Pre-Operative Clearance and Management for Cataract Surgery
Surgical Clearance Decision
This patient can proceed with bilateral cataract surgery under local/MAC anesthesia despite his blood pressure of 151/82 mmHg and well-controlled diabetes (HbA1c 6.1%). 1, 2
Blood Pressure Management
The patient's blood pressure of 151/82 mmHg is well below the threshold for proceeding with cataract surgery, which is <180/110 mmHg according to joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and British Hypertension Society. 1
Cataract surgery is classified as low-risk surgery, and the American Heart Association/American College of Cardiology recommend deferring surgery only for patients with SBP ≥180 mmHg or DBP ≥110 mmHg who are undergoing elevated-risk surgery. 1
Continue lisinopril throughout the perioperative period as recommended by the American Heart Association for chronic antihypertensive medications. 1
The elevated reading may reflect situational anxiety ("white coat hypertension"), which is common on the day of surgery. 1
Diabetes Management for Surgery
His HbA1c of 6.1% is optimal for proceeding with elective eye surgery, falling within the recommended target range of 6-8% per the American Diabetes Association. 2
On the day of surgery, hold metformin as recommended by the American Diabetes Association for perioperative management. 2, 3
The patient should be scheduled early in the surgical day to minimize disruption to his medication and meal routine. 3
Local/MAC anesthesia is the preferred approach for diabetic patients undergoing eye surgery, as it minimizes glycemic fluctuations and allows quicker return to normal eating patterns. 2
Capillary blood glucose should be measured on arrival with target range 5-10 mmol/L (90-180 mg/dL), and monitored during the procedure if lengthy. 2, 3
Resume oral feeding and regular diabetes medications as soon as possible postoperatively. 2, 3
Elbow Lesion Management
Right Elbow Non-Healing Wound
Do not prescribe antibiotics for the right elbow wound, as there are no clinical signs of active bacterial infection. The patient's description reveals delayed wound healing without fever, warmth, erythema, or progressive swelling—all indicators that this is a chronic wound healing problem rather than an infectious process.
Key Clinical Features
The wound shows delayed healing with dark, hard skin and intermittent white discharge, which represents chronic wound exudate and fibrinous material, not purulent infection.
Diabetes is a major risk factor for impaired wound healing due to microvascular disease, neuropathy, and altered immune function, even when HbA1c is well-controlled at 6.1%. 4
The patient's history of smoking (currently vaping) and recent alcohol use further impair wound healing capacity.
Appropriate Management Strategy
Refer to wound care specialist or dermatology for evaluation of chronic wound management, not general surgery since the patient refuses surgical consultation.
Consider advanced wound care modalities including moisture-retentive dressings, debridement of non-viable tissue, and assessment for underlying osteomyelitis if bone was involved in original debridement.
Optimize wound healing factors: strict glycemic control (continue current regimen), smoking/vaping cessation counseling, nutritional assessment for protein and micronutrient deficiencies.
Protect the wound from repeated trauma during sleep with padding or protective dressing.
Left Elbow Fluid Collection (Olecranon Bursitis)
Conservative management is appropriate for the asymptomatic left elbow fluid collection; aspiration is not indicated in the absence of infection or functional impairment.
The description of a fluctuant, non-tender, non-erythematous fluid collection without warmth is consistent with asymptomatic olecranon bursitis.
Aspiration increases infection risk and often leads to recurrence, as evidenced by the right elbow's poor outcome after drainage and debridement.
Recommend protective padding to prevent trauma, avoidance of direct pressure, and observation for development of infectious signs (warmth, erythema, tenderness, fever).
If the patient develops signs of septic bursitis, then aspiration with culture and antibiotics would be indicated, but this is not the current clinical picture.
Medication Change Request (Tadalafil to Sildenafil)
The switch from tadalafil to sildenafil 100 mg can be accommodated, but requires cardiovascular risk assessment given his pulmonary hypertension and mitral regurgitation.
Cardiovascular Considerations
Both PDE5 inhibitors are generally safe in patients with controlled hypertension on lisinopril. 4
Pulmonary hypertension requires careful consideration: if the patient has pulmonary arterial hypertension being treated with tadalafil, switching to sildenafil for erectile dysfunction may be inappropriate. Clarify whether tadalafil was prescribed for pulmonary hypertension or erectile dysfunction.
His mitral regurgitation and pulmonary hypertension suggest underlying cardiac disease that warrants ensuring he has had recent cardiology follow-up. 5
Practical Prescribing
If tadalafil was prescribed for erectile dysfunction and the patient simply prefers sildenafil based on past experience, prescribe sildenafil 50 mg initially rather than 100 mg, as this is the recommended starting dose for most patients, especially those over 65 years.
Counsel on nitrate contraindication (absolute), alpha-blocker interaction risk (relative), and timing of administration.
Document that the patient is not taking nitrates and has no unstable angina.
Common Pitfalls to Avoid
Do not delay cataract surgery for blood pressure <180/110 mmHg, as this leads to unnecessary patient inconvenience and no demonstrated improvement in outcomes. 1
Do not prescribe antibiotics for chronic non-healing wounds without signs of active infection, as this promotes antibiotic resistance without addressing the underlying healing impairment.
Do not aspirate asymptomatic olecranon bursitis, as this increases infection risk and recurrence rates.
Do not abruptly discontinue lisinopril perioperatively, as ACE inhibitor withdrawal can cause rebound hypertension. 1
Do not assume the patient's drowsiness postoperatively is solely from anesthesia—monitor for hypoglycemia, especially since he may have hypoglycemia unawareness given his diabetes duration. 2