One week post cataract surgery: use data to calculate second eye

Uday Devgan

Tina Geis

With the advances in surgical techniques, the 1-week and 1-month post cataract surgery follow-up visits will be exciting appointments for your patients and for you as their primary care eye doctor. You will share the experience of their newfound freedom and guide their expectations as they continue to adjust and adapt to the modern technology that grants such a wide range of clear vision. The journey has just begun.

I usually ask patients at the 1-week visit: “How’s your vision coming along? How is the clarity? Can you see colors more vividly?” With rare exception, patients report that their vision is coming along very well; they are amazed at the clarity and detail of their new vision. I always give encouragement and remind them that healing takes time, and the ultimate visual outcome will arrive gradually.

The 1-week exam

When checking visual acuity at week 1, I display a single Snellen line and typically start around the 20/50 level. This will be simple for most patients, and we can generate enthusiasm as we work our way down the chart. Continue to provide positive reinforcement. Remember, the patient will be watching your reaction and will be thrilled if you are half as excited as he or she is with the progress.

Next, for patients with presbyopia-correcting IOLs, such as accommodating IOLs, intermediate/near acuity is measured. I situate the overhead lamp and hand them the reading card about newspaper distance away (about 2 feet from the eyes). Remember to have them begin by reading the largest paragraph first. It takes time for the accommodating muscles to reactivate and manipulate the new IOL. Intermediate/near vision will generally continue to improve for several months.

Postoperative visit: Fluorescein dye has been instilled to check applanation tonometry. The IOL is well-centered, the cornea is clear and there is a minimal amount of inflammation. The patient has achieved excellent vision from this surgery and now desires the same procedure for the other eye. Image: Devgan U

I recommend performing a refraction at the 1-week visit to see where the residual Rx is at this stage and to monitor their best-corrected visual acuity. This information is used to calculate the second eye (the surgeon may decide to make minor adjustments in the lens selection according to each individual’s healing response). Push plus on your refraction, because patients implanted with certain IOLs may have some degree of accommodation at this visit. Keep in mind that there may be a mild refractive shift for 2 to 4 weeks after surgery.

Goldmann applanation tonometry should now demonstrate normal values between 10 mm Hg and 22 mm Hg that match the patient’s pre-surgery pressures.

The slit lamp exam should reveal a well-centered IOL in the capsular bag. The anterior chamber should be deep, with mild inflammation. It is common to have a 1+ cells/flare reaction at this point. The cornea should be clear with no or minimal edema. Older patients may still have slight corneal edema over the incisions. The limbal relaxing incisions, if present, should be well healed. Contact your surgeon if the incisions are gaping open.

Reemphasize the importance of being gentle and remind patients to overcome the urge to rub their eyes. All normal activities that do not pose a threat to ocular trauma may be resumed at this point (no kick boxing, diving or inverted yoga poses). Confirm compliance of the medication routine: discontinue the antibiotic, continue the steroid four times daily for 3 weeks (shake well) and continue the nonsteroidal anti-inflammatory drug four times daily for 6 weeks.

The 1-month exam

As the primary care eye doctor, the 1-month postoperative cataract appointment is extremely rewarding. It provides a unique bonding opportunity as you share in the emotional transformation of regaining visual clarity and freedom. At this point, the majority of patients will have undergone phacoemulsification and IOL implantation in both eyes. Most patients are ecstatic about their vision and want their friends, family and the whole world to know. This presents countless practice building avenues, as long as you are prepared to engage in the enthusiasm and guide their expectations.

The first questions I usually ask are: “How’s your vision coming along? Are your eyes working well together?” With rare exception, patients report that their vision is coming along well, their eyes are adjusting and trying to work together, and they are thrilled with the freedom. I always give encouragement and remind them that it will take time for their eyes to work together as a successful team again.

When checking visual acuity at 1 month always test both eyes together. At this point we want to encourage binocularity and confirm that their visual system is adapting to the modality that was selected.

In our practices, most patients receive bilateral accommodating or multifocal lens implants to address presbyopia at the same time as the cataract surgery. Encourage patients and provide positive feedback as they work their way down the distance Snellen chart. Transition to binocular intermediate/near testing with the reading card at newspaper distance. Always start with the large paragraphs and gradually work down to the small print. Feel free to push them at this visit and vocalize your goal for them – activating dormant accommodating muscles. It is time for an ocular workout.

I always perform a manifest refraction at the 1 month visit to see if there is residual Rx at this stage and to monitor their BCVA. Remember to push plus on your refraction in patients with presbyopia-correcting lens implants. These patients should be spectacle-free for most activities. For extended reading or detailed near tasks, mild readers may be helpful. These patients may also benefit from vision therapy (accommodative exercises) if better near visual acuity is desired. A mild prescription to undo any surgical monovision may be helpful during prolonged night driving.

A fraction of patients will have aggressive healing that causes a slight shift in the IOL position and induces a mild refractive error in the myopic direction. Once the refraction is stable, our offices offer an excimer laser enhancement free of charge for patients with premium lens implants and refractive errors greater than 1 D.

Goldmann applanation tonometry should match the patient’s presurgery values.

Check the IOL position first. Confirm it is centered and in the capsular bag. Next, examine the posterior capsule for clarity. If significant posterior capsule opacification is present, refer the patient back to the surgeon for a YAG laser capsulotomy. This can be done as early as postop day 1.

The anterior chamber should be deep with no residual inflammatory reaction – no cells or flare. The cornea is expected to be perfectly clear.

A dilated fundus exam is often performed at the 1-month appointment to check the retina in detail. Prior myopes are at a higher risk for retinal detachment.

Give patients permission to resume all normal activities, even diving. Verbalize the drop routine for each eye individually. They should be using only the NSAID four times daily for 6 weeks in the first operated eye. The second eye schedule is: antibiotic four times daily for 1 week, steroid four times daily for 3 weeks (shake well) and NSAID four times daily for 6 weeks.

For more information:

• Uday Devgan, MD, FACS is in private practice at Devgan Eye Surgery in Los Angeles, Beverly Hills and Newport Beach, Calif. Dr. Devgan is also chief of ophthalmology at Olive View-UCLA Medical Center and an associate clinical professor at the Jules Stein Eye Institute at the UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; (800) 337-1969; fax: (310) 388-3028; e-mail: devgan@gmail.com; Web site: www.DevganEye.com.
• Tina Geis, OD, specializes in the preoperative evaluation and postoperative care of patients at Maloney Vision Institute. She can be reached at 19021 Wilshire Blvd. #900, Los Angeles, CA 90024; (310) 208-3937; fax: (310) 208-0169; e-mail: drgeis@maloneyvision.com.