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CATARACT SURGERY 1. PRE-OPERATIVE EVALUATION a. History of Present Illness b.

Ocular History Glaucoma Uveitis High myopia Prior retinal surgery Prior ocular trauma Pseudoexfoliation Prior refractive surgery Contact lens wear c. Medical History Steroid Systemic disease Conditions that compromise a patients ability to cooperate or be positioned during surgery Ocular Conditions d. Medication Corticosteroid Anticoagulant e. Allergies/Adverse Reaction f. Family History g. Social History Alcohol Smoking 2. PRE-OPERATIVE EXAMINATION a. Introduction b. Visual acuity c. Keratometry Keratometry is used for IOL calculations and must be performed in both eyes as an internal control. d. Corneal topography e. Pupils f. Intraocular Pressurelity g. Motility h. External i. Slit Lamp Lids/lashes Blepharitis or meibomitis may increase the risk of endophthalmitis and should be treated before surgery. Blepharophimosis can limit surgical exposure. Ptosis can be exacerbated by speculum use. Conjunctiva/sclera The presence of prior surgery such as filtering blebs may alter the approach to surgery. Symblepharon, conjunctival scarring, or scleral thinning may alter the surgical approach as well. Cornea Guttata may represent early Fuchs dystrophy, which can worsen with cataract surgery, especially with extended phacoemulsification times. Corneal pathology such as scars or peripheral degenerations may alter the surgical approach. Pigment on the endothelial surface may be a clue to pseudoexfoliation. Anterior chamber Narrow angles with elevated IOP may require laser peripheral iridotomy (LPI) before cataract surgery. If anterior chamber IOL (ACIOL) placement is likely, gonioscopy is necessary to look for peripheral anterior synechiae or angle neovascularization. Iris Determine the maximal dilation and check for posterior synechiae. Debris present at the pupillary margin may represent pseudoexfoliation.

Lens Determine cataract density to plan the surgical approach. Check for lenticular stability by either having the patient look back and forth quickly or hitting the slit lamp table while observing the lens. Identify lenticular dislocation or subluxation. Pseudoexfoliation is most obvious on the anterior lens capsule. Also check for posterior polar cataracts because they are associated with an increased risk of posterior capsular rupture with vitreous loss. Anterior vitreous Asteroid hyalosis and vitreous hemorrhage can make visualization very difficult in the operating room. As an adjunct to complete slit lamp examination, retinoscopy can provide valuable information regarding the visual impact of cataracts that are unimpressive at the slit lamp. j. Fundus Retina Any retinal pathology such as AMD, ERM, vitreomacular traction, macular hole, scars, or diabetic retinopathy that could be responsible for decreased vision should be identified and discussed with the patient to give him or her appropriate expectations for postoperative vision. Optic nerve The optic nerve should also be thoroughly evaluated for pallor or cupping and treated or referred appropriately. USG Should cataract density prevent adequate visualization of the posterior pole, B-scan ultrasonography should be used to rule out gross abnormalities such as tumors or retinal detachments. k. Neuropshyciatric Comprehension and the ability to follow commands during the examination are clues to how the patient will behave in the operating room. Patients that are not able to follow commands should be offered general anesthesia. 3. POST-OPERATIVE MEDICATIONS a. Antibiotics b. Dilating drops

Drug Flurbiprofen 0.03% Ketorolac 0.5% Diclofenac 0.1% Nepafenac 0.1% Bromfenac 0.09%
c. NSAID

FDA-Approved Indication Inhibition of intraoperative miosis Treatment of inflammation associated with cataract surgery Treatment of inflammation associated with cataract surgery Treatment of inflammation associated with cataract surgery Treatment of inflammation associated with cataract surgery

FDA-Approved NSAIDs Diclofenac (Acular [Allergan, Inc, Irvine, Calif]) Ketorolac (Voltaren [Novartis, Dorval, Quebec]) Nepafenac (Nevanac [Alcon Inc]) Bromfenac (Xibrom [ISTA Pharmaceuticals, Irvine, Calif])
d. Corticosteroids

Postoperative Dosing QID QID TID BID