Patient Management
Cataract Surgery Pharmacology
A leading surgeon shares several ways he's improved his medication protocol and raised his standard of care.
By James Gills, M.D.

Back in the 1980s, our practice was surprised to discover that the balanced salt solution (BSS) we'd been using was being recalled. Recent batches of the solution had been contaminated with Candida parapsilosis, and patients in several other practices had developed endophthalmitis as a result.

We found that 110 of our patients had been exposed to the contaminated solution -- but none had become infected. I be-lieve one important reason for this was that we had recently begun filtering our irrigating solutions through a micron filter.

Since that event, I've made filtration a standard procedure for every case. Before we instigated this protocol, our incidence of endophthalmitis was 1 to 2 cases per 1,000 -- about the same as the national average. After we added the filtration process, our overall incidence dropped to 1 out of every 8,000 to 10,000 cases. Today, our incidence is 1 in 25,000.

Making the most of medication

Providing my patients with value-added service -- giving more than what is conventionally considered "standard of care" -- has always been a high priority for me. I've tried to integrate this principle into every aspect of patient care.

As part of achieving this goal, we've worked hard to improve the safety and predictability of cataract surgery. One of the main ways we've accomplished this has been by developing a medication protocol that targets three major areas:

• efficient and comfortable drug delivery
• prevention of discomfort (both intraoperatively and postoperatively)
• eliminating the potential for endophthalmitis.

We've refined this protocol (or "recipe," as my staff calls it) over the years as new drugs, surgical techniques and equipment have become available. Here, I'd like to discuss the "recipe" we use (for the specific details, see the facing page) and some of the issues associated with it.

Using pledgets

One of the most important additions to our drug delivery regimen in the last several years has been the use of pledgets, placed in the lower fornix, for delivery of pre- and postoperative medications. Pledgets provide continuous, consistent administration of medication without irritation.

Equally important, because they achieve the desired effect with a smaller quantity of medication, they minimize the toxic effect of multiple drops. As a result, our patients are more comfortable, and the eye is exposed to fewer preservatives. (Preparation of the pledgets is described in Step 1 of the recipe.)

Anesthesia and patient comfort

Delivering anesthesia safely and comfortably is a major hurdle we've cleared in the last decade. I've used topical anesthesia since 1992; I added the prophylactic use of intracameral Xylocaine (lidocaine) to our regimen in 1995.

This addition offers several benefits:

• Fewer patients require sedation.
• It decreases the risk of intraoperative problems such as squeezing lids.
• Our studies (and others') have shown improved patient comfort and safety using this protocol.

Initially, I administered lidocaine via the irrigating solution, but I've found that we can provide a much more controlled dosage using intracameral injection. Also, because the sting of the lidocaine is bothersome, we buffer the solution.

The combined topical and intraocular technique described in Step 2 of our "recipe" completely anesthetizes the two major sites of pain reception, the cornea and iris. Lidocaine's anesthetic effect lasts more than 10 minutes. (The dosage can be reinjected during the procedure, although it's rarely necessary.)

Using this protocol, 95% of my routine cataract surgery patients can receive topical anesthesia. We only resort to peribulbar anesthesia in select cases, such as combined glaucoma or strabismus procedures, if the patient is senile or has significant hearing loss, or if a language barrier exists.

Keeping the patient calm

Eliminating patient discomfort also depends on keeping the patient calm. In the past we used IV sedation for this purpose. However, patients have frequently remarked that the IV is the most uncomfortable part of the procedure.

Fortunately, because of our current anesthesia techniques, IV sedation is rarely needed. Today, we only start an IV in select cases, such as when patients have cardiac problems, hypertension or hypotension, diabetes, latex sensitivity, or if the patient is extremely anxious.

If a patient is just a little anxious, we offer sublingual Versed approximately 10 minutes before surgery. Also, while medical sedation is important, there's no substitute for a soothing atmosphere and an operating room staffed with calm, experienced personnel. Our nurse anesthetists hold patients' hands, and we speak to patients throughout the procedure.

Preventing endophthalmitis

Years ago, I used antibiotics in the irrigating solution. Now I inject medication at the end of the case for a controlled and accurate dosage. (See Steps 1 and 3 of the "recipe.") The solution also contains a steroid and NSAID (for minimizing inflammation). I also use this solution to hydrate the incision and irrigate the anterior chamber at the end of the case.

The issue of prophylactic antibiotics has been the subject of long and heated debates for years. However, developing resistance within the eye is very unlikely, and taking that risk is a far better alternative than losing eyes from infection.

To eliminate flora in the cul-de-sac and create an aseptic field, my protocol includes diluted topical Betadine solution, which we administer at the beginning and end of each case.

After the surgery

Once the patient is out of the OR, we instill another drop of anesthetic and offer anti-inflammatory medications (see Step 4). Unless my patients are returning the following day for surgery on the fellow eye, we perform the first postoperative check about 1 hour after the operation.

Patients leave with their postoperative medications and begin using them the same day. Along with Pred Forte and Voltaren (as outlined in Step 5) we recommend the use of artificial tears. (The other medications tend to exaggerate dry eye symptoms early on.)

Multiple benefits

Ironically, our continuing effort to provide patients with "value-added" service has probably been our most effective marketing plan. Even in today's managed care environment where patient choice is limited, patient awareness that we go the extra mile to maximize comfort and safety and provide the best possible outcomes has resulted in practice growth.

I encourage you to aim for the same goal in your practice. And if some of the strategies we've devised can help your practice achieve this goal, all the better.

Dr. Gills is the founder and director of St. Luke's Cataract & Laser Institute, and clinical professor of ophthalmology at the University of South Florida. ASCRS' Innovator of the Year in 1996 and author of seven medical books, Dr. Gills sits on the Duke Board of Visitors and the Johns Hopkins Wilmer Advisory Board.