Postoperative care

Published on 08/03/2015 by admin

Filed under Opthalmology

Last modified 22/04/2025

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CHAPTER 18 Postoperative care

Modern cataract surgery has become a triumph of logistics over inconvenience. The postoperative period has become short but is nevertheless important. Distinct from the days of spending 6 weeks in bed with sand-bags supporting the head because there were no sutures used, many units do not review the patient at all and some only once in the post-surgical period. This has been facilitated by the development of secure wounds, drugs which prevent infection and inflammation, and rapid lines of communication if problems do occur. Several studies have shown no worsening of outcomes 1,2.

Preparations for the postoperative period begin intraoperatively with wound stromal hydration as this has been shown to increase wound stability in the first hour postoperatively 3.

The patient is transferred from the operating theater to a recovery area where it can be ensured that the patient is comfortable and has all the information necessary to look after the operated eye, medication to help this, and contact numbers in case of problems (perceived or real).

Some surgeons still like the eye to be covered with a pad and/or an eye shield in the first postoperative day, partly to protect the anesthetic eye from undetected trauma and partly to allow the eye to settle under a closed lid for a period of time.

Clearly, adequate information about what to expect and what to do and not to do in the postoperative period is important. This should be written as well as verbal so that reference can be made to it later.

A contact telephone number should be made available to the patient in case of problems and the person answering that number should have the experience and expertise to decide whether the patient needs to be assessed sooner than their routine preoperative appointment or not. If no such service is available, then clear instructions regarding access to local emergency services should be given to the patient or their carers.

Clear instructions about the frequency of administration of postoperative medication are best written down as well as being discussed with the patient.

Topical steroid and antibiotic are most commonly used four times a day and, for diabetic patients or those with pre-existing uveitis, a topical non-steroidal anti-inflammatory has been shown to reduce the incidence of postoperative cystoid macular edema.

Complicated surgery may require more frequent drop administration, and co-morbidity such as glaucoma may require other topical agents such as anti-hypertensives and more frequent or sooner postoperative review.

Anti-glaucoma regimes may need modifying if an eye has been left aphakic as prostaglandin analogs used in this situation may induce or prolong macular edema.

The timing of postoperative review is less critical than the information regarding what to do if a problem occurs before such an appointment is due; however, such review must be tailored to each patient to ensure appropriate care. For example, a patient with pre-existing diabetic macular edema may need review and laser treatment within a few days of the cataract surgery whilst a more routine case may be reviewed at 2–3 weeks.

Facilities should exist for assessing and dealing with postoperative problems such as wound leak, endophthalmitis, raised intraocular pressure, or any of the myriad of postoperative problems which may occur.

This means that there must be 24-hour access to emergency eye care facilities to ensure that problems which are sight threatening are dealt with in a timely fashion.

Refractive stability of the eye is usually evident 3–4 weeks after the operation and any refraction testing should be left until at least this time. Contact lens wear may be resumed after first postoperative assessment if required, but re-fitting of such a lens should be undertaken to take account of changed corneal parameters as well as any refractive changes which may have occurred.

Pre-existing co-morbidity must not be forgotten in the postoperative period and the patient given appropriate appointments outside the cataract care pathway to ensure follow-up of such conditions such as glaucoma or diabetic retinopathy screening.

Restriction of physical activity after modern small incision cataract surgery is not particularly important, but wound stability may be endangered if pressure is applied to the back edge of the wound, particularly if it is not sutured. It is sensible to mobilize patients as soon as is feasible following the surgery and to avoid wound distortion (for example by rubbing the eye) for 1–2 weeks after the operation. Very heavy physical activity (such as weight lifting in a gym) should be restricted for a similar time but normal activities can be resumed virtually straight away. A caution about ‘sensible’ physical activity is usually well-received and gives the patient a chance to adapt to the new optical state of the eye as well.

The operating surgeon’s responsibilities are not properly discharged until the eye is seen to be quiet and properly healed and the optical comfort of the patient addressed.

For trainees, getting access to assessing eyes in the immediate postoperative period can be difficult but is nevertheless important. Gaining experience of what should be expected in the early phase of post-surgical recovery in differing circumstances will allow the accurate assessment of symptoms and signs associated with complications such as inflammation, infection, and pressure-related problems.

Keeping an open mind about patients’ complaints in the postoperative period is more likely to result in timely intervention if problems do occur.

1 Tan JHY, Newman DK, Klunker C, et al. Phacoemulsification cataract surgery: is routine review necessary on the first post-operative day? Eye. 2000;14(1):53-55.

2 Tufail A, Foss AJ, Hamilton AM. Is the first day postoperative review necessary after cataract extraction? Br J Ophthalmol. 1995;79:646-648.

3 Vasavada AR, Praveen MR, Pandita D, et al. Effect of stromal hydration of clear corneal incisions: Quantifying ingress of trypan blue into the anterior chamber after phacoemulsification. J Cataract Refract Surg. 2007;33(4):623-627.

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