24-hour interval one review following cataract surgery: are we seeing the precise details?

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  1. D Gohone,
  2. N Lim2
  1. 1Royal Surrey County Hospital, Guildford GU2 5XX, UK
  2. 2The Western Centre Hospital, Marylebone Road, London NW1 5YE, UK
  1. Correspondence to: Dr Goh; davidgoh1{at}aol.com

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  • cataract surgery

The Purple College of Ophthalmologists published cataract surgery guidelines1 in Feb 2001. This document includes protocols relating to postoperative visits suggesting that in that location are no boosted risks to patients who are not reviewed on the start postoperative day. This is a change in recommendation from previous higher guidelines in 1995 suggesting a review within 48 hours.

At that place may follow a growing impetus for ophthalmologists to manipulate with the first day review, given the reduced demand on clinician time and the corresponding accrual of staffing and financial resource benefits. While we applaud the dissemination of practice guidelines, they constitute "simply tools, non rules" to help clinical decision making. They may accept inherent limitations in particular circumstances and may require evaluation for constructive application in clinical settings.

Four studies were quoted by the guideline authors, three of which advocated the omission of day after review2– 4 and one of which was equivocal,5 suggesting that it was unsafe to abandon this exercise unless raised intraocular pressures (IOP) were controlled. The numbers of patients included ranged from 100 to 387. The results of these studies are shown in Table 1.

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Table 1

24-hour interval one postoperative complications noted in clinical studies

Comment

In our view, deriving meaningful conclusions that may underpin clinical practice are difficult, attributable to the varying methodological approaches used in these studies. In Tufail'south study,2 extracapsular cataract extraction was the predominant surgical technique used. Cohen et al five excluded more than than 50% of patients with complicated ocular histories or complicated surgery and Whitefield et al 3 had similar extensive exclusion criteria, although the number excluded was not mentioned.

We would describe attention to a recently published written report by McKellar and Elder,vi which to our knowledge is one of the largest cohort studies, aside from national cataract surveys, reporting on first and seventh day complications of cataract surgery. Of thou patients, the study establish that on the offset postoperative day, complications were observed in 10% of eyes, of which 88% was raised IOP. Unlike most of the previous studies, all patients with available records were eligible, including those with preoperative risk factors and those with surgical complications. These figures align more closely with our "golden standard" of the National Cataract Surgery Surveyseven than the previous mentioned studies. The events virtually frequently occurring within 48 hours afterward surgery in the national survey were corneal oedema (9.5%), raised IOP (7.ix%), and uveitis (5.6%). Overall, 23.3% of patients had early postoperative complications ranging from minor to sight threatening atmospheric condition. The survey also constitute that several hazard indicators were associated with poorer visual outcomes and complications related to cataract surgery: age, ocular co-morbidity (glaucoma, macular affliction, amblyopia, and previous ocular surgery), diabetes mellitus, stroke, type of surgical process, and grade of surgeon.

In summary, upwardly to 20 000 patients a year in the United Kingdom (10%) may have an undetected early postoperative complication such as corneal oedema or raised IOP, if kickoff day review was abandoned. And if McKellar's study is representative, then 5% of patients would have raised pressure without whatever previous history or surgical complexity and 0.9% of patients could have other potentially serious early on complications. Nationally, that equates to nearly 12 000 patients annually. Information technology is worth noting that the American Academy of Ophthalmology in its white paper,8 concludes that there are plenty significant early postoperative complications to warrant first 24-hour interval review. Are we sufficiently confident in our own practices to diverge?

Credit should be apportioned to the distinguished authors of the cataract surgery guidelines suggesting 24 hour follow up of patients who had undergone complicated surgery, had coexisting eye illness, or had large incision cataract surgery. We would similar to reiterate the importance of explicit criteria equally part of any review policy and suggest that clinical interpretation of private circumstances is paramount.

To reconcile the need for an efficient, cost effective review protocol together with a necessity to requite due consideration to the entirety of detrimental post-cataract complications, especially given the NHS resource constraints, is difficult. A pragmatic approach may be for clinicians to be discriminately aware of those patients nigh at risk of developing early on complications and instituting review policies accordingly, together with an open door policy for patients who need or desire reassurance on the first 24-hour interval following uncomplicated surgery. Furthermore, a multiprofessional management approach involving the extended function of trained ophthalmic nurses in postoperative care may reduce demands on medico time.

At the moment, there is a paucity of a good prospective literature on the subject and a need for future studies to accost whether those identified complications would consequence in a alter of management at the first postoperative solar day visit and whether patients would have a poorer consequence if the changes were not instituted.

References

  1. ↵

    Royal Higher of Ophthalmologists. Cataract surgery guidelines. London: RCO, 2001.

  2. ↵

    Tufail A, Forse AJE, Hamilton AMP. Is the offset 24-hour interval postoperative review necessary after cataract extraction? Br J Ophthalmol 1995;79:646–8.

  3. ↵

    Whitefield Fifty, Crowston J, Niggling BC. First day follow-up for routine phacoemulsification? Br J Ophthalmol 1996;80:148–50.

  4. ↵

    Tan JHY, Newman DK, Klunker C, et al. Phacoemulsification cataract surgery: is routine review necessary on the first postoperative day. Center 2000;14:53–5.

  5. ↵

    Cohen VM, Demetria H, Jordan K, et al. Beginning day post-operative review post-obit uncomplicated phacoemulsification. Eye 1998;12:634–6.

  6. ↵

    McKellar MJ, Elderberry MJ. The early on complications of cataract surgery: is routine review of patients i week after cataract extraction necessary. Ophthalmology 2001;108:930–5.

  7. ↵

    Desai P, Minassian DC, Reidy A. National cataract surgery survey 1997–1998: a report of the results of the clinical outcomes. Br J Ophthalmol 1999;83:1336–40.

  8. ↵

    American Academy of Ophthalmology, American Club of Cataract and Refractive Surgery. White newspaper on cataract surgery. Ophthalmology 1996;103:1152–6.

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Copyright 2002 British Journal of Ophthalmology