Pre-operative Care
Chat Highlights
January 21, 2004

Norma Devine, Editor

On Wednesday, January 21, 2004, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pre-operative Care."

Moderator:  The topic tonight is pre-operative care.  Dr. Wilson, what should patients be aware of before they have surgery?

Dr. Rick Wilson:  Be aware of medicines that can cause enough bleeding to imperil the surgical results. These include blood thinners such as aspirin, and nonsteroidal anti-inflammatory medicines (NSAIDS) like Motrin, Plavix, Coumadin, warfarin, vitamin E, etc.  These medicines should be discussed with your surgeon to see if he or she feels that the medicines should be discontinued and how far ahead of time.  Then, the medicines need to be discussed with your medical doctor to see what the risk of stopping their use for a week and a couple days would be, to balance the different risks.  All of them lose most of their effect in five to seven days.  The problem is that they often are prescribed for a definite reason, and the medical doctor may feel it is too much of a risk of heart attack or stroke to be off the medicines for long.

P:  You mentioned vitamin E as a supplement that should be stopped before surgery.  What other supplements should be discontinued? How would a patient check on this if the doctor isn't very familiar with supplements?

Dr. Rick Wilson:  Sometimes I stop all vitamins, since they encourage healing.  But most times I don't, since the effect may not be that strong.

P:  I read that vitamin C is good before surgery, because it protects against infections.

Dr. Rick Wilson:  I don't think the effect is sufficiently proven to advocate for or against vitamin C preoperatively.

P:  Do you agree that (1) using topical ophthalmic NSAIDs for three days before cataract surgery decreases the amount of patients’ postoperative inflammation, and (2) continuing to use steroids postoperatively reduces the duration of the inflammation?

Dr. Rick Wilson:  Yes.

P:  Are most patients instructed to use certain eye drops before surgery?   

Dr. Rick Wilson:  Although we are probably just "treating" the lawyers, many doctors, including myself, start antibiotic eye drops a day or two ahead of surgery.

P:  Are there restrictions about eating and drinking before surgery?

Dr. Rick Wilson:  Usually, anestheologists do not want a patient  who is getting sedated to eat or drink after midnight.  If the surgery is in the afternoon, they may allow clear liquids for breakfast, but usually not.

Moderator:  Do you ever need to contact another specialist about stopping medications?  

Dr. Rick Wilson:  Because of the risk involved, I talk to cardiologists and internists all the time to resolve the risk-benefit ratio of stopping blood thinners pre-operatively.

P:  If it's too risky to stop heart medications, what can be done for the person's eye?

Dr. Rick Wilson:  Sometimes a laser procedure, even though it will be more dangerous or not be as effective.  Sometimes just removing a cataract, which doesn't require stopping blood thinners, will help.  Sometimes we are just plain stuck, because the patient's health problems hamper our ability to operate on them safely.

P:  When a patient who is using an oral medication, such as Neptazane to lower IOP (intraocular pressure), is taken off the medication before surgery so the IOP in the eye undergoing surgery doesn't get too low, how is the IOP controlled in the other eye?  

Dr. Rick Wilson:  If possible, with extra medicine. Otherwise, the other eye will need surgery shortly.  Topical carbonic anhydrase inhibitors like Trusopt and Azopt can do almost everything that Neptazane can, but in drop form.  It is hoped that stopping the Neptazane may not cause much of an IOP spike.

P:  My daughter is already on every eye drop that she can be on: Cosopt, Alphagan, Xalatan, pred forte and Lotomax. 

Dr. Rick Wilson:  Then the Cosopt should be covering about 90% of the effect of the Neptazane.

P:  Three days before my daughter's first eye surgery, she was put on gentamicin. 

P:  What is gentamicin?

Dr. Rick Wilson:  Gentamicin is an antibiotic.  The chances of having an infection during glaucoma surgery is rare, perhaps 1 in 1,500 to 1,800. 

P:  Her sister, my youngest child, is on a strong antibiotic (Leviquin) after the removal of her eye.  In the hospital, she received three different kinds of antibiotics intravenously.  It wasn't even determined whether or not she had an infection. 

Dr. Rick Wilson:  When a foreign body like the implant is used to replace the bulk of the eye, we always use serious antibiotics to prevent infection from the foreign body. 

Moderator:  Because infection is rare, do you NOT use antibiotics before the surgery? 

Dr. Rick Wilson:  For the first 15 years of practice, I didn't use preoperative antibiotics and never had an infection with a trabeculectomy.  As I said earlier, I am now probably "treating" the lawyers, rather than the patients, with the antibiotics.  

P:  If the intraocular pressure is too high before a trabeculectomy, what can be done to reduce the pressure?  

Dr. Rick Wilson:  The higher a pressure is preoperatively, the harder it is for the eye to adjust to the drop in IOP.  If the IOP is high preoperatively, we give mannitol to lower the IOP before entering the eye, or use a tiny needle to drain some of the fluid at the very start of the procedure to allow the eye to adjust.

P:  I was traveling for the last six weeks and my trabeculectomy is scheduled for February 3.  I do not have a scheduled appointment with my doctor before the day of the surgery.  I have instructions, but isn't it also important to have a check-up just before surgery? 

Dr. Rick Wilson:  That's probably not necessary if you have a long-standing problem.

P:  Thank you.  Mine is a long-standing problem and I already have instructions.   

P:  Before I went into the operating room, I was asked the same questions by each person I saw in the doctor's office.  I was repeatedly asked whether I had anything to eat that morning, what meds I had taken, etc.  It seemed so repetitive.  Is there a particular reason for that?

Dr. Rick Wilson:  Yes, to ensure that at least one person asks important questions and nothing is missed.

P:  I am having laser cyclophotocoagulation on Friday.  Are there any pre-op instructions?  Should I call my doctor?  I am very nervous.  

Dr. Rick Wilson:  If the laser cyclophotocoagulation is not accompanied by any cutting, there is really no pre-operative preparation.

P:  I was so scared that the doc would not know which was the correct eye to be operated on that he good-naturedly marked an X over the eye to be operated on.  That calmed me right down.

Moderator:  Dr. Wilson, do you mark the eye with an X?

Dr. Rick Wilson:  An X is mandatory in most operating rooms now.  

P:  My eight-year-old daughter will have her first eye surgery tomorrow.  Her intraocular pressure has been about 25 to 36 mm Hg for a year now.  She has JRA (juvenile rheumatoid arthritis).  What are the chances that the surgery will reduce the IOP and that she won't suffer complications from the procedure?

Dr. Rick Wilson:  What type of surgery is she having?

P:  She is having a goniotomy.     

Dr. Rick Wilson:  A goniotomy has a lower chance of success, but little risk of complications.

P:  What percentage of kids having a goniotomy will get good pressure relief?

Dr. Rick Wilson:  It is not the procedure I usually use for inflammatory glaucoma, so I can't give you odds. 

P:  What is a goniotomy?

Dr. Rick Wilson:  An incision is made through the outer tissue covering the Schlemm's canal in the drainage angle.  A goniotomy is performed from the inside of the eye with a needle reaching across the eye.

P:  Before surgery, should a patient continue eating the same diet and exercising as usual until the day before surgery? 

Dr. Rick Wilson:  Yes.  

Moderator:  Do you ever prescribe medication to calm nerves before surgery?  

Dr. Rick Wilson:  I leave that up to the anesthesiologists, and they have a large armamentarium.

P:  Is a local anesthetic normally used?  

Dr. Rick Wilson:  Yes, except in children and those who cannot speak a language of anyone in the operating room.  

Moderator:  If a patient is overly anxious about another operation, do you prescribe a tranquilizer? 

Dr. Rick Wilson:  Not usually.  If the patient needs a relaxant in the days or weeks leading up to the surgery, I leave that up to their internist, who knows their medical history and the medicines they are on that might interact with one used during the surgery.  

P:  Do you think some patients take tranquilizers before surgery without telling the doctor?

Dr. Rick Wilson:  Probably.  They should tell the anesthesiologists so they know the level of medicine the patients are already on and don't overdose them.

P:  My blebs are scarred over and barely working.  The IOP is too high for a damaged eye.  What would be your next consideration?  An anti-scarring agent, 5-Fluorouracil (5-FU) was injected into the eye after the last surgery, but the bleb still scarred over.   

Dr. Rick Wilson:  If the doctors didn't use mitomycin, that is the next option.  If they did, then a shunt would be my next choice.

P:  Do you agree that (1) using topical ophthalmic NSAIDs for three days before cataract surgery decreases the amount of patients’ postoperative inflammation, and (2) continuing to use steroids postoperatively reduces the duration of the inflammation?

Dr. Rick Wilson:  Yes.

P:  Thank you so much, Dr. Wilson. This chat has reassured me about the surgery I will be having. 

Dr. Rick Wilson:  It may not be nearly as bad as you are thinking it will be. 

P:  A reassuring doctor before surgery can be as relaxing as medications. 

Dr. Rick Wilson:  That's true.  

End of highlights for January 21, 2004.

On January 28, Dr. Werner discussed "Bleb Complications" in the Chat room. Click here for highlights of that meeting.

Click here for the most recent glaucoma chat highlights and links to the chat archives.

Click here for upcoming glaucoma chat events.