Chapter 3

Although there is a growing movement toward the use of topical anesthesia for cataract surgery, the role for anesthesia providers has not diminished.1 Even under topical anesthesia, the proper preoperative evaluation of the patient, sedation before and during the procedure, and intraoperative monitoring all contribute to the prevention of systemic complications from ocular anesthesia. A full discussion of anesthesia is beyond the scope of this chapter, but a brief overview of systemic complications will be presented.

According to several studies, approximately 90% of cataract patients are over 50 years old and two-thirds are over 65. It is not uncommon to perform such operations on patients over 80 years of age. Therefore, many of the anesthetic considerations are those found in any procedure involving elderly patients.

PREOPERATIVE EVALUATION

The preoperative evaluation fulfills several functions. The most important is the medical evaluation of the patient prior to anesthesia and surgery. Another is reducing anxiety by educating the patient and administering preoperative medications. Both the medical evaluation and preoperative sedation contribute to preventing systemic complications in the patient having ocular surgery.

The requirements of the preoperative history and physical are variable. The history includes the major anatomic and physiologic systems, all medications, drug allergies, previous surgical procedures, and any complications related to prior anesthetics. The cardiovascular history, including previous myocardial infarction, congestive heart failure, strokes, or hypertension, is particularly important. A history of pulmonary diseases, especially asthma or severe chronic obstructive pulmonary disease (COPD), diabetes mellitus, or hepatic or renal insufficiency is also important. Each of these has implications for the administration of the anesthetic or potential complications that may occur.

The physical examination includes auscultation of the heart and lungs, an evaluation of the airway, and any abnormal system suggested by the patient’s history.

Unlike in the past, there is no prescribed list of laboratory tests that all patients undergo prior to surgery. Testing is now individualized to the patient’s underlying medical history. Diabetics should have a finger-stick blood sugar level performed immediately prior to surgery. Patients on digitalis or diuretics should have a recent potassium level, and coumadin users should have a prothrombin time/partial thromboplastin time (PT/PTT) done prior to surgery, especially if a peri/retrobulbar block is used as the anesthetic. Other tests may be indicated depending on the patient’s history.

A recent electrocardiogram (EKG) is indispensable in the elderly population, especially in patients with a history of cardiac disease or diabetes, which may mask the existence of severe cardiac disease. Studies vary widely as to what percentage of patients have unknown cardiac disease discovered on a routine preoperative EKG, but even in this cost-conscious environment, the consensus is that EKGs are indicated in all patients over 50 years old.

Once the preoperative evaluation is complete, an IV is started and the patient is placed on monitors, including an EKG, blood pressure cuff, and pulse oximeter. These monitors are sufficient in the free-standing ambulatory surgery center or hospital out-patient surgery department. If the patient requires more extensive monitoring, the surgery should be done only in a hospital setting.

Most cataract surgeries today are performed under a retrobulbar or peribulbar block.1

Stay updated, free articles. Join our Telegram channel

Join