Determine patients’ past, present medication use before cataract surgery

One key to effectively comanaging cataract surgery patients is to solicit a thorough list of current and prior drugs used by the patient to avoid intraoperative or postoperative surgical complications.

Ask about non-prescription agents

For example, practitioners should ask their pending cataract surgery patients if they are on any anticoagulants, such as aspirin, as these products can increase the risk of bleeding during cataract surgery. “Many patients undergoing cataract surgery are older, so there is a high likelihood that they are taking aspirin prophylactically,” Leonid Skorin Jr., OD, DO, FAAO, FAOCO, senior staff ophthalmologist at the Albert Lea Eye Clinic in Albert Lea, Minn., told Primary Care Optometry News in an interview. “Older patients may also have had some cardiac event or a previous cerebral vascular event for which they were put on an 81-mg low-dose aspirin or they may be taking adult aspirin.”

Similarly, patients scheduling cataract surgery may have problems with arthritis or have other aches and pains. “These patients may be taking nonsteroidals, such as Advil (ibuprofen, Wyeth), Aleve (naproxen, Bayer) and Motrin (McNeil, ibuprofen). You can list a whole slew,” Dr. Skorin said. “Often, these products are being taken by patients on their own. The physician may not even be aware.”

Other popular over-the-counter medications are ginkgo biloba, used primarily as a memory enhancer and anti-vertigo agent and high doses of vitamin E. “All of these products can definitely act as anticoagulants,” Dr. Skorin said. “But patients may not think of listing them as a medication. Therefore, it is important that the practitioner ask the patient if he or she is taking any over-the-counter medications or vitamin supplements or any pain medications independently. Otherwise, the surgeon may find increased bleeding that is not anticipated during cataract surgery.”

Prescription drugs

Dr. Skorin tells his cataract patients to stop taking all anticoagulant medicines 1 week before surgery. “When I see my patients the next morning after surgery, I let them know they can resume these products the same day, if they are recovering well,” he said. “However, if someone has had a serious cardiac event or multiple strokes and is directed to be on aspirin by a doctor, I may not stop the aspirin. But I will make a note in my records, so when I perform the actual surgery I will take different precautions.

“I request that patients stop Coumadin (warfarin, DuPont) 2 to 3 days before surgery, unless there is some contraindication,” he continued.

One of Dr. Skorin’s recent cataract surgery patients had a pulmonary embolism and was taking Coumadin. “This is a patient I did not take off Coumadin or she may have died,” he said. “But most patients are able to stop the medication before surgery. Then after seeing them the day after surgery, they resume Coumadin, assuming that everything checks out well.”

Systemic alpha-adrenergic receptor antagonists or blockers used to treat the urinary symptoms of benign prostatic hypertrophy (BPH) should also be given special consideration so intraoperative floppy iris syndrome (IFIS) can be controlled. The prostate drug tamsulosin HCl (Flomax, Boehringer Ingelheim) “is the most commonly prescribed drug in this class because it is more specific and selective,” Dr. Skorin said. “Compared to the other drugs in this class, Flomax does not cause as much of a blood pressure drop in the patient.”

Alpha-adrenergic receptor antagonists are also used off-label by urologists to treat women with urinary retention or urinary hesitancy.

Other prescription medications in this class for treating BPH are terazosin (Hytrin, Abbott Laboratories), doxazosin mesylate (Cardura, Pfizer) and alfuzosin (Uroxatral, Sanofi-Synthelabo).

In addition, saw palmetto (sereon repens) is a non-prescription herb used by some people as a natural treatment for BPH. “Anecdotally, this herb has been shown to perhaps cause IFIS,” Dr. Skorin said.

Dr. Skorin does not advise his patients to stop taking any of these drugs “because most studies indicate that the damage that occurs to the iris muscle is permanent. So you’re not going to gain any benefit from stopping the medication,” he said. “This has also been my own experience with patients. However, if the OD can identify medication currently or previously prescribed, the comanaging surgeon should be notified. This will allow surgery to be performed differently than standard cataract surgery.”

Another red flag for potential complications with cataract surgery is patients who chronically use narcotics. “Narcotics will cause a permanently small pupil,” Dr. Skorin said. “Some patients will be taking pain medications that contain narcotics. With narcotics, the pupil will not dilate with standard eye drops, so you may need to intervene with hooks during surgery.

“Another option is for the patient to stop taking narcotics for a while before surgery,” he continued. “But this can be difficult for chronic users because of the severe pain that regular medication does not help. So usually I use stronger dilating drops prior to surgery or hooks/rings during surgery to manually open the pupil.”

Intraoperative techniques

In such cases, Dr. Skorin inserts four flexible iris retractors into the eye. “These retractors stretch the pupil open and keep it open while I remove the cataract,” he said. “The problem with the alpha-1 blockers is that they affect the iris dilator smooth muscle. As a result, the pupil does not stay dilated.”

Two other strategies are pupil expansion rings and high-density viscoelastic agents. “However, I don’t like using high-density viscoelastics because they are difficult to remove and can cause higher pressure postoperatively,” Dr. Skorin said.

Less influence today

“The good news is that very few medications have any impact on patients who are receiving modern cataract surgery,” Christopher J. Quinn, OD, FAAO, a Primary Care Optometry News Editorial Board member and president of Omni Eye Services in Iselin, N.J., said in an interview. “The days when extreme caution may have been advised is now not necessarily the case because of advances in surgery. Fortunately, cataract surgery has evolved to the point where systemic medications have little influence on either the intraoperative course or postoperative course of patients.”

Dr. Quinn acknowledged that previously patients taking Coumadin and aspirin-related products were told to stop before surgery because of the additional risk of bleeding.

“However, as the incisions have moved from the scleral tunnel incisions to the clear corneal incisions, the need for patients to discontinue those medications prior to surgery is reduced or eliminated,” he said. “This is really good for patients because we no longer have to put their general health at risk by stopping medication.”

For alpha-1 blockers, “obviously, it is important for surgeons to be aware of the fact that patients are on those, so they can take measures to intraoperatively anticipate and manage patients who may develop IFIS,” Dr. Quinn said. “We don’t want patients taking medications such as narcotics that can inhibit in any way their ability to provide informed consent.”

For most surgeries today, patients continue their normal medical therapies. “This is particularly helpful to diabetics, because not all patients need to fast prior to surgery,” Dr. Quinn said. “Diabetics no longer have to recalibrate their insulin dosages. It is pretty simple for patients.”

Despite the lessening impact of drugs on cataract surgery today, “I like to plan in advance what I am going to do in surgery, especially if it is not a routine case,” Dr. Skorin said. “The surgical staff can then have special instruments available in the room if I need them.”

For more information:

• Leonid Skorin Jr., OD, DO, FAAO, FAOCO, is a senior staff ophthalmologist at the Albert Lea Eye Clinic in Albert Lea, Minn., and a Primary Care Optometry News columnist. He may be contacted at the Albert Lea Eye Clinic, Mayo Health System, 1206 W. Front St., Albert Lea, MN 56007; (507) 373-8214; fax: (507) 373-2819; e-mail: skorin.leonid@mayo.edu.
• Christopher J. Quinn, OD, FAAO, a Primary Care Optometry News Editorial Board member and president of Omni Eye Services, can be reached at Omni Eye Services, 485 Route 1, Ste. A, Iselin, NJ 08830-3009; (732) 750-0400; fax: (732) 750-1507; e-mail: cqod@comcast.net. Neither Dr. Skorin nor Dr. Quinn has a direct financial interest in the products mentioned, nor is either a paid consultant for any companies mentioned.