What are the preoperative requirements for cataract surgery fitness?

Preoperative Requirements for Cataract Surgery Fitness

The operating ophthalmologist should perform a comprehensive preoperative assessment that includes a thorough ophthalmic examination, review of medical history, and evaluation of the patient's ability to cooperate during surgery, while routine preoperative medical testing is not indicated for most cataract surgery patients and does not reduce perioperative complications. 1, 2

Ophthalmic Evaluation

• Complete eye examination to:

  • Document visual function decline that no longer meets patient's needs
  • Confirm cataract as the primary cause of visual impairment
  • Evaluate for ocular comorbidities that may affect surgical outcomes
  • Assess for contraindications to surgery

• Specific measurements:

  • Visual acuity testing
  • Refraction
  • Intraocular pressure measurement
  • Slit lamp examination
  • Dilated fundus examination
  • Biometry for IOL power calculation
  • Corneal topography/keratometry

• Dry eye disease (DED) screening:

  • Preoperative DED should be identified and treated before surgery
  • Tear break-up time (TBUT) testing or non-invasive tear break-up time (NITBUT)
  • Surgery should be postponed if visually significant ocular surface disease is detected 1

Medical Evaluation

• Targeted approach rather than routine testing:

  • No routine preoperative laboratory testing is required for most patients
  • Three randomized clinical trials have shown that routine preoperative medical evaluation does not reduce complications 1, 2
  • Only 0.1-0.5% of preoperative tests result in changes to perioperative management 2

• Selective testing for high-risk patients:

  • Patients with severe systemic diseases may benefit from targeted evaluation:
    • Chronic obstructive pulmonary disease
    • Poorly controlled hypertension
    • Recent myocardial infarction
    • Unstable angina
    • Poorly controlled congestive heart failure
    • Poorly controlled diabetes 1, 2

Patient Assessment

• Mental and physical status:

  • Ability to cooperate during surgery
  • Ability to position appropriately for the procedure
  • Cognitive capacity to understand and follow instructions 1

• Communication assessment:

  • Identify barriers such as language or hearing impairment
  • Ensure effective communication channels 1

• Postoperative care planning:

  • Confirm patient's ability to attend follow-up visits
  • Assess transportation arrangements
  • Evaluate ability to administer postoperative medications
  • Identify caregiver support if needed 1

Informed Consent

• Discussion should include:

  • Risks, benefits, and expected outcomes of surgery
  • Patient's expected surgical experience
  • Anticipated refractive outcome
  • Postoperative care requirements
  • Alternative treatment options 1

• Patient information preferences:

  • Studies show patients most want to know benefits and risks, even very small risks
  • Written information should be provided to reinforce verbal discussions 3

Medication Review

• Identify medications that may affect surgery:
  • Anticoagulants generally do not need to be discontinued
  • Alpha-1 adrenergic antagonists (e.g., tamsulosin) may increase surgical complications 4
  • Medications that could cause pupil dilation and induce angle closure (e.g., anticholinergics) 1

Contraindications to Surgery

Surgery should not be performed when:

• Tolerable refractive correction provides vision that meets patient's needs
• Surgery is not expected to improve visual function with no other indication for lens removal
• Patient cannot safely undergo surgery due to coexisting medical or ocular conditions
• Appropriate postoperative care cannot be arranged
• Patient is unable to give informed consent for non-emergent surgery 1

Common Pitfalls to Avoid

1. Overtesting: Avoid routine preoperative tests that won't change management

   • Studies show no reduction in perioperative events with routine testing 5
   • Focus on targeted evaluation based on specific medical conditions 2

2. Inadequate dry eye assessment:

   • DED is highly prevalent and often asymptomatic
   • Untreated DED can compromise surgical outcomes and measurements
   • Preoperative preparation should focus on restoring the ocular surface 1

3. Poor biometry:

   • Inaccurate IOL power calculation is a common cause of suboptimal outcomes
   • Ensure proper biometry technique and equipment calibration 6

4. Inadequate informed consent:

   • Patients want comprehensive information about risks and benefits
   • Written information should supplement verbal discussions 3

5. Neglecting postoperative planning:

   • Ensure patient has transportation and support for postoperative period
   • Confirm ability to administer medications and attend follow-up visits 1

By following these preoperative requirements, ophthalmologists can optimize patient selection, surgical planning, and outcomes for cataract surgery while avoiding unnecessary testing and delays.