Statistics from Altmetric.com
The Royal College of Ophthalmologists published cataract surgery guidelines1 in February 2001. This document includes protocols relating to postoperative visits suggesting that there are no additional risks to patients who are not reviewed on the first postoperative day. This is a change in recommendation from previous college guidelines in 1995 suggesting a review within 48 hours.
There may follow a growing impetus for ophthalmologists to dispense with the first day review, given the reduced demand on clinician time and the corresponding accrual of staffing and financial resource benefits. While we applaud the dissemination of practice guidelines, they constitute “merely tools, not rules” to aid clinical decision making. They may have inherent limitations in particular circumstances and may require evaluation for effective application in clinical settings.
Four studies were quoted by the guideline authors, three of which advocated the omission of day after review2–4 and one of which was equivocal,5 suggesting that it was unsafe to abandon this practice unless raised intraocular pressures (IOP) were controlled. The numbers of patients included ranged from 100 to 387. The results of these studies are shown in Table 1.
In our view, deriving meaningful conclusions that may underpin clinical practice are difficult, owing to the varying methodological approaches used in these studies. In Tufail's study,2 extracapsular cataract extraction was the predominant surgical technique used. Cohen et al5 excluded more than 50% of patients with complicated ocular histories or complicated surgery and Whitefield et al3 had similar extensive exclusion criteria, although the number excluded was not mentioned.
We would draw attention to a recently published study by McKellar and Elder,6 which to our knowledge is one of the largest cohort studies, aside from national cataract surveys, reporting on first and seventh day complications of cataract surgery. Of 1000 patients, the study found that on the first postoperative day, complications were observed in 10% of eyes, of which 88% was raised IOP. Unlike most of the previous studies, all patients with available records were eligible, including those with preoperative risk factors and those with surgical complications. These figures align more closely with our “gold standard” of the National Cataract Surgery Survey7 than the previous mentioned studies. The events most frequently occurring within 48 hours after surgery in the national survey were corneal oedema (9.5%), raised IOP (7.9%), and uveitis (5.6%). Overall, 23.3% of patients had early postoperative complications ranging from minor to sight threatening conditions. The survey also found that several risk indicators were associated with poorer visual outcomes and complications related to cataract surgery: age, ocular co-morbidity (glaucoma, macular disease, amblyopia, and previous ocular surgery), diabetes mellitus, stroke, type of surgical procedure, and grade of surgeon.
In summary, up to 20 000 patients a year in the United Kingdom (10%) may have an undetected early postoperative complication such as corneal oedema or raised IOP, if first day review was abandoned. And if McKellar's study is representative, then 5% of patients would have raised pressure without any previous history or surgical complication and 0.9% of patients could have other potentially serious early complications. Nationally, that equates to almost 12 000 patients annually. It is worth noting that the American Academy of Ophthalmology in its white paper,8 concludes that there are enough significant early postoperative complications to warrant first day review. Are we sufficiently confident in our own practices to diverge?
Credit should be apportioned to the distinguished authors of the cataract surgery guidelines suggesting 24 hour follow up of patients who had undergone complicated surgery, had coexisting eye disease, or had large incision cataract surgery. We would like to reiterate the importance of explicit criteria as part of any review policy and suggest that clinical interpretation of individual circumstances is paramount.
To reconcile the need for an efficient, cost effective review protocol together with a necessity to give due consideration to the entirety of detrimental post-cataract complications, especially given the NHS resource constraints, is difficult. A pragmatic approach may be for clinicians to be discriminately aware of those patients most at risk of developing early complications and instituting review policies accordingly, together with an open door policy for patients who need or want reassurance on the first day following uncomplicated surgery. Furthermore, a multiprofessional management approach involving the extended role of trained ophthalmic nurses in postoperative care may reduce demands on physician time.
At the moment, there is a paucity of a good prospective literature on the subject and a need for future studies to address whether those identified complications would result in a change of management at the first postoperative day visit and whether patients would have a poorer outcome if the changes were not instituted.