Sunday, October 02, 2005

Chapter 4- Post-Operative Care

Phacoemulsification

  • Usually requires 2 or 3 post operative visits

    • same afternoon 4-6 hours later (to catch IOP peak) or next AM
    • (optional) one week later (to check on inflammation)
    • 3-4 weeks later to give glasses



First Visit

RAPD, VFF to CF

VA

  • expect about 20/40 better with pinhole

Slit Lamp Examination (SLE)

  • expect corneal edema proportional to ultrasound time
  • 1-2 cell and flare
  • look for corneal abrasion especially if patched

IOP

  • if < 8 look hard for leak with Seidel test
  • if 9 - 29 probably OK
  • if > 30 start with CoSopt, Alphagan recheck in 45 min
  • if > 40 suppress aqueous and bleed until pressure is stable <30 consider seeing the next day
  • lower these guidelines in patients with history of diabetes, anterior ischemic optic neuropathy, etc

Usually can see fundus without dilation. Document no RD or choroidal

Plan

    • Tobradex 1 drop qid (or separate floroquinolone and prednisolone acetate)
    • follow up 2-4 weeks later in routine cases
    • see patients one week later with IOP spike, vitreous loss, history of uveitis
    • next day with wound leak, big corneal abrasion, etc...

give

  • a simple large print post operative instruction sheet

Week #1

RAPD, VFF to CF

VA

  • expect about 20/30 pinhole 20/20

SLE

  • expect little corneal edema and trace to 1 cell and flare

Consider fundus exam with poor vision, diabetes, floaters, etc..

plan

  • taper Tobradex: 1 drop tid for 7 more days, then 1 drop bid for 7 days, etc.
  • or (stop fluoroquinolone/taper steroid as above)
  • follow up usually 3-4 weeks later
  • full activity

Week #2-4

RAPD, VFF to CF

VA

expect about 20/25 pinhole 20/20

Manifest Refraction (MR)

consider suture induced astigmatism

plan

give manifest refraction (MR) for glasses

follow up 1 year


ECCE or ICCE

  • Usually at least 3 post operative visits
    • same afternoon 4-6 hours later (to catch IOP peak) or next AM
    • one week later (to check on inflammation)
    • 4-5 weeks later to check astigmatism for suture removal or give glasses

  • Much of the emphasis is on suture removal for astigmatic control


Day #1

RAPD, VFF to CF

VA

expect about 20/200 better with pinhole

SLE

expect significant corneal edema
2-3 cell and flare
look for corneal abrasion especially if patched

IOP

if < 8 look hard for leak with Seidel test
if 9 - 29 probably OK
if > 30 start with CoSopt, Alphagan recheck in 45 min
if > 40 suppress aqueous and bleed until pressure is stable <30 consider seeing the next day
lower these guidelines in patients with history of diabetes, anterior ischemic optic neuropathy, etc

Usually can see fundus without dilation and, document no RD or choroidal.

plan

fluoroquinolone 1 drop qid
prednisolone acetate 1 drop qid
Cyclogyl 1% bid
follow up one week later usually
see patient next day with wound leak, big corneal abrasion, etc.

Give

a post operative instruction sheet

Week #1

RAPD, VFF to CF

VA

expect 20/100 and about 20/50 with pinhole
keratometry for fun -- expect about 7 diopters of astigmatism
don't waste time with refraction

SLE

expect little corneal edema and 1-2 cell and flare

usually can see fundus when on cyclogyl, document no RD

plan

Discontinue antibiotic (tell patient to keep bottle in refrigerator for suture removal)
Discontinue Cyclogyl if inflammation is less than 1 ; o/w continue
Taper Prednisolone: 1 drop qid for 7 more days, then
1 drop tid for 7 days, then
1 drop bid for 7 days, then
1 drop qd for 7 days, then
discontinue

Follow up 5 weeks later (allows healing time before suture removal)

Week #6

RAPD, VFF to CF

VA

expect 20/80 and about 20/40 with pinhole

keratometry

expect about 5.0 diopters at 90
don't get confused and read backwards
e.g. for 5.0 D at 90: left dial could read 40 D right dial reads 45 D

Manifest Refraction (MR)

Start with streak retinoscopy or auto refract (usually on with clear media)

Start with 2/3 of cylinder from K's and adjust SE to -1.0 (usually very close)

SLE

Look at the wound and decide which sutures look tight.

suture lysis

Indicated when cylinder is >= 2 D on Manifest Refraction (MR), or
>= 3 D on K's (if you did not do Manifest Refraction (MR))
if less than 2 D on Manifest Refraction (MR), stop, high fives, don't cut anything
Remove tightest suture near axis of cylinder on Ks
only cut one suture at week 6-8 visit
can cut two beyond week 8
If tight axis is between sutures cut both (think vectors)

plan

Full activity
Antibiotic drop 1 drop qid for 4 days (following each suture removal)

follow up

If no sutures need to be removed (will never happen)

  • give glasses -- usually 2.5 D add for bifocals with manifest refraction (MR)
  • follow up 1 year.

otherwise return every 1-2 weeks for additional suture lysis

After that,

you really have about three three choices (don't stall):

  1. pull a stitch (i.e. cylinders at axis of stitch is greater than 2 D on MR)
  2. give glasses (i.e. no stitch to pull or cylinder is less than 2 D on MR)
  3. get FFA or OCT because you suspect CME

Don't waste time thinking about other possibilities because not everybody is going to be 20/20.



WARNING SIGNS OF POST-SURGICAL INFECTION (ENDOPHTHALMITIS)

  • increased pain
  • sudden drop in vision
  • increased redness
  • mucopurulent discharge
  • usually occurs within 1-2 weeks post-operatively
  • when in doubt, see your patient


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