POLSKI
INTRODUCTION
The approach to cataract surgery procedures in Poland has undergone significant changes within the last several years. In the year prior to the COVID-19 pandemic (2018), about one million Poles were eligible for cataract surgery, leading to an approximate two-year waiting time for the procedure. In 2019, with the removal of limits on cataract surgeries financed by the National Health Fund (NFZ), the waiting time was reduced to about five months. In the first year of the COVID-19 pandemic (2020), the number of cataract surgeries decreased by 34% compared to 2019, with 355,000 procedures in 2019 and 250,000 in 2020. The pandemic has had no effect on the cataract surgery mode, which remains in compliance with European standards: 98-99% of cataract surgeries are now performed as day cases (average calculated for 2020-2022, Poland).
The Polish Society of Ophthalmology allows the operator and patient to decide whether to perform cataract surgery on one or both eyes simultaneously. Binocular surgery is especially relevant for patients requiring general anesthesia, such as those with intellectual disabilities. It is important to note that surgery on the second eye is treated as a separate operation, ensuring full sterility for both procedures.
ELIGIBILITY ASSESSMENT
When assessing patient eligibility for cataract surgery, it is essential to consider concomitant systemic and ophthalmic disorders due to their potential impact on the risk of intra- and postoperative complications. Performing surgery is ruled out in patients with active systemic and local infections. Patients with blood pressure exceeding 180/110 mm Hg are ineligible for the procedure. Before surgery under local anesthesia (other than drip anesthesia), especially periocular or extraocular, or when additional intraoperative manipulations are anticipated (e.g. removal of posterior synechiae, iridoplasty, mechanical mydriasis), modification of the patient’s anticoagulant treatment should be considered [1]. Patients undergoing immunosuppressive treatment (including chemotherapy and biologic treatment) should continue their therapy without modifications. Other chronic systemic medications should also be maintained. Ophthalmic conditions that should be treated before cataract surgery include abnormal eyelid positioning (especially when entropion causes the eyelashes to erode the cornea), flare-ups of chronic blepharitis, infectious conjunctivitis, keratitis, uveitis, and dacryocystitis. Preoperative normalization of intraocular pressure is crucial, especially for patients with glaucoma. Alternatively, combining cataract surgery with antiglaucoma surgery may be considered. Special attention should be given to patients with chronic or recurrent uveitis, with surgery recommended only after a 3-month period of disease inactivity. For these patients, preoperative oral glucocorticosteroid administration or intraoperative intravitreal injection should be considered [2].
Another group requiring special attention comprises patients with wet age-related macular degeneration (wAMD). Based on current knowledge, cataract surgery is recommended for all patients with wAMD, regardless of preoperative central retinal thickness, if the cataract is likely to impair visual acuity [3]. Furthermore, delaying surgery in these patients results in an avoidable decline in their quality of life [4]. The main controversy revolves around determining the optimal timing for surgery during wAMD treatment. According to expert consensus, patients with lens opacity that obscures the fundus should undergo surgery as soon as possible. Patients with stable subretinal fluid levels can proceed with surgery without prior preparation [5]. Some studies have suggested that a six-month course of anti-VEGF therapy before cataract surgery offers advantages [6]. The optimal effect is achieved if the injection is administered within one month before cataract surgery [7]. However, some reports indicate an increase in central retinal thickness and subretinal fluid levels three months post-cataract surgery. The hypothesized mechanism involves a specific predisposition to developing Irvin-Gass syndrome. Administering topical NSAIDs for at least three weeks post-surgery has been shown to mitigate this issue. Despite an objective decline in OCT parameters, cataract surgery did not lead to an increase in the number of postoperative anti-VEGF injections or negatively affect final visual acuity in this group of patients when compared to the control group. Also, there is no evidence that intraoperative administration of anti-VEGF agents is more effective. Given the known risks of blue light phototoxicity, considering an intraocular lens with a blue light filter is advisable. However, EBM does not indicate any advantage for these lenses in AMD patients [8]. Notably, the improvement in visual acuity after cataract surgery in patients with wAMD typically ranges within 2 Snellen lines (7-9 ETDRS letters) [7].
A distinct group comprises children with cataract, where a strong focus should be placed on accurate diagnosis and identifying the underlying cause of the condition.
PRE-CATARACT SURGERY CARE
In patients with preexisting clinically significant blepharitis and associated dry eye syndrome, eyelid margin hygiene and tear film stabilization should be considered before calculating lens power for precise implant selection [9]. Preoperative administration of a nonsteroidal anti-inflammatory drug (NSAID) for two days prior to surgery is recommended as it has been proven to aid in achieving stable intraoperative mydriasis. Conflicting reports exist regarding the use of a topical antibiotic before the day of procedure. Some authors advocate using a fluoroquinolone two days prior to surgery to reduce the risk of endophthalmitis. However, there is insufficient scientific evidence in line with evidence-based medicine (EBM) to support this routine practice. However, starting prophylaxis with topical fluoroquinolone one day before surgery and continuing it on the day of the procedure is recommended in infants and young children.
INTRAOPERATIVE CARE
On the day of surgery, it is advisable to use NSAIDs and mydriatics (tropicamide, phenylephrine, cyclopentolate) in drop form prior to the procedure. As an alternative to mydriatics in drops, intraoperative administration of 0.2 ml of a sterile, ready-made preparation containing 2 mg of lidocaine, 0.04 mg of tropicamide, and 0.62 mg of phenylephrine or adrenaline solution into the anterior chamber should be considered. The administration of mydriatics via intravitreal injection is believed to mitigate the adverse effects of surgery on the ocular surface.
Preventive measures for postoperative endophthalmitis include:
preoperative disinfection of the skin of the eyelids and eye area with 10% povidone-iodine solution for 2-3 minutes, or 0.1-0.5% chlorhexidine solution in patients with hypersensitivity to povidone-iodine [10, 11];
preoperative disinfection of the conjunctival sac with 5% povidone-iodine solution for at least 3 minutes, or 0.02-0.1% chlorhexidine solution in patients with hypersensitivity to povidone-iodine [12];
intraoperative administration of a sterile ready-to-use antibiotic preparation into the anterior chamber (cefuroxime 1 mg/0.1 ml is the medication of choice, but 0.5 mg/0.1 ml moxifloxacin or 1 mg/0.1 ml vancomycin can be used in the rare cases of immediate hypersensitivity to β-lactams) [12, 13].
It is important to note that povidone-iodine is statistically more effective in preventing postoperative endophthalmitis than chlorhexidine. Literature indicates an increased risk of endophthalmitis when aseptic conditions with povidone-iodine and cefuroxime are not maintained in the anterior chamber.
POSTOPERATIVE CARE
Postoperative care is focused primarily on minimizing the most common complications that could lead to permanent vision loss, such as endophthalmitis and postoperative macular edema.
Postoperative care includes the administration of:
a fluoroquinolone antibiotic for 7 days, with levofloxacin being the preferred active substance [14];
a nonsteroidal anti-inflammatory drug with a high potential for penetrating the posterior segment of the eye, administered for 4-6 weeks after surgery to prevent Irvine-Gass syndrome [16-19];
a glucocorticosteroid for 2-4 weeks post-surgery (preferably loteprednol, which has a low potential to induce elevated intraocular pressure, or dexamethasone) [20];
moisturizing and regenerating preparations for the ocular surface, particularly for patients with preexisting ocular surface disease (e.g. preoperatively diagnosed dry eye syndrome, recurrent corneal erosion syndrome). It is important to note that antibiotic, corticosteroid and NSAID preparations administered as part of standard surgical procedure can induce or exacerbate symptoms of dry eye syndrome. In such cases, it is advisable to recommend preservative-free moisturizing eye drops [21].
The recommended minimum interval between drops administered into the conjunctival sac is 3-5 minutes.
It is essential to recognize that a major challenge in postoperative care is patient compliance. Studies reveal that over 75% of patients do not consistently wash their hands before administering drops, and more than 40% fail to reach the conjunctival sac [22]. On the day of discharge, patients should be informed about the correct technique for applying drops to the conjunctival sac and the transient ophthalmological symptoms that may occur after cataract surgery, such as burning sensation, dryness, a gritty feeling under the eyelids, and tearing.
Reports suggest that dropless cataract surgery (performed without prescribing drugs to be administered to the conjunctival sac postoperatively but instead using intraoperative drug injections or drug-releasing implants) may be a viable option for some patients. However, the current lack of available preparations in Poland and the cost-effectiveness aspect of the procedure prevent its widespread standard application [23].
Another important consideration is reducing physical activity after cataract surgery. The main restrictions include avoiding swimming (especially in swimming pools) for 4-6 weeks post-surgery, and refraining from heavy lifting during the initial weeks after the procedure.
