For each installment of "Today's Topics," section editor John F. Doane, MD, will identify a hot-button topic in cataract and refractive surgery and ask several experts to share their thoughts.
What are your thoughts on performing the first postoperative visit on the same day as cataract surgery and IOL implantation rather than 1 day after the surgery?
J. Michael Garrett, MD
I began performing the initial postoperative visit on the same day as the patient's cataract surgery after the advent of topical anesthesia (approximately 10 years ago). On the day after surgery, patients receive a follow-up phone call and are asked to return to the office if they are experiencing any problems. Previously, I had performed the first follow-up visit 1 day postoperatively.
The concept of same-day postoperative follow-up has been well accepted by my patients and their families, many of whom have had to travel long distances or arrange for drivers.
There are also several medical scenarios in which a same-day visit is more beneficial than following up 1 day after IOL surgery. These include:
- Patients with high IOP from retained viscoelastic (the literature notes that the best time to catch a spike in IOP is 3 to 7 hours postoperatively1);
- Patients with an undetected corneal abrasion;
- Patients with a leaking wound and a flat anterior chamber;
- Patients who rub their eyes and dislodge the IOL or incarcerate the iris;
- Patients who are confused by the postoperative regimen;
- Noncompliant patients who may not otherwise take their medication in the early postoperative period; and
- Patients with unanticipated hyphema (from a variety of causes).
In all of these situations, patients benefit from the doctor's quickly addressing the problem. I have found that patients (and family members) who return to have their complication treated on the same day are far more accepting of the inconvenience than those who must return the next day. Readmitting patients on the same day as their original surgery may also be more cost effective.
A 1-day follow-up examination may be better for the early detection of endophthalmitis or toxic anterior segment syndrome, and it is more appropriate for patients who were patched overnight after a peribulbar block.
Other individuals may need to be seen on the day of surgery as well as on the subsequent day. They include:
- End-stage glaucoma patients who cannot tolerate increased IOP or hypotony;
- Patients with only one functioning eye; and
- Patients who experience complications on the same day as their cataract surgery.
Ultimately, I believe that the timing of follow-up visits must be individualized to the patient and the type of practice. There is no one-size-fits-all approach. I receive far fewer calls in the middle of the night, however, from patients whom I saw on the day of versus the day after surgery. With same-day postoperative care, it seems that my patients and I both sleep better.
David B. Leach, MD
I switched to a same-day postoperative examination for my cataract surgery patients about 8 years ago. Originally, I changed because I had to be at a remote satellite clinic the next morning and could not see these patients at that time. I also felt that I could achieve all of the basic goals of the first postoperative visit on the same day just as well—if not better—than I could on the next day.
Same-day scheduling helps me to detect and treat the occasional spike in IOP that may occur during the first few hours postoperatively, and it enables me to treat patients with unstable corneal incisions or complications with regard to the IOLs' position.
Patients benefit from same-day postoperative visits—especially if they experienced information overload at the ambulatory surgical center. They can ask questions in a familiar environment within a few hours of their surgery and ensure their clear understanding of their postoperative instructions. Additionally, at rural practices like mine, patients are spared another long commute into town the following morning.
All told, I feel that I am providing a better service to my cataract surgery patients by performing the postoperative examination on the day of surgery, and my patients continue to be grateful for the convenience.
Jack A. Singer, MD
I began examining my patients within 3 hours of cataract/IOL surgery in 1995, when I began using topical anesthesia. I examine patients at the slit lamp after they are discharged but before they travel home. My technicians then follow up with phone calls 1 to 2 days postoperatively. This protocol has reduced patients' travel time and frees up clinical time for other patients.
Practice guidelines outlined by the AAO state that the first postoperative visit should be performed within 48 hours of surgery for patients who are not at high risk for or symptomatic of possible complications.2 Those at high risk for intraoperative complications and glaucoma and functionally monocular patients should be seen within 24 hours of surgery. Additionally, it is advantageous to detect and manage an elevation in IOP, wound leaks, and dislocated IOLs on the same day as surgery.
Because I do not routinely use a miotic at the end of surgery, many of my patients are still widely dilated for their same-day postoperative examination. This allows me to examine their posterior segment and retina. In one case, I diagnosed a peripheral retinal tear at the patient's 2-hour postoperative examination and was able to refer him for treatment the same day.
In rural Vermont, where I practice, patients are at greater risk of being injured in an automobile accident while driving to a 1-day postoperative visit than an undiagnosed surgical complication when this first postoperative examination is performed on the day of surgery.
Section editor John F. Doane, MD, is in private practice with Discover Vision Centers in Kansas City, Missouri, and he is Clinical Assistant Professor for the Department of Ophthalmology, Kansas University Medical Center. Dr. Doane may be reached at (816) 478-1230; firstname.lastname@example.org.
J. Michael Garrett, MD, is in private practice at Garrett Eye Center in Iron Mountain, Michigan. Dr. Garret may be reached at (906) 774-1404; email@example.com.
David B. Leach, MD, is in private practice at ClearView Eye Clinic & Laser Vision in Moscow, Idaho. Dr. Leach may be reached at (208) 882-4662; firstname.lastname@example.org.
Jack A. Singer, MD, is in private practice at Singer Eye Center in Randolph, Vermont. Dr. Singer may be reached at (802) 728-9993; email@example.com.