I. TRENDS IN CATARACT CARE
A. Aging population
B. Innovations in surgery
C. The intraocular lens (IOL)
D. Ambulatory Surgery Centers
E. Optometric “comanagement” – patient choice
II. PRE-OPERATIVE CATARACT CARE
A. Special instrumentation
1. Glare testing
2. Contrast acuity testing
3. Potential acuity testing
4. A/B scan
5. Endothelial cell counts
B. Clinical examination
1. Subjective - visual symptoms and history
2. Objective - complete ocular evaluation and vision documentation
3. Assessment - correlation of subjective and objective
4. Plan - patient counseling with discussion of pros/cons of cataract surgery including potential risks,
benefits and complications; follow-up care; optical considerations.
C. Other
1. Pediatric cases
2. Secondary implants
3. Traumatic cataracts
4. Subluxated lenses
5. IOL repositioning
6. Combined procedures (keratoplasty, trabeculectomy)
III. POST-OPERATIVE CATARACT CARE
A. Uncomplicated post-operative course visits and procedures
B. Early (more emergent) post-operative complications
NOTE: CONSULT WITH SURGEON MAY BE INDICATED
1.
Elevated IOP
a.
Open angle
1) Hyphema - Treat significant pressures, increase topical steroid, monitor, reassurance
2) Inflammatory (trabeculitis) - Topical steroid plus antiglaucoma medicines
b.
Angle closure
1) Pupillary block - Break synechiae with dilation, possible YAG iridotomy, antiglaucoma
medicines
2) Malignant glaucoma - Topical and/or oral steroid, antiglaucoma medicines, possible
choroidal tap
2.
Ocular hypotension with flat AC
a.
Wound leak - Seidel test
b.
Choroidal detachment - Monitor if mild, cycloplege plus topical and/or oral steroid if severe,
mpohl\masters\catcare.doc
c.
choroidal tap if persistent or diminishing vision
Ciliary body shutdown - Monitor
3.
Endophthalmitis - IMMEDIATE TREATMENT; may include topical, injectable, and oral antibiotics
and steroids, vitrectomy, IV medicines, hospitalization
4.
Iris prolapse/vitreous to wound - Lysis with YAG laser; surgical repair of iris, anterior vitrectomy
5.
Retinal break/detachment - Treatment may include laser photocoagulation, cryopexy, pneumopexy,
scleral buckling
6.
IOL dislocations - Surgical relocation or replacement
C. Early (less emergent) post-operative complications
1.
Glaucoma (steroid-induced) - Antiglaucoma medicines; consider other steroid or NSAID
2.
Hyphema - Treat significantly elevated IOP, increase topical steroid, monitor, reassurance
3.
Persistent iritis - Topical steroid
4.
Wound leak with well-formed AC - Pressure patch with Ab ung, stop topical steroid, monitor
5.
Retained lens material
6.
a.
Cortical - Monitor; increase topical steroid if increase inflammatory response
b.
Nuclear – Surgical removal; increase topical steroid
IOL malpositions
a.
Decentrations - monitor; consider repositioning or replacement if visual symptoms significant
b.
Pupillary capture – Monitor; consider repositioning or replacement if visual symptoms significant
7.
Diplopia - Monitor; consider prism or surgical correction if persisting at time of spectacle Rx.
8.
Ptosis - Monitor; consider surgical repair if persisting after 3 months
9.
Corneal edema
10.
a.
Epithelial - If persistent, hypertonic solution and/or ointment
b.
Stromal - Monitor, increase topical steroid or add NSAID
c.
Striate keratopathy - If persistent, may be secondary to inflammation or high IOP; treat
accordingly
Anterior ischemic optic neuropathy (AION) – Rule out temporal arteritis
D. Intermediate to late post-operative complications
1.
Cystoid macular edema (CME) – Topical/periocular/oral corticosteroids and/or topical/oral NSAIDs
2.
Corneal decompensation (pseudophakic bullous keratopathy) - Treatment may consist of hypertonic
solution and/or ointment, topical steroid and/or NSAID, and antiglaucoma medicines; consider PKP
in persisting, visually debilitating cases
3.
Recurrent iritis - Topical steroid
4.
Glaucoma - Antiglaucoma medicines, steroids if inflammatory etiology
5.
Diplopia - Differential diagnosis is important to rule out other etiologies such as mass lesion, vascular,
myasthenia gravis; treat symptoms and consider referral to neuroophthalmology or neurology
6.
Ptosis – Determine etiology; consider surgical repair if persisting and stable after 3 months
7.
Retinal detachment – Same approach as early complication
mpohl\masters\catcare.doc