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Cataract Surgery Protocol
Cataract Surgery Protocol
(Preoperative, Surgery and Postoperative)

Standardized pre-operative protocol for cataract surgery
The following were standardised by the participating hospitals cataract
surgery protocol, which includes pre-operative, surgery and post-op 1. Admission: Admission is done one day earlier or 4 hours prior to - Checking of Xylocaine sensitivity (Optional). - Patient is seen by the ward duty Doctor/Nurse. - Slit lamp examination in detail and to look for conjunctival congestion, discharge, cornea, AC depth, lens maturity (in Phaco cases) and phacodonesis. Posterior segment evaluation - Asking history of systemic illness/ allergy to drugs. - To explain about possible conversion to routine ECCE with IOL in cases with small pupil and advanced nuclear sclerosis who - One-eyed patient should be given extra day of topical antibiotic. _____________________________________________________________________ 1 Cataract Surgery Protocol
a) Routine Investigations: For all cases b) Additional investigations: For GA cases c) Conjunctival culture report is required in the following cases - History of chronic infection eg. Blepharitis - Duct not free & partially free with clear fluid - Any history of previous intraocular surgery (preferably) _____________________________________________________________________ 2 Cataract Surgery Protocol
- Other systemic problems if any (To be decided by doctor) 3. Decision Making on patients with systemic diseases. With FBS < 160 mgs % (160 – 180 mgs%) A recent ECG & clearance by physician concerned Surgery to be undertaken a minimum of 6 months after myocardial Infarction Asthma should be controlled with drugs To continue the medicines during hospital stay _____________________________________________________________________ 3 Cataract Surgery Protocol
e) Dental infection, history of purulent discharge, or any septic focus. Treat adequately before surgery. 4. Premedication -Topical antibiotic: 6 – 8 times previous day and hourly on the day ofsurgery (preferable antibiotics – Ciprofloxacin or - Diazepam 5 mg: Previous night (optional) - Diamox – 2 tablets one hour before going to OT (optional) - Non - HT - Tropicamide with phenylephrine 1 drop every 15 - 1% cyclogic 1 drop every 15 min. 3 times - Hair cut if necessary previous to surgery - To avoid applying kumkum, ash to the forehead _____________________________________________________________________ 4 Cataract Surgery Protocol
- Anti-diabetic medication to be decided according to food in take - One eyed and diabetics patients to be given preference in - Clean clothing to be worn by the patients - Operation theatre gown to be worn by the patient

PRE-OPERATIVE PROTOCOL FOR OTHER SURGERIES

DCR:-
Hb, BG, BT, CT and ENT opinion to be taken, and rule out systemic
diseases if any (as mentioned before)
DCT:-
Control of systemic diseases if any.
Retinal surgery:

- Physician's clearance is a must for all cases - Pre-medication to be given before surgery - Patient to be shifted on the stretcher _____________________________________________________________________ 5 Cataract Surgery Protocol
- Don't dilate for Trab + Trab, Trab, phacomorphic glaucoma. - IV mannitol to be given if the IOP is more than 25mm HG. - To stop Pilocor 2 days prior & Propine to the operating eye at - To use T. Diamox & Flur to stabilize blood aqueous barrier - No massage for any re-surgery or where any other Intra – - To look for systemic congenital deformities - To note the age of the child at the time of presentation - Ask for history of previous anesthesia or surgery - HB, RBC count and weight of the baby to be taken - Patient to be seen by GA nurse and the doctor posted in pediatric clinic before and after surgery - Fasting for minimum 6 hours prior to surgery _____________________________________________________________________ 6 Cataract Surgery Protocol
- PKP - In phakic patient when cataract surgery is not planned pupil to be constricted with pilocarpine - If cataract extraction is also planned with PKP, pupil to be - TKP and penetrating injuries - facial block first and then ciliary block to be given. Avoid repeating the block. No massage to be - Pterygium excision with conjunctival transplantation and bowman's cautery - both ciliary and facial blocks are necessary SURGICAL PROTOCOL FOR CATARACT SURGERY
- Block room doctor should wash his hands - Checking of emergency kit (adrenaline, atropine, deriphylline, dexamethasone, hydrocortisone, phenergan, mephentin, diazepam, O2 cylinder with kit, I V Kit, syringes, plaster, scissors, I V normal saline, Intubation kit, Suction apparatus, _____________________________________________________________________ 7 Cataract Surgery Protocol
- To all normal patients 2% Xylocaine with adrenaline (1:100,000) - To patients with hypertension and cardiac diseases 2% xylocaine with 1 amp hyalase with Sensorcaine (1:1) - Autoclaving of both the above needles for 20 min / disposable - To keep adequate needles ready to decrease waiting time. _____________________________________________________________________ 8 Cataract Surgery Protocol
- Confirm the name of the patients. If you find two or more with the same name, confirm patient’s relative and relationship. Eg. - Check whether stickers are attached and completeness of - Recheck for specific systemic diseases (eg. asthma, etc.) - Any systemic diseases like DM (Diabetes Mellitus), HT(Hypertension), IHD (Ischemic Heart Disease) - Any complicating conditions like – PXF (Pseudo exfoliation), - Whether diabetes controlled - FBS < 140mg% _____________________________________________________________________ 9 Cataract Surgery Protocol
- Massage is to be either digital or by super pinky. Contra indicated in - Sub-luxated lens - Re-surgeries - Perforating injury Vigorous massage avoided in - PXF - Myopia - Traumatic cataract - Hyper mature cataract - Corneal status, anaesthesia and akinesia checked - 2.5 cc per kg body weight of 20% mannitol to be given about - Avoid in uncontrolled HT, cardiac patients, and renal diseases - Before starting drip check BP, CVS examination - Patient is moved on the stretcher and is told to avoid ambulation _____________________________________________________________________ 10 Cataract Surgery Protocol
- Inform the operating surgeon in case of any complicating - Inform if surgery other than cataract / IOL - Patients with the same name, check the address in details & 11. Decision regarding postponing the case - BP - diastolic > 100mmhg, systolic > 160mmhg - Local factors - any infection of lids and adnexa - IOP of more than 30mmhg in spite of all medications except - The patient is to be made to lie down in supine position and the legs raised up. The room should be airy. - The patients clothes should be loosened _____________________________________________________________________ 11 Cataract Surgery Protocol
- Give IV atropine one amp. If there is bradycardia or - To keep resuscitation equipment ready like - oxygen cylinder, endotracheal tube, laryngoscope, ambu bag, scalp vein set, - Periodic check of expiry dates of emergency drugs. - To inform anesthetist or physician if patient does not have - Start patient on diamox, check tension _____________________________________________________________________ 12 Cataract Surgery Protocol
- Check the name of the patient and go through the case sheet - Betadine drops at least 5 min. before surgery - Eyebrows and eyelids cleaned properly with Betadine - Wire speculum preferred in deep sockets - Fornix based flaps of conjunctiva is preferred - First conjunctiva and then tenon's capsule separated - Conjunctival section should be equal or just more than the - Contra indicated, old scleritis & Scleral thinning _____________________________________________________________________ 13 Cataract Surgery Protocol
Large sections are preferred in one or more of the following i. Smaller sections are preferred for younger patients. _____________________________________________________________________ 14 Cataract Surgery Protocol
- Very soft eye – Hydro dissect - take nucleus into anterior chamber, extract with irrigating vectis. - Positive pressure cases - closed chamber aspiration or dry visco - Single piece, biconvex, all PMMA, modified C loop, without hole, is preferable (size 6 - 7mm optic, 13-14mm length) - Put suture if there is positive pressure before implanting the - Equal bites equidistant, radial sutures/ continuous sutures - No. of sutures corresponding to section _____________________________________________________________________ 15 Cataract Surgery Protocol
- 1/2 cc. Decadron + 1/2 cc. Genticyn is used. If tissue handling - Injection to be given in the inferior fornix. Small Incision Cataract Surgery
- Proportionate to the size of tunnel (6 to 6.5 mm) - Size: Proportionate to the size of nucleus 3. Side Port: 4. Viscoelastics: 5. Capsulotomy: - 6. Hydro Dissection 7. Nucleus delivery into AC: - Cornea, Iris, Zonules, Posterior Capsule should be taken care. _____________________________________________________________________ 16 Cataract Surgery Protocol
- Corneal endothelium and iris should be taken care - Tunnel should be extended according to nucleus size 9. Cortex aspiration 10. IOL Implantation: - If under Visco - It should be fully aspirated after implantation - If tunnel is leaking put adequate sutures - If side port is leaking do stromal hydration
12. Proper repositioning of conjunctiva, may use cautery to reposition
conjunctiva at limbus
13. After speculum and bridle suture removal check AC depth
14. Sub-conjunctival injection


_____________________________________________________________________ 17 Cataract Surgery Protocol

Medical Supplies

- Ringer lactate in glass bottle to be autoclaved and cooled before - IOLs both side should be washed before insertion - Adequate precaution should be taken before reusing the suture Cautery should not be used in patients with pace makers. Stand by physician or anesthetist (optional) Special care for ventilation while draping Use Oxygen during surgery if the patient is uncomfortable. Inj. Deriphylline / Decadron 1 amp. IV, SOS _____________________________________________________________________ 18 Cataract Surgery Protocol
POST-OPERATIVE MANAGEMENT

Routine Management of uncomplicated cases:
Planned ECCE with IOL / without IOL / Phaco
First dressing can be done 8 hours after surgery.
Look for the following findings (pupil to be dilated)
* Section
- Apposition of Wound / Wound Leak / Gape * PC (Posterior Capsule) - Opacity, Rent, Vitreous disturbance
The main aim of postoperative examination in the morning is to look for
any early sign of infection, as one has to withhold the steroids and start
other intensive measures.
Routine Medication
As a routine Antibiotic and Steroid eye drops are applied four to five
times per day. Mydriatic / Cycloplegic 1 time per day. Immediate post-
op analgesic tablets.
_____________________________________________________________________ 19 Cataract Surgery Protocol

On discharge:
Advise the patient regarding tapering dose of steroids.
Cycloplegics 1 OD for 15 days. (Optional) - Precautions
Management of complications:
I) Lid Edema / Chemosis on the first postoperative day can be managed
with NSAID. One has to look for signs of infection if associated with
severe pain.
II) Wound gaping, Iris Prolapse, Broken sutures:
As these cases require resuturing, antibiotic drops alone should be
applied. If needed, patients may be started on parenteral steroids. Explain
the condition, to the patient and about the second procedure.
_____________________________________________________________________ 20 Cataract Surgery Protocol
III) Cornea a) SK/DM Folds & Edema – Observation, Steroid Drops, Timolol if needed b) DM Detachment - If large resuturing, Air Injection into Anterior c) Epithelial Defect - Antibiotic Ointment and Bandage. Review the next day. IV) Anterior Chamber a) Shallow AC Look for integrity of the wound, intra ocular pressure and treat Examine Fundus- If due to Choroidal detachment, treat with systemic steroids. Drainage can be planned if needed, after 5 days. Give bed rest, Vitamin C, topical steroids. Hypothesizes (if necessary). c) Loose cortex: - Irrigation and aspiration of the cortical material should be done under - If there is a piece of nucleus or epinucleus left behind - If a large piece of cortex in AC is covering pupillary area _____________________________________________________________________ 21 Cataract Surgery Protocol
V) Iris
Iritis: Mild / Moderate / Severe and fibrin membrane
If no infection, if only inflammation start steroids good dilation, S/C
steroids and systemic steroids whenever indicated.
Hypopyon:
Clinical judgement as to whether it is inflammatory or infection is the first
step.
If inflammatory start on intensive steroid treatment along with
cycloplegic.
Endophthalmitis

Corneal Infiltration / infection: Intensive topical antibiotic treatment
should be started preferably with Broadspectrum antibiotics. USG and
Retina Clinic opinion/Cornea clinic opinion are to be obtained. An
emergency Ac tap/Vitreous tap with intravitreal antibiotics should be
planned.
(Vancomycin - Gram positive, Amikacin/Ceftazidime - Gram negative)
A frequent topical antibiotic drop (hourly or half hourly) is better than
giving a sub. Conjuctival injection.
Systemic antibiotics may be started immediately.
Vitrectomy to be decided if there is no response to topical & intra vitreal
injection
Pre operative culture report should be reviewed.
Fresh culture and sensitivity from conjunctiva can be taken, as very often
the infecting organisms have been cultured from the conjunctiva.
Recheck the patency of the Lacrimal duct and Diabetic status.
_____________________________________________________________________ 22 Cataract Surgery Protocol
VI) Pupil: Peaking of the pupil is commonly due to incarceration of anterior capsular flap or vitreous in the wound or due to sphincter tear. Rarely it is due to haptic in AC or iris incarceration in the wound. VII) IOL position: Look for centration, subluxation, and dislocation. Haptic in AC: Continue antibiotic eye drops, stop topical steroids and repositioning at the earliest. VIII) Posterior capsular rent: With vitreous disturbance / without vitreous disturbance. Management - If vitreous present in the wound vitrectomy should be done. All the vitreous should be removed from the wound. Continue steroids for a longer time along with NSAID.
IX) Leucocoria or Poor vision with normal anterior segment
Detailed posterior segment examination. USG

3.Timing of resurgeries:

1. Cases which have to be taken immediately. 2. Decentration (Clinical judgement to be used) _____________________________________________________________________ 23 Cataract Surgery Protocol

4. Routine follow up
Phaco
1st day – Slit lamp examination (SLE)
1st week - Vision pin hole, slitlamp examination and fundus examination.
If vision less than 6/12 do refraction (RR), Fundus (F) to look for the
cause.
1st month - Refraction, SLE - (F) if vision is good – glass prescription
(GP), and follow up SOS. If visual acuity is not good look for CME.

Planned ECCE with IOL:
1st Week - Vn with PH, SLE (F)
4th Week – Vn with PH, SLE (F)
8th Week – Vn with PH, RR, SLE (F) & Suture removal if necessary.
If Vn is not good - look for cause, (F) refer to concerned department.

Emergency Management:

1. Severe post-operative Iritis, emergency treatment should be started
2. Hypopyon - Clinical judgement inflammatory or infection? Treat 3. Look for against the rule astigmatism and weak wound re-
4. Scleral necrosis, stop steroids use only antibiotics ointment, NSAID _____________________________________________________________________ 24 Cataract Surgery Protocol

Suture removal / relaxation

• Indication for suture removal: 8-o sutures removed after 8 weeks; 10-o
• If loose suture is causing accumulation of mucus remove it and if wound integrity is not good consider for resuturing. • If suture removal is done - topical broad-spectrum antibiotics - hourly for first day and 4 times a day for one week.
Special Instruction during Discharge

• Normal diet from the day of operation (liquid diet 2 hours after • No river or pond bath (dip in) for 3 months • After suture removal no pond or river bath for at least 1 week • TV viewing & reading (within a week in Phaco & 15 days for • Not to drive two wheelers up to one month • Not to lift heavy weight for at least 2 months • Dark glasses to be used for one month for outdoor activities till _____________________________________________________________________ 25

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