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Today's Topics | Aug 2009

The First Visit After Cataract Surgery

Do you consider an examination 1 day after cataract extraction and IOL implantation to be the standard of care, or does a follow-up visit 1 to 2 weeks after surgery suffice?

I think that we surgeons should avoid characterizing anything as mandatory or as a standard of care, particularly in regard to the day 1 postoperative appointment. There is general agreement among ophthalmologists that, in purely practical medical terms, most patients would do fine without it. If the day 1 postoperative visit were missed, would (and should) it be malpractice not to see the patient within a 24-hour period, whatever the inconvenience and cost to you and/or the patient?

I think it is good medical practice, however, to perform a check 1 day after surgery whenever possible. Many conditions can be treated, avoided, and explained such as high IOP or corneal abrasions. At this visit, questions may also be answered, and instructions regarding drug regimens can be clarified. Much anxiety for the patient and his or her family can be avoided by our taking the time to address these issues on the day after surgery as opposed to weeks later. As practitioners, we often underestimate patients' intense desire for simple reassurance. As someone who has undergone procedures myself, I certainly like to be told how I am doing a day or so after surgery. A great deal of good medicine is patients' perception that they are receiving good, thoughtful care from a physician interested in them and their outcome. This is certainly the case; why not show it?

The day 1 postoperative visit mainly serves as a chance to reassure patients that everything looks good, especially if their vision is not already excellent. It also provides an opportunity to address questions as well as to clarify instructions about how to administer postoperative eye drops. So much of what is discussed immediately after surgery will be forgotten due to the effects of the sedative. From the standpoint of patients' satisfaction, however, this is still an important visit for many individuals.

From a medical standpoint, a number of conditions might be detected at the day 1 postoperative visit that require management, including elevated IOP, corneal abrasions, and heavy inflammation or toxic anterior segment syndrome. Although these situations are not common, they would alter the medical regimen.

I offer many patients who are not from my geographic area the option of having a postoperative check on the afternoon of their surgery so that they do not have to return the next morning. Years ago, I always examined patients 1 week after the procedure, but I no longer routinely do so, because the benefit to patients seems very low unless they need to schedule a second eye surgery.

I see patients 1 day and 1 to 2 weeks after surgery, because this is what I would like after surgery on my own eyes. The term standard of care should be used cautiously, because I am not sure that there is definitive proof that a postoperative day 1 visit is best or absolutely required. Instead, I look at it this way: What are the chances that I will need to intervene to best manage my patient's recovery?

Intervention may be required on the day after surgery for problems such as a leaking incision, high IOP, excessive inflammation, a refractive surprise, a malpositioned IOL, or retained lenticular material. I want to see my patients on the day after surgery to make sure that none of these conditions exists, but if any do, I will offer an intervention to help or resolve the issue. Although the odds of the aforementioned conditions are lower at later postoperative visits, endophthalmitis, cystoid macular edema, or another late-presenting complication is possible. There is an art and a science to ophthalmology, of which surgical judgment is a part. It makes sense to me to see patients on the day after surgery.

Examining the postcataract patient 1 day after surgery is simply good medicine and reflects my own standard of care. This visit allows for the early detection and treatment of potential complications, including endophthalmitis, toxic anterior segment syndrome, ocular hypertension, a leaking wound, iritis, corneal edema, and retained nuclear fragments. It also allows me to assess patients' postoperative refractive status. Additionally, I can make recommendations regarding spectacles or other visual aids to keep patients functioning until their vision is stable or their other eye has undergone surgery. Finally, the examination provides another opportunity for me to ensure that patients understand and are following the postoperative drug regimen and other instructions and that all of their questions have been answered.

Looking back over my years of treating thousands of cataract patients, I realize that the most common conditions that I have needed to manage on the day after surgery were related to the ocular surface, the IOP, and intraocular inflammation. Granted, these issues are rare and might have resolved on their own. I believe, however, that immediate intervention leads to a quicker and more comfortable visual recovery, lowers the incidence of early posterior capsular opacification due to chronic inflammation, and instills in patients a higher level of confidence—especially if their contralateral eye needs surgery in the future. Quickly evaluating and managing minor issues on day 1 can be a small investment of time compared with tackling bigger problems at 2 weeks and beyond.

Despite the many advances in IOL surgery, I believe that an examination 1 day after surgery is mandatory if the patient's best interests are to be served. A leaking wound, a malpositioned IOL, and increased IOP are all potential problems that can often be resolved without sequelae after their prompt recognition and treatment. Delayed recognition and treatment may cause avoidable but permanent harm to the patient's vision.

Section editor John F. Doane, MD, is in private practice with Discover Vision Centers in Kansas City, Missouri, and he is a clinical assistant professor for the Department of Ophthalmology, Kansas University Medical Center in Kansas City, Kansas. Dr. Doane may be reached at (816) 478-1230; jdoane@discovervision.com.

William I. Bond, MD, is the medical director of Bond Eye Associates in Pekin, Illinois. Dr. Bond may be reached at (309) 353-6660; pekineye@yahoo.com.

David F. Chang, MD, is a clinical professor at the University of California, San Francisco, and he is in private practice in Los Altos, California. Dr. Chang may be reached at (650) 948-9123; dceye@earthlink.net.

Uday Devgan, MD, is in private practice in Los Angeles, chief of ophthalmology at the Olive View UCLA Medical Center, and an associate clinical professor at the UCLA School of Medicine. Dr. Devgan may be reached at (800) 337-1969; devgan@gmail.com.

Jay S. Pepose, MD, PhD, is a professor of clinical ophthalmology and visual sciences at the Washington University School of Medicine, and he is the director of the Pepose Vision Institute in St. Louis. Dr. Pepose may be reached at (636) 728-0111; jpepose@peposevision.com.

Stephen A. Updegraff, MD, is the medical director of Updegraff LASIK Vision in St. Petersburg, Florida. Dr. Updegraff may be reached at (727) 822-4287; updegraffmd@lasik4me.com.

J. Trevor Woodhams, MD, is the surgical director of the Woodhams Eye Clinic in Atlanta. Dr. Woodhams may be reached at (770) 394-4000; twoodhams@woodhamseye.com.

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