University of Gondar

University of Gondar
CMHS
Department of Optometry
seminar on pre and post operation evaluation of
cataract surgery
Presenter: Marshet Gete (1st yr. MSc student)
Moderators: Dr. Dagmawi A (MD, Asst.professor in opth)
Mr. Tarekegn (MSC in clinical optometry)

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 Objectives

At the end of this seminar students should be able to:

• List the indication for cataract surgery
• Identify the evaluation of pre and post op cataract surgery
• Complication of cataract surgery

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 Outline

• Introduction
• consideration in the evaluation and management of cataract
• Indication for cataract surgery
• Preoperative Evaluation
• Systemic Preoperative Assessment
• Ophthalmic preoperative assessment
• Post op assessment
• Complications

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 Introduction

• Cataract is the leading cause of avoidable blindness

worldwide, accounting for nearly half (47.8 %) of all cases
of blindness.
• WHO – 18 -20 million people worldwide are blind from
bilateral cataracts.
• High quality, affordable and accessible surgery should be
provided for the population.

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 consideration in the evaluation and management of
cataract

 Functional impact of the cataract

 Morphological characteristics of the cataract
 Indication of surgery
 Patient’s expectations regarding the refractive results of
surgery
 Patient have ocular or systemic
 Barriers to obtaining informed consent or to ensuring
good postoperative care

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 Indication for cataract surgery

• Patient’s desire for improved vision – is the most common

indication for cataract surgery
• For management- lens induced conditions
• To enable fundus examination - to help in diagnosis or
management of other ocular conditions like DR, AMD,
glaucoma
• Cosmetic indication - restoration of a black pupil in blind
eye.

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 Preoperative Evaluation

• Goal

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 Systemic Preoperative Assessment

 Diabetic patients
• Has increased risk of post operative infection, marked post
op inflammation, poor wound healing and has increased
risk of GA
• Optimal glycemic control is vital - in avoiding CNS
dysfunction
• Oral hypoglycemic medications are usually withheld the
day of surgery

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 Con’t

 Pulmonary Disease - patient with severe chronic

obstructive pulmonary disease or asthma - Optimization
of pulmonary function
 Patients with Uncontrolled cough increases risk of
complications in intraocular surgery, careful screening
and management before consideration for surgery.

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 Con’t

 Uncontrolled blood pressure increases risk of perioperative

cardiovascular complications.
 Optimal blood pressure is also unclear
 Recommend target BP below 160 mm Hg systolic and 100
mm Hg diastolic prior to elective surgery

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 Con’t

 Patient’s drug sensitivities and use of medications.

 A patient who has ankylosing spondylitis with
cervical immobility.

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 Pertinent ocular history
 Help to identify conditions that could affect the surgical
approach and the visual prognosis.
 Understanding of the patient’s history of refractive error
and spectacle or contact lens correction.
 Active uveitis should be controlled before cataract surgery
-the eye is quiet without the use of topical corticosteroids
for at least 3 months before surgery.

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 Con’t
• In glaucoma patients, optimal control IOP should be
achieved prior to cataract surgery.
• Preserve superior conjunctiva in glaucoma patient who
may require future filtration surgery.
• The patient’s occupation, hobbies, lifestyle and family
support should be considered.
• Family history of retinal detachment is a risk factor for
postoperative retinal detachment.

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 Ophthalmic preoperative assessment

• Visual Acuity Testing - measure both under lighted and

darkened examination.
• Refraction - Careful refraction must be performed on both
eyes.
• Useful for calculating the IOL power to obtain the desired
postoperative refraction.

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 Con’t

 Post–operative refraction planning

• Emmetropia is typically the desired postoperative
refraction.
• Spectacles will be needed for near vision since a
conventional IOL cannot accommodate
• Many surgeons aim for a small degree of myopia (about
−0.25 D) to offset possible errors in biometry
• Postoperative hypermetropia is less well tolerated than
myopia.

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 Con’t

 Glare Testing
• Testing can be done with a non projected eye chart in
ambient light conditions or with a projected eye chart and
an off-axis bright light directed at the patient
• Patients with significant cataracts commonly show a
decrease of 3 or more lines compared with results obtained
when visual acuity is tested in a darkened room.
 Contrast Sensitivity should be done.

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 Con’t

 Ocular motility and alignment

• Abnormal motility may suggest preexisting strabismus
with amblyopia as a cause of vision loss.
• Cover testing should be performed to document any
muscle deviation.
• Experience diplopia after Cataract surgery if they have a
significant tropia resulting in disruption of fusion.
• Ocular dominance can be important if considering
monovision.

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 Slit-Lamp examination

 Ocular adnexa
• Dacryocystitis, blepharitis, chronic conjunctivitis,
lagophthalmos, ectropion, entropion and tear film
abnormalities may predispose to endophthalmitis.
• The presence of enophthalmos or prominent brow should
be dealt before surgery.

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 Con’t
 Sclera
• If eye is large or the sclera thin (e.g. high myopia), peri- and
retrobulbar local anesthesia should be avoided.
• Ocular inflammation such as scleritis and uveitis should be
controlled.

 Conjunctiva
• Vascularization, the presence of a filtering bleb or scarring
of the conjunctiva may indicate compromised healing and
limit surgical exposure.

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 Con’t
 Cornea
• Corneal pachymetry useful for indirectly assessing the
function of the endothelium.
• , significantly increased central corneal thickness (>640 μm)
is poor prognosis for corneal clarity.
• Endothelial cell counts less than 1000/mm2 could increase
the risk of poor healing and decompensation
postoperatively.

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 Con’t
• Descemet membrane irregularity associated with may affect
the view of the lens during surgery and limit visual acuity.
• Scarring possibly consistent with a history of herpetic eye
disease are present ,prophylactic antiviral medication to
avoid reactivation.
• Corneal topography is useful in diagnosing and quantifying
irregular astigmatism.

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 Con’t
• A shallow anterior chamber can render cataract surgery
difficult.
• The presence of iridodonesis or exfoliation pupil may
indicate weakened or absent zonular attachments and may
affect the surgical plan.
• RAPD should be carefully evaluated as its presence implies
extensive retinal disease or optic nerve dysfunction.

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 Con’t

 Crystalline Lens
• Evaluate the appearance before and after dilatation.
• Assess the type of cataract and its contribution to visual
deficit.
• The position of the lens and the integrity of the zonular
fibers should also be evaluated.

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Con’t…….

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 Fundus Evaluation

• To detect AMD or other maculopathy that may limit visual

outcome
• Diabetic patients examined carefully for the presence of any
diabetic signs.
• Increase risk of anterior or posterior neovascularization in
patient with retinal ischemia if posterior capsule is rupture
intraoperative
• Retinal periphery examination may reveal presence of
vitreoretinal traction or preexisting retinal holes and lattice
degeneration.
• Optic nerve assessed for cupping and pallor or any abnormality
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 Macular function tests
• B-scan ultrasonography – to detect retinal detachment,
vitreous opacity, posterior pole tumor, or staphyloma
• Gross color vision test
• Photostress recovery test
• Maddox rod test
• Potential Acuity Meter, or PAM
• OCT and fluorescein angiography
• 2-point discrimination

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 Visual Field Testing

• It help us to identify visual loss resulting from disease

processes besides cataract.
• Confrontation visual fields should be tested in all cataract
patients.
• In patient with dense cataracts light projection is used to test
the peripheral visual field.
• Patients with a history of glaucoma, ON disease, or retinal
abnormality needs VF evaluation by static or kinetic
methods.

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 IOL Power Determination
 Based on the measurements of:

 Axial length
 Cornea power
 Effective lens position (ELP)

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 1. Axial length

• Ocular axial length (AL) is a key component of IOL power

calculations.
• 1 mm error in the AL measurement can lead to significant
postoperative refractive error, especially shorter eye.
• The difference in AL between the 2 eyes is typically no
greater than 0.3 mm.

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 Ocular Biometry

• Noncontact instruments that use optical coherence

reflectometry instead of ultrasound to measure.
• Used to measure AL, corneal curvature, anterior chamber
depth, lens thickness, and corneal diameter.
• Can’t be used during significant optical media opacity,
dense cataract , corneal opacity or vitreous hemorrhage.

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 A-scan ultrasonography

• A-scans measure the time required for a sound pulse to

travel from the cornea to the retina and back again
• Measures AL by using either an
Immersion technique or
Contact applanation method

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 2. Central Corneal power/K

• Corneal power can be estimated by keratometry or corneal

topography.
• K - is the second most important factor in the calculation
formula; a 1.0 D error in corneal power causes a 1.0 D
postoperative refractive error.
• The standard manual keratometer measures only a small
central portion (3.2-mm diameter) of the cornea and views
the cornea as a convex mirror.

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 3. Effective Lens Position

• Is an estimate of the distance behind the cornea at which the

intraocular lens will be located.
• was previously called the anterior chamber depth (ACD).
• Its one of the causes of residual refractive error - 1 mm
measurement error of ACD result in 1.5 D of refractory
error.

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 IOL Power Determination

• P = A − (2.5L) − 0.9K
where
P = lens implant power
L = axial length (mm)
K = average keratometric reading (diopters)
A = constant specific to implant to be used

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 Con’t

• The Hoffer Q formula has been shown to be more reliable

for eyes with a short AL, while the SRK/T and Haigis
formulas have shown to be more reliable in eyes with a long
AL.

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 Pediatrics IOL power determination

• IOL power selection for children much more complex than

that for adults due to:
• Challenge of obtaining accurate AL and corneal
measurements – usually performed under GA.
• Small size of a child’s eye or shorter AL causes greater IOL
power errors.
• Challenge of selecting an appropriate target IOL power for
expected growth of the eye or change in axial length.
• IOL power formulae derived from adult data – predictability
in children is uncertain.
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 Con’t

• Challenge of selecting an appropriate target IOL power for

expected growth of the eye or change in axial length.
• To counteract the large myopic shift that occurs, it is
advisable to under correct in children with IOLs so that
they can grow into emmetropia or mild myopia in adult life.

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Con’t

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 Informed consent

• The surgeon must obtain informed consent preoperatively

• Patient should have a clear understanding of the surgery.
• The risks and benefits, the alternatives to surgery.
• The surgical technique, and IOL options.

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 Patient preparation & informed consent

• Informed written consent should be taken

• Pupil should be adequately dilated
• Anesthesia
• Skin & conjunctiva preparation & draping in sterile fashion
• Medication

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 Preoperative Medications
 Mydriatics: Good pupillary dilatation is very crucial for
MSICS
 Nonsteroidal anti-inflammatory drugs (NSAIDs):
To prevent intraop constriction of pupil.
It is important to instill these drugs at least half an hour
before surgery.
 Povidone iodine is used universally in ocular surgery unless
there is a case of proven allergy to it.

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 Surgical Technique

• ICCE
• ECCE
• MSICS
• Phacoemulsification

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 Con’t

• ICCE- cryoprobe is used to remove the lens complete with

its capsule.
• ECCE- Cortical matter is then aspirated, leaving behind a
sufficiently intact capsular bag to support an IOL. Suturing
of the incision is required.

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 Con’t

• MSICS- for high volume surgical treatment of patients with

dense cataracts.
• Creation of a small self-sealing sclerocorneal tunnel,
staining of the anterior capsule to facilitate
capsulorhexis,manual one-piece expression of the nucleus,
manual aspiration of the cortex and IOL implantation.

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 Con’t

 Phacoemulsification
• It employs high-frequency ultrasound energy to fragment
and emulsify the nucleus of cataract lens with complete
aspiration of this emulsate and cortex.

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 Post operative care

• Examined for the first time within 24 hours of the surgical

procedure.
• This initial examination is the most critical for ruling out
unexpected intraoperative complication.

 VA: unaided/aided
 Wounds site
 Cornea: clarity
 AC: formed, activity

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 Postoperative Medications

Anti- inflammatory
• Topical corticosteroids
• Tapered over a 4–6 weeks period.
Antibiotics
• There is less controversy on the postoperative use of
antibiotics.
• Fluoroquinolones are the most commonly prescribed
medications.
Cycloplogic
Others drugs:- anti glaucoma, lubricant
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 Patients must be instructed to:

• The appropriate care of surgical wounds.

• The timing of postoperative evaluations and the application
of medication.
• The type and amount of pain to be expected and how to
manage it.
• Activity restrictions.
• warning signs or symptoms requiring contact with physician
and immediate attention.

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 Complication
• Preoperative complications
• Intraoperative complications
• Early postoperative complications
• Delayed (late) postoperative complications
• IOL-related complications

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 Operative complications

• Excessive bleeding
• Injury to the cornea
• Iris injury and iridodialysis
• Posterior capsular rupture
• Vitreous loss

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 Early postoperative complications

• Hyphaema
• Iris prolapse
• Flat/ shallow anterior chamber
• Postoperative anterior uveitis
• Bacterial endophthalmitis

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 Late postoperative complications

• Posterior Capsule Opacification

• Cystoid macular edema
• Delayed chronic postoperative endophthalmitis
• Pseudophakic bullous keratopathy
• Retinal detachment

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 IOL-related complications

• UGH
• Pupillary capture of the IOL
• Toxic lens syndrome
• Malposition of IOL

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 Reference

• BCSC lens and cataract 2020-2021

• Yanoff
• Slide share

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Thank you

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