ARTICLE

Deferral of first review after uneventfulphacoemulsification cataract

surgery until 2 weeks

Randomized controlled study

Ayman Saeed, MRCOphth, Mark Guerin, MB, Irfan Khan, MB, Pearse Keane, MRCOphth,Jim Stack, MSc, PhD, Patrick Hayes, FRCS, Peter Tormey, FRCS, Mark Mullhern, FRCOphth,

Stephen Beatty, FRCOphth

PURPOSE: To investigate the safety of deferring the ophthalmic review after uneventful phacoemul-sification cataract surgery until 2 weeks after the procedure.

SETTING: Waterford Regional Hospital, Waterford, Ireland.

METHODS: After uneventful cataract surgery, 233 patients were randomized to have ophthalmic re-view 2 hours after the procedure and 2 weeks postoperatively (Group 1) or to forego any ophthalmicreview before the 2-week postoperative visit in the outpatient department (Group 2).

RESULTS: Of the 115 patients randomized to Group 1, 25 (21.7%) had intraocular pressure (IOP)spikes of 30 mm Hg or greater and 2 (1.7%) had a corneal abrasion in the immediate postoperativeperiod. Group 1 and Group 2 were statistically similar in terms of problems encountered in the first2 postoperative weeks and anterior segment findings and visual acuity at the 2-week postoperative visit.

CONCLUSIONS: The results of this randomized controlled study indicate that the first ophthalmicreview after uneventful cataract surgery can be safely deferred until 2 weeks postoperatively in pa-tients in whom a transient IOP spike would not be deemed clinically deleterious. Such a policy willenhance the efficiency of day-surgery units.

J Cataract Refract Surg 2007; 33:1591–1596 Q 2007 ASCRS and ESCRS

Cataract extraction is one of the most commonly per-formed and successful surgical procedures.1 Giventhe aging population and the resulting increase inthe number of cataract procedures that will be re-quired in the future, there is a need to facilitate thedevelopment of high-volume cataract surgery ina cost-effective manner. The safety and efficiency ofambulatory cataract surgery are well established.2–5

Accepted for publication May 7, 2007.

From the Waterford Regional Hospital (Saeed, Guerin, Khan, Keane,Hayes, Tormey, Mullhern, Beatty) and Waterford Institute ofTechnology (Stack), Waterford, Ireland.

No author has a financial or proprietary interest in any material ormethod mentioned.

Corresponding author: Dr. Ayman Saeed, Waterford Regional Hos-pital, Waterford, Ireland. E-mail: aymansaeed2003@yahoo.com.

Q 2007 ASCRS and ESCRS

Published by Elsevier Inc.

Since the advent of small-incision phacoemulsifica-tion cataract surgery, the necessity of close follow-upin the early postoperative period has been ques-tioned.6–15 From the patient’s perspective, day-casecataract surgery is more attractive if there is no need toreturn on the first postoperative day for review, espe-cially for patients in a rural setting who live a consider-able distance from the surgical center. Certainly, it hasbeen established that the follow-up on the first postop-erative day can be safely dispensedwith if the patient isreviewed a few hours after surgery. Indeed, an oph-thalmic review the same day as the procedure is morelikely to detect intraocular pressure (IOP) spikes thanan examination the following day,6,8,9 although thereis no compelling evidence that transient IOP spikes inhealthy eyes result in significant permanent damage.16

The Cataract Surgery Guidelines (2004) of the RoyalCollege of Ophthalmologists17 recommend that ‘‘thepatient is discharged by an appropriately trained

0886-3350/07/$dsee front matter 1591doi:10.1016/j.jcrs.2007.05.022

1592 DEFERRING FIRST POSTOPERATIVE PHACOEMULSIFICATION EXAMINATION

member of staff who ensures that the eye is examinedand if there are any problems, eg, shallow anteriorchamber or hyphema, an ophthalmologist is called tosee the patient.’’ Tinley et al.7 report that a nurse-ledophthalmic review (which did not include an IOPmeasurement) performed the same day as cataract

Table 1. Demographic, ophthalmic, and surgical data.

ParameterGroup 1(n Z 115)

Group 2(n Z 118)

P Value(2 Tailed)

Demographic detailMean age (y) G SD

(range)75 G 9(41–93)

74 G 10(48–96)

.46

Sex, n (%) .17Male 51 (44) 42 (36)Female 64 (56) 76 (64)

Ocular comorbidity, n (%)Pseudoexfoliation 9 (8) 5 (4) .25Glaucoma 10 (9) 8 (7) .58Corneal opacities 3 (3) 0 (0) .08Maculopathy 17 (15) 20 (17) .65Previous RD surgery 1 (1) 1 (1) .99Uveitis 0 (0) 1 (1) .32

Surgical detail, n (%)Surgeon grade .01

Consultant 43 (37) 48 (40)Registrar 52 (45) 64 (54)Senior house officer 20 (17) 6 (5)

Type of anesthesia .12Topical 83 (72) 97 (82)Sub-Tenon’s 31 (27) 19 (16)General 1 (1) 2 (2)

OVD used .15Healon 41 (36) 43 (36)Amvisc Plus 68 (59) 74 (63)Viscoat 6 (5) 1 (1)

Site of corneal section .33Superior 114 (99) 115 (97)Temporal 1 (1) 3 (3)

Intraoperative detail, n (%)Dense cataract 11 (10) 9 (8) .6Small pupil 6 (5) 10 (9) .33Deep-seated globe 5 (4) 1 (1) .09Shallow AC 1 (1) 4 (3) .18Placement of corneal suture .89

Yes 38 (33) 40 (34)No 77 (67) 78 (66)

Prophylactic oral acetazolamide postoperatively* n (%) .94Yes 55 (48) 57 (48)No 60 (52) 61 (52)

AC Z anterior chamber; Amvisc Plus Z sodium hyaluronate 1.6%; Hea-lon Z sodium hyaluronate 1%; OVD Z ophthalmic viscosurgical device;RD Z retinal detachment; Viscoat Z sodium hyaluronate 3%–chondroi-tin sodium 4%.*Single dose (250 to 500 mg) given orally immediately after surgery

J CATARACT REFRACT SURG

surgery was sufficient to ensure that the clinical out-comes of the surgery were not compromised.

However, an ophthalmic review of patients a fewhours after cataract surgery represents a substantial lo-gistical burden to the day-care unit as members of themedical and/or nursing staff are required to examinethe operated eye. Moreover, the need for such reviewsmay delay, for considerable time, vacating day-careward beds and/or chairs that will be needed to facili-tate the preparation of other patients for cataract sur-gery, thereby impairing the unit’s ultimate efficiency.The efficiency of the day-care unit would be greatly en-hanced in terms of management of time, space, andmotion if same-day review after uneventful cataractsurgery could be safely dispensed with.

We conducted a randomized controlled study to in-vestigate the safety of deferring the first ophthalmicreview after uneventful phacoemulsification cataractsurgery until 2 weeks postoperatively.

PATIENTS AND METHODS

The study protocol was approved by theWaterford RegionalHospital Ethics Committee, and the study was conducted inaccordance with the tenets of the Declaration of Helsinki. Allpatients attending the Department of Ophthalmology atWaterford Regional Hospital, Ireland, for elective phaco-emulsification cataract surgery between June 6, 2006, andAugust 18, 2006, were invited to participate. Exclusion crite-ria included intraoperative complications, intellectual im-pairment, or younger than 18 years. When surgery wasuneventful, recruited patients signed informed consentforms and an independent member of the staff in the eyeday-ward randomized patients to have an ophthalmic re-view by an ophthalmologist 2 hours after the procedure(Group 1) or to forego any ophthalmic review until 2 weeks

Total number of potentiallyeligible participants

268

Patients randomized toGroup1 or Group 2

233

Group 1 115

Group 2 118

Declined invitation to participate:7 (2.6%)

Ineligible (see exclusion criteria):11 (4%)

Ineligible for randomization because ofintraoperative event: 17 (6%)

Figure 1. Recruitment pathway for randomized controlled study ofophthalmic review in the immediate postoperative period versus de-ferral of first ophthalmic review until 2 weeks after surgery (Group1 Z patients randomized to an ophthalmologist-led review 2 hoursafter the procedure and a standard review 2 weeks after that; Group2Zpatients randomized to forego any scheduled ophthalmic reviewbefore the clinic visit 2 weeks after the procedure).

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Table 2. Postoperative details the first 2 weeks after surgery.

Parameter Group 1 (n Z 115) Group 2 (n Z 118) P Value (2 Tailed)

At 2-hour ophthalmic review, n (%)Wound-related problems 0 NA d

IOP (20–29 mm Hg) 44 (38.2)* NA d

IOP spikes (R30 mm Hg) 25 (22)† NA d

Corneal abrasions 2 (1.7) NA d

Between discharge and 2-week review, n (%)Reassurance 1 (0.7) 4 (3.3) .18Corneal abrasion 5 (4.3) 3 (2.5) .45Wound-related problems 0 0 1.00IOP R 30mm Hg 0 0 1.00Uveitis 1 (0.7) 1 (1) .99Endophthalmitis 0 0 1.00Other 0 1 (1)z .32Total 7 (6.1) 9 (7.6) d

At 2-week review, n (%)Corneal abrasions 1 (1) 0 .31Wound-related problems 0 0 1.00IOP R30 mm Hg 0 1 (1)x .32Uveitis 0 1 (1){ .32Endophthalmitis 0 0 1.00

Mean IOP (mm Hg) G SD (range)At 2 hours 23 G 9.2 (2 to 48) NA d

At 2 weeks 14 G 2.4 (8 to 23) 14 G 3 (7 to 30) .69Mean VA (pinhole) G SD (range)

Preoperative 0.62 G 0.6 (3 to �0.1) 0.63 G 0.7 (3 to �0.1) .90Postoperative 0.27 G 0.3 (2 to �0.1) 0.24 G 0.22 (1 to �0.1) .39

IOP Z intraocular pressure; NA Z not applicable; VA Z visual acuity*Three (6.8%) had established glaucoma and received a single dose (250 to 500 mg) of oral acetazolamide.†All received a single oral dose (250 to 500 mg) of oral acetazolamide.zWas a reaction to the drops.xSteroid responder; IOP decreased as steroid drops were tapered.{Uveitis was controlled by increasing frequency of steroid drops.

after the procedure (Group 2). Patients who had the 2-hourreview (Group 1) also had the standard 2-week review afterthe procedure.

The ophthalmic reviews after cataract surgery, whetherpatient initiated or scheduled (at 2 hours and/or at 2 weeks)included measurement of uncorrected and pinhole-assistedvisual acuity, IOP measurement by Goldmann applanationtonometry, anterior segment examination by slitlamp biomi-croscopy, and assessment of wound integrity by fluoresceintesting. All ophthalmologists performing a review, whetherscheduled (2-week review) or unscheduled, were maskedto whether patients had an ophthalmic review in the imme-diate postoperative period.

At the 2-hour review, all eyes with an IOP of 30 mmHg orhigher as well as patients with an IOP between 20 mm Hgand 29mmHgwho had coexisting glaucoma or reported sig-nificant ocular discomfort were treated by a single dose(250 to 500 mg) of oral acetazolamide (Diamox). Patientswith glaucoma in the 2 study groupswere advised to resumetheir antiglaucoma treatment the day of surgery.

Before the patients were discharged, appropriate postop-erative care guidelines, including the importance of symp-toms such as ocular pain and markedly reduced vision,were explained and written information, including contact

J CATARACT REFRACT SURG -

numbers in case of emergency, were given to patientsand/or their caretakers. The Department of Ophthalmologyat Waterford Regional Hospital does not have a policy oftelephone consultations or home visits on the first postoper-ative day.

Group 1 and Group 2 were compared in terms of baselinedata, interventions, complications arising before or at thescheduled ophthalmic review 2 weeks after surgery and pin-hole-assisted visual acuity at the 2-week review. Measure-ment data in the 2 groups (age, IOP, visual acuity) wereanalyzed using the independent-samples t test. Count datawere analyzed using standard contingency table chi-squaretests. A P value of less than 0.05 was considered statisticallysignificant. Snellen visual acuities were converted to log-MAR values for statistical analysis.

RESULTS

Table 1 shows the demographic, ophthalmic, andsurgical details by group. Figure 1 shows the recruit-ment pathway for this randomized controlled study.Table 2 shows the postoperative results in Group 1and Group 2.

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Table 3. Findings in and details of previous studies that investigated the value of ophthalmic review in the immediate and early period aftercataract surgery.

Surgeon Grade (%)

Study/Year Design Pt (n) C T

Current Prospective randomized controlled 233 39 61Thirumalai6/2003 Prospective nonrandomized noncontrolled 100 U UTinley7/2003 Prospective randomized controlled 362 27 73Tranos8/2003 Prospective nonrandomized controlled 141 53.6 46.4Ahmed9/2002 Retrospective 465 U U

Dinkaran10/2000 Retrospective 71 100 0Tan11/2000 Prospective nonrandomized noncontrolled 238 34 66Herbert12/1999 Retrospective 392 90 10Cohen13/1998 Retrospective 201 U UAllan14/1997 Retrospective 651 U UWhitefield15/1996 Prospective nonrandomized noncontrolled 100 U U

C Z consultant ; G Z general; GLZ glaucomatous eyes; IP Z iris prolapse; L Z local; NDR Z next-day review;NGLZ nonglaucomatouseyes; PB Z peribulbar; Pt Z patients; RB Z retrobulbar; SDR Z same-day review; ST Z sub-Tenon’s; T Z trainee; TOP Z topical; U Zunspecified; WL Z wound leakage*IOP R30 mm Hg, IOP measured 2 hours postoperativelyzIOP O25 mm Hg in the same-day discharge group before the scheduled appointmentxIOP O30 mm Hg, IOP measured 4 to 6 hours postoperatively†IOP R35 mm Hg, IOP measured 2 hours postoperatively{IOP R28 mm Hg, IOP measured 3 to 7 hours postoperatively**IOP R30 mm Hg, IOP measured on first postoperative day††IOP spike not specified

DISCUSSION

We believe the Cataract Surgery Guidelines (2004) ofthe Royal College of Ophthalmologists17 were aimedat early detection of potentially serious complications,including iris prolapse, shallow anterior chamber, andelevated IOP, that may go otherwise undetected. Areview before discharge may also reassure patients ofthe uncomplicatednature of the surgery theyhave had.

In our study, an ophthalmic review 2 hours after un-eventful cataract surgery identified several clinicalevents that required intervention, including IOPspikes to 30 mm Hg or higher (25 cases; 22%) and cor-neal abrasions (2 cases; 1.7%). Of note, our incidence ofIOP spikes in the immediate postoperative period iscomparable with that in the published literature.8,9

It would appear, therefore, that many patients inGroup 2, in whom an ophthalmic review in theimmediate postoperative period was not done, mighthave had IOP spikes that went undetected. Of note,in Group 1, only 6 (24%) of 25 patients with IOP of30 mm Hg or higher reported ocular discomfort inthe immediate postoperative period and 3 (6.8%) of44 had established glaucoma. These findings are im-portant because the guidelines published by the RoyalCollege of Ophthalmologists do not insist on IOPmea-surement in the immediate postoperative period.17 If,however, the surgeon wishes to detect and treat a rise

J CATARACT REFRACT SURG

in IOP, perhaps in eyes deemedparticularly vulnerableto damage by an IOP spike (eg, those with glaucoma),eyes predisposed to anterior ischemic optic neuro-pathy, and ‘‘only’’ eyes, it would seem prudent toperform tonometry on the same day of surgery ratherthan on the first postoperative day.6,8,9

Patients in Group 1 (examined in the immediatepostoperative period and 2 weeks after surgery)were statistically comparable to patients in Group 2(no scheduled ophthalmic review until 2-week postop-erative visit) in clinical events requiring interventionafter discharge, unscheduled visits to the eye depart-ment, and anterior segment findings, including appla-nation tonometry, at the 2-week review. The questionarises, therefore, whether ophthalmic review in the im-mediate postoperative period or on the first postoper-ative day can be safely dispensedwith in the setting ofmodern day-case, small-incision cataract surgery.

Ten studies investigated the value of ophthalmicreview in the early postoperative period (on thesame day as or on the first day after cataract surgery)(Table 3).6–15 Of these, 3 studies, all retrospective, con-cluded that an ophthalmic review on the first postop-erative day was necessary,10,12,13 whereas 7 studies (5prospective, 2 retrospective) concluded such a reviewwas of no clinical value.6–9,11,14,15 All these studies con-cluded that an ophthalmic review immediately after

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Anesthesia (%) Postoperative Event (%)

TOP ST G L PB RB IOP Spike WL IP UV Authors’ Conclusion

77.2 21.5 1.3 d d d 22* 0 0 2 SDR and NDR can be dispensed withd d U U d d 10† U U U SDR safe and more efficacious than NDR3 d 18 d 79 d 1z 0 1 1 NDR unnecessary9.5 d 1.6 d 89 d 24.6x 3.2 0 1.6 SDR safe and more efficacious than NDR

100 d d d d d GL, 46.4{;NGL, 18.4{

0.2 0 1 SDR safe and more efficaciousthan NDR

d d 31 69 d d 10** 0 0 0 NDR necessaryd d 3 97 d d 1.3** 0 0 0.4 NDR unnecessary2.2 d 1.8 d 96 d 1.5** 0 0.20 1.8 NDR necessary

d U d d U U 6** 0 0 0 NDR necessaryU d U d U d 2.3†† 0 0 0.9 NDR unnecessaryd d 14 86 d d 3** 0 0 0 NDR unnecessary

Table 3 (cont.)

cataract surgery is useful in detecting IOP spikes.However, to our knowledge, there are no publishedstudies of the safety of dispensing with any ophthal-mic review until several weeks after uneventful cata-ract surgery. It is worth noting that Tinley et al.7

conducted a prospective randomized controlled studyin which patients were examined with a penlight bya nurse before going home; no ophthalmic reviewwas performed by an ophthalmologist until 2 weeksafter the procedure. The authors conclude that sucha nurse-led ophthalmic review, which did not includeIOP measurements, is sufficient and that further re-view is unnecessary until 2 weeks after the procedure.

Our study, however, represents the first random-ized controlled study of whether patients can be safelydischarged after uneventful cataract surgery in the ab-sence of any review, nurse led or ophthalmologist led,in the immediate postoperative period or on the firstpostoperative day. The results of our study indicatethat the first ophthalmic review can be safely deferreduntil 2 weeks after surgery in cases inwhich a transientand asymptomatic IOP spike would not be deemedclinically important.

Limitations of this study include the relatively smallnumber of patients to detect differences in rare comp-lications, such as endophthalmitis, and that cornealpachymetry was not performed; therefore, IOP

J CATARACT REFRACT SURG

measurements should be interpretedwith full appreci-ation of this limitation. However, pachymetry was notdone in either group at the 2-week visit, negating a po-tential source of bias.

Some investigators suggest that telephone reviewwould be a satisfactory substitute for ophthalmic re-view in the immediate postoperative period or onthe first postoperative day.18 In our experience, how-ever, such telephone consultations are unreliable,time consuming, anxiety provoking, and subject tomisunderstanding arising from the high prevalenceof hearing impairment in the cataract age group.

The advantages of same-day discharge after cataractsurgery without review may be classified into thosethat benefit patients and those that benefit the healthcare provider. Patients will be pleased to returnhome at their earliest convenience without having towait for a review by a doctor and/or nurse, which isoften subject to delay for unforeseen andunforeseeablereasons. The advantages to the health care provider in-clude early vacating of day-care beds/chairs, whichcan then be used to prepare other patients for surgery.Also, if the need for an ophthalmologist to review thesecases can be safely dispensed with, there will be mini-mal disruption of the smooth running of the ophthal-mic operating room or of another department withinthe ophthalmic unit. Finally, nursing timewill be saved

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in units in which nurses perform the ophthalmic re-view or nurses must locate an ophthalmologist to re-view the case before discharge. In other words, theefficient management of high-volume day-case cata-ract surgery depends on optimum management oftime, space, and motion, and this will be greatly facili-tated if patients can be safely discharged without oph-thalmic review in the immediate postoperative period.

In conclusion, the results in our study indicate thatpatients can be safely discharged after uneventful cat-aract surgerywithout review in the immediate postop-erative period and that such an approach does notcompromise the clinical outcome. However, given thatasymptomatic IOP spikes are relatively common in theimmediate postoperative period, it may be prudentto perform same-day ophthalmic review, includingapplanation tonometry, in eyes in which a transientIOP spike would be considered clinically deleterious.

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