POST-OPERATIVE CATARACT DOCUMENTS



POST-OPERATIVE CATARACT DOCUMENTS

Patient eligibility for post operative community cataract clinic

The vast majority of patients can be seen by an optometrist whether in a hospital or community setting, provided the outcome is communicated back to the secondary care unit. (NICE Guidelines, October 17)

Patients eligible for assessment by optometrists under this protocol include:

• Uncomplicated Surgery

• No Ocular co-morbidities requiring further management or treatment unless unaffected by cataract surgery and managed elsewhere.

There should be a clear route in place for postoperative complications to be identified, reported and treated, ensuring that there is prompt access to any specialist ophthalmological services if required. To cover this we have established an Optometry Led Triage Line which is outlined below.

Patient assessment

Patients should be seen 4-6 weeks post operatively and prior to this they should be sent to HES for any complications. As the triage line is only staffed Monday-Friday 9am-5pm it may be advantageous to see patients within these periods where possible. Below is an outline of the tests that we perform within the hospital clinics, however your own clinical judgement should be used.

History and Symptoms

• As usual history and symptoms but please document any prescribed medication and compliance

Clinical Investigations

• Vision (unaided and with PH)

• Refraction

• Near acuity

• Full Anterior Segment Slit Lamp Examination to include incision point and for negative seidel’s sign

• Anterior Chamber

• Any Iris Trauma

• Pupil Shape

• IOL status

• IOP-ICare or Tonopen if Goldmann not possible

• Dilation if;           

o Best corrected acuity worse than expected (worse than 6/9 if no comorbidities known)

o Any surgical complications

o Complaining of flashes and/or floaters or any other symptoms that warrant dilation

o No/poor pre-operative fundus view

o Posterior segment co-morbidity

• Slit Lamp binocular indirect Examination

• Posterior segment OCT if indicated

• Other clinical investigations that may be warranted

Advice to patients

Reiterate advice from hospital,

• bending, heavy lifting, swimming and hair washing are not advised in the week post operatively

• Flying is allowed after the first week

Management

• Discharged HES patients: If eye is settled, second eye is not indicated and no complications or co-morbidities noted continue routine GOS review.

• If the patient attends for co-morbidity a follow up should have been arranged for this-this should be highlighted within the audit form and will be checked by HES on return of this.

• Post op Complications:

o If IP treat any condition found as per the management protocol set out in the cataract post operative management guidelines and shown in the summary table below.

o If not IP, follow triage guidance below.

• A new referral will need to be initiated for any new co-morbidity noted.

• Please note a new referral will be required for second eye surgery if not otherwise indicated on the post operative audit form.

o Indications for Referral for Second Eye ;

• PSC Opacity

• Driver

• Symptomatic

• Vision of 6/12 or less

• Anisometropic >1.50

Post Operative Cataract Triage

The vast majority of these patients will be managed within community; however there will be some who require a return to HES. This will be done via an optometrist led triage service. This service will be provided at the following locations;

• GGH

• RAH and IRH

This triage service will be provided for patients attending their routine post operative check, any presentation out with this will still be referred via ARC.

The triage number at GGH 07717300116 will be available between 9.00-5pm Monday to Friday. We will have the ability to book the patients to our available slots or back to the consultant clinic if required. There is a guidance table below which indicates treatment options and whether triage is required.

GGC triage protocol is only valid for patients who have undergone surgery at GGC sites. For patients treated at Golden Jubilee they have their own nurse led triage system available on 01419515459

Post-Operative Cataract Management Guidance for Community and Triage

|AREA |COMPLICATION |MANAGEMENT (At Post Op) |OTHER INFORMATION |

|Incision |Leakage-Surgical complication. |Urgent-HES TRIAGE | |

|(Seidels Sign with | | | |

|NaFL) | | | |

|Conjunctiva |Localised injection/haemorrhage inferonasal |Common finding following sub-tenons|Normally more severe if patient |

| |quadrant |local anaesthetic- Self resolving |taking blood thinning medication |

| | |within a few weeks, no treatment | |

| | |required | |

|Cornea |Guttata/Decompensation |HES TRIAGE |Check other eye as important to |

| | | |note signs if proceeding with |

| | | |second eye and please note on |

| | | |audit form. |

| |Dry eyes |Reassurance and ocular lubricants |May be associated with post op |

| | | |drops |

|Anterior Chamber |Mild inflammation/Asymptomatic |Discharge |Advice to attend if becomes |

| | | |symptomatic. |

| |Grade 2+ cells/flare |Continue Steroids for 2/52 and |Advice to attend if becomes |

| |pain with a normally placed lens |Discharge. |symptomatic. |

| |asymptomatic/minimally symptomatic |HES TRIAGE if not IP | |

| |IOP normal | | |

| |Grade 3+ Cells |HES TRIAGE or manage if IP. | |

| |Mishapen pupil |Likely to be the result of iris | |

| | |hooks or other dilation aids, if | |

| | |unsure or not documented can call | |

| | |triage to check | |

| |A/C depth | |Worth noting shallow A/C depth on|

| | | |Audit form to inform second eye |

| | | |surgery |

|IOP Spike |21-30 |Stop Steroids or start treatment if|Review IOP in your clinic 1-2/52.|

| | |IP. | |

| | |HES TRIAGE-if history of Glau. | |

| |>30 |HES TRIAGE | |

|Lens Placement |If placement not as expected/refractive |HES TRIAGE |Check Toric markers if Toric |

| |surprise. | |lens. |

|Vitreous |PVD/Tobacco Dust/Haemorrhage |HES TRIAGE | |

|Macula |CMO |Acular t.d.s |Only OCT if VA 6/9 or less. (or |

| | |Maxidex q.d.s 4/52 |amblyopic eye) |

| | |HES TRIAGE if not IP or if Px | |

| | |Diabetic or attends Macula clinic. | |

| |Wet AMD |Follow normal pathway | |

| |ERM |HES-Triage | |

|Suspicious Discs |Suspicious Discs and/or increased IOP |Refer Routine Glau |Carry out 24-2 if possible. |

|Binocular vision |Shadowing from anisometropia post operatively |Reassure and explain, include on | |

| | |audit to inform second eye. | |

| |True diplopia |BV assessment, consider if new | |

| | |neurological event may be | |

| | |responsible, refer appropriately | |

Audit forms

• First eye forms will be printed in pink

• Second eye forms will be printed in blue

• A secondary white audit form may be issued in the instance where a patient has attended hospital triage following initial post op appointment

• All triage forms will be sent with a prepaid addressed envelope for return

• Audit forms will also trigger the process for listing for second eye where appropriate and are therefore also of clinical importance

If a patient attends without an audit form an electronic copy will be circulated by AOC and post op information can be added to this and returned.

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Phone managed by Optometrists 07717300116 or on call ophthalmology if outwith these hours.

Optometrist Contacts Triage Service if required. If out of hours contact on call ophthalmology.

HES Triage

Fill in triage form and follow guidance.

Booked for Consultant Review.

Advice given to Community Optometrist.

Optometrist Cataract triage appointment or ARC appointment

See ARC or consultant for further advice, or onward referral.

Treat and arrange follow up.

Treat and Discharge

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