By Virginia Bice, OD   |  PCLI—Kennewick, wa

Questions If you have questions, feel free to contact any of our optometric physicians. We’re always happy to help.

Ami Halvorson, OD

 

PCLI—Portland, OR

From the EDITOR   In the optometric world, some medications for systemic and ocular conditions can affect our patients’ eye health and outcomes of cataract surgery and laser vision correction. While they do not usually need to be discontinued or adjusted before surgery, patients often benefit from education about possible side effects and post-op expectations. In this issue, my colleague, Virginia Bice, discusses the meds most commonly addressed during pre-op evaluations.

BEFORE PROCEEDING with any ocular surgery, we need to consider patients’ overall health and how the medications they use for ocular or systemic conditions might affect their healing and vision. Join me in a review of the most common drugs we address during evaluations for cataract surgery and laser vision correction.

CATARACT SURGERY

• Topical Hypotensives:

Cataract patients often ask if they should discontinue glaucoma medication after surgery, especially when treatment includes minimally invasive glaucoma surgery (MIGS). They should, in fact, continue their same glaucoma medication regimen. Post-op IOP may fluctuate due to many factors, including retained viscoelastic immediately after surgery or a steroid response 1-2 weeks later. Because patients with glaucoma are susceptible to IOP fluctuations and are at a greater risk of optic nerve damage, they must continue their current eye drop regimen after surgery. However, after about a month, when IOP is typically stabilized and the steroid has been discontinued, it is reasonable to reassess glaucoma severity, IOP, and topical hypotensive use and consider a new regimen.

For patients with well-managed glaucoma, cataract surgery with MIGS may be an excellent way to decrease glaucoma medications, especially if a particular drop is impacting their ocular surface or is a financial burden. However, some patients are best served with topical hypotensives in addition to the IOP reduction from cataract surgery with MIGS. This is a discussion to have before and after cataract surgery to manage expectations of future use of eye drops.

• Anticoagulants and Antiplatelets:

Patients needing cataract surgery are often taking blood thinners, including:

•  Anticoagulants—like Coumadin (warfarin), Xarelto (rivaroxaban), and Eliquis (apixaban), which slow down clot formation.
• Antiplatelets—like aspirin and clopidogrel, which prevent blood from easily sticking together to make a clot.

These medications are often prescribed to avoid life-threatening conditions like heart attack and stroke, and are commonly used by patients with pre-existing conditions like coronary artery disease, peripheral vascular disease, and atrial fibrillation. Bleeding and bruising are side effects.

Because blood thinners are typically discontinued before general surgery to prevent intraoperative bleeding and other post-op complications, patients frequently ask if they should do the same for cataract surgery. However, because the benefits of preventing heart attack and stroke greatly outweigh the risks of post-op bleeding around the eye, we usually recommend these medications be continued before, during, and after cataract surgery. Because the risk of post-op sub-conjunctival hemorrhage, hyphema, and periorbital ecchymosis is greater for these patients, I let them know in advance to expect some bruising and bleeding, which will gradually resolve in a few weeks. By doing so, patients will not be as alarmed when they see a bruise or “shiner” around their eye after surgery.

Topical anesthesia decreases the risk of bleeding versus the use of a retrobulbar injection. However, just because someone is on blood thinners does not make them an ideal candidate for topical cataract surgery. We want every patient to have a comfortable experience. And those with extreme light sensitivity, excessive eye movements, difficulty holding still, hearing or communicating will likely feel more at ease with their eye completely numb from a retrobulbar block.

• Alpha Blockers:

These medications are commonly prescribed to manage benign prostate hyperplasia in men and less commonly to manage urinary tract symptoms in women. They include Flomax (tamsulosin), Minipress (prazosin), Hytrin (terazosin), and Cardura (doxazosin). Intraoperative floppy iris syndrome (IFIS) is a known side effect of Flomax usage and may also be associated with other alpha blockers that I have listed. These medications affect alpha receptors on the iris dilator muscle and can also cause it to atrophy. As a result, the pupil may not dilate well for cataract surgery and may lose its dilation or even prolapse towards the incision.

Patients may have dilation problems during cataract surgery, even when alpha blockers are stopped. Therefore, we recommend that they be continued. However, I let patients know that the surgeon may need to utilize pupil expanders or other instruments to maintain a good view and safely perform surgery. I also inform them that MIGS may not be possible during cataract surgery. If the iris prolapses, there may not be an adequate view of the angle to implant a stent or perform a canaloplasty. Pre-op education helps these patients have reasonable expectations of cataract surgery.

LASER VISION CORRECTION

• Antidepressants, Antipsychotics, and Antianxiety medications:

Most of these drugs have anti-cholinergic properties that work against the parasympathetic nervous system. This network of nerves normally controls our body’s response during times of rest. When we feel safe and relaxed, our body moves into a “rest and digest” mode. Salivation for digesting food increases, as does lacrimation to lubricate our eyes. However, anti-cholinergic medications can decrease lacrimation and cause dry eye symptoms. This is especially important after laser vision correction because all patients are prone to more dryness as their eyes heal. For some, dryness persists for several months and can become chronic. I don’t recommend discontinuing these medications because they are necessary for maintaining mental health. However, consistent dry eye treatment should be planned and continued.

• Accutane:

Laser vision correction patients may be taking Accutane (isotretinoin), an oral treatment for severe nodular (cystic) acne that decreases oil production in facial glands. However, it does the same for the Meibomian glands, which significantly impacts tear film. This can lead to severe dryness, blepharitis, poor wound

healing, or ulceration after surgery. Patients are advised to postpone laser vision correction until Accutane has been discontinued for six months and not restart until six months after surgery.

CONCLUSION

While there is no comprehensive list of medications that impact ocular health and surgery outcomes, those we’ve discussed are most commonly encountered during evaluations for cataract surgery and laser vision correction. Most of the time, they do not need to be discontinued or adjusted before surgery, but educating patients about possible side effects and post-op expectations can help provide a positive surgery experience.