson nor Dr. Temnycky has a direct financial interest in any of the products mentioned in this article, nor is either a paid consultant for any company mentioned.