Examination of Patients Pre-Cataract Surgery – Episode 65

Cataract surgery has advanced tremendously over the last decade. For most patients, the decrease best-corrected visual acuity caused by cataracts will successfully be treated and provide patients a substantial improvement in vision. There will be several patients at some point that will develop posterior capsular opacification or fibrosis. This can, fortunately, be treated with a yag laser that is applied to the opacified tissue, which then clears the vision again. Because of the predictability of the results, we typically have a standard post-operative period where we can expect a significant reduction in inflammation very quickly after the surgery, along with the three-month postoperative period that very rarely is associated with complications. There seems to be a honeymoon phase for a number of patients where they are remarkably pleased with their visual outcomes, but for some, this honeymoon phase post-operatively is then followed by a visual response that may not be optimal. After a substantial improvement in vision following cataract surgery, many patients love their new vision. But over the next several months, the patient then becomes a much more highly astute observer. If a patient has an underlying dry eye disease, fluctuations in the stability of the tear film will affect a pseudophake much more so than the individual whose vision is decreased because of an existing cataract. So it’s critical to identify patients who have ocular surface disease when examining them for candidacy for cataract surgery. Not surprisingly, those patients who have classic symptoms such as burning, or irritated eyes are much easier to identify. But oftentimes the fluctuating vision we may expect the patient to have with dry eye may be masked with cataracts because of the reduced vision secondary to cataracts. It becomes increasingly important to aggressively examine the ocular surface to identify underlying abnormalities. The utilization of fluorescein and lissamine green dyes allows for ocular surface abnormalities to be exposed on the conjunctiva, cornea, and lid wiper area. Examination of the lid margin for blepharitis and also the quality of meibum that’s produced is critical. Assessing meibomian glands structure with transillumination, as can be seen here or with more advanced technologies, is also an important strategy. Additionally, incorporating advanced point of care tests, such as measuring tear osmolarity, measuring the lipid layer thickness of the tear film, and inflammatory markers such as matrix metalloproteinase-9 is also critical to identify these individuals. Identifying and appropriately treating these patients will be critical to optimize visual outcomes. Cataract surgeries are a remarkable procedure for individuals requiring it. In order to truly optimize the visual outcomes, it is critical to identify patients with underlying ocular surface disease to avoid visual consequences that are unexpected after surgery. Take extra time to question the symptoms that patients may have that are consistent with the ocular surface disease. And make sure to appropriately look for signs of ocular surface disease. Doing so will allow you to appropriately identify and treat these patients and provide them with better visual outcomes. We hope that this has been clinically insightful.

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