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): pull a stitch (i.e. cylinders at axis of stitch is greater than 2 D on MR) give glasses (i.e. no stitch to pull or cylinder is less than 2 D on MR) 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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