To determine whether cataract surgery is advisable, the following information is obtained, and the suggested parameters are tailored to the individual patient.
General Health of the Patient
A complete medical history is the starting point for the preoperative evaluation. The ophthalmologist can work with the patient’s primary care physician to achieve optimal management of all medical problems, especially diabetes mellitus, ischemic heart disease, chronic obstructive pulmonary disease, bleeding disorders, or adrenal suppression caused by systemic corticosteroid use. The ophthalmologist should be aware of the patient’s drug sensitivities and use of medications that might alter the outcome of surgery, such as immunosuppressants and anticoagulants. Given the low risk of significant hemorrhage with scleral tunnel or clear corneal incisions, anticoagulant medications generally do not need to be discontinued prior to routine cataract surgery. Any alteration in the patient’s use of these medications is ideally done in consultation with the prescribing physician.
It is important to specifically ask the patient about the use of systemic α1-adrenergic antagonist medications (including prazosin, terazosin, doxazosin, silodosin, alfuzosin, and tamsulosin, as well as herbal supplements, such as saw palmetto) for the treatment of benign prostatic hyperplasia, urinary incontinence, urolithiasis, and hypertension. These medications are strongly associated with intraoperative floppy iris syndrome (IFIS) and fluctuations in pupil size. All α1-blockers can bind to postsynaptic nerve endings of the iris dilator muscle for a prolonged period, causing excessive iris mobility and diffuse atrophy of the iris dilator smooth muscle. This effect may occur after only 1 dose of the medication and may persist indefinitely, even after discontinuation of the drug. Anecdotal reports document potential α1-antagonist properties and potential associations with IFIS in other medications, including certain antipsychotic and antihypertensive medications. See Chapter 10 in this volume for further discussion of IFIS.
It is important for the ophthalmologist to inquire about and document any allergies, adverse reactions, and sensitivities to sedatives, narcotics, anesthetics, povidone-iodine, and latex. Factors limiting the patient’s ability to cooperate in the operating room or to lie comfortably on the operating room table (eg, deafness, language barriers, dementia, claustrophobia, restless legs syndrome, head tremor, musculoskeletal disorders, psychiatric disorders including anxiety) will influence the choice of anesthesia and the surgical plan.
The extent of the formal medical preoperative evaluation is based on the patient’s overall health and may be guided by requirements of the facility where the procedure is to take place. Screening with self-reported information gained from health questionnaires may help identify patients who are at higher risk for medical difficulties related to surgery, but this method should not be the only form of evaluation. Certainly, for all patients with risk factors related to their ability to undergo surgery, a history should be obtained, and a physical examination and relevant laboratory work should be performed. However, routine medical testing before routine cataract surgery has not been shown to increase the safety of the procedure.
See also Chapter 12 in this volume and BCSC Section 1, Update on General Medicine, for specific recommendations for preoperative cataract surgery planning in patients with special medical conditions.
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.