The early complications of cataract surgery: is routine review of patients 1 week after cataract extraction necessary?

OBJECTIVE: This study sought to define the nature and frequency of complications present 1 week after cataract surgery, to determine whether these complications are predictable, and to ascertain if patients undergoing cataract surgery require routine review at this time. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: One thousand consecutive patients undergoing cataract removal by either phacoemulsification or extracapsular extraction at a large teaching hospital between January 1996 and May 1998. Patients with both complicated and uncomplicated histories and surgeries were included. MAIN OUTCOME MEASURES: Nature and frequency of complications present 1 week after cataract surgery. RESULTS: At the routine 1-week visit, postoperative complications were observed in 41 of 1000 patients (4.1%). Twenty-one (51%) of these patients had a completely unremarkable history to that point, and whereas only four (19%) were symptomatic, 20 (95%) required a change to their postoperative management. The most significant unexpected complications were uveitis (seven cases), cystoid macular edema (four cases), and vitreous to the wound, exposed knots, and loose suture (one case of each). Complications were present in 20 of 257 (7.8%) patients with a preoperative or surgical risk factor, and there was a significant relationship between preoperative (P = 0.02), and combined preoperative and intraoperative risk factors (P = 0.001), and complications present at the 1-week review. The relationship between surgical risk factors and 1-week complications was not significant (P = 0.07). There were coexistent pathologic features in 19% of all eyes. Registrars performed 38% of surgeries, and 96% of cataracts were removed by phacoemulsification. Operative complications occurred in 6.7% of patients, most commonly a posterior capsule tear (4.4% of all cases). Complications were observed in 10% of eyes on the first postoperative day. Raised intraocular pressure was the complication in 88% of these patients. CONCLUSIONS: This study provides an overview of modern cataract surgery in a large teaching hospital and indicates that abandonment of routine 1-week review may result in the failure to detect significant postoperative complications.     

First day review after uncomplicated phacoemulsification: is it necessary?

PURPOSE: To determine whether first day follow-up is necessary after routine uncomplicated phacoemulsification cataract surgery. METHODS: Data collected prospectively at day 1 postoperative review. RESULTS: In 510 consecutive cases, serious complications occurred in 8 (1.6%) (wound leak [4], corneal abrasion [2], iris prolapse [1], hyphema [1]). Intraocular pressure (IOP) >30 mmHg was found in 26 (5.1%) and was strongly associated with a diagnosis of pre-existing glaucoma or ocular hypertension (odds ratio [OR] 7.7). Symptoms of headache or ocular discomfort occurred in 40 (7.8%), mostly in association with raised IOP, and were also associated with pre-existing glaucoma or ocular hypertension (OR 4.7). Central corneal edema was found in 61 (12.0%). In the absence of corneal edema, IOP was >30 mmHg in only two cases (0.39%). CONCLUSIONS: Few sight-threatening complications were detected on the morning after an uncomplicated procedure. First day follow-up may be safely omitted if adequate patient counseling is undertaken and there is provision of adequate access to eye services. Review prior to discharge on the day of surgery would provide an opportunity to detect these few surgical complications and for counseling. A diagnosis of glaucoma or ocular hypertension is a risk factor for significantly raised next day IOP and these patients are more likely to experience postoperative discomfort. They may benefit from prophylactic treatment.     

Complications of phacoemulsification on the first postoperative day: can follow-up be safely changed?

PURPOSE: To establish the rate of complications detected on the first postoperative day and therefore the need for evaluation on that day. SETTING: Hinchingbrooke Hospital, Huntingdon, England. METHODS: Complications detected on the first day after phacoemulsification cataract surgery were retrospectively reviewed over 8 months. Ophthalmic nurse practitioners performed the 1 day postoperative examination and kept a log of patients seen, recording complications detected and whether referral to a physician was required. All patients had had routine phacoemulsification with intraocular lens implantation without anterior vitrectomy or trabeculectomy, as identified from the log book and cross-checked with operating theater records. Notes were reviewed if a complication or referral was recorded. Most cases were performed under local anesthesia as day cases using a temporal corneal approach. Sections were routinely left unsutured unless enlarged or closure was not satisfactory at the conclusion of surgery. RESULTS: The review yielded 392 patients. Six (1.53%) had intraocular pressure (> or = 30 mm Hg) requiring treatment, 1 (0.26%) had painless iris prolapse, 11 (2.81%) had corneal abrasions, and 7 (1.78%) were given a more intensive steroid regime. No cases of fibrinous uveitis were recorded. CONCLUSIONS: Potentially sight-threatening complications present on the first postoperative day, albeit infrequently. With our current practice and case mix, the need for this review persists. It is possible to reduce the demand on physician time by using appropriately trained nonmedical practitioners.     

Artery, Vein, Neither, Both?

Combined central retinal vein and central retinal artery occlusion is a rare complication of compressive or infiltrative optic nerve disease. In this case combined retinal arterial and venous occlusive disease was the presenting sign of metastatic adenocarcinoma to the optic nerve sheath. An optic nerve sheath biopsy led to the diagnosis. Clinicians should be aware that retinal vascular disease can be due to optic nerve disorders including metastatic carcinoma.     

A day at the beach: Does visually perceived distance depend on the energetic cost of walking?

It takes less effort to walk from here to the Tiki Hut on the brick walkway than on the sandy beach. Does that influence how far away the Tiki Hut looks? The energetic cost of walking on dry sand is twice that of walking on firm ground (Lejeune et al., 1998). If perceived distance depends on the energetic cost or anticipated effort of walking (Proffitt, 2006), then the distance of a target viewed over sand should appear much greater than one viewed over brick. If perceived distance is specified by optical information (e.g., declination angle from the horizon; Ooi et al., 2001), then the distances should appear similar. Participants (N = 13) viewed a target at a distance of 5, 7, 9, or 11 m over sand or brick and then blind-walked an equivalent distance on the same or different terrain. First, we observed no main effect of walked terrain; walked distances on sand and brick were the same (p = 0.46), indicating that locomotion was calibrated to each substrate. Second, responses were actually greater after viewing over brick than over sand (p < 0.001), opposite to the prediction of the energetic hypothesis. This unexpected overshooting can be explained by the slight incline of the brick walkway, which partially raises the visually perceived eye level (VPEL) and increases the target distance specified by the declination angle. The result is thus consistent with the information hypothesis. We conclude that visually perceived egocentric distance depends on optical information and not on the anticipated energetic cost of walking.     

Is visual outcome compromised when next day review is omitted after phacoemulsification surgery? A randomised control trial

AIMS: To examine the safety implications of omitting first day clinical review following phacoemulsification cataract surgery. METHODS: 362 patients were randomly assigned to "same day discharge" (SDD) or "next day review" (NDR). All patients were reviewed approximately 2 weeks after surgery. RESULTS: Of the 174 patients randomised to NDR, 14 (8.0%) were treated for raised intraocular pressure (25-48 mm Hg) on the first postoperative day. Four received increased topical steroids for uveitis (two) and corneal oedema (two). One patient was treated for a significant wound leak. 12 (6.9%) required additional reviews before 2 week follow up for treatment of the following complications: drop toxicity (six), raised intraocular pressure (five), and corneal abrasion (one). Of the 188 randomised to SDD, six (3.2%) returned to the department before the planned review for reassurance of patients' concerns regarding eye symptoms (three), drop toxicity (one) and follow up of previously raised intraocular pressure (one). There were two cases of iris prolapse in the SDD group. In one case, the complication was anticipated and early review had been arranged. Postoperative acuities of 6/12 or better were achieved in 83% of both SDD and NDR patients (p = 0.96 by chi(2) test). Postoperative quality of life scores at 4 months indicating "no or hardly any concern about vision" (VCM1 questionnaire index <1.0) were achieved in 67% SDD and 72.5% NDR (p = 0.26). CONCLUSION: The intention to discharge patients on the day of surgery, with planned postoperative review at 2 weeks, was associated with a low frequency of serious ocular complications. Differences in the proportions achieving a good visual outcome between the two groups, based on 2 week visual acuity and 4 month quality of life, were not significant.     

True, True and Related?

Several chorioretinal lesions have been observed that are associated with bone marrow transplantation (BMT), such as cotton-wool spots, macular stars, ischemic changes due to microangiopathy, “BMT retinopathy” and choroidal infiltration. Central serous retinopathy (CSR) has rarely been described in the BMT setting. We present a patient who underwent allogeneic BMT and subsequently developed severe chronic graft versus host disease (CGvHD) complicated with CSR.     

The phlycten,a come-back?

In February 1980 acute keratoconjunctivitis was seen in a girls' class in a school in Rotterdam. Bacteriological and virological examination was performed on 20 girls. The agent causing this epidemic could not be demonstrated. Three patients had phlyctens at the limbus. In the year following this observation (March 1980 till March 1981) 42 cases of phlyctenular keratoconjunctivitis were examined prospectively. The condition was most commonly seen in 13- to 18-year old girls. The phlycten can be considered as an elementary form of inflammation in the conjunctiva and cornea, based on an immune reaction of the delayed type (Gell and Coombs' type IV). The hypersensitivity to tuberculin, which was formerly an important feature of this inflammation (scrofulous ophthalmia), is of little importance in the Netherlands at the present day. However, in every case of phlyctenular keratoconjunctivitis tuberculosis should still be excluded by the medical history, and if necessary by a Mantoux reaction.