Difference between revisions of "Cataract surgery"

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'''Cataract surgery''' is usually an elective surgery in which the opacified lens of the eye is replaced with an artificial intraocular lens. This common surgical procedure is usually performed among elderly patients as the most common etiology is age-related (90% of cases). Cataract surgery is commonly performed via an extracapsular technique, which involves removing the lens through a small incision in the anterior lens capsule, and phacoemulsification. This is generally preferred to the intracapsular technique, which involves removing the lens and surrounding capsular bag, as the extracapsular approach has improved visual outcomes and fewer adverse reactions.  {{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type = MAC
| anesthesia_type = MAC
| airway = Nasal Canula
| airway = Noninvasive O2
| lines_access = Peripheral IV
| lines_access = Peripheral IV
| monitors = Standard ASA / 5 Lead EKG
| monitors = Standard
5-lead ECG
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative = Dysrhythmias, Oculocardiac Reflex
| considerations_intraoperative = Dysrhythmias
Oculocardiac reflex
| considerations_postoperative =  
| considerations_postoperative =  
}}
}}
'''Cataract surgery''' is an elective procedure in which the opacified lens of the eye is replaced with an artificial intraocular lens. This common surgical procedure is usually performed among elderly patients as the most common etiology is age-related (90% of cases). Cataract surgery is commonly performed via an extracapsular technique, which involves removing the lens through a small incision in the anterior lens capsule, and phacoemulsification. This is generally preferred to the intracapsular technique, which involves removing the lens and surrounding capsular bag, as the extracapsular approach has improved visual outcomes and fewer adverse reactions.


==Preoperative management==
==Preoperative management==
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|-
|Respiratory
|Pulmonary
|
|
* Patients with chronic cough may warrant general anesthesia.
* Patients with chronic cough may warrant general anesthesia.
|-
|-
|Gastrointestinal
|Gastrointestinal
|Assess patient's risk  
|
* Assess for GERD.  Patient will need to lay flat and therefore at increased risk for aspiration
|-
|-
|Hematologic
|Hematologic
|Antiplatelet or anticoagulant drugs generally do not have to be stopped prior to cataract surgery given the low risk and minimal blood loss
|
* Antiplatelet or anticoagulant drugs generally do not have to be stopped prior to cataract surgery given the low risk and minimal blood loss
|-
|-
|Renal
|Renal
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|Endocrine
|Endocrine
|
|
*
|-
|-
|Other
|Other
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===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->===
===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->===
* N/A


===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
* Nasal cannula
* Drape retractor for comfort (optional)


===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===
===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===
* N/A


===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===
* Retrobulbar or sub-tenon block can be used in procedure room and OR environments


==Intraoperative management==
==Intraoperative management==
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* Nasal cannula is commonly used for oxygen supplementation
* Nasal cannula is commonly used for oxygen supplementation
* Patients are usually awake and alert during procedure, with topical medication commonly administered to operative eye
* Patients are usually awake and alert during procedure, with topical medication commonly administered to operative eye
* Lidocaine-propofol-alfentanil mixtures<ref>{{Cite journal|last=Fang|first=Zhuang T.|last2=Keyes|first2=Mary A.|date=2006|title=A novel mixture of propofol, alfentanil, and lidocaine for regional block with monitored anesthesia care in ophthalmic surgery|url=https://linkinghub.elsevier.com/retrieve/pii/S0952818005003508|journal=Journal of Clinical Anesthesia|language=en|volume=18|issue=2|pages=114–117|doi=10.1016/j.jclinane.2005.08.007|via=}}</ref> can be used for induction during application of retrobulbar or sub-tenon blocks by proceduralist
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
* Placement of retrobulbulbar or peribulbar blocks can be briefly very painful - consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg)
** Be prepared to treat sudden decrease in blood pressure or apnea


===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===
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* Cataract surgeries are often very short in duration, with case duration ranging on average from 15 mins to 1 hour  
* Cataract surgeries are often very short in duration, with case duration ranging on average from 15 mins to 1 hour  
* Anesthesiologists should monitor
* Coughing or valsalva should be avoided as much as possible
* If any cautery is used, the delivered FiO2 < 30%
* Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure. 
** Stop surgical manipulation, give [[atropine]]/[[glycopyrrolate]]
 
=== Second Eye Effect ===
* Patients report more unpleasant experience with their second eye surgery.
*Before the surgery on their second eye, patients report less anxiety and have higher expectations. However, almost 50% of patients say that their second eye was less pleasant compared to their first. <ref>{{Cite web|date=2015-02-25|title=Study confirms “second eye” effect in cataract surgery|url=https://www.aao.org/education/editors-choice/study-confirms-differences-in-patients-subjective-|access-date=2024-09-12|website=American Academy of Ophthalmology|language=en}}</ref>
*This may be due to an "expectation gap"


===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
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* Patients usually have minimal pain after procedure (Pain score 1-2)
* Patients usually have minimal pain after procedure (Pain score 1-2)
* PO or IV acetaminophen
*  
*  


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|+
|+
!
!
!Variant 1
!Femptosecond Laser
!Variant 2
!Astigmatism Correcting
Lens insertion
!Combined Case
|-
|-
|Unique considerations
|Unique considerations
|
|Two rooms required
|Surgeon must have eye
 
marked prior to sedation
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|-
|Position
|Position
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|-
|Surgical time
|Surgical time
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|-
|EBL
|EBL
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|-
|Postoperative disposition
|Postoperative disposition
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|-
|-
|Pain management
|Pain management
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|-
|-
|Potential complications
|Potential complications
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[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />
[[Category:Ophthalmology]]

Latest revision as of 18:22, 11 September 2024

Cataract surgery
Anesthesia type

MAC

Airway

Noninvasive O2

Lines and access

Peripheral IV

Monitors

Standard 5-lead ECG

Primary anesthetic considerations
Preoperative
Intraoperative

Dysrhythmias Oculocardiac reflex

Postoperative
Article quality
Editor rating
In development
User likes
0

Cataract surgery is an elective procedure in which the opacified lens of the eye is replaced with an artificial intraocular lens. This common surgical procedure is usually performed among elderly patients as the most common etiology is age-related (90% of cases). Cataract surgery is commonly performed via an extracapsular technique, which involves removing the lens through a small incision in the anterior lens capsule, and phacoemulsification. This is generally preferred to the intracapsular technique, which involves removing the lens and surrounding capsular bag, as the extracapsular approach has improved visual outcomes and fewer adverse reactions.

Preoperative management

Patient evaluation

System Considerations
Neurologic
  • Uncontrolled movement disorders, significant anxiety, or agitation may warrant general anesthesia.
Cardiovascular
Pulmonary
  • Patients with chronic cough may warrant general anesthesia.
Gastrointestinal
  • Assess for GERD. Patient will need to lay flat and therefore at increased risk for aspiration
Hematologic
  • Antiplatelet or anticoagulant drugs generally do not have to be stopped prior to cataract surgery given the low risk and minimal blood loss
Renal
Endocrine
Other

Labs and studies

  • N/A

Operating room setup

  • Nasal cannula
  • Drape retractor for comfort (optional)

Patient preparation and premedication

  • N/A

Regional and neuraxial techniques

  • Retrobulbar or sub-tenon block can be used in procedure room and OR environments

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5 Lead EKG
  • 1 Peripheral IV

Induction and airway management

  • Nasal cannula is commonly used for oxygen supplementation
  • Patients are usually awake and alert during procedure, with topical medication commonly administered to operative eye
  • Lidocaine-propofol-alfentanil mixtures[1] can be used for induction during application of retrobulbar or sub-tenon blocks by proceduralist
  • Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
  • Placement of retrobulbulbar or peribulbar blocks can be briefly very painful - consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg)
    • Be prepared to treat sudden decrease in blood pressure or apnea

Positioning

  • Supine, table usually rotated 90 - 180 degrees
  • Protect non-operating eye

Maintenance and surgical considerations

  • Cataract surgeries are often very short in duration, with case duration ranging on average from 15 mins to 1 hour
  • Coughing or valsalva should be avoided as much as possible
  • If any cautery is used, the delivered FiO2 < 30%
  • Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure.

Second Eye Effect

  • Patients report more unpleasant experience with their second eye surgery.
  • Before the surgery on their second eye, patients report less anxiety and have higher expectations. However, almost 50% of patients say that their second eye was less pleasant compared to their first. [2]
  • This may be due to an "expectation gap"

Emergence

Postoperative management

Disposition

  • Patients usually return home same day after short post-operative observation

Pain management

  • Patients usually have minimal pain after procedure (Pain score 1-2)
  • PO or IV acetaminophen

Potential complications

Procedure variants

Femptosecond Laser Astigmatism Correcting

Lens insertion

Combined Case
Unique considerations Two rooms required Surgeon must have eye

marked prior to sedation

Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ Fang, Zhuang T.; Keyes, Mary A. (2006). "A novel mixture of propofol, alfentanil, and lidocaine for regional block with monitored anesthesia care in ophthalmic surgery". Journal of Clinical Anesthesia. 18 (2): 114–117. doi:10.1016/j.jclinane.2005.08.007.
  2. ↑ "Study confirms "second eye" effect in cataract surgery". American Academy of Ophthalmology. 2015-02-25. Retrieved 2024-09-12.

Top contributors: Eeshwar Chandrasekar, Nirav Kamdar, Jashvin Patel, Barrett Larson, Tony Wang and Chris Rishel

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