A 73-year-old female post-cataract surgery patient presented for her one-day post-op visit complaining of deep pain behind the eye, headache and blurry vision. Examination revealed 20/80 VA and an IOP of 39 mmHg in the post-surgical eye. As she did not have any overt inflammatory reaction, I diagnosed her with an iatrogenic IOP spike.

Here, I discuss, the post-op visit: what to anticipate, complications to identify* and the management of such complications.

At each post-op visit, review the patient’s medication regimen to ensure compliance. Consider creating a patient-related handout. At my practice, the typical drop regimen is as follows: a fourth-generation fluoroquinolone, four times a day, for three days prior to surgery and seven days post-surgery; a topical steroid, three times a day, three days before surgery and seven days post-surgery; and a topical NSAID, started three days prior to surgery, once a day. Note that drop decisions will vary depending on the surgeon and agreed co-management options. Also, the co-managing doctor may have to make adjustments as the post-operative visits may not reveal ideal results.

ONE-DAY POST-OP

• Anticipation. Patient reports of slight blurry vision, ocular dryness and grittiness (secondary to the surgical incisions), presence of subconjunctival hemorrhages, conjunctival injection, minor cells and flare and a slight ptosis (secondary to the surgical clamps). The IOL should look centered, the pupil should be round, and some corneal edema around the incision or some striae may be present. (For ocular dryness, prescribe a dry eye medication to add to the post-surgical regiment drops, which include artificial tears.)
• Complications/management protocol.
  A. Iatrogenic IOP. If slight, prescribe glaucoma medication to be used one to three weeks, depending on severity. If the IOP remains slightly high, consider additional glaucoma drops or, refer the patient back to the surgeon for further investigation. For a severe IOP spike (above 30 mmHg), burp the wound, or have the surgeon do it, if beyond your state scope of practice. Evaluate IOP the following day. There should be no need for further intervention.
  B. Moderate to severe wound leakage. When the anterior chamber is intact, treat with a bandage contact lens until healed, typically 24 to 48 hours. Additionally, reduce topical steroid use to twice a day, employ cycloplegia to decrease aqueous loss, and prescribe tear inhibitors to safeguard the patient from possible infection, especially endophthalmitis. See this patient daily until the wound leak resolves. Then, have the patient return to the normal post-op medication regimen and follow-up schedule. Should this patient’s anterior chamber appear flat, however, refer them back to the surgeon for repair, as this is a sign of very low IOP.
  C. Corneal abrasions. Mild abrasions can heal via topical antibiotics given at the normal post-op medication schedule. More severe cases heal via a bandage contact lens, worn 24 to 48 hours.
  D. Lens fragments in the anterior and/or posterior chamber. Depending on the size, they may break down over a short period of time and need no surgical intervention. It is important to monitor inflammation and the IOP, as they may be affected by the foreign material. If after a month of normal treatment, the lens fragments remain, refer the patient back to the surgeon for removal.
  E. Irregular pupil. In most cases, no treatment can make a difference.
  F. Vitreous wick. Immediately refer the patient back to the surgeon to excise it and place the patient on a topical antibiotic.
  G. Decentered multifocal IOL, off-axis toric IOL and tilted or decentered monofocal IOL. Refer the patient back to the surgeon to fix these problems.

THREE DAYS TO ONE-WEEK POST-OP

• Anticipation. Patient reports of better vision (clearer and brighter vs. the non-IOL eye, typically 20/40) than at the first appointment, along with light sensitivity and glare. The wound and corneal abrasions, if any, are now well healed, minor inflammatory cell, flare and subconjunctival hemorrhage is present, any ptosis is typically resolved (or at least less noticeable), the pupil is back to normal (surgical dilation has worn off), and IOP is within normal limits.
• Complications/management protocol.
  A. Unexpected corneal edema or increased cell and flare. In most cases, corneal edema is clear within the first month. The addition of a hyperosmotic drop will help to expedite clearance. If increased cell and flare is not accompanied by retained lens material, keep the anti-inflammatory drops at their current level until the swelling resolves.
  B. Endophthalmitis. Immediately refer the patient back to the surgeon, who will likely send them to a retinal specialist for retrobulbar injections of fortified antibiotics until resolved. This patient will be under the care of the retinal specialist and surgeon until the endophthalmitis is completely resolved, which takes between four to six weeks.
  C. Unexpected residual prescription in the IOL. If unexpected cylinder, discuss with the patient and communicate with the surgeon to determine a strategy for resolution, if needed. If the patient needs a prescription laser enhancement, the surgeon will refer them back to you after the treatment for follow-up. I tell patients who may need a laser enhancement, “Your vision is not quite what we predicted it would be. We’re going to let it stabilize, which should take about a month, and if it is still where it is today, the surgeon will perform a laser procedure that will fine-tune your prescription.”
  If, however, manifest refraction reveals the patient’s post-op vision is “normal,” or what was expected, at this visit I typically prescribe reading and/or computer glasses, if needed, with the caveat that the prescription may change at the one-month post-op visit. I find that most cataract patients today are active and don’t want to wait for the one-month visit, at which most O.D.s provide the prescription, to get their glasses, if needed.
  D. Adverse reactions to any of the prescribed post-op medications. Consult with the surgeon regarding the possible reaction and which medication is most appropriate.

ONE MONTH POST-OPc

• Anticipation. Patient reports of a clear and comfortable eye, prompting the discontinuation of the post-op medication regimen. This is the visit at which you will fine-tune the patient’s post-op vision, if needed, and provide them with a final glasses prescription, if required.
• Complications/management protocol.
  A. Lingering glare associated with the premium IOLs. Assuage the patient’s concerns by reminding her that it is normal, as discussed prior, and typically takes between three to six months for full neuroadaptation. Also, recommend sunglass wear to help with the neuroadaptation and protect their retina.
  B. Cystoid macular edema (CME). Prescribe a topical NSAID and a topical steroid in conjunction with the surgeon. Have the patient return in a month to determine improvement. A persistent CME will need a steroid injection and, thus, a referral to a retinal surgeon.
  C. Vitreomacular traction syndrome. With decreased vision, a retinal referral is in the patient’s best interest. Consult with the surgeon as to what they advise.
  D. Posterior opacification. Refer the patient back to the surgeon for a YAG procedure. If at the six-month follow-up, the patient continues to report less than optimal vision, check for residual refractive error, as this may be the cause. Also, look at binocularity, as some patients with moderate phorias may decompensate after cataract surgery and have asthenopia. For these situations, vision therapy may be a great help, as well as adding prism to the glasses.

THREE-MONTH POST-OP

• Anticipation. The patient reports satisfaction with their result, and you note total healing. If they have a premium IOL, they may still be adapting, which, again, they should be told can take up to six months.
• Complications/management protocol.
• Posterior capsular opacification. (See above.)
• CME. (See above.)

THAT PATIENT

To relieve the 73-year-old patient’s IOP spike, I burped the wound and saw her the next day for follow-up. Her IOP had decreased from 39 mmHg to 18 mmHg, and she healed normally from that moment on. Cataract surgery is an amazing procedure and one of the few that has such a high success rate. Preparation, knowledge and proper patient education and communication are paramount to a successful procedure. Remember to over deliver and under promise to create happy patients. OM

* To allow for adequate discussion of more common complications, rare post-op complications are not discussed in this article.

DR. GEFFEN is in private practice at Gordon Schanzlin New Vision. He speaks on refractive surgery and contact lens compliance issues, as well as specialty lens designs, and has published many related articles. Dr. Geffen is a speaker for Alcon, Bausch+Lomb, Johnson & Johnson Vision surgical division, Shire, Sun Pharmaceuticals and Tear Lab.