Post-Operative Cataract

Patients should be seen 4-6 weeks post operatively and prior to this they should be sent to HES for any complications. As the triage line is only available Monday-Friday 9am-4.30pm it may be advantageous to see patients within these periods where possible. Below is an outline of the tests that we perform within the hospital clinics, however your own clinical judgement should be used.

History and Symptoms

• As usual history and symptoms but please document any prescribed medication and compliance

Clinical Investigations

• Vision (unaided and with PH)
• Refraction and VA
• Full anterior segment slit lamp examination to include:
  • Incision point and Seidel’s sign
  • Anterior Chamber activity
  • Any Iris Trauma
  • Pupil Shape
  • IOL status
• IOP 
  • Preferably Goldmann/Perkins but iCare or Tonopen acceptable
• Dilation if;
  • Best corrected acuity worse than expected (worse than 6/9 if no comorbidities known)
  • Any surgical complications
  • Complaining of flashes and/or floaters or any other symptoms that warrant dilation
  • No/poor pre-operative fundus view
  • Posterior segment co-morbidity
• Slit lamp binocular indirect examination
• Posterior segment OCT if indicated
• Any other clinical investigations that may be warranted

Advice to patients

Reiterate advice from hospital:

• Bending, heavy lifting, swimming, and hair washing are not advised in the first week post-operatively
• Flying is allowed after the first week

• Discharged HES patients: If eye is settled, second eye is not indicated, and no complications or co-morbidities noted then continue routine GOS review

• If the patient attends HES for any pre-existing co-morbidity a follow-up appointment should have been arranged for this and should be highlighted within the audit form. On return of the form, HES will check that follow-up has been arranged

• Post op Complications:
  • If IP, treat conditions within your scope of practice as per the management protocol set out in the cataract post operative management guidelines and shown in the summary table below
  • If not IP, or if complication outside your scope of practice, follow triage guidance below

• A new referral will need to be initiated for any new co-morbidity noted. The audit form is not a referral letter; please use the usual referral system for new co-morbidities.

• Please note a new referral will be required for second eye surgery if not otherwise indicated on the post-operative audit form

The vast majority of these patients will be managed within community; however there will be some who require a return to HES. This will be done via an optometrist led triage service. Triage clinic appointments will be provided at Gartnavel General Hospital, Royal Alexandra Hospital, and Inverclyde Royal Hospital.

This triage service will be provided for patients attending their routine post-operative check 4 weeks or more after surgery; any complication presenting prior to four weeks should be referred via the Acute Referral Centre.

The triage number is based at Gartnavel 07717300116 (for optometrist use only) and will be available between 9.00am – 4.30pm Monday to Friday. We will have the ability to book patients to our available slots or back to the consultant clinic if required. There is a guidance table below which indicates treatment options and whether triage is required.

Please note that this triage line is manned by optometrists concurrently with clinics; if all staff are with patients, please leave a voicemail message and an optometrist will call back as soon as clinic allows.

GGC triage protocol is only valid for patients who have undergone surgery at GGC sites. For patients treated at the Golden Jubilee they have their own nurse-led triage system available on 0141 951 5459 (switchboard # 951 5000) (for optometrist use only).

Post-operative cataract triage 

Post-operative cataract triage

Incision (Seidels Sign with NaFL)

Conjunctiva

Cornea: Guttata/Decompensation

Finding: Guttata/Decompensation

Management (at post op appointment): HES TRIAGE

Other information: Check other eye as important to note signs if proceeding with second eye. Please note on audit form

Cornea: Dry eyes

Finding: Dry eyes

Management (at post op appointment): Reassurance and ocular lubricants

Other information: May be associated with post op drops

Anterior Chamber: Mild inflammation/Asymptomatic

Finding: Mild inflammation/Asymptomatic

Management (at post op appointment): No further management required

Other information: Advice to attend if becomes symptomatic

Anterior Chamber: Grade 2+ cells/flare; pain with a normally placed lens asymptomatic/minimally symptomatic; IOP normal

Finding: Asymptomatic/minimally symptomatic grade 2+ cells/flare; pain with a normally placed lens; IOP normal

Management (at post op appointment): If IP, continue steroids for 2/52 and monitor in practice; HES TRIAGE if not IP

Other information: Advice to attend if becomes symptomatic or symptoms worsen

Anterior Chamber: Grade 3+ Cells

Finding: Grade 3+ Cells

Management (at post op appointment): If IP, treat and monitor in practice; HES TRIAGE if not IP

Anterior Chamber: Mishapen pupil

Finding: Mishapen pupil

Management (at post op appointment): Likely to be the result of iris hooks or other dilation aids, if unsure or not documented can call triage to check

Anterior Chamber: A/C depth

Finding: A/C depth

Other information: Note if shallow A/C depth on Audit form to inform second eye surgery

IOP Spike: 21-30

Finding: 21-30

Management (at post op appointment): Stop Steroids or (if IP) start treatment; HES TRIAGE if history of Glaucoma

Other information: Review IOP in your clinic 1-2/52

IOP Spike: >30

Finding: >30

Management: HES TRIAGE

Lens Placement

Finding: If placement not as expected/refractive surprise.

Management (at post op appointment): HES TRIAGE

Other information: Check Toric markers if Toric lens

Vitreous

Finding: PVD/Tobacco Dust/Haemorrhage

Management (at post op appointment): HES TRIAGE

Macula: CMO

Finding: CMO

Management (at post op appointment): If IP, prescribe Acular TDS & Maxidex QDS for 4/52; HES TRIAGE if not IP or if Px Diabetic or attends Macula clinic 

Other information: Monitor OCT in 4/52

Macula: Wet AMD

Finding: Wet AMD

Management (at post op appointment): Follow normal pathway

Macula: ERM

Finding: ERM

Management (at post op appointment): HES Triage

Suspicious Discs

Finding: Suspicious Discs and/or increased IOP

Management (at post op appointment): Refer Routine Glaucoma

Other information: Carry out 24-2 VF if possible

Binocular vision: Shadowing from anisometropia post operatively

Finding: Shadowing from anisometropia post operatively

Management (at post op appointment): Reassure and explain, include on audit form to inform second eye surgery

Binocular vision: True diplopia

Finding: True diplopia

Management (at post op appointment): BV assessment, consider if new neurological event may be responsible, refer appropriately

• First eye forms will be printed on pink
• Second eye forms will be printed on blue
• A secondary white audit form may be issued in the instance where a patient has attended HES triage following initial post op appointment and requires a second refraction subsequent to HES triage
• All audit forms will be sent with a prepaid addressed envelope for return
• Audit forms will also trigger the process for listing for second eye where appropriate and are therefore also of clinical importance

When completing audit forms

• Please check patient details are recorded at top of form
• Please include date of post-op exam
• If a complication or co-morbidity is identified, please record any action taken (e.g. treated and monitoring in practice/new referral sent/phoned post-op triage line and HES appointment booked, etc)

Blank audit form

• If the patient has lost their form, please print the next page of this document
  • Fill in the patient name, CHI (or date birth if CHI unknown), and post-operative information
  • Please return the form to Gartnavel General Hospital Optometry Department
• If you are treating a complication in practice, please print and send in a new audit form after treatment is complete and the eye is settled. This allows us to audit the final refraction and VA results.

Audit form