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Klinika Oczna / Acta Ophthalmologica Polonica
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SCImago Journal & Country Rank
3/2024
vol. 126
 
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Wytyczne/zalecenia

Wytyczne opieki okołooperacyjnej w chirurgii zaćmy w Polsce

Jacek P. Szaflik
1, 2
,
Alina Bakunowicz-Łazarczyk
3
,
Dariusz Dobrowolski
4, 5, 6
,
Iwona Grabska-Liberek
7
,
Bartłomiej Kałużny
8
,
Jakub Kałużny
9
,
Wojciech Lubiński
10
,
Jerzy Mackiewicz
11
,
Katarzyna Michalska-Małecka
12
,
Marta Misiuk-Hojło
13
,
Ewa Mrukwa-Kominek
14
,
Agnieszka Nowak
15, 16
,
Wojciech Omulecki
17
,
Weronika Pociej-Marciak
15, 16
,
Bożena Romanowska-Dixon
15, 16
,
Marcin Stopa
18, 19
,
Joanna Przybek-Skrzypecka
1, 2

  1. Department of Ophthalmology, Medical University of Warsaw, Poland
  2. Independent Public Clinical Ophthalmology Hospital in Warsaw, Poland
  3. Department of Paediatric Ophthalmology with Strabismus Treatment Centre, Medical University of Bialystok, Poland
  4. Department of Ophthalmology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Poland
  5. SP ZOZ District Railway Hospital in Katowice, Poland
  6. Department of Ophthalmology, St. Barbara’s Regional Hospital No. 5, Trauma Center – Sosnowiec, Poland
  7. Ophthalmology Clinic, Medical Center of Postgraduate Education in Warsaw, Poland
  8. Department of Ophthalmology and Optometry, Department of Eye Diseases, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
  9. Department of Sensory Organ Research, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
  10. 2nd Department of Ophthalmology, Pomeranian Medical University in Szczecin, Poland
  11. Clinic of Retinal and Vitreous Surgery, Department of Ophthalmology, Medical University of Lublin, Poland
  12. Department of Ophthalmology, Medical University of Gdansk, Poland
  13. Department of Ophthalmology, Wroclaw Medical University, Poland
  14. Department of Ophthalmology, Medical University of Silesia in Katowice, Poland
  15. Department of Ophthalmology and Ophthalmic Oncology, Department of Ophthalmology, Jagiellonian University Collegium Medicum in Krakow, Poland
  16. Clinical Department of Ophthalmology and Ophthalmic Oncology, University Hospital in Krakow, Poland
  17. Clinical Department of Ophthalmology with a Children’s Section, Medical University of Lodz, Poland
  18. Department of Eye Diseases and Optometry, Poznan University of Medical Sciences, Poland
  19. Eye Diseases Clinic, Heliodor Swiecicki University Clinical Hospital in Poznan, Poland
KLINIKA OCZNA 2024, 126, 3: 115-118
Data publikacji online: 2024/10/09
Pliki artykułu:
- KO-00528_EN.pdf  [0.13 MB]
- KO-00528_PL.pdf  [0.14 MB]
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INTRODUCTION

The approach to cataract surgery procedures in Poland has undergone significant changes within the last several years. In the year prior to the COVID-19 pandemic (2018), about one million Poles were eligible for cataract surgery, leading to an approximate two-year waiting time for the procedure. In 2019, with the removal of limits on cataract surgeries financed by the National Health Fund (NFZ), the waiting time was reduced to about five months. In the first year of the COVID-19 pandemic (2020), the number of cataract surgeries decreased by 34% compared to 2019, with 355,000 procedures in 2019 and 250,000 in 2020. The pandemic has had no effect on the cataract surgery mode, which remains in compliance with European standards: 98-99% of cataract surgeries are now performed as day cases (average calculated for 2020-2022, Poland).

The Polish Society of Ophthalmology allows the operator and patient to decide whether to perform cataract surgery on one or both eyes simultaneously. Binocular surgery is especially relevant for patients requiring general anesthesia, such as those with intellectual disabilities. It is important to note that surgery on the second eye is treated as a separate operation, ensuring full sterility for both procedures.

ELIGIBILITY ASSESSMENT

When assessing patient eligibility for cataract surgery, it is essential to consider concomitant systemic and ophthalmic disorders due to their potential impact on the risk of intra- and postoperative complications. Performing surgery is ruled out in patients with active systemic and local infections. Patients with blood pressure exceeding 180/110 mm Hg are ineligible for the procedure. Before surgery under local anesthesia (other than drip anesthesia), especially periocular or extraocular, or when additional intraoperative manipulations are anticipated (e.g. removal of posterior synechiae, iridoplasty, mechanical mydriasis), modification of the patient’s anticoagulant treatment should be considered [1]. Patients undergoing immunosuppressive treatment (including chemotherapy and biologic treatment) should continue their therapy without modifications. Other chronic systemic medications should also be maintained. Ophthalmic conditions that should be treated before cataract surgery include abnormal eyelid positioning (especially when entropion causes the eyelashes to erode the cornea), flare-ups of chronic blepharitis, infectious conjunctivitis, keratitis, uveitis, and dacryocystitis. Preoperative normalization of intraocular pressure is crucial, especially for patients with glaucoma. Alternatively, combining cataract surgery with antiglaucoma surgery may be considered. Special attention should be given to patients with chronic or recurrent uveitis, with surgery recommended only after a 3-month period of disease inactivity. For these patients, preoperative oral glucocorticosteroid administration or intraoperative intravitreal injection should be considered [2].

Another group requiring special attention comprises patients with wet age-related macular degeneration (wAMD). Based on current knowledge, cataract surgery is recommended for all patients with wAMD, regardless of preoperative central retinal thickness, if the cataract is likely to impair visual acuity [3]. Furthermore, delaying surgery in these patients results in an avoidable decline in their quality of life [4]. The main controversy revolves around determining the optimal timing for surgery during wAMD treatment. According to expert consensus, patients with lens opacity that obscures the fundus should undergo surgery as soon as possible. Patients with stable subretinal fluid levels can proceed with surgery without prior preparation [5]. Some studies have suggested that a six-month course of anti-VEGF therapy before cataract surgery offers advantages [6]. The optimal effect is achieved if the injection is administered within one month before cataract surgery [7]. However, some reports indicate an increase in central retinal thickness and subretinal fluid levels three months post-cataract surgery. The hypothesized mechanism involves a specific predisposition to developing Irvin-Gass syndrome. Administering topical NSAIDs for at least three weeks post-surgery has been shown to mitigate this issue. Despite an objective decline in OCT parameters, cataract surgery did not lead to an increase in the number of postoperative anti-VEGF injections or negatively affect final visual acuity in this group of patients when compared to the control group. Also, there is no evidence that intraoperative administration of anti-VEGF agents is more effective. Given the known risks of blue light phototoxicity, considering an intraocular lens with a blue light filter is advisable. However, EBM does not indicate any advantage for these lenses in AMD patients [8]. Notably, the improvement in visual acuity after cataract surgery in patients with wAMD typically ranges within 2 Snellen lines (7-9 ETDRS letters) [7].

A distinct group comprises children with cataract, where a strong focus should be placed on accurate diagnosis and identifying the underlying cause of the condition.

PRE-CATARACT SURGERY CARE

In patients with preexisting clinically significant blepharitis and associated dry eye syndrome, eyelid margin hygiene and tear film stabilization should be considered before calculating lens power for precise implant selection [9]. Preoperative administration of a nonsteroidal anti-inflammatory drug (NSAID) for two days prior to surgery is recommended as it has been proven to aid in achieving stable intraoperative mydriasis. Conflicting reports exist regarding the use of a topical antibiotic before the day of procedure. Some authors advocate using a fluoroquinolone two days prior to surgery to reduce the risk of endophthalmitis. However, there is insufficient scientific evidence in line with evidence-based medicine (EBM) to support this routine practice. However, starting prophylaxis with topical fluoroquinolone one day before surgery and continuing it on the day of the procedure is recommended in infants and young children.

INTRAOPERATIVE CARE

On the day of surgery, it is advisable to use NSAIDs and mydriatics (tropicamide, phenylephrine, cyclopentolate) in drop form prior to the procedure. As an alternative to mydriatics in drops, intraoperative administration of 0.2 ml of a sterile, ready-made preparation containing 2 mg of lidocaine, 0.04 mg of tropicamide, and 0.62 mg of phenylephrine or adrenaline solution into the anterior chamber should be considered. The administration of mydriatics via intravitreal injection is believed to mitigate the adverse effects of surgery on the ocular surface.

Preventive measures for postoperative endophthalmitis include:

  • preoperative disinfection of the skin of the eyelids and eye area with 10% povidone-iodine solution for 2-3 minutes, or 0.1-0.5% chlorhexidine solution in patients with hypersensitivity to povidone-iodine [10, 11];

  • preoperative disinfection of the conjunctival sac with 5% povidone-iodine solution for at least 3 minutes, or 0.02-0.1% chlorhexidine solution in patients with hypersensitivity to povidone-iodine [12];

  • intraoperative administration of a sterile ready-to-use antibiotic preparation into the anterior chamber (cefuroxime 1 mg/0.1 ml is the medication of choice, but 0.5 mg/0.1 ml moxifloxacin or 1 mg/0.1 ml vancomycin can be used in the rare cases of immediate hypersensitivity to β-lactams) [12, 13].

It is important to note that povidone-iodine is statistically more effective in preventing postoperative endophthalmitis than chlorhexidine. Literature indicates an increased risk of endophthalmitis when aseptic conditions with povidone-iodine and cefuroxime are not maintained in the anterior chamber.

POSTOPERATIVE CARE

Postoperative care is focused primarily on minimizing the most common complications that could lead to permanent vision loss, such as endophthalmitis and postoperative macular edema.

Postoperative care includes the administration of:

  1. a fluoroquinolone antibiotic for 7 days, with levofloxacin being the preferred active substance [14];

  2. a nonsteroidal anti-inflammatory drug with a high potential for penetrating the posterior segment of the eye, administered for 4-6 weeks after surgery to prevent Irvine-Gass syndrome [16-19];

  3. a glucocorticosteroid for 2-4 weeks post-surgery (preferably loteprednol, which has a low potential to induce elevated intraocular pressure, or dexamethasone) [20];

  4. moisturizing and regenerating preparations for the ocular surface, particularly for patients with preexisting ocular surface disease (e.g. preoperatively diagnosed dry eye syndrome, recurrent corneal erosion syndrome). It is important to note that antibiotic, corticosteroid and NSAID preparations administered as part of standard surgical procedure can induce or exacerbate symptoms of dry eye syndrome. In such cases, it is advisable to recommend preservative-free moisturizing eye drops [21].

The recommended minimum interval between drops administered into the conjunctival sac is 3-5 minutes.

It is essential to recognize that a major challenge in postoperative care is patient compliance. Studies reveal that over 75% of patients do not consistently wash their hands before administering drops, and more than 40% fail to reach the conjunctival sac [22]. On the day of discharge, patients should be informed about the correct technique for applying drops to the conjunctival sac and the transient ophthalmological symptoms that may occur after cataract surgery, such as burning sensation, dryness, a gritty feeling under the eyelids, and tearing.

Reports suggest that dropless cataract surgery (performed without prescribing drugs to be administered to the conjunctival sac postoperatively but instead using intraoperative drug injections or drug-releasing implants) may be a viable option for some patients. However, the current lack of available preparations in Poland and the cost-effectiveness aspect of the procedure prevent its widespread standard application [23].

Another important consideration is reducing physical activity after cataract surgery. The main restrictions include avoiding swimming (especially in swimming pools) for 4-6 weeks post-surgery, and refraining from heavy lifting during the initial weeks after the procedure.

DISCLOSURES

The authors declare no conflict of interest.

This research received no external funding.

Approval of the Bioethics Committee was not required.

References

1 

Makuloluwa AK, Tiew S, Briggs M. Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye (Lond) 2019; 33: 1044-1059.

2 

Jamil MU, Naz U, Naz S. Intravitreal versus Oral Steroids for Inflammation Control in Uveitic Patients Undergoing Cataract Surgery. Ocul Immunol Inflamm 2024; 32: 707-712.

3 

Karesvuo P, Elbaz U, Achiron A, et al. Effect of cataract surgery on wet age-related macular degeneration activity. Acta Ophthalmol 2022; 100: e262-e269.

4 

Porela-Tiihonen S, Roine RP, Sintonen H, et al. Health-related quality of life after cataract surgery with the phacoemulsification technique and intraocular lens implantation. Acta Ophthalmol 2016; 94: 21-25.

5 

Starr MR, Mahr MA, Barkmeier AJ, et al. Outcomes of Cataract Surgery in Patients With Exudative Age-related Macular Degeneration and Macular Fluid. Am J Ophthalmol 2018; 192: 91-97.

6 

Daien V, Nguyen V, Morlet N, et al. Outcomes and Predictive Factors After Cataract Surgery in Patients With Neovascular Age-related Macular Degeneration. The Fight Retinal Blindness! Project. Am J Ophthalmol 2018; 190: 50-57.

7 

Kessel L, Koefoed Theil P, Lykke Sorensen T, Munch IC. Cataract surgery in patients with neovascular age-related macular degeneration. Acta Ophthalmol 2016; 94: 755-760.

8 

Hecht I, Kanclerz P, Achiron A, et al. The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Glaucoma. J Glaucoma 2023; 32: 451-457.

9 

Agarwal S, Srinivasan B, Harwani AA, et al. Perioperative nuances of cataract surgery in ocular surface disorders. Indian J Ophthalmol 2022; 70: 3455-3464.

10 

Ali T, Jung K, Montan PG. Eyelid skin disinfecting and conjunctival bacteria in cataract surgery. Acta Ophthalmol 2013; 91: 114-117.

11 

O’Rourke M, Knowles SJ, Curry A i wsp. In vitro study examining the effectiveness of antiseptic prophylaxis for antibiotic-resistant bacterial endophthalmitis. J Cataract Refract Surg 2021; 47: 1581-1586.

12 

Peyman A, Hosseini M, Narimani T. Comparison of the Effects of Povidone-Iodine 5%, Polyhexamethylene Biguanide, and Chlorhexidine as a Preoperative Antiseptic in Endophthalmitis Prophylaxis in Patients Undergoing Phacoemulsification Cataract Surgery. Adv Biomed Res 2020; 9: 15.

13 

Shi SL, Yu XN, Cui YL, et al. Incidence of endophthalmitis after phacoemulsification cataract surgery: a Meta-analysis. Int J Ophthalmol 2022; 15: 327-335.

14 

Kato A, Horita N, Namkoong H, et al. Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes. Sci Rep 2022; 12: 17416.

15 

Rizzo S, Gambini G, De Vico U, et al. A One-Week Course of Levofloxacin/Dexamethasone Eye Drops: A Review on a New Approach in Managing Patients After Cataract Surgery. Ophthalmol Ther 2022; 11: 101-111.

16 

Kim S, Ko BY, Koh JW, et al. Comparison of a preservative-free nonsteroidal anti-inflammatory drug and preservative-free corticosteroid after uneventful cataract surgery: multicenter, randomized, evaluator-blinded clinical trial. J Cataract Refract Surg 2022; 48: 710-716.

17 

Wielders LHP, Schouten JSAG, Winkens B, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg 2018; 44: 429-439.

18 

Ahmad A, Haq SU, Hussain J, Rasul J. Comparison of the efficacy of Diclofenac 0.1% and Nepafenac 0.1% on anterior chamber cells in patients undergoing cataract surgery: A prospective clinical practice trial Pak J Med Sci 2023 39: 1361-1365.

19 

Li SS, Wang HH, Wang YL, et al. Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs and corticosteroid drugs for prevention of cystoid macular edema after cataract surgery. Int Ophthalmol 2023; 43: 271-284.

20 

Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate 1.0% for the treatment of inflammation after cataract surgery. J Cataract Refract Surg 2013; 39: 168-173.

21 

Bharucha K, Zanzarukiya J, Hegade A, et al. A comparative study to evaluate the effect of various postoperative treatment protocols on dry eye and patient satisfaction after phacoemulsification. Indian J Ophthalmol 2023; 71: 1638-1642.

22 

An JA, Kasner O, Samek DA, Levesque V. Evaluation of eyedrop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg 2014; 40: 1857-1861.

23 

Fisher BL, Potvin R. Transzonular vitreous injection vs a single drop compounded topical pharmaceutical regimen after cataract surgery. Clin Ophthalmol 2016; 10: 1297-1303.

 
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