Medical evaluation by the patient’s primary care physician may be part of the preoperative planning process. Conditions such as hypertension and diabetes mellitus should be stabilized. Patients often are required to fast prior to surgery; insulin or oral hypoglycemic medication may need to be adjusted in diabetic patients. For these patients, it is preferable to schedule procedures early in the day to minimize large fluctuations in blood glucose levels.
In patients with lung disease, pulmonary function should be optimized prior to and during surgery; for instance, patients may be permitted to bring their inhalers into the operating room. Patients with lung disease may be prone to coughing, which can damage ocular structures during surgery and threaten wound security. Medication can be used to control coughing, and the patient can be advised to tell the surgeon of any need to cough. With small-incision surgery, the risk of such intraoperative complications can be reduced and wound security enhanced. Patients with chronic obstructive pulmonary disease (COPD), bronchitis, congestive heart failure, or obesity may benefit from being placed in the reverse Trendelenburg position to reduce venous congestion in the head and neck and lessen the risk of vitreous loss and choroidal hemorrhage.
Patients with severe arthritis may have difficulty lying comfortably during surgery. The surgical table can be adjusted, and pillows can be added to provide comfort without interfering with surgical access to the eye. Patients with ankylosing spondylitis and cervical immobility present an extreme challenge in surgical positioning (Fig 12-1); if no systemic medical contraindications exist and if adequate access cannot be attained otherwise, general anesthesia can be considered.
Patients with prostate conditions and those with hypertension may be on α-antagonist medication. The surgeon may encounter intraoperative floppy iris syndrome (IFIS) in these patients. Although no benefit has been shown for discontinuing the medication prior to surgery, special caution is warranted, and surgical modifications may be indicated (eg, intracameral lidocaine with epinephrine or pupillary expansion devices). For further discussion of ocular surgery in patients with systemic disease, see BCSC Section 1, Update on General Medicine.
Figure 12-1 Inflammatory systemic disease. Individuals with ankylosing spondylitis, such as the patient shown in these photos, often have cervical immobility. Evaluating patients in the office examination chair allows the surgeon to anticipate accommodations necessary for carrying out surgery safely and comfortably for both patient and surgeon in the operating room. This patient requires adjustment of the headrest to provide adequate support of his head and neck.
(Courtesy of Lisa Rosenberg, MD.)
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.