Pertinent Ocular History
The ocular history helps the ophthalmologist identify conditions that could affect the surgical approach and the visual prognosis. Trauma, inflammation, amblyopia, strabismus, glaucoma, optic nerve abnormalities, or retinal disease might affect the visual outcome after cataract removal. In addition, an understanding of the patient’s history of refractive error and spectacle or contact lens correction, as well as the patient’s experience with monovision or progressive lenses, may aid refractive planning for cataract surgery.
Controlling active uveitis before cataract surgery is performed helps minimize the risk of complications from postoperative inflammation, such as macular edema and iris adhesion to the lens implant. Ideally, the eye is quiet without the use of topical corticosteroids for at least 3 months before surgery. This is not always possible, and surgery may be needed before the clinician is able to completely quiet the eye. Systemic immunomodulation may be necessary to achieve remission. Systemic steroids may be required perioperatively to manage ocular inflammation, even in eyes that were quiet prior to surgery. The presence of zonular abnormalities, fibrin membranes, and posterior synechiae will require the surgeon to adjust his or her surgical technique, as discussed in Chapter 12 of this volume.
A family history of retinal detachment or a history of retinal pathology in either of the patient’s eyes is a risk factor for postoperative retinal detachment. Previous vitrectomy for the treatment of retinal disease or vitreous hemorrhage may cause intraoperative chamber fluctuations, which increase the risk of posterior capsule disruption and loss of nuclear fragments posteriorly.
Ideally, in patients with glaucoma, optimal control of intraocular pressure (IOP) is achieved prior to cataract surgery. If this cannot be accomplished, the surgeon may wish to consider a combined operation (cataract surgery along with an intervention to lower IOP). New techniques combining cataract surgery with minimally invasive glaucoma surgery (MIGS) may allow for the reduction of medications while maintaining a risk profile similar to that of cataract surgery alone. See Chapter 12 in this volume and BCSC Section 10, Glaucoma.
Past records document the patient’s visual acuity before the development of cataract. If the patient has had cataract surgery in the fellow eye, it is important to obtain information about the operative and postoperative course. If problems such as IFIS, elevated IOP, vitreous loss, cystoid macular edema, endophthalmitis, hemorrhage, or a refractive surprise occurred during or after the first operation, the surgical approach and postoperative follow-up could be modified for the second eye in order to reduce the risk of similar complications.
If the patient has previously undergone refractive surgery, it is helpful to perform additional ocular measurements prior to and after the cataract surgery. See Chapters 7 and 12 for further discussion on surgical preparation.
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.