Strong OD-MD partnership ensures best outcomes for cataract surgery

Optometrists can monitor patients postoperatively for iritis, floaters, cystoid macular edema, posterior capsular opacification and dry eye.

John A. Hovanesian

Paul M. Karpecki

Cataract surgery has become the most commonly performed surgical procedure in the United States. In the coming years, aging baby boomers and a shrinking number of eye surgeons will lead many patients to seek postoperative care with their primary eye doctors. Even now, leading surgical practices across the country are integrating postoperative care more closely with primary care optometrists.

Despite historical conflict between optometry and ophthalmology, we believe a natural alliance should and will develop between the two professions, catalyzed by mutual trust and education and centered on continuously improving the care of our shared patients.

Figure 1. Ocular coherence tomography appearance of cystoid macular edema in a diabetic patient. Best corrected vision is 20/200. Image: Hovanesian JA and Karpecki PM

In this article, we will focus on management of postoperative cataract surgery issues that pertain to all cases, rather than those associated just with presbyopia-correcting implants.

What to expect the first week

In a typical comanagement arrangement, the first 7 to 10 days of care are provided and billed by the surgeon. However, variables such as patient choice, travel distance, experience and comfort of the primary eye care provider and the doctor-to-doctor working relationship may dictate that the optometrist sees some patients as early as day 1 postoperatively.

During this time, anterior segment inflammation causes variable visual acuity and intraocular pressure along with microscopically visible striate corneal edema and anterior chamber cell and flare. Management is focused on monitoring for acute postoperative problems such as dangerously high pressure spikes, which can be managed by topical or oral medications or by simply “burping” fluid from the anterior chamber at the slit lamp via a “side-port” paracentesis incision. Acute endophthalmitis is the most feared postoperative complication of cataract surgery – most typically marked by pain and hypopyon and poor or worsening vision – and usually occurs during this time period.

After the first 10 postoperative days, acute inflammation has subsided, the cornea clears and attention is shifted toward the patient’s visual rehabilitation. Refraction typically becomes stable about 15 to 30 days after surgery (closer to 30 days for accommodative implants), at which time it is appropriate to prescribe correction for any residual refractive error.

During the weeks that follow surgery, a number of complications and complaints can arise. Rebound iritis typically occurs during week 3 to 4 after surgery.

Longer follow-up: rebound iritis

Most patients with rebound iritis will report that they withdrew (or reduced) their postoperative steroid drop 1 to 3 days before they first noticed symptoms, which usually consist of aching, blurring, light sensitivity and sometimes redness. The slit lamp exam will reveal grade 1+ or 2+ anterior chamber cells, which are absent by this time in normal patients.

Treatment consists of restarting topical steroids, typically four times daily for about a week, then discontinuing. If adequate steroid is used, cycloplegia is not necessary because pain will be reduced fairly quickly and synechia will not form. If the pain is intense or the anterior chamber is torpid with acute phase reactants and proteins, a little cycloplegia may be helpful. However, in practice we almost never use cycloplegics for postoperative iritis.

We also recommend contacting or referral back to the surgeon when rebound iritis occurs, so that he or she may rule out chronic forms of endophthalmitis, such as those caused by Propionibacterium acnes or Staphylococcus epidermidis, which mimic prolonged postoperative iritis but do not allow the cessation of steroid.

Postoperative floaters

Floaters become visible after cataract surgery just as soon as some patients regain clear vision. In many cases, patients are now more aware of vitreous opacities that were previously masked by a dense cataract. In others, the manipulation of surgery causes “lakes” of fluid suspended in the vitreous body that reach the retina, where they cause a rapid detachment of cortical vitreous.

Because there is no way of knowing whether symptomatic floaters are new or old, every patient needs dilated funduscopy with a thorough examination for retinal tears or breaks. Naturally, either of the latter findings would necessitate a prompt referral back to the surgeon or retina specialist.

CME common among diabetics

Cystoid macular edema (CME) affects vision in about 1% of patients after cataract surgery and is most common among diabetics. It consists of a painless blurring of central vision and is sometimes discovered weeks after an uneventful recovery from surgery.

Refraction may show a mild hyperopic shift because of the forward displacement of the swollen macula. Vision may be reduced to 20/25 or be as poor as counting fingers. Fundus exam may show subtle elevation of the central macula with transparent cysts around the fovea. These can best be viewed with a Goldmann contact fundus lens. OCT technology is also helpful in making this diagnosis.

Treatment of this complication consists of topical steroids and nonsteroidal anti-inflammatory drops. The surgeon should be contacted as, sometimes, intracameral injections of triamcinolone or Avastin (bevacizumab, Genentech) – an off-label use of this medication – can help reduce swelling and restore vision.

Potential long-term complications

Posterior capsule opacity (PCO) can occur a few weeks to many years after cataract surgery and is seen in 40% of patients. When corrected vision is symptomatically impaired, referral back to the surgeon for Nd:YAG laser capsulotomy is warranted. This simple procedure eliminates these symptoms and has virtually no down-time, but carries about a 1% risk of retinal detachment.

Most surgeons prefer to wait three months before performing Nd:YAG capsulotomy because of the risk of inducing CME with this procedure in the early postoperative period.

Dry eye often becomes more symptomatic following any type of eye surgery and may remain symptomatic for up to a year. Management consists of addressing its causes (meibomian gland dysfunction, aqueous deficiency, eyelid issues) and reassuring the patient that dry eye symptoms will return to “baseline” with time.

In anticipation of these problems, some surgeons are now pre-medicating known dry eye patients for 2 to 4 weeks before cataract surgery with cyclosporine twice daily or treating the blepharitis with azithromycin (once daily) eye drops. Both of these medications have been shown to enhance postoperative visual recovery among dry eye sufferers.

Fortunately, few patients undergoing cataract surgery by an experienced surgeon develop significant problems. Indeed, most optometrists who begin sharing in the care of postoperative cataract patients enjoy great satisfaction from work with patients who are rediscovering their world through improved eyesight. We have learned that a strong partnership between optometrist and surgeon will bring about the best possible outcome for both straightforward and challenging patients alike.

• John A. Hovanesian, MD, FACS, is a member of the Primary Care Optometry News Editorial Board and can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; (949) 951-2020; fax: (949) 380-7856; drhovanesian@harvardeye.com.
• Paul M. Karpecki, OD, FAAO, is clinical director of Corneal Services and Ocular Disease Research for Koffler Vision Group and a member of the PCON Editorial Board. He can be reached at 120 N. Eagle Creek Drive, Suite 431, Lexington, KY 40509; (859) 227-7781; fax: (859) 263-5694; paul@karpecki.com.