Ang, Gere Ganixon Ophtha251 Cataract Assignment

What parts of the eye are involved in the surgery? functions and surgical steps involving each (15pts)
1. Bulbar Conjunctiva- the membrane covering the eye surface and stopping at the limbus. A
subconjunctival injection is used for shorter procedures. A retrobulbar block (inj. site: lower lid
margin) is used for longer procedures.
2. Limbus (corneaoscleral junction)- where the discission into the lens is made. Scleral tunnel
wound is watertight and self-sealing, so suturing isn’t required, unlike a limbal incisision.
3. Anterior chamber- the aqueous-containing space between the corneal endothelium and the iris.
A deeper AC during surgery improves maneuverability, so a viscoelastic is injected to create and
maintain space as well as pressurisation.
4. Lens capsule- The anterior capsule must be opened in order to gain access to the lens.
Capsulorhexis is done in a continuous curvilinear (CCC) method to avoid radial tears.
5. Lens Cortex and Nucleus- Depending on the type of cataract, the anterior or posterior cortex or
the nucleus may be opacified. The lens is removed and replaced with the IOL.
What measures can be taken preoperatively in order to avoid surgical site infection? (10pts)
1. Treatment of conditions that increase infection risk- conditions e.g. conjunctivitis, blepharitis,
contact lens wear, etc. increase the presence of bacteria on the ocular surface and are risk
factors endophthalmitis. These should be corrected or treated prior to surgery.
2. Topical 5% povidone-iodine into the conjunctival sac- this greatly reduces the risk of infection
as the antimicrobial effects occur within 1min of irrigation and lasts for at least one hour. This
shows to be more effective in reducing infection than preoperative antibiotics.
3. Careful draping of the eyelid and lashes- reduces the presence of bacteria in the surgical field.
Trimming lashes is not recommended and does not reduce periocular bacterial flora.
What measures can be taken intraoperatively in order to avoid surgical site infection? (15pts)
1. Proper hand washing, wearing face mask, sterile gloving and gowning, sterile measures-
proper sterile technique is necessary during any surgery to reduce risk of infections.
2. Watertight, 3-plane corneal incision- reduces risk of leaks and infections. The initial incision
being in the vascular limbal region increases fibroblastic response, promoting healing.
3. Careful IOL implanation and opting for IOLs with acrylic optics- avoiding the ocular surface by
folding the IOL and inserting it into the eye directly through a cartridge reduces the risk of
endophthalmitis. IOLs with silicone optics is assoc. with an increased risk of endophthalmitis.
4. Minimise surgical time and Manage surgical complications appropriately- prolonged surgical
time and intraoperative complications such as posterior capsule rupture increase the risk for
endophthalmitis, as the post. capsule acts as a “barrier”

References (Part 1): AC;, N. (n.d.). Cataract. Retrieved October 02, 2020, from https://pubmed.ncbi.nlm.nih.gov/30969521/ |Behrens-Baumann, W. (n.d.).
Prevention and Treatment of Post-cataract Surgery Infection. Cataract and Refractive Surgery Essentials in Ophthalmology, 167-175. doi:10.1007/3-540-
26678-x_10 | ESCRS guidelines for Prevention and Treatment of ... (n.d.). Retrieved October 2, 2020, from https://www.escrs.org/endophthalmitis/guidelines.
pdf | Isenberg, S. J., Apt, L., Yoshimori, R., Pham, C., & Lam, N. K. (1997). Efficacy of Topical Povidone-Iodine During the First Week After Ophthalmic
Surgery. American Journal of Ophthalmology, 124(1), 31-35. doi:10.1016/s0002-9394(14)71640-x | Kamalarajah, S., Ling, R., Silvestri, G., Sharma, N. K., Cole,
M. D., Cran, G., & Best, R. M. (2006). Presumed infectious endophthalmitis following cataract surgery in the UK: A case–control study of risk factors. Eye,
21(5), 580-586. doi:10.1038/sj.eye.6702368
Ang, Gere Ganixon Ophtha251 Cataract Assignment

5. Intracameral inj. of cefuroxime (1mg in 0.1mL PNSS) at the end of cataract surgery- reduces
the occurrences of endophthalmitis by 5-6 folds. Vancomycin as an irrigating fluid is not
recommended due to its lack of protective effects plus increasing antibiotic resistance.
What measures can be taken postoperatively in order to avoid surgical site infection? (10pts)
1. Application of 1.25% povidone-iodine post-operatively- leads to a significant reduction in
conjunctival contamination. Data shows that the antimicrobial effect of antisepsis is superior to
that of a topical antibiotic for the first day post-op.
2. Topical antibiotics for days post-op for appropriate cases- This includes cases such as
complicated surgeries, for patients with coexisting diseases (e.g. uveitis or glaucoma, or patients
with 1 eye left), or for patients with inaccessible eye care. This is due to a higher rate of sight-
threatening complications. Topical antibiotics should not be routine because there is insufficient
evidence on the effectivity of topical antibiotic several days post-op.
3. Monitoring for any complications and proper patient education- Ask the patient to cleanse the
area around the surgical site properly and to avoid possible inoculation means (e.g. wearing
makeup, touching the area with dirty hands, etc.). Monitor for vision loss, pain, light
flashes/floaters, and nausea/vomiting, and to consult immediately if any occur.
Why is cataract blindness common? What factors hinder patients fr. receiving treatment? (20pts)
The high elderly population in the Philippines coupled with aging as the most common cause
makes cataract common in the Philippines. Other factors contributing to high prevalence in the
country include the Philippines being near the equator (high UV index), smoking, and malnutrition.
Cataract Blindness is common due to the poor healthcare system in place. Patients are unable to
seek ophthalmologic care that is accessible, affordable, and available, so the cataract continually
progresses until blindness develops. Factors hindering patients from receiving treatment include:
1. Inaccessible and unavailable healthcare-Despite the increasing number of ophthas, most
are localised in cities. Moreover, the devolved healthcare system does not ensure that all
hospitals are equipped with the necessary equipment to carry out the cataract surgery.
2. Unaffordable healthcare- the cost of cataract surgery ranges from Php10k-110k. Although
this is covered by Philhealth at Php16k per eye, this does not factor in the indirect financial
burdens such as lost wages from absence from work, travel costs, communication costs, etc.
3. Fear of surgery and lack of support from family or friends- Considering that the senile
elderly are the most commonly affected and how the surgery will require post-op care as the
eye is healing, lack of support is a hindrance to accessing treatment. Also, most elderly are
unable to drive, and household members attribute the slow movement and poor eating to
habits of old age instead of a visual impairment.
References (Part2): Mamalis, N., Kearsley, L., & Brinton, E. (2002). Postoperative endophthalmitis. Current Opinion in Ophthalmology, 13(1), 14-18.
doi:10.1097/00055735-200202000-00004 |Olson, R. J., Braga-Mele, R., Chen, S. H., Miller, K. M., Pineda, R., Tweeten, J. P., & Musch, D. C. (2017).
Cataract in the Adult Eye Preferred Practice Pattern®. Ophthalmology, 124(2). doi:10.1016/j.ophtha.2016.09.027|Ophthalmology, N. (n.d.). Community Eye
Health Journal " Endophthalmitis: Controlling infection before and after cataract surgery. Retrieved October 02, 2020, from https://www.cehjournal.org/
article/endophthalmitis-controlling-infection-before-and-after-cataract-surgery/ | Prophylaxis of postoperative endophthalmitis following cataract surgery:
Results of the ESCRS multicenter study and identification of risk factors. (2007). Journal of Cataract & Refractive Surgery, 33(6), 978-988.
doi:10.1016/j.jcrs.2007.02.032