What precautions should be taken when a child with a known seizure disorder undergoes cataract surgery?

Preoperative Assessment for Cataract Surgery in a Child with Seizure Disorder

Children with known seizure disorders can safely undergo cataract surgery with appropriate precautions, but must continue their antiseizure medications throughout the perioperative period and require careful anesthetic planning to avoid medications that lower the seizure threshold. 1, 2

Seizure Control Assessment

Current Seizure Status

• Document the frequency of recent seizures, as patients with frequent baseline seizures are significantly more likely to experience perioperative seizures (P < 0.001) 2
• Timing of the most recent seizure is critical - recent seizure activity significantly increases perioperative seizure risk (P < 0.001) 2
• The overall perioperative seizure rate in children with known seizure disorders is 3.4%, but this varies substantially based on baseline control 2

Antiseizure Medication (ASM) Management

• All antiseizure medications must be continued throughout the perioperative period without interruption 1, 2
• Document the number and types of ASMs - patients on multiple medications have higher perioperative seizure rates (P < 0.001), indicating more refractory disease 2
• Ensure a plan for medication administration on the day of surgery, including timing and route (oral, IV equivalents if NPO) 1
• Missed doses of antiepileptic medications are a significant risk factor for perioperative seizures 2

Anesthetic Considerations

Medication Selection

• Avoid anesthetic agents that significantly lower the seizure threshold 1
• Identify medications that pose significant pharmacological interactions with the child's specific antiepileptic drugs 1
• The type of anesthesia (general vs. local/regional) does not affect seizure frequency in this population, so choose based on surgical requirements 2

Pediatric-Specific Sedation Monitoring

• For children under 6 years or those with developmental disability, sedation for preoperative imaging carries additional risk and requires careful planning 3
• Pulse oximetry with tone changes provides immediate aural warning of desaturation 3
• Capnography is valuable for diagnosing apnea or airway obstruction, particularly important as it detects respiratory depression several minutes before pulse oximetry alone 3

Multidisciplinary Planning Requirements

Preoperative Team Discussion

A personalized perioperative plan must be developed that includes: 3

• Specific instructions for operating room staff regarding positioning, temperature control, and monitoring
• Anesthesia type and associated medication choices
• Postoperative monitoring requirements based on seizure history
• Pain management plan that avoids seizure-threshold-lowering agents

Risk Stratification for Cataract Surgery

• Cataract surgery is generally considered low-risk (short anesthesia duration, minimal blood loss, limited tissue manipulation, non-neurological organ) 3
• However, children with poorly controlled seizures should be considered higher risk and may warrant enhanced monitoring 3

Ocular Surface Considerations

Preoperative Dry Eye Assessment

• Screen for dry eye disease before surgery, as it can affect surgical outcomes and measurements 3
• Patients on multiple medications, including antiseizure drugs, may have higher risk of ocular surface disease 3
• Ensure accurate biometry measurements (keratometry, topography, optical biometry) before proceeding 3

Critical Perioperative Safeguards

Day of Surgery

• Verify that morning ASM dose was administered or arrange for IV equivalent 1
• Avoid sleep deprivation, which is a known seizure trigger in the perioperative period 2
• Have emergency seizure management protocols immediately available, including benzodiazepines (midazolam 0.1-0.2 mg/kg IV) 3

Postoperative Monitoring

• The perioperative period extends 3 days after anesthesia - maintain vigilance throughout this window 2
• Resume oral ASMs as soon as the child can tolerate oral intake 1
• Most perioperative seizures are related to the underlying condition rather than the surgical procedure itself 2

Common Pitfalls to Avoid

• Do not discontinue or reduce ASMs perioperatively - this dramatically increases seizure risk 1, 2
• Do not assume well-controlled epilepsy eliminates perioperative seizure risk - 3.4% still experience breakthrough seizures 2
• Do not delay surgery unnecessarily - with proper precautions, the type of surgery does not affect seizure frequency 2
• Do not overlook the need for preservative-free eye drops postoperatively if the child is on multiple systemic medications 3