I am a bit of an over-achiever.

I want all my patients to have perfect outcomes, and I don’t like surprises. When I send a patient for surgery, I make a note in my referral letter as to what the patient desires from surgery, what options I have discussed, if they wear contacts, if I have been treating their ocular surface disease and anything else I feel the surgeon should know. I am not typically a yeller, but I do put important notes in bold in my referral letter to ensure they don’t get missed.

When the patient returns to my office after surgery, I have a protocol that the staff follows to ensure that nothing gets missed. If there is a problem, I like to find it quickly and work on fixing it before the patient becomes agitated. I have found the following protocol to work well the first time I see a patient after surgery.

When my technician calls my patient from the waiting room the day after surgery, I always have the technician ask how the patient is doing, and how they slept the night before. How they are, indicates how they are typically feeling overall about their surgery, and how they slept indicates how things went the day before. If there was an issue, the patient usually tells my tech about it then. For example, my surgeon of choice uses an extremely light sedation, and patients remember their surgery. While that is not typically a problem, they also remember what the OR staff were discussing during their surgery. That may be a problem if the staff forgets my surgeon uses light sedation. If anyone on the staff has a “Vegas-style” weekend and they talk about it, my patients will tell me all about it.
The following tests will be performed at this visit prior to the eye being touched or administration of drops:

Autorefraction

I like an objective assessment of residual refractive error. It is a quick method to assess their level of vision without them panicking if they are blurry. I like to compare the autorefraction to the planned target. If they paid for a toric lens, I anticipate minimal astigmatism. If they paid for a multifocal, I anticipate functional vision at distance, intermediate, and may check near. If the ocular surface is an issue, the technicians will have trouble obtaining the data, and they note this on the chart.

If available, I repeat biometry if the residual refractive error is more than 0.50D off the planned refraction. This is easily performed in the surgical setting but may not be available in nonsurgical practices. The technicians compare the autorefraction to the planned refraction on the biometer data sheet where the surgeon circles the selected intraocular lens power.

Then the patient is taken to the exam lane and the following tests are performed on every patient the day after surgery.

Case history

Is the patient happy with the visual outcome in the operative eye? Are they having any physical symptoms? They should be functionally happy and comfortable. Anything else needs to be addressed.

If this is the first eye, and second is slated for surgery, document comments on vision of the cataractous eye for insurance purposes.

Visual acuity without spectacles for the right eye left eye and binocularly. This is to determine the level of function and anisometropia is this is for the first eye. If the planned refraction was myopic for reading, the technician tests near vision as well in the same manner.

If the patient is complaining of vision, or the unaided vision is worse than 20/30, I perform a quick manifest refraction starting from the autorefraction at distance to determine the BVA.

If best-corrected vision is NOT 20/20, I ask myself “Why?” and proceed with an examination to explain it. Prior to examination of the patient, I perform a quick look back in the chart to determine what I may have noted in the visit prior to referral that might explain a vision loss. Did I discuss a toric lens and the patient elected to forgo this option leaving them with residual refractive error? If they have a history of a macular hole, a corneal scar, LASIK, or severe glaucoma, I consider how that history related to the current level of vision. If I had a limited view of the posterior segment due to the cataract, I repeat the OCT now that the cataract is removed.

Biomicroscopy is performed to assess the anterior segment looking for a problem with the corneal incision, iris, anterior chamber inflammation, and IOL position. I document the IOL status in the operative eye, and the level of cataract if applicable.

Intraocular pressure testing using Goldmann or Tonopen of both eyes. Only testing one eye gets my technicians a date with my office manager on the second event after a dirty look from me.

I rarely dilate on the first postoperative day, but if the patient reports sudden vision loss, or significant new floaters, bombs away on the trapicamide.

My goals for the postoperative day one visit are to rule out complications, reassure the patient that all is as expected, and ensure all went as planned. If it did not go as planned, I have documentation that I can send to the surgeon demonstrating the problem and initiate a plan for correction. This protocol is done on every patient so we do not miss any issues. The patients leave confident in their outcome and our commitment to their ocular health.

If this is the first eye, I take additional steps to document the cataract present and the patient’s complaint regarding that cataract. If anisometropia results from phacoemulsification of the first eye, I note this in the chief complaint and in my assessment. I also note the cataract is visually significant after the first eye surgery, that I recommend surgery, and the patient elects to proceed with surgery.

I also review our emergency protocol with each patient after surgery so they know how to reach our office if they note increased redness, pain or significantly reduced vision that fails to resolve with eyedrops. They sleep with eye shields for 7 nights and are told not to lift anything, bend so their head goes below their knees, or swim. This is when my patients report, “I do not swim” except for my patient that actually worked on hot tubs. I called his boss personally.

By performing this protocol on each post-operative patient immediately after surgery, I am able to identify any issues that might cause the patient to be upset and address them. It is reassuring to me to have the data and reassuring to the patient that all is as expected.