Cataract surgery

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
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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 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.
  • 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.
• This may be due to an "expectation gap"

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

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