1104: Playlist: Post-Op Day 1

Modern day cataract surgery has a very high success and safety record, with the vast majority of patients having a smooth post-op recovery. There are, however, a few rare issues that may arise after routine phacoemulsification. Examining our patients on post-op day one is helpful in detecting these issues and addressing them.

Intra-ocular pressure issues

One of the most common post-operative issues is high intra-ocular pressure which is typically the result of retained viscoelastic and not a steroid-response glaucoma. While we need viscoelastic to perform a safe cataract surgery, we do not typically want to leave this OVD inside the eye at the end of a routine case. The OVD will block the trabecular meshwork which will result in a high intra-ocular pressure for at least a few days.

Ideally, we want to fully remove the OVD at the end of the cataract surgery, including from behind the IOL optic, using our irrigation/aspiration probe. We can also use the angle sweep technique to ensure that viscoelastic is not blocking the angle. Using a 27g blunt cannula and a 3cc syringe filled with balanced salt solution, we can irrigate at the angle of the eye to release any hidden OVD which can then be aspirated or flushed out of the anterior segment.

The angle sweep technique helps to remove all viscoelastic at the end of the surgery in order to avoid high intra-ocular pressure on post-op day 1.

The intra-ocular pressure can also be very low on the day after surgery and this typically means that there is a leak from one of the surgical incision sites. If a leak is detected it is important to seal the incision using additional hydration or a temporary suture. Another technique to help seal the incision is using a hypotonic solution such as tetracaine, soaked into a small surgical sponge which is then placed over the incision for 30 seconds. The osmotic gradient will draw the fluid from the sponge into the corneal tissue and will help to seal the incision.

suture complications are also possible — this video was also in last week’s playlist, but it’s so important that we are showing it again this week.

Anterior segment inflammation

Though it is rare, we can see toxic anterior segment syndrome (TASS) which is an acute, severe inflammatory response including corneal edema presenting the day after cataract surgery. Aggressive treatment with steroids will help to resolve the inflammation and the patient should be followed closely.

It is important to differentiate TASS from endophthalmitis which is treated very differently due to its infectious nature. Endophthalmitis is an emergency and the patient should undergo a tap and inject on the same day that the diagnosis is made. The tap aspirate is sent for culture and identification of the bacteria and antibiotics are injected into the vitreous. These patients may also require a pars plana vitrectomy depending on the severity of the infection in order to decrease the bacterial load. Other causes of post-op corneal edema include excessive phaco energy and corneal endothelial trauma.

IOL position

The IOL is ideally placed completely within the capsular bag at the time of cataract surgery. This is its most natural and secure position and it will produce the best long term results. If the IOL is somewhat decentered on post-op day one, look carefully for other signs like a bulge behind the iris that indicate improper positioning. Using the retro-illumination technique allows us to see the outline of the capsulorhexis and in this case, we can see the optic in front of the anterior capsule with the inferior haptic in the sulcus.

It is important to be able to recognize an issue such as a mispositioned IOL on post-op day 1.

The IOL should be repositioned within the first week or so, prior to the capsular bag contracting. We should avoid leaving the IOL haptic in the sulcus because it will scrape the back of the iris and cause retro-illumination defects and UGH syndrome which is the triad of uveitis, glaucoma, and hyphema. The tilt of the misplaced optic will also induce a refractive effect like astigmatism. In the resident case shown here, we repositioned the IOL to place it completely within the capsular bag on post-op day 1. The patient went on to recover nicely and achieve an excellent visual outcome.

The first post-operative day after cataract surgery is important to detect any of these issues and address them. It is also enjoyable to see the happiness of our patients who now have restored vision. 

We can also see patients where the post-op target was missed. How do we analyze the situation to figure out why?

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