1 Overview of the Causes of Suboptimal Outcomes Following Cataract Surgery: Role of Preoperative Screening and Adequate Counseling Abstract The causes of suboptimal outcomes following a cataract surgery can range from tear film abnormality to posterior segment disorder. Adequate preoperative screening and proper counseling help achieve an optimal result that eventually builds up the doctor–patient relationship to a satisfied and happy patient. Keywords: preoperative screening, suboptimal outcomes, cataract screening, counseling, specular microscopy, informed consent There can be varied causes for suboptimal outcomes after cataract surgery that on a broad spectrum can range from the instability of tear film to corneal involvement and disorders, intraoperative inflammation, raised intraocular pressure (IOP) to vitreoretinal, and optic nerve involvement to a more serious condition such as endophthalmitis. On a lighter note, it can be an error of wrong intraocular lens (IOL) power calculation and insertion of a wrong IOL although the repercussions of this are quite serious as it leads to residual refractive error, and especially in the era of premium IOL surgeries, patients’ expectations are quite high and the surgeon has a constant challenge to meet these expectations. However, with the involvement of each layer or tissue of an eye in a detailed and multiple ways, the cause for suboptimal outcomes can be multiple. All the potential causes and preexisting ocular comorbidities should be diagnosed and evaluated, and the prospective outcomes should be discussed with the patient. Preoperative screening and examination although a routine is an essential prerequisite before surgical procedures that helps stratify risk, direct anesthetic choices, and guide the postoperative management. The preoperative screening is guided by the patient’s clinical history, comorbidities, and physical examination findings. This decision is multifactorial and involves consideration of visual status: individual patient’s vision requirements, patient motivation, ability of the eye to withstand surgical stresses, and the motivation or desire of the patient to proceed with a surgical option. Although there is one treatment option for cataract, the complexity is multifold in a way from choosing the right IOL to the right IOL calculation formula, from preexisting retinal disorders to compromised endothelium, and from complexity of diagnostic tests to the risk of significant complications or comorbidities that may lead to suboptimal cataract surgery outcomes. Proper medical history evaluation of the patient is essential, and leading questions from the surgeon asking for any systemic illness such as hypertension, diabetes ( Fig. 1.1 Fundus image of diabetic retinopathy. History of any previous refractive or ocular surgery should also be evaluated. In case of history of refractive surgery, proper preoperative evaluation is again needed as to the calculation of the IOL power by applying appropriate IOL power calculation formulas after taking all the aspects into consideration. In cases with higher or asymmetric refractive errors in both the eyes, amblyopia should be ruled out and possible causes and outcomes should be evaluated. Detailed history about the visual status of the patient few years ago can go miles in explaining the preoperative status of the eye. History of previous retinal surgery or an intravitreal injection should draw a cataract surgeon’s attention to the aspect of performing a cataract surgery in previtrectomized eyes and the possibility of an increase incidence of intraoperative posterior capsular rupture.1,2,3,4,5,6,7 Previous intravitreal injections have the probability of damaging the posterior capsule and a preoperative B-scan or, if possible, an optical coherence tomography (OCT) examination to assess the integrity of the posterior capsule should be performed. Recording visual acuity helps evaluate the functional visual capacity of the patient who is to undergo a surgery. The fall in vision should be correlated to the degree of cataract in the eye, and in case the functional vision loss exceeds the degree of cataract, other causes must be evaluated for the relevant fall of visual capacity. Squint analysis should always be performed and microtropia should always be assessed as it directs an underlying cause of amblyopia that may be present in a cataractous eye. Assessment of ocular motility should always be done to rule out any paralytic component. In addition to this, cover–uncover test, assessment of head posture, detection of cyclotorsion, or any associated nystagmus should also be performed. Specular microscope ( Patients with diseases such as glaucoma, iridocyclitis, or diabetes, or with history of previous ocular surgery are at increased risk of ECD loss and its adverse effects on cornea postsurgery ( Essential preoperative testing includes keratometry readings, ultrasound axial length of the eye (A-scan), corneal topographic scanning, and a calculation of implant power requirements using a modern implant formula. Optional testing also might include potential visual acuity testing and ophthalmic photography.
1.1 Overview of the Causes of Suboptimal Outcomes
1.2 Preoperative Screening
1.3 History Evaluation
1.3.1 Medical/Metabolic Illness
Fig. 1.1), thyroid disorder, cardiac, or any other disorder for which the patient needs to take any medicine should be evaluated. In males above 50 years of age, leading question of any drug consumed for prostate enlargement should be asked for as it can lead to intraoperative floppy iris syndrome. Anticoagulants and blood-thinning agents should be stopped at least 3 to 4 days before the surgery is planned and can be resumed once the surgery is over.
1.4 Vision
1.5 Ocular Motility and Alignment Analysis
1.6 Specular Microscopy and Pachymetry
Fig. 1.2a) helps detect corneal endotheliopathy (
Fig. 1.2b; 
Fig. 1.3) and forms an essential component of preoperative screening before a cataract surgery. A normal cataract surgery leads to 4 to 10% of the endothelial cell density (ECD) loss following surgery. This loss can be more in cases with preexisting endotheliopathies with less ECD count. Additionally, constant use of contact lens wear along with previous intraocular surgery also has a detrimental effect on the corneal endothelium. Assessment of all these corneal conditions helps determine a treatment plan for cases with diseased endothelium. Low ECD counts (
Fig. 1.3) with distorted ECD morphology invoke the application of endothelium-saving strategies that prevent further cell loss.
Fig. 1.4). In accordance with specular microscopy, pachymetry should also be performed to assess the corneal thickness in eyes with compromised corneas.
1.7 Intraocular Lens Power Calculation and Intraocular Lens Choices
Ento Key
Fastest Otolaryngology & Ophthalmology Insight Engine
