Sir,

Phacoemulsification with a small self-sealing incision is currently the commonest method of cataract surgery in the UK, and is increasingly becoming a day case procedure.1

There remain however, unresolved issues with regard to postoperative review. National policy2 is not evidence-based; different surgeons have varying individual protocols. Some propose a single postoperative review incorporating refraction at 3–6 weeks3 with patient self-referral for any interim complications. With regard to earlier review, some advocate same or following day review,4,5 whilst others are willing to dispense with this altogether.6

Suggested reasons for review on the first postoperative day include the detection and management of early complications, patient education regarding postoperative care, technical feedback for the surgeon and patient perceptions of the necessity of review.7

We report a case of uncomplicated phacoemulsification with severe asymptomatic postoperative ocular hypertension.

Case report

A 65-year-old man underwent uncomplicated second eye phacoemulsification with intraocular lens implantation, through a temporal clear corneal incision. A single 10/0 nylon suture was used to seal the wound following failure of corneal hydration. Preoperative unaided visual acuity was 6/18, improving to 6/9 with pinhole. The other (pseudophakic) eye had an unaided acuity of 6/6.

At first postoperative day review the patient reported subjective visual improvement despite mild discomfort overnight. The acuity remained unchanged at 6/18, improving with pinhole to 6/6. Slit-lamp examination revealed mild conjunctival injection, well-sealed corneal incisions, mild diffuse corneal epithelial oedema and 1+ cells in the anterior chamber. The intraocular pressure measured 66 mmHg.

Three hours later, despite the administration of 500 mg of oral acetazolamide, the intraocular pressure had risen to 74 mmHg. Removal of the nylon suture had no effect on the IOP; aqueous was therefore released, by pressure on the wound margin with a sterile 26 gauge needle, reducing intraocular pressure to 22 mmHg.

At discharge the following morning the intraocular pressure measured 26 mmHg. Subsequent follow-up was uneventful.

Comment

Despite dangerously elevated intraocular pressure, this intelligent and articulate patient with previous experience of cataract surgery perceived his discomfort and hazy vision as normal and did not mention them until specifically asked. If not for early review, he would certainly have been subject to significant risk of permanent visual damage.

The frequency of clinical intervention on the first postoperative day reflects the incidence of complications.8 Intervention rates of around 3% have been documented,5,9 involving complications such as corneal abrasions, iris prolapse, corneal oedema and most commonly, elevated intraocular pressure, which left untreated, can result in irreversible optic neuropathy.8 It is however, worthy of note that most case series report selected cohorts of patients; isolated case reports therefore serve the valuable function of drawing attention to problems that may arise in everyday circumstances, involving a wide variety of patients and surgeons.

Apart from its efficacy as a screening tool for early complications, first-day review also affords valuable feedback to improve surgical technique.10 Cataract surgery in the UK is commonly performed by ophthalmic trainees. It is significant that, even during closely supervised surgery, it can be difficult for the supervising surgeon to judge the completeness of aspiration of viscoelastic at the conclusion of the procedure, so essential to the prevention of post-operative ocular hypertension. Moreover, when the surgery is performed by a non-expert trainee (even if supervised), early review would intuitively appear to be a sensible practice, especially when it is considered that this involves but a brief examination with no history taking, the surgeon being familiar with the history and operative procedure.

Dispensing with early postoperative review certainly presents financial advantages and adds to patient convenience; however, we submit that the risks entailed, though small, perhaps do not justify this measure at least until evidence based national guidelines are available.