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Preoperative prophylactic care is key to cataract surgery success
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Practitioners agree that perioperative therapeutic regimens for cataract surgery are crucial toward achieving a successful outcome. While certain pre- and postoperative standards have been established, each patient’s individual condition and medical history should be considered.
“The preoperative regimens that I generally use are based on the concept that the eye is otherwise normal,” said Robert S. Vandervort, OD, a practitioner based in Omaha, Neb. “But if ongoing inflammation of the lids or conjunctiva exists, for example, we will delay surgery until that is resolved.”
Preoperative prophylaxis regimens
Preoperative regimens for cataract surgery are necessary to prevent intraocular infection and often consist of doses of antibiotics. “Our current standard is to prescribe an antibiotic four times a day starting 1 day preop,” Dr. Vandervort said.
He commonly uses Ciloxan (ciprofloxacin HCl, Alcon) or Ocuflox (0.3% ofloxacin, Allergan). “We are presently using Ciloxan most often,” he said.
Richard L. Lindstrom, MD, a practitioner based in Minneapolis and a member of the Editorial Board of Primary Care Optometry News, said his preoperative prophylaxis regimens consist of Quixin (levofloxacin ophthalmic solution 0.5%, Santen), Voltaren (diclofenac sodium 0.1%, Novartis Pharmaceuticals) and Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb).
“I use Quixin, Voltaren and Lotemax every 10 minutes times three with dilation preop,” he said, “plus a drop of each at the end of the case and in the recovery room just before going home.”
Dr. Lindstrom explained that the rationale behind this regimen is to “preload the eye with the drug prior to incision and reload just after.”
Postoperative care
Dr. Vandervort continues the antibiotic regimen postoperatively, in addition to other drugs. “We continue the antibiotic for 2 weeks postop, unless the patient is experiencing some reaction to it or has some problem with it,” he said. “But we try to keep patients on the antibiotic for at least 1 week, preferably 2 weeks.”
Dr. Vandervort also starts the patient on Econopred (prednisolone acetate, Alcon) immediately after surgery. “We start them on a four-times-daily dosage of Econopred Plus or 1% prednisone acetate eye drop,” he said. “We continue them on this for a minimum of 4 weeks.”
Dr. Lindstrom recommends Quixin four times daily for 1 week postoperatively and Voltaren and Lotemax four times daily for 1 week, then twice daily for 3 to 4 weeks.
At-risk patients
For at-risk patients, different pre- and postoperative protocols may be followed.
“For patients with significant systemic problems, we will have them see their family physician for a pre-op physical before cataract surgery,” Dr. Vandervort said. “We may change our postoperative regimens for certain patients, such as diabetics and macular degeneration patients. For those cases, we may add Voltaren 4 times daily to the steroid for 4 weeks. We would also consider extending the steroid or doing a more gradual taper.”
Dr. Vandervort added that he would use Voltaren in some cases of diabetes or macular degeneration. He said certain other conditions might warrant special pretreatment regimens.
“If the patient had a history of chronic blepharitis, for instance, or some sort of chronic bacterial lid disease, we may pretreat him or her for a week or so prior to surgery,” he said. “You don’t want to go into surgery with an eye that is inflamed or has problems.”
Dr. Lindstrom also uses a slightly different regimen for at-risk cases. “I would use Lotemax and Voltaren longer and more frequently, usually four times daily for 1 month, then twice daily for 2 months,” he said. “But it depends on the clinical course. If the patient develops cystoid macular edema, steroids are used more frequently. I often switch to Pred Forte (prednisolone acetate, Allergan) and occasionally subconjunctival Kenalog (triamcinolone acetonide, Squibb).”
Because an occurrence such as a broken capsule may increase the risk of cystoid macular edema, this type of case would warrant a slightly different postoperative regimen, practitioners said.
“We might add some postoperative medications for a patient who has a broken capsule, or maybe for a diabetic patient or for a patient with a significant amount of soft drusen in the macula,” Dr. Vandervort said. “This would apply to anybody we might think would be a higher risk for cystoid macular edema.”
Dr. Vandervort said he might add Voltaren or Acular (ketorolac tromethamine, Allergan) postoperatively four times daily. “So, if the capsule is broken, we would have the Econopred going four times daily, along with the nonsteroidal medication such as Voltaren or Acular four times daily,” he said. “We would continue that as a precaution.”
Another situation in which Dr. Vandervort would use Voltaren or Acular postoperatively would be one in which the patient has developed cystoid macular edema. “We use Voltaren or Acular four times daily in that situation,” he said. “Anecdotally, we have had good luck in many instances of resolving CME. Of course, it always begs the question of whether it would have resolved on its own.”
Dr. Lindstrom said he would handle a broken capsule in the same way in which he would other at-risk cases: using Lotemax and Voltaren longer and more frequently, usually four times daily for 1 month and then twice daily for 2 more months. Dr. Vandervort said this type of problem is not often encountered in cataract surgery.
“We don’t break very many capsules,” he said. “But in the event of a broken capsule, we always add a nonsteroidal to the postoperative regimen.”
For Your Information:
- Robert S. Vandervort, OD, is the center director for the Omaha Eye & Laser Institute. He can be reached at 11606 Nicholas St., Omaha, NE 68154-4478; (402) 493-2020; fax: (402) 493-8987. Dr. Vandervort has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Richard L. Lindstrom, MD, is a practitioner based in Minneapolis and a Primary Care Optometry News Editorial Board member. He can be reached at 710 E. 24th St., Minneapolis, MN 55404; (612) 813-3633; fax: (612) 813-3660. Dr. Lindstrom has a direct financial interest in Lotemax and is a paid consultant for Allergan, Santen and Bausch & Lomb.