Perioperative and Postoperative Care; Urgent/Emergent Triage
Perioperative and triage items test recognition of the sight-threatening postoperative complication and the correct emergency action.
Postoperative red flags
Endophthalmitis presents within days of cataract surgery with pain, decreased vision, hypopyon, and no red reflex - obtain a vitreous tap and inject intravitreal antibiotics (vancomycin plus ceftazidime), with vitrectomy for severe cases. Cystoid macular edema appears weeks later with reduced acuity and macular thickening. Retinal detachment, IOL dislocation, corneal edema, and wound leak each have distinct findings. After refractive surgery, diffuse lamellar keratitis causes interface haze and requires flap lift and irrigation; ectasia presents with progressive astigmatism and topography change.
Triage principles
Chemical burns need immediate irrigation for 15 to 30 minutes and pH verification before anything else. Open globe: shield, no pressure, no drops, keep NPO, and arrange urgent surgery. Acute angle closure, giant cell arteritis, orbital cellulitis, and macula-on retinal detachment are same-day emergencies. "Worst headache of life" needs urgent neuroimaging. Sudden painless vision loss with a cherry-red spot is CRAO, where treatment is limited but stroke workup is essential.
Worked example
Three days after uncomplicated cataract surgery, a patient reports severe pain and acuity of 20/200 with a 20 percent hypopyon and no red reflex. Reasoning: acute endophthalmitis. Call the surgeon or retina service immediately; do not prescribe drops and review in a week. Definitive management is intravitreal antibiotics after tap, with vitrectomy if vision is very poor.
Traps
Reassuring a postoperative patient with pain; irrigating a chemical burn for only a minute; applying pressure to a suspected open globe; and delaying referral for a macula-on detachment.