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Preop screening, therapeutic protocols vital to successful postop results
DALLAS — Primary Care Optometry News gathered a group of clinicians here during the Southwest Council of Optometry annual meeting to discuss their current preoperative and postoperative therapeutic protocols. All participants agreed on the importance of the preoperative screening process, treatment of pre-existing conditions and prophylaxis of LASIK and cataract surgery patients. They also agreed that optometrists should be active in the postoperative management by identifying and treating most complications.
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Primary Care Optometry News: Are you prescribing any therapeutic agents prior to the day of surgery, and, if so, what agents?
Robert P. Wooldridge, OD, FAAO: Treating these patients preoperatively is actually more important than treating them postoperatively. The surgeons in my practice take the normal preoperative/perioperative steps, including the postop drops, but also have just recently switched to Ciloxan (ciprofloxacin HCl, Alcon) four times daily starting 3 days prior to surgery. There’s probably greater evidence for the benefit there. While it is a routine practice, I don’t know of a good study showing that there’s any real benefit of postoperative topical antibiotics in preventing endophthalmitis.
Typically, when you have a case of endophthalmitis, the bacterium was introduced at surgery. So, if we’re trying to sterilize the eye and lid, it certainly makes sense to do so prior to surgery.
William D. Townsend, OD: If we have patients who have lid disease, we get that under control before cataract surgery.
David A. Cockrell, OD, FAAO: We treat preoperatively as well. We work on lid disease on a preoperative basis and use Ciloxan for 72 hours prior to the procedure.
Dr. Wooldridge: If you think the patient has blepharitis, are you using the topical Ciloxan drops or are you using Ciloxan ointment?
Dr. Cockrell: If we think a patient has topical blepharitis, we use Ciloxan ointment 2 days prior to the procedure.
Bruce E. Onofrey, OD, RPh, FAAO: Our philosophy has been to aggressively manage any pre-existing lid diseases well in advance. That is critical regarding any surgery. We initiate an aggressive lid hygiene process prior to surgery, and then the day of surgery is when antisepsis takes place. We give one drop of a fluoroquinolone every 5 minutes for four doses. Just prior to surgery, we use povidone iodine 5% disinfectant for the preop management of bacterial endophthalmitis.
John A. McGreal, OD: We also believe that aggressively managing any pre-existing lid disease is important. Most of the causative agents of exogenous endophthalmitis are from the patient’s lid, so we believe in managing blepharitis aggressively with compresses and bacitracin ointment. It’s an old antibiotic, but it is still very effective, with limited resistance.
Sometimes, oral doxycycline is helpful in the management of the more advanced lid disease that we often see in seniors. We use Ciloxan preoperatively four times a day starting 2 days prior to the surgery. Also, just preoperatively, our patients have higher pulses of Ciloxan drops in addition to 5% povidone iodine solution. The povidone is antiseptic, and the antibiotic is bactericidal, so that gives you statistically the best chance of preventing postoperative endophthalmitis.
Changes in preop protocol
PCON: Has your preop protocol changed much over the past 5 years or so?
Dr. Onofrey: It’s been pretty stable. Ciloxan is our current drug, and treatment on the day of surgery has worked very well.
Dr. McGreal: The fourth-generation fluoroquinolones will become the drug of choice and the standard of care preoperatively and postoperatively.
Dr. Onofrey: It’s pretty clear that povidone iodine is the number one periocular disinfecting agent at 5%, and even skin can be treated with 10%. It kills essentially all pathogens, including HIV, viruses, fungi, etc., within 30 seconds of contact.
Dr. Wooldridge: We have been using Ciloxan four times a day for 3 days prior to surgery. I expect that we will switch to Vigamox (moxifloxacin ophthalmic solution 0.5%, Alcon) now that it is approved.
Dr. Onofrey: We do not use any periocular antibiotic irrigating solutions. Most of the organisms that cause ocular complications are gram-positives, and some people believe in using an infusion of vancomycin during surgery. We believe the toxicity produces a risk-benefit ratio that doesn’t pay for its use.
Postop regimens
PCON: What about your postop regimens?
Dr. Onofrey: In addition to not using irrigation, we don’t do any subconjunctival injections with aminoglycosides at the end of surgery. Our belief is, instead of extending the period of time for the surgery, we put patients on intensive therapy — a drop every 2 hours for the first 2 days and then every 6 hours for an additional 5 days. We generally discontinue the antibiotic by the end of the first week and then continue the steroid for about 2 to 3 weeks.
Dr. McGreal: For our cataract patients, we keep them on the fluoroquinolone four times a day for 1 week postoperatively. We keep them on a full-strength steroid four times a day for 3 weeks. For our LASIK patients, we use Ciloxan four times a day for 1 week and a mid-strength steroid four times a day for 1 week. So, our LASIK patients are off both antibiotics and steroids in 1 week, and our cataract patients are off antibiotics in 1 week. For the cataract patients, we continue the steroid until the bottle runs out, which is usually 3.5 weeks.
Dr. Cockrell: Our cataract patients are given a fluoroquinolone four times a day for 1 week and Pred Forte (prednisolone acetate, Allergan) four times a day for 3 weeks. We follow that up with an NSAID twice daily for an additional 3 weeks. Our refractive surgery patients are given a fluoroquinolone and Pred Forte, both four times a day for 4 days.
Dr. Townsend: Our postop cataract patients are given a fluoroquinolone four times a day for 1 week and Pred Forte four times a day, which we taper down until the bottle is gone. We don’t put them on a generic because we’ve found that it’s just not as effective. These patients also are typically given a nonsteroidal for 1 week.
Dr. Wooldridge: Our cataract patients are typically given a fluoroquinolone four times a day until they finish the bottle and a steroid four times a day for 2 weeks and then twice a day until they finish the bottle. Diabetic patients will also get a topical nonsteroidal agent. In fact, our surgeon likes to pretreat diabetics with Acular (ketorolac tromethamine, Allergan) four times a day 1 week prior to surgery and thereafter.
The LASIK patients typically are similar in that they get a fluoroquinolone and steroid postop, typically four times daily until they run out.
Follow-up schedule
PCON: How about the follow-up schedule? How often are you seeing those patients back, and when does it end? When is the last time you would see them postoperatively?
Dr. Townsend: The surgeon sees our cataract patients at day 1 and then, depending on the patient, day 8, and then they are transferred back to us. We see the patient at 1 month and at 2 months. If there’s an indication to be seen more often, then I will see them back more frequently.
For LASIK patients, the follow-up schedule depends on the patient. The first few days are critical. We usually see them back after just a few days. They see the surgeon back on the first day, and then we follow them once a week for the first 2 or 3 weeks. If they’re doing well, then we cut back to a month. Then, we see the patients typically at 6 months. After a year, they come back for a full examination. That’s assuming a nice postoperative course. If you’re not having the postoperative course you expect, then you’re going to modify that schedule to see patients more frequently.
Dr. Onofrey: Ours is a little less conservative. In a non-complicated case, patients see the surgeon at 1 day and 1 week. At 1 month, we dilate and do a full exam. I’m considering modifying that to a 2-month or even a 3-month exam for final refraction. The next evaluation would be at 6 months postop. That works quite well in most cases. Diabetics are watched much more closely, and studies have found that the prolonged use of a topical steroid in diabetics helps reduce the complications of surgery. Prolonged use means up to 6 months with a slow taper.
Dr. Cockrell: We see our cataract patients at 1 day postop, 1 week postop, 4 weeks postop and 2 months postop. At that 2-month visit, the patient is dilated. Our LASIK patients are seen at 1 day, 1 week, 1 month, 3 months, 6 months and then at 1 year. Then, it’s an annual examination. Of course, we modify that regimen depending on the course of their recovery.
Dr. McGreal: Our postoperative schedule for cataract surgery is 1 day, 1 week and 1 month. For LASIK, it’s 1 day, 1 week, 1 month, 3 months, and then we see them for annual or semi-annual exams depending on their age and other existing conditions.
Changes in follow-up regimen
PCON: Have you altered your postop follow-up schedule over the past 5 to 10 years because of improved techniques in both cataract and LASIK surgery?
Dr. Cockrell: With cataract patients, we’ve found that refractive error is not stable at 4 weeks, so we’ve moved that exam out an additional 4 weeks. In terms of LASIK, we have not altered our schedule.
Dr. Onofrey: We have reduced the frequency of visits based on the efficacy of Ciloxan and the improvement in surgical techniques and surgical technology. Because the risk of complications has gone down, we have fewer visits.
Dr. Wooldridge: We haven’t changed our schedule in the past 5 years. If we go back over the 20-year span that I’ve been in practice, we see cataract patients less frequently given the smaller incision, no sutures, etc.
Dr. McGreal: Once cataract surgery became a no-stitch technique, our postoperative care changed to involve considerably less frequent follow-up. Patients with stitches often need to have suture adjustments for astigmatism modification and/or foreign body sensations. A lot of that labor intensive work has gone away with improved techniques and sutureless cataract implant surgery. With topical anesthesia, the eyes are a lot less inflamed, and the surgical time and phaco time is decreased.
Complications
PCON: What complications are you most concerned about, and how do they influence your postop therapeutic choice?
Dr. Cockrell: In cataract procedures, we’re most concerned about endophthalmitis. We try to prevent those by pre-treating and aggressively treating after the fact.
With LASIK, we are most concerned about poor refractive outcomes. We’re not as concerned about dry eye because, hopefully, we’ve done our job prior to surgery and determined the level of dryness.
PCON: Are you seeing much endophthalmitis anymore?
Dr. McGreal: No. I have actually only seen two cases in the past 5 years, and both were in cataract surgery. The incidence of postoperative exogenous endophthalmitis is very small. Most people estimate it to be anywhere from 0.1% to 0.2%. However, it is disastrous when it happens, and these cases typically don’t present on the first day. It’s usually somewhere between the third day and the third week.
Optometrists need to keep endophthalmitis symptoms in mind. These patients have a rapid decrease in vision and rapid increase in pain. If a patient complains of pain, it is easy to assume that it is incisional pain. If you jump to that conclusion and you’re wrong, and you delay diagnosis and treatment, it really adds to the morbidity.
If a patient calls in with pain, but retains good vision, then it’s probably not essential to see that patient right away. However, if a patient calls in with pain and a rapid decrease in vision, he or she needs to be seen right away. Even a delay of 12 to 24 hours in initiating endophthalmitis treatment can really spell disaster.
Dr. Wooldridge: For optometrists seeing postoperative patients, it is important to ask whether their symptoms are getting better or worse or are staying the same. We expect and hope to see their symptoms improving. As soon as things take a turn for the worse, your level of concern needs to go up.
Dr. Townsend: Several studies have shown that the earliest symptom in endophthalmitis, even before there’s pain, is vision change. We know that, but it’s very important to communicate that to our staff. If a patient calls anytime after cataract surgery and complains that his or her vision is getting worse, staff members need to consider that a red flag and get the patient in that day.
Dr. Onofrey: Most optometrists are very alert to the cardinal signs of infectious complications following cataract surgery and LASIK. All infection basically hurts, but precursors to endophthalmitis, like blebitis, have to be recognized and treated appropriately.
Additionally, many of us deal with postop LASIK patients. Although bacterial keratitis following LASIK surgery is rare, it can be a disaster. One of the mistakes that could be made is to try to treat a bacterial keratitis following LASIK surgery as we would bacterial keratitis associated with contact lens wear. That would be a big mistake because of the compromised cornea and the types of organisms that tend to produce postop LASIK bacterial keratitis.
These cases have to be treated differently. They have to be cultured immediately, and the patients need to be put on broad-spectrum therapy.
The standard of care currently for that would be an aminoglycoside called amikacin, not tobramycin. It’s critically important that we don’t confuse the treatment of a post-LASIK bacterial keratitis with that of a corneal-induced bacterial keratitis.
Dr. McGreal: Culturing in a postop LASIK patient is an important point, because there is a tendency toward fewer microbiology investigations today, given the efficacy of the fluoroquinolones. In any post-LASIK infection, particularly in the interface, those flaps need to get lifted, and those eyes need to get cultured. You have to treat it aggressively.
Dr. Wooldridge: Another issue for optometrists involved in postoperative care is accessibility. If the patient has been discharged by the surgeon back to us for postoperative care, we need to be available or have someone available to respond to emergencies after hours.
Dr. Townsend: We also need to be sensitive to the fact that diffuse lamellar keratitis (DLK) is not common, but it does happen. We need to know what it looks like, how it should be managed and that time is of the essence.
Dr. McGreal: You can see DLK anytime from the first postoperative day throughout the first postoperative week. In my experience, there is some degree of DLK in most patients.
To treat DLK, we use hourly prednisolone eye drops, and we taper that down, subject to the patient’s response. DLK can present early or late, but it has to be recognized. If the patient progresses into grade II or grade III DLK, then there tends to be a higher risk for the collagen in the cornea to become more friable.
Dr. Wooldridge: If you identify DLK, should you immediately refer the patient back to the operating surgeon? Or should we treat it ourselves?
Dr. Cockrell: I absolutely think we should be treating it ourselves. Optometry signed on board to follow these patients for the short term and the long term. Certainly, optometry has an education base that puts it in the position to be able to recognize an adverse outcome for many of these procedures, and the treatment is straightforward. There may be a certain point in time where the individual optometrist sends it upstairs to the next higher level, but I think initially optometrists should be involved.
Dr. McGreal: I agree. There should be no delay in the initiation of increased steroid treatment. However, personal communication between the optometrist and the surgeon would be indicated.
For Your Information:
- Robert P. Wooldridge, OD, FAAO, can be reached at the Eye Foundation of Utah, 201 East 5900 South, Suite 201, Salt Lake City, UT 84107; (801) 268-6408; fax: (801) 262-9216; e-mail: rpwod@aol.com.
- William D. Townsend, OD, can be reached at1801 4th Ave., Suite C, Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbill1@cox.net.
- David A. Cockrell, OD, FAAO, can be reached at 1711 W. Sixth St., PO Box 2017, Stillwater, OK 74076; (405) 372-1715; fax: (405) 372-3350; e-mail: dacockrell@cockrelleyecare.com.
- Bruce E. Onofrey, OD, RPh, FAAO, can be reached at Lovelace at Journal Center, 5150 Journal Center Blvd NE, Albuquerque, NM 87109; (505) 275-4226; fax: (505) 262-3366; e-mail: Eyedoc3@aol.com.
- John A. McGreal, OD, can be reached at Missouri Eye Associates, 11710 Old Ballas Rd., St. Louis, MO 63141; (314) 569-2020; fax: (314) 569-1596; e-mail: jamod1@aol.com.
- Drs. Wooldridge, Townsend, Cockrell, Onofrey and McGreal have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.