When to use it

• This aid is in development.
• It may be helpful to use this for some consultations, particularly in patients where it is difficult to make a decision.
• The tool may be more useful to the doctor...remind him how to explain the decision making process to the patient (this will only be necessary in the minority of consultations).
• Decision making tools may be useful (see), but naturally this depends on how they are used.
• Naturally very experienced surgeons have lower risks, especially in 'high risk' patients. Similarly, less experienced surgeons have higher risks.
• This tool is really designed to give patients an idea as to how decisions are made, it cannot be very accurate.
• It may be particularly helpful if a patient is hoping for a better result than the surgeon expects.
• A patient happy with their level of vision is less likely to want surgery. If a patient is coping well and happy despite their cataracts, then surgery is not usually needed.
• Eg: An 80y patient with heart disease who drives, with glare at night and wants to drive at night but who still has good reading vision, with 6/9 surgery, may want surgery. But if that patient has risk factors, as below, such as being on anticoagulants, he may be best without surgery for the time being.
• Many patients believe they will not need to wear spectacles after cataract surgery, and hence ask for surgery even if their cataract is in its early stages: if patients want good sight then spectacles are usually needed. High expectations can lead to unhappy patients.
• Take into account the best achievable visual acuity. For example, if the patient's sight is very poor, due to cataract AND a condition such as macular disease, then operate only if the risks are low.

• Use your mouse and move it over the risk slider (a blue blob), and move it to the appropriate risk (vertical, y, axis).
• Do the same with the horizontal visual acuity slider (another blue blob), and line it up to the 'appropriate' visual acuity for that patient (the x axis) (Visual acuity in the eye being considered for surgery).
• If the target circle is on red, surgery may be best, if on green, no surgery at this stage may be best.
• Use the tool with the patient watching on your desktop PC monitor. Alternatively, print this page and use the static image at the bottom, marking the lines with a pen with the patient present.
  

Interpreting risk, some ideas

with some ideas from Muhtaseb's & Mahmood study.

• good general health
• no eye risk factors/pathology
• aware of small risk of problems
• may need spectacles after surgery (needs to be aware of this)
• must be able to lie comfortably for time of surgery
• Blood pressure less than 140 systolic

• reasonable general health
• mild eye problems, such as controlled glaucoma
• controlled diabetes & no retinopathy
• professionals see

one point in Muhtaseb's study

• Previous vitrectomy
• Corneal scarring
• Small pupil (<3mm)
• Shallow anterior chamber (<2.5mm)
• age >88years
• high ametropia: >6d myopia or hypermetropia
• posterior capsule plaque
• poor eye position (e.g. enophthalmos, narrow palpebral fissure)
• tremor
• communication difficulties
• breathing difficulties
• using flomax any time in the last 2 years If the pupil dilates fully pre-operatively, the risk is lower. If the pupil does not dilate, expect iris prolapse during surgery (flomax=tamulosin).

...and Good Hope adds

• mild fuchs dystrophy
• other risks
• emphysema
• background diabetic retinopathy (may develop maculopathy)
• previous trabeculectomy and controlled pressure and dilated pupil (slightly greater risk if pupil small/experienced surgeon)
• difficult lying still for 10-40 minutes
• anticoagulants
• Blood pressure higher than 140 systolic...increases risk of cystoid macular oedema etc
• obesity...shallow AC

• incomplete pupil dilation (59.5% vs 8.8%) Mahmood
• Dense/total/white or brunescent cataract..use procedures such as vision blue
• Pseudoexfoliation (5.6% vs 1.4%) Mahmood
• phacodonesis
• severe dry eyes
• a combination of the above risk factors
• previous vitrectomy (7.8% vs 2.2%) Mahmood
• related to surgical experience, topical (14.3% vs 3.1%) and sub-Tenon's (51.4% vs 37.2%) anaesthesia Mahmood
• requirement for vision blue (trypan blue ophthalmic solution) (13.7% vs 2.4%). Mahmood

..and Good Hope adds

• severe breathing difficulties or very poor health
• posterior polar cataract..may need vitrectomy
• severe fuchs dystrophy
• poor general health
• uncontrolled glaucoma
• diabetic maculopathy/retinopathy
  (if active, this gets worse after surgery)
• emphysema on oxygen therapy at home
• advanced glaucoma with very little visual field remaining.
• active blepharitis
• severe atopic conjuncitivitis as below
• extreme obesity

• expect problems if AC <2mm and lens thickness >5mm
• high risk axial length (AL) <20mm...
  nanophthalmos
• use AC maintainer 20-22 mm
• vitrectomy first for highest risk <20mm, especially if lens thickness/axial length ratio >20%, and AC maintainer for cataract surgery: large PI with vitrector probe at end
• use Hoffer Q formula

at time of listing

• treat blepharitis with lid hygiene
• severe cases need systemic oxytetracycline/doxycyline if tolerated
• use chloramphenicol (or alternative drops) to clear blepharitis
• active blepharitis..AVOID SURGERY if possible
• check repsonse 2 weeks before surgery

week pre-operatively

• start intensive chloramphenicol drops 3-7 days prior to surgery (or alternative drops)
• check for active blepharitis

pre-operatively

• use polvidone iodine to clean eye, and leave it to clean for several minutes before local anaesthetic
• repeat before sstarting surgery

post-operatively, if lid not completely clean

• check patient frist day and 2-3 days later
• warn patient to attend as an emergency if the eye becomes achy, painful, with decreasing vision

• Avoid 'Maxitrol' drops after cataract surgery if you have dry eyes or conjunctival disease. It can cause very severe corneal problems (Midland Ophth Meeting, 2005).
• Preservative free drops for severe cases
• Maxidex AND chloramphenical (with preservatives, in combination, as separate drops) are well tolerated in mildly dry eyes.
• Use a schirmers tears test prior to cataract surgery if the patient's history suggests dry eyes. Also, if the patient has significant rheumatoid arthritis.
• Use lacrimal plugs...normally we insert these AFTER the operation, perhaps at the first post-op visit.

• Usually increase steroids 4-8 weeks before surgery
• pre-operatively boost steroids with a pulse
• FHC patients certainly benefit from pulsed methylprednisolone just before surgery, and have much higher risk of problems
• Non-steroidal anti-inflammatory NSAID drops help to prevent post-op macular oedema. They are not yet given routinely because of the expense. Even starting 2 days pre-operatively can be helpful.NSAID after cataract surgery are just as effective (but more expensive).
• Steroids or NSAID should be given 2 weeks pre-operatively in uveitis patients... uveitis experts often have local guidelines.

• cataracts are a common complication
• atopes...develop anterior cortical cataracts... surgery is difficult needs vision blue; rhexis turns out; cortex leaks out; young patients especially atopes have double risk; zonules weak; fibrosed lids-shallow fornix..cicatricial changes increase risks further;
• postop...capsule phimosis; hole in post cap...more likely to detach retina
• sodium Hyaluronate drops (vismed); hyalocomod; help lubricate after surgery

Pre-operative antibiotic drops have been proven to reduce endophthalmitis risk. Chloramphenicol starting 3 days before is ideal. Olfoxacin is not as effective.

5% polvidone iodine to clean the eye is more important & essential (unless allergic). This should be done twice...first before the anaesthetic (and not wiped off), then again by the surgeon before the operation.

This drug may cause a floppy iris etc. Effects are reduced with intracameral phenylephrine.  See paper, not summarised in detail here. First 1% lignocaine intracameral (?without preservative) to prevent pain, then  0.25 mls of 2.5% minims phenylephrine hydrochloride, mixed with 1.0 ml balanced salt.

Doxazosin