What eye drops are recommended for a patient with hypertension undergoing cataract surgery?

Eye Drop Management for Hypertensive Patients Undergoing Cataract Surgery

For hypertensive patients undergoing cataract surgery, phenylephrine 2.5% ophthalmic solution should be used instead of the 10% concentration to minimize cardiovascular risks while achieving adequate pupil dilation.

Preoperative Considerations

Patient Assessment

• Evaluate blood pressure control before surgery
• Determine if the patient has other cardiovascular risk factors
• Review current antihypertensive medications
• Consider postponing elective surgery if SBP ≥180 mmHg or DBP ≥110 mmHg 1

Medication Management

• Continue antihypertensive medications until the day of surgery 1
• Beta blockers should be continued if the patient is already taking them 1
• Consider discontinuing ACE inhibitors or ARBs 24 hours before surgery to reduce intraoperative hypotension risk 2
• Never abruptly discontinue beta blockers or clonidine as this can cause rebound hypertension 1

Recommended Eye Drops for Hypertensive Patients

Mydriatic (Pupil Dilating) Agents

1. Phenylephrine 2.5% (preferred for hypertensive patients)

   • Contraindications: The 10% concentration is contraindicated in patients with hypertension 3
   • Rationale: Lower concentration reduces risk of cardiovascular complications while still providing adequate mydriasis
   • Application: One drop every 3-5 minutes up to maximum of 3 drops per eye 3

2. Alternative mydriatic agents (if needed):

   • Tropicamide (parasympatholytic) - has minimal cardiovascular effects
   • Cyclopentolate - has minimal cardiovascular effects

Intraoperative Management

• Monitor blood pressure closely during the procedure 2
• Early monitoring and control of blood pressure has been shown to effectively manage perioperative hypertension 4
• Be prepared to treat significant elevations in blood pressure with appropriate IV medications 1

Potential Complications and Management

Cardiovascular Risks

• Phenylephrine 10% has been associated with serious cardiovascular reactions including:
  • Ventricular arrhythmias
  • Myocardial infarctions
  • Marked increase in blood pressure 3

Risk Factors for Intraoperative Hypertension

• Female sex
• Age >80 years
• Anxiety 5
• History of hypertension (10.9% incidence of preoperative BP rise vs 3.7% in normotensive patients) 6

Management of Intraoperative Hypertension

• For significant hypertension during surgery, consider:
  • Clevidipine
  • Esmolol
  • Nicardipine
  • Nitroglycerin 1

Special Considerations

Anxiety Management

• Consider preoperative anxiolytic medication as anxiety is a major risk factor for intraoperative hypertension 5
• Early monitoring of blood pressure before entering the operating room can help identify patients needing intervention 4

Post-Operative Care

• Resume antihypertensive medications as soon as clinically feasible 2
• Monitor for ocular hypertension after surgery, especially in patients with history of glaucoma 7
• Teach proper eye drop administration technique to minimize systemic absorption:
  • Consider nasolacrimal occlusion or tissue press method to reduce systemic absorption of eye medications 8

Common Pitfalls to Avoid

1. Using phenylephrine 10% in hypertensive patients
2. Starting beta blockers on the day of surgery (increases mortality risk)
3. Abruptly discontinuing chronic antihypertensive medications
4. Failing to monitor blood pressure before, during, and after the procedure
5. Overlooking anxiety as a significant contributor to intraoperative hypertension

By following these guidelines, the risk of cardiovascular complications during cataract surgery in hypertensive patients can be minimized while still achieving adequate pupil dilation for successful surgery.