History of Present Illness (HPI)
A 70-year-old woman presents for her postoperative day 1 appointment after cataract surgery right eye (OD). She underwent an uncomplicated phacoemulsification with implantation of a one-piece intraocular lens into the capsular bag. She complains of some foreign body sensation and mild discomfort but otherwise no significant pain. After taking off her shield, she immediately complains that her vision is significantly worse than before the surgery.
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Questions to ask the patient:
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Were you told before surgery that your cataract was particularly bad or complex?
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Were there any complications during the surgery?
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Questions for the cataract surgeon:
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How dense was the cataract? What total phacoemulsification energy was used?
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Were any surgical adjuvants used?
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What prophylactic medications, if any, were used perioperatively?
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Based on preoperative notes and the operative report, the cataract was described as 2 to 3+ nuclear sclerosis (NS), and the total phacoemulsification energy was not unusual. No surgical adjuvants were used during the case other than standard viscoelastics. Subconjunctival cefazolin and dexamethasone were used at the end of the case as prophylaxis. The patient reports that she was told the surgery went smoothly and that her cataract was fairly standard ( Fig. 20.1 ).
| OD | OS | |
|---|---|---|
| Vision | 20/400 | 20/25 |
| IOP | 29 | 13 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | 1+ injection | White and quiet |
| Cornea: | See Fig. 20.1 | Clear |
| AC: | 3+ cells | Deep and quiet |
| Iris: | Slightly irregular pupil | Flat |
| Lens: | Posterior chamber intraocular lens (PCIOL) | Clear |
| Dilated fundus examination (DFE): | Poor view | Not performed |
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