OD News Articles

9th April 2019

Thinking Beyond the Eye in Ocular Surgery

by Kerri Norris, OD Kennewick, WA

The eye is a small and complex organ. But as optometric physicians, our job doesn’t stop there. Seeing our patients as a whole, taking into account systemic and infectious disease, mental status, and other concerns enables us to provide the very best care. And as patients consider eye surgery, thorough pre-operative evaluations provide the foundation for successful outcomes.

The glare caused by bright lights while driving at night can be a problem.

As a referral center that works closely with hundreds of private practice colleagues, we believe patients are best served by the collaborative efforts of a team of professionals. You are a crucial part of this team. As we partner to assess patients for surgery, I thought it might be helpful to review some of the “whole-patient” markers that guide our decisions.

Systemic Disease

Diabetes and hypertension are becoming increasingly common, and we always review the stability of these patients. When a diabetic cataract patient is on insulin or has retinopathy, the addition of a prophylactic post-op topical NSAID may be indicated. When retinal pathology is discovered, such as hemorrhage, edema or signs of ischemia secondary to systemic disease, we may recommend evaluation or treatment by a retinal specialist before surgery. Some treatments are also best coordinated with surgery. For example, patients who have proliferative diabetic retinopathy or diabetic macular edema receive a protective benefit when their anti-VEGF injection is done a week before cataract surgery.

For the safety of our surgery patients, treatment will be cancelled if they arrive at our facility outside of these guidelines:

  • Blood sugar between 70 and 350 mg/dl
  • Systolic pressure between 100 and 199 mm Hg
  • Diastolic pressure between 50 and 100 mm Hg
  • Pulse between 50 and 90 beats per minute

When patients have suffered a heart attack or stroke, or undergone cardiac surgery in the past 90 days, elective ocular surgery such as cataract extraction should be postponed. Before proceeding, patients must be stable, so it may also be prudent to obtain medical clearance from the treating physician.

With corneal surgery like LASIK, PRK, PTK and corneal crosslinking, it is essential to consider the possible impact of collagen vascular and systemic autoimmune diseases. These include:

    A nurse takes an elderly gentlemamn's blood pressure.
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Sjögren’s syndrome
  • The HLA B27 family

These diseases increase the risk of ocular manifestations and are considered a relative (not an absolute) contraindication to laser vision correction. The decision to proceed with surgery can be assessed on a case-by-case basis for patients who:

  • Are not on systemic steroids
  • Are well controlled without a high dose or numerous medications
  • Have few ocular manifestations including the absence of dry eye
Immune Status

We need to be mindful of added risk for patients with compromised immunity—including those undergoing chemotherapy. Chemo reduces the body’s ability to fight infection, and a low platelet count is a common side effect. We generally postpone elective surgery until the body’s immune system and ability to properly clot have recovered. Our rule of thumb is to:

  • Avoid elective surgery when platelet counts are under 50,000 per mL.
  • Approach necessary surgery with caution during active chemo when platelet counts are between 50,000 and 80,000 per mL. As this range is considered thrombocytopenia, medical clearance should be obtained from the patient’s oncologist specifically addressing their platelet count and ability to fight infection.

With cataract surgery, most of our surgeons prefer mini-scleral tunnel incisions. However, when we operate on immunocompromised patients who are at risk for hemorrhage, a clear corneal incision with topical anesthesia may be used to avoid vascular tissue and the needle stick of a retrobulbar block.

Infectious Disease

When patients are being followed for an infection or are on any form of antibiotics, it is best to allow time for complete resolution before cataract surgery. In my experience, patients rarely volunteer the fact that they are being treated for an infection on their leg, not imagining it could be relevant during an eye exam. So a thorough review of systems must be performed to get the complete medical history—including any oral antibiotics that are being used.

For those suffering active ocular herpetic infection, we suggest these guidelines:

  • Postpone elective eye surgery until 6 to 12 months after resolution.
  • Consider waiting 3 months before proceeding with cataract surgery on the non-affected side.
  • When patients have a history of herpes simplex ocular conditions, prophylactic antivirals can be started 1 week before cataract surgery and continued until topical steroids have been stopped.
Physical and Mental Ability

Before eye surgery, we need to consider patients’ physical ability to lie still throughout treatment. Even with procedures that only take a few minutes, several factors can prevent them from safely or comfortably getting through treatment in our facility:

  • Those with an impaired mental ability such as severe dementia or Down’s syndrome might benefit from general anesthesia.
  • Hospital-based surgery may also be more appropriate for very claustrophobic patients and those with severe head or body tremor.

Patients with back, neck, or ambulatory issues who would like treatment with us can make arrangements to come into our surgery suite, lay on the reclining chair, and undergo a trial run with our surgical team. This allows us and them to see if our setting will be suitable before scheduling surgery.

    irregular corneal surface

Our medical and surgical chairs have limitations on the weight they can safely accommodate. Also, the patient’s weight can obstruct a practitioner’s ability to provide care should they become unresponsive. For this reason, patients are asked their weight before scheduling. In our facility, patients 300 to 350 lbs. are individually assessed, and we help them determine if hospital-based surgery is appropriate. This decision is made case by case and might include a trial run in our surgery suite. However, patients over 350 lbs. are best served with hospital surgery.

Conclusion

It is always good to remember that the knee bone is connected to the shin bone. Considering the complete individual in our chair and their specific needs can only improve their surgery experience and post-operative outcome.

Questions?

If you ever have questions, feel free to contact any of our optometric physicians. We’re always happy to help.