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Cataract surgery

Continuing our new series on postoperative care in general practice, Miss Abha Gupta, Miss Roxane Hillier and Mrs Fiona Carley outline what GPs can expect when patients are discharged into the community

Continuing our new series on postoperative care in general practice, Miss Abha Gupta, Miss Roxane Hillier and Mrs Fiona Carley outline what GPs can expect when patients are discharged into the community


Cataract is an opacity of the crystalline lens, and a common cause of treatable blindness. Most cataract surgery is performed as a daycase procedure, under local or topical anaesthesia. A small incision is made close to the limbus (junction of cornea and sclera) to enter the eye, the capsular bag containing the lens is opened and the cataractous lens is removed using phacoemulsification (ultrasound) and aspiration. An artificial lens is then placed in the capsular bag.

In most cases corneal sutures are not required, as the wound is self-sealing, but sutures may be used occasionally. These are usually, but not always, absorbable.

Following discharge – what to expect

• A clear plastic eye shield should remain in place for the first 24 hours following surgery, and overnight for the first week.

• Usually a combination of topical antibiotic and steroid is prescribed four times daily for four weeks.

• The first postoperative visit can vary from one day up to four weeks, depending on local departmental policy.

• Spectacles are not usually prescribed until the drops have been completed (three to six weeks post surgery).

Complications – what to look for

Following routine cataract surgery most patients will experience minor ocular irritation, epiphora (watering) and foreign body sensation. In the immediate hours following surgery patients may experience diplopia due to extraocular muscle paresis, as a result of periocular anaesthesia.

These symptoms usually resolve within a week, and reassurance is all that is required. However, prolonged (more than one week) or worsening symptoms warrant discussion with the ophthalmologist.It is not usual for patients to experience ocular pain, unrelieved by simple analgesia, following surgery. Visual acuity may not improve immediately postoperatively due to periocular anaesthesia or refractive error. But worsening visual acuity should arouse concern. Ocular pain or reduced visual acuity always warrant urgent ophthalmic referral.The indications for referral back to hospital are shown in the box on page 41.

Getting back to work

Patients may resume normal daily activities 48 hours after routine cataract surgery, although a protective eye shield should be worn at night and in busy public places for the first week.

Contact sports, heavy lifting and swimming should be avoided for three weeks. Patients may only return to driving once they have visited their optician for a sight test, and obtained up-to-date spectacles (usually three to four weeks following surgery).

Miss Abha Gupta and Miss Roxane Hillier are specialist registrars in ophthalmology at Manchester Royal Eye HospitalMrs Fiona Carley is a consultant ophthalmologist at Manchester Royal Eye Hospital

Competing interests None declared

Referring back to hospital

Early complications (within two weeks)

Endophthalmitis

• Symptoms: increasing pain, rapidly decreasing vision.

• Signs: lid swelling, chemosis (conjunctival oedema), conjunctival hyperaemia, corneal clouding, hypopyon (figure 1), reduced red reflex.Endophthalmitis is a devastating intraocular infection which carries a poor visual prognosis. It occurs in approximately one in 700 cases following cataract surgery. When endophthalmitis is suspected, immediate aqueous and vitreous sampling is required for microscopy. Prompt injection of intravitreal antibiotics may salvage the eye, if not vision. This is an ophthalmic emergency requiring immediate referral.Raised intraocular pressure

• Symptoms: nausea, pain, reduced vision.• Signs: conjunctival injection, corneal oedema.Immediate ophthalmic referral is required.Postoperative iritis• Symptoms: pain, photophobia, decreasing vision.• Signs: conjunctival hyperaemia, anterior chamber cells and flare, corneal oedema and hypopyon in severe cases.Severe postoperative iritis and endophthalmitis can be difficult to distinguish. Therefore immediate ophthalmic referral is indicated to ascertain whether the inflammation is sterile or infective.Intermediate complications (within six weeks)Drop toxicity• Symptoms: ocular discomfort, itchy sensation, slightly reduced vision.• Signs: conjunctival hyperaemia of the inferior fornix, punctate staining of the corneal epithelium, subtarsal papillae.In many cases this does not represent a drop allergy, but a toxic effect of preservatives in the drops (commonly benzalkonium chloride). Substitution for preservative-free equivalent drops may be helpful.Routine referral to the ophthalmologist is required.Late complicationsLoose/broken suture• Symptoms: foreign body sensation, epiphora.• Signs: the protruding suture may be identified with a direct ophthalmoscope or pen torch. Fluorescein staining may be helpful.Residual corneal sutures may loosen or break causing ocular irritation at any stage in the postoperative period. A broken suture may act as a focus for infection, resulting in a corneal abscess (figure 2). This may occur many months after cataract surgery has taken place. Urgent ophthalmic referral is required. Corneal decompensation • Symptoms: decreased vision (especially on waking).• Signs: corneal oedema.Routine referral to the ophthalmologist is required.Posterior capsule opacification• Symptoms: glare, reduced vision.• Signs: characteristic disturbance of red reflex (figure 3).This is treated by YAG laser capsulotomy, a painless procedure performed at the slit lamp. Routine ophthalmic referral is required.Subluxation of lens implant• Symptoms: monocular diplopia.• Signs: curved lens edge may be visible on red reflex (figure 4).Routine ophthalmic referral is warrantedCystoid macular oedema• Symptoms: decreased vision.• Signs: loss of foveal light reflex, however slitlamp biomicroscopy or fluorescein angiography is required to secure the diagnosis.Routine referral to the ophthalmologist is required.Retinal detachment• Symptoms: new onset floaters, photopsia, curtain across vision.Retinal detachment is most commonly a late complication of cataract surgery, but may occur at any stage in the postoperative period. If suspected, immediate ophthalmic referral is required.

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