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OP8.4 | Cataract Surgery: Anaesthesia, ECCE Steps, Complications and Postoperative Treatment — SDL Guide (Part 3)
Postoperative Treatment Protocol
The post-operative treatment regimen is standardised and evidence-based — its purpose is to prevent infection, control inflammation, and promote wound healing. Compliance with this regimen is the most modifiable determinant of post-operative outcome, and you as the treating clinician are responsible for prescribing it correctly and explaining it to the patient with enough clarity that they actually follow it. This matters more than it may appear: most post-cataract endophthalmitis cases in India are linked to inadequate antibiotic coverage or poor patient compliance, not surgical error. The regimen typically runs for four to six weeks and must be tapered, not stopped abruptly, to prevent rebound anterior uveitis from steroid withdrawal. You should also be able to counsel the patient about what is expected — mild grittiness, slight watering, mild photophobia — and what is not expected and requires urgent return: pain, redness, severe photophobia, or worsening vision after an initial period of improvement.
Standard Post-Operative Eye Drop Regimen:
- Antibiotic eye drops (e.g. moxifloxacin 0.5% or ofloxacin 0.3%) — 4 times daily for the first 2–4 weeks. Prevents post-operative bacterial infection. Prophylactic intravitreal vancomycin at the end of surgery is also used in some high-volume Indian centres to further reduce endophthalmitis risk.
- Topical steroid eye drops (e.g. prednisolone acetate 1% or dexamethasone 0.1%) — started at 4–6 times daily, tapered gradually over 6 weeks. Controls post-operative inflammation (anterior uveitis, CMO). Typical taper: 4×/day (week 1–2) → 3×/day (week 3–4) → 2×/day (week 5) → 1×/day (week 6) → stop.
- Topical NSAID eye drops (e.g. ketorolac 0.4% or bromfenac 0.09%) — used by many surgeons, particularly in diabetics or those at risk of CMO, typically for 4–6 weeks. Reduces prostaglandin-mediated inflammation and CMO risk.
- Lubricating eye drops (preservative-free artificial tears) — for patients with dry eye (common after cataract surgery due to corneal incision cutting corneal nerves), used as needed.
Post-Operative Precautions (to be explained to every patient):
- Do NOT rub the operated eye
- Use the protective eye shield at night for 2–4 weeks (prevents accidental rubbing during sleep)
- Avoid swimming and water entry into the eye for 4 weeks
- Avoid dusty or smoky environments for 2–4 weeks
- Heavy lifting and strenuous exercise: avoid for 2 weeks
- Reading and watching television are permitted from day 1 if comfortable
Follow-Up Schedule:
- Day 1 post-operative: First post-op check — remove pad/shield, check VA, IOP, corneal clarity, wound integrity, anterior chamber, red reflex
- Day 7: Check wound healing, VA, any signs of uveitis or IOP rise; review drop compliance
- Week 6: Final post-operative review — refract for glasses prescription, check for CMO, assess posterior capsule clarity
- Earlier urgent review if: pain, redness, decreased vision, watery discharge — signs of endophthalmitis (refer same day)
Red flag symptoms (patient to return IMMEDIATELY):
- Severe eye pain developing after initial comfort
- Sudden reduction in vision
- Increased redness, discharge, or photophobia
- 'White ball of pus in the eye' (hypopyon visible to patient)
These red flags must be communicated verbally to every patient and written on their discharge instructions card.
CLINICAL PEARL
Endophthalmitis post-cataract surgery is an ophthalmological emergency. The classic 'rule' is: any post-cataract patient presenting with pain + red eye + reduced vision after day 1 has endophthalmitis until proven otherwise. The window for effective intravitreal antibiotics is narrow — delay of even 24 hours worsens visual outcomes significantly. When you see such a patient in a primary care or casualty setting, do not reassure, do not prescribe extra drops, and do not wait for a specialist appointment. Refer the same day as an emergency. The Endophthalmitis Vitrectomy Study defines the threshold for vitrectomy: hand motion (HM) or worse vision → vitrectomy + intravitreal antibiotics; better than HM → intravitreal antibiotics alone (both with intravitreal corticosteroids for most surgeons). Getting this referral right is one of the most important clinical acts you can perform for a post-operative ophthalmic patient.
SELF-CHECK
A patient presents to your primary care clinic 4 days after uneventful right eye cataract surgery. She has a painful, intensely red right eye, hypopyon, and vision reduced to counting fingers. What is the most appropriate immediate action?
A. Prescribe topical antibiotic drops and review in 2 days
B. Refer urgently to the ophthalmology unit for same-day intravitreal antibiotic treatment
C. Add oral ciprofloxacin and await specialist appointment next week
D. Reassure — post-operative uveitis is common and usually resolves with drops
Reveal Answer
Answer: B. Refer urgently to the ophthalmology unit for same-day intravitreal antibiotic treatment
This presentation — pain, hypopyon, and severe visual loss (CF) on day 4 after cataract surgery — is post-operative endophthalmitis until proven otherwise. It is a sight-threatening emergency requiring same-day intravitreal antibiotics (vancomycin + ceftazidime). Given vision is CF (better than hand motion), intravitreal antibiotics alone may be sufficient per EVS criteria, but this decision rests with the ophthalmologist. Prescribing topical drops alone, adding oral antibiotics, or deferring referral are all dangerous in this setting. The correct primary care action is immediate emergency ophthalmology referral — same day.
Self-Assessment — Cataract Surgery, Anaesthesia, and Postoperative Care
Self-assessment anchors learning at the end of each SDL module and prepares you for the integrated clinical questions seen in CBME OSCE and theory examinations. Work through each question independently, then check your reasoning against the SDL content. Focus on clinical application — why a step is performed, what goes wrong if it is omitted, and how you would recognise and respond to a complication at the bedside or in the postoperative clinic. The questions below test sequential reasoning about surgical steps, complication recognition and management, anaesthetic decision-making, and postoperative counselling — all of which appear in the CBME ophthalmology assessment framework. A student who can answer these questions fluently has demonstrated not just memorisation, but the integrated clinical understanding that competency-based education targets. If any question exposes a gap, return to the relevant section of this SDL rather than moving on — the surgical management of cataract is a knowledge structure in which each element supports the others.
Examination-Style Application Questions:
- Compare phacoemulsification, MSICS, and ECCE across the following parameters: (a) incision size, (b) corneal endothelial cell loss, (c) visual recovery time, (d) suitability for a Morgagnian hypermature cataract, (e) resource requirements. Which technique would you recommend for a high-volume cataract camp in a rural district hospital, and why?
- A patient develops sudden severe pain, redness, and photophobia on day 3 after uncomplicated ECCE. Examination shows a hypopyon. (a) What is the most likely diagnosis? (b) What is the standard treatment protocol? (c) What are the risk factors for this complication, and how can they be minimised?
- Describe the steps of ECCE in sequence, naming the instrument used at each step and the complication most likely if that step is performed incorrectly.
- A patient on warfarin for atrial fibrillation is scheduled for cataract surgery. What anaesthetic considerations apply? What alternatives to retrobulbar block are available and what are their advantages?
- Six months after cataract surgery, a patient returns reporting gradual blurring of vision that had initially cleared completely after the operation. (a) What is the most likely diagnosis? (b) Describe the mechanism. (c) What is the treatment, and what does the patient need to understand about it?