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Senile Cataract Follow-up

  • Author: Vicente Victor D Ocampo, Jr, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc  more...
 
Updated: Mar 01, 2016
 

Further Outpatient Care

On the first postoperative day, visual acuity should be consistent with the refractive state of the eye, the clarity of the cornea and media, and the visual potential of the retina and optic nerve. Mild edema of the eyelid may be evident, as well as some conjunctival injection. The cornea is normally clear with minimal edema and striae. The anterior chamber should be deep with mild cellular and flare reaction. It is important to check whether the posterior capsule is intact and whether the IOL is positioned properly. The red reflex must be strong and clear and the intraocular pressures should be within normal limits. Transient intraocular pressure elevations may be observed and attributed to retained viscoelastic.

Significant improvement of these initial findings is to be expected in subsequent postoperative evaluation as the ocular inflammation subsides typically within 2 weeks. Topical steroids and antibiotics are tapered accordingly. Refraction is believed to be stable at the sixth to eighth postoperative week, at which time corrective lenses can be prescribed. Significant postoperative astigmatism following ECCE or ICCE can be addressed by suture removal after the sixth postoperative week as guided by keratometry, refraction, or corneal topography.

In a prospective, randomized, double-masked trial involving 59 patients undergoing cataract surgery, use of a tapered-release dexamethasone punctum plug after surgery, compared with the use of a placebo plug (Dextenza, Ocular Therapeutix), resulted in fewer cells in the anterior chamber (ie, less evidence of ocular inflammation), lower use of additional anti-inflammatory medications, and less light sensitivity.[38]

The mean pain score in the dexamethasone group on the first day following surgery was three times below that in the placebo group (0.6 vs 2.0), while the ocular pain score on day 14 was 11 times lower than that in the placebo patients. No long-term, plug-associated intraocular pressure spikes or adverse events were observed.

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Further Inpatient Care

Most cataract surgeries are performed on an outpatient basis, especially with the widespread adoption of phacoemulsification performed under topical anesthesia. Often, patients are discharged from the clinic as soon as they have recovered from the emotional stress of the procedure. Patients are sent home on topical steroids, NSAIDs, and antibiotics either separately or in combination. An optional eye shield is placed on the newly operated eye and removed a few hours later.

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Inpatient & Outpatient Medications

During the postoperative period, the patient is prescribed a topical steroid such as 1% prednisolone acetate, which is applied every hour for the first day, then tapered depending on the inflammatory state of the eye. Studies have shown that topical ketorolac tromethamine provides adequate postoperative control of intraocular inflammation without the risk of increased intraocular pressure, which may be associated with steroid use. A broad-spectrum topical antibiotic also is given 4-6 times a day for 1-2 weeks.

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Deterrence/Prevention

Age is believed to be the most significant risk factor for senile cataract and, as such, it is essentially inevitable that some degree of lens opacity develops as one becomes older. No study has established firmly whether avoidance of some of the risk factors for senile cataract (eg, UV exposure, hypercholesterolemia, tobacco use, diabetes mellitus) will lessen the chance of developing a senile cataract.

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Complications

Major intraoperative complications encountered during cataract surgery include the following:

  • Shallow or flat anterior chamber
  • Capsular rupture
  • Corneal edema
  • Suprachoroidal hemorrhage or effusion
  • Expulsive choroidal hemorrhage
  • Retained lens material
  • Vitreous disruption and incarceration into wound
  • Iridodialysis
  • Retinal light toxicity

Major immediate postoperative complications encountered during cataract surgery often seen within a few days or weeks after the operation include the following:

  • Flat or shallow anterior chamber due to wound leak
  • Choroidal detachment
  • Pupillary block
  • Ciliary block
  • Suprachoroidal hemorrhage
  • Stromal and epithelial edema
  • Hypotony
  • Brown-McLean syndrome (peripheral corneal edema with a clear central cornea most frequently seen following ICCE)
  • Vitreocorneal adherence and persistent corneal edema
  • Delayed choroidal hemorrhage
  • Elevated intraocular pressure (often due to retained viscoelastic)
  • Cystoid macular edema - Studies have shown that diclofenac was more effective than topical steroids in preventing CME. [39]
  • Retinal detachment - Significant risk factors include axial length greater than 25 mm, age younger than 65 years, and intraoperative complications. [40]
  • Acute endophthalmitis
  • Toxic anterior segment syndrome (TASS), a noninfectious acute inflammatory reaction to particulate, chemical, or toxic matter placed in the anterior chamber during surgery - Most commonly implicated are sterile denatured lens proteins retained by surgical instruments, epinephrine solutions that contain bisulfites, and powder from surgical gloves; many mini-epidemics of TASS reveal no obvious proven cause despite intensive investigation
  • Uveitis-glaucoma-hyphema (UGH) syndrome

Major late postoperative complications seen weeks or months after cataract surgery include the following:

  • Suture-induced astigmatism
  • Pupillary capture, decentration, or iris atrophy
  • Decentration and dislocation of the IOL
  • Corneal edema and pseudophakic bullous keratopathy
  • Chronic uveitis
  • Chronic endophthalmitis
  • Wrong power of IOL used

At any postoperative stage, the risk of uveitis, noninfectious endophthalmitis, and infectious endophthalmitis exists. Noninfectious endophthalmitis is believed to be a multifactorial process or an idiosyncratically variable response to a common factor, similar to a hypersensitivity reaction. Treatment may range from the use of topical, transseptal, or oral steroids to the rare explantation of the intraocular lens.

Although of low incidence, infectious endophthalmitis may lead to severe vision loss and blindness.[41] Staphylococcus epidermidis is the most commonly isolated organism in acute cases, and rupture of the posterior capsule is one of the most common risk factors.[41] Of late, a significant increase in the incidence of gram-positive bacteria in bacterial isolates from postoperative eyes suspected of having endophthalmitis has been observed. Furthermore, a significant increase in resistance to ciprofloxacin and other fluoroquinolones has occurred. Seemingly, the spectrum of bacteria causing postcataract endophthalmitis is changing, partly perhaps because of an increased resistance to mainstay antibiotics in the prevention of endophthalmitis. Delayed-onset infectious endophthalmitis is most commonly caused by Propionibacterium acnes.

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Prognosis

In the absence of any other accompanying ocular disease prior to surgery that would affect significantly the visual outcome (eg macular degeneration or optic nerve atrophy), a successful uncomplicated standard ECCE or phacoemulsification carries a very promising visual prognosis of gaining at least 2 lines in the Snellen distance vision chart. The main cause of visual morbidity postoperatively is CME. A major risk factor affecting visual prognosis is the presence of diabetes mellitus and diabetic retinopathy.

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Patient Education

To date, no established guidelines are available for the prevention of senile cataracts. Education programs are geared toward early detection and surgical intervention when vision is impaired functionally. With the advent of phacoemulsification, patients are advised against delaying lens extraction to the point when the cataract is hard and mature and the likelihood of postoperative complications increases.

For patient education resources, see the Eye and Vision Center and Cataracts.

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Contributor Information and Disclosures
Author

Vicente Victor D Ocampo, Jr, MD Head, Uveitis and Ocular Immunology Service, Veterans Memorial Medical Center, Philippines; Head, Uveitis and Ocular Immunology Service, Ospital ng Makati Medical Center, Philippines; Consulting Staff, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines

Vicente Victor D Ocampo, Jr, MD is a member of the following medical societies: American Academy of Ophthalmology, Philippine Ocular Inflammation Society, Philippine Academy of Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Additional Contributors

Richard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic

Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

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