Cataract and systemic disease

A thorough preoperative exam is essential to find any disease outside of the eyes

Roibeard O’hEineachain

Posted: Sunday, March 28, 2021

Betty Lorente Bulnes MD, FEBO

Looking beyond the eye during preoperative assessment can optimise the outcomes of cataract surgery in patients with systemic disease with ocular manifestations, said Betty Lorente Bulnes MD FEBO, Spain, at the 25th ESCRS Winter Meeting.
“Sometimes we are too focused on the eyes of our patients and we forget that they might have diseases outside of their eyes,” Dr Lorente Bulnes said.
She noted that a thorough preoperative exam is crucial in determining systemic diseases that might affect the patient’s ability to cooperate and collaborate with the surgeon. This would include Down syndrome, Alzheimer’s, Parkinson’s disease and musculoskeletal disorders. As an example, she described a recent case where due to an arthritis condition the patient could not bring the back of his head on to the operating table and she had to perform the operation while standing up.
Also important is careful questioning of the patient regarding the medical history. For example, in patients with a history of prostatic disease, even a brief regimen of alpha blockers such as tamsulosin can leave its imprint on the iris many years later. In such cases, the surgeon will need to be prepared to deal with intraoperative floppy iris syndrome. Research conducted 10 years ago now shows that intracameral phenylephrine is very effective inducing pupil dilation in these eyes, Dr Lorente Bulnes noted.
“Another aspect that is really frequent in our patients is antithrombotic agents. We should take all of this into account before bringing our patients into the OR, studying the risks and benefits of stopping these drugs in these major diseases,” she added.
Marfan’s syndrome is another condition that requires modifications in cataract procedures. Special instrumentation such as iris retractors and capsular tension rings should be ready to hand in such cases in order to stabilise the bag, she said.
She added that eyes with a history of uveitis, whether it is caused by infection or autoimmunity, also require special consideration. For example, patients at her centre currently receiving corticosteroids require an adjustment of their regimen in the week prior to surgery. In addition, those receiving biologic treatments undergo surgery between treatments and those with herpetic uveitis or a history of herpetic eye disease receive prophylactic treatment
Dr Lorente Bulnes also noted that in patients with ocular surface disease one should be careful not to rule out pemphigoid, a very aggressive and underdiagnosed disease that can masquerade as less serious conditions such as chronic blepharitis or chronic conjunctivitis.