Irritable eyes after cataract surgery

The question: 

A 72-year-old lady presents for a post-cataract operation check-up at your practice. The operation was four weeks ago, and this was the first eye to be done. She is unhappy with the operation: her vision is no better than before the surgery, and her eye is still red, irritable and watery. She has finished the post-operative drops. 

OT’s panel says... 

Ankur Trivedi: The scenario is suggestive of a post-operative complication, so we need to identify both the factors leading to the complication and what the actual complication is. 

It would be useful to know if there were any complications or issues during the surgery. I am assuming not, as normally if this were the case I would expect the provider to have retained the patient for an in-house cataract post-op follow-up. 

Was it a straightforward phacoemulsification, or was it more involved – could it have been a combined procedure? If the patient is under ophthalmology care for pre-existing ocular hypertension or glaucoma, they may have used the opportunity to combine the procedure with a minimally invasive glaucoma surgery (MIGS) or other glaucoma procedure.  

If the patient is unhappy, are they aware of any issues during the procedure? Did it take longer than had been suggested by the operating surgeon prior to the surgery? It would be useful to delve more into whether there is any reason for them being unhappy other than the presenting vision and redness. 

If we have previous history for the patient from previous visits to the practice, that can be helpful. An idea of the pre-operative best corrected visual acuity of the eye is useful to confirm if the visual acuity is actually no better. If the cataract was particularly dense, it will have required more energy to be used on the phacoemulsification machine and a longer procedure. This can increase the risk of certain post-op complications. 

An idea of the pre-operative best corrected visual acuity of the eye is useful to confirm if the visual acuity is actually no better

The next bit of information I would want to know is the medication regimen they were placed on following surgery. Patients are generally placed on a course of corticosteroid and antibiotic cover to be used for a period following surgery. I have seen some providers use intraoperative antibiotic cover, which is delivered via intracameral injections.  

Also, some patients may be prescribed other medications, such as non-steroidal anti-inflammatory drugs, where the patient’s history or general health may place them at an increased risk of an inflammatory post-operative complication, for example, cystoid macular oedema (CMO), which is more likely if the patient is a diabetic. 

Regarding the complaint of no improvement to vision and a red eye: when did the symptoms begin? Was it straight after surgery, soon after, or days or weeks after? Have the symptoms escalated, and if so have both issues increased at a similar rate?  

The complications on my list of differential diagnoses before I examine the patient are, starting with the most serious possibility: 

• Endophthalmitis – however, depending on the severity of the cataract, I would expect vision to be reported as worse than pre-op rather than ‘no better’  
• A wound-related issue – unusual with modern, small incisional phacoemulsification. However, larger incisions may have been required if it was a complex surgery. A stitch or stitches may have been required to seal the wound or wounds. This ties in with infection risk as per endophthalmitis   
• IOL dislocation – possible cause of vision issue and other related complications   
• Cystoid macular oedema – this would explain below expected visual acuity, but not the redness or discomfort – there would need to be a comorbidity  
• Persistent post-op inflammation – either the drops regimen has not been completed as required due to patient running out of the drops, poor understanding of the importance of the regimen, or other issues leading to poor compliance  
• Posterior capsular opacification (PCO) – however, again it would not explain the redness or discomfort, so there would need be a comorbidity. 

Ceri Smith-Jaynes: As Ankur said, there are a lot of potential complications here.  

Refraction will be revealing. It may be a refractive surprise, or perhaps the patient had opted for myopia, in order to be able to read without spectacles. If the best corrected visual acuity doesn’t match that expected, I’d like to do an OCT to check for cystoid macular oedema (CMO).  

As the eye is irritable and watery, I’ll be carefully looking at tear quality and for any ocular surface staining whilst comparing it to the other eye. Is it simply a reaction to the drops – BAK preservative in Pred Forte or Maxitrol (I gather the neomycin could also be the culprit)? If it is this, then it’ll take a few weeks to calm down and we’d need to ensure the cataract surgery provider is informed, before the second eye is done and routine drops are prescribed again. I’d get her to use plenty of preservative free lubricants for comfort. I hear some surgery providers are asking patients to use lubricants in the run up to surgery, to improve tear and ocular surface quality ahead of biometry and then surgery. I also ask them to treat any blepharitis with diligent lid hygiene. 

There may be anterior chamber cells or flare, in which case they’d need to go back on steroid drops. If I find anterior or posterior inflammation, I contact the surgery provider for this because it’s their patient. Our local providers usually make an appointment to see the patient in their own clinic within a day or two and then take responsibility for prescribing any NSAIDs or steroids.   

As the eye is irritable and watery, I’ll be carefully looking at tear quality and for any ocular surface staining whilst comparing it to the other eye

Kevin Wallace: I agree with the others that it’s vital to rule out important causes for the potentially poor outcome – particularly persistent inflammation or CMO. I do like to do a macular OCT for any patient who has had cataract surgery – it’s such a quick way to rule out CMO. 

A lot of these patients just need an examination and reassurance that there isn’t anything that needs treatment. It doesn’t happen too often, but I get the occasional one where there’s nothing to see but their visual acuity isn’t quite as good as expected and they just look uncomfortable. What they need is just a little more time to let the eye settle – they’ve probably heard of people being perfect the next day and are disappointed, but sometimes that can happen. 

I’d definitely want to have a good look at the anterior eye to rule out all the usual suspects, such as an infection, and see if their vision improves with a pinhole. 

It’s also important to consider that the problems may be unrelated to the surgery – they could have developed different pathology, like macular degeneration or a retinal detachment, so depending on what I’ve found they may require a more thorough examination of the internal eye. 

If everything looks fine, I agree with Ceri that a good regime of drops for a few weeks and then a review would be appropriate. I’d always remind the patient as usual that I expect things to gradually get better – but if they get worse then I want to see them sooner.