Diabetic Retinopathy

Perioperative Care for Eye Surgery

“Perioperative Care for Eye Surgery. What a person with Diabetes should know?”

Dr Subhadra Jalali , Consultant, Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases

Every minor or major eye surgery has a risk of complication that can be vision threatening and so all patients undergoing any surgery to the eye must be fully counselled and be aware of safe and effective perioperative care. Diabetic patients are however much more at risk and these high risks revolve around three major concerns

  1. Higher risk of infections
  2. Higher risk of bleeding and higher risk of loss of blood supply (called ischemic events)
  3. Higher risk of Systemic complication events
  1. Higher risk of infections: : Diabetic tissues are at risk of infection due to i. raised blood sugar which acts as a good ‘sugary’ place for all types of bugs to happily stay and multiply ii. The relatively lower blood supply in many long standing diabetic tissues does not give the self-protection against these bugs and so resistance to infection is low.(referred to as ‘low immune status’).
  2. Higher risk of bleeding (haemorrhages) and higher risk of loss of blood supply (called ischemic events): The small blood vessels in diabetic patients are often not healthy (referred as ‘microangiopathy’) and this is largely due to uncontrolled sugar and tobacco use but also to some extent not related to sugar levels/tobacco and is part of the many years of the diabetic process itself. Due to this problem, any surgery in diabetic patient can be complicated by higher bleeding events during or after surgery and also higher chance of tissue damage due to loss of blood supply to a part or whole of tissue due to closure (called occlusion) of one or more abnormal blood vessel branches. Patients with additional uncontrolled blood pressure, those who take blood thinners etc. adds to this problem. Diabetic retinopathy and glaucoma screening needs to be done before any type of eye surgery especially cataract surgery and regularly post operatively life- long to avoid blindness, because especially diabetic retinopathy is a silent killer of vision and sometimes gets ignored. Hence the final results may not be as expected or may not last very long after initial successful outcome.
  3. Higher risks of systemic complications: Due to other organ damage especially due to ‘’microangiopathy’’, a diabetic patient always is at risk of minor or major complications in other organs of the body while undergoing eye surgery. These include, but are not limited to, problems such as heart attack, brain attack (stroke), breathlessness or heart failure, bed sores, kidney failure or urinary tract infections etc.
  4. Floaters: Floaters are characterised by presence of seeing small dots/ black spots in front of the eye. These are more often seen in a well lit room. Floaters often are normal, but can sometimes indicate a more serious eye problem, such as retinal detachment, especially if they are accompanied by light flashes.

TEN GOLDEN RULES: What a person with Diabetes should be counselled to do, and should be aware of in the perioperative period, so as to avoid or minimise the above known risks of eye surgery

  1. Team Building: The team of the diabetic patient, family attendant, nurse, general or specialist physician of the patient and the eye doctor need to form a close well informed team when a diabetic patient is going in for eye surgery. Ensure that communication lines are open and clear, all phone numbers are at bedside of patient and with the attendant and the ‘team’ is fully geared up and knows their individual role clearly for the safety and best results of surgery in their patient. Just like ‘Know your customers’ (KYC), the team should fully well know and understand the whole details of the patient and not be casual or put responsibility on other members of the team!
  2. Ensure that there are no infection points, anywhere, currently in the body. These include any skin boils, infected facial pimples, nail infections, lid and lacrimal sac infections, any partly healed abscess, urinary or dental or nasal infections, sore throat etc. All infections should be thoroughly treated before going in for any eye surgery.
  3. Maintain strict hygiene including hair wash and bathing, shaving/ beard trimming, nail trimming, face wash, frequent soap and hand wash, etc on day of surgery both for the patient and the attending family member. All eye drops in the peri-operative and post operative period must be instilled in the eyes with soap washed, and dried clean hands. Do not touch the nozzle of the eye drops bottle to anything and keep it properly closed after usage so that the eye drops do not get infected. Tie the hair properly so that it does not fall onto the eyes.
  4. Do not rub or touch your eyes repeatedly with your hands. If after putting drops you need to wipe eyelids, use only sterile cotton or fresh tissue paper. After surgery, any touching/ cleaning/ wiping of eyes should be only with sterile eye pads or sterile cotton. Sterile material is available either from medical shops or can be prepared at home by daily boiling cotton balls, squeezing away the water and using these cooled down cotton swabs with clean hands.
  5. Do not put any water inside the eye immediately before or after surgery as water carries the maximum possibility of infections. For how many days after surgery water is not allowed depends on type of surgery and so discuss this with your doctor. Do not use any type of eye make-up (mascara/ kajal/ eye shadow/ eye-liner etc) on day of surgery and thereafter till cleared by your doctor.
  6. Before booking date for any planned eye surgery a diabetic must discuss ‘timing’ and duration of surgery both with the eye specialist and with his diabetic-care doctor. This is a very important aspect which many diabetic doctors and sometimes eye doctors also neglect thinking ‘it is only an eye surgery’ and later regret whenever a complication occurs which could have been prevented or at least anticipated! The blood pressure, blood sugars, heart and lung condition, kidney and urinary/prostrate condition, body electrolytes and bleeding/clotting condition all need to be evaluated before surgery. Common aspects, to be decided as a team, based on individual patient and some established guidelines include: Should blood thinners be stopped? For how long? Can Aspirin at least continue? What would be safe sugar and BP levels for the given surgery? What pain killers to avoid? How to adjust dialysis schedule and eye surgery day? What other drugs to avoid and what type of perioperative cardiac monitoring will be needed if patient has a heart problem? All these aspects should be well planned so that in perioperative period one is ready for a safe surgery.
  7. What routine medicines to take on day of surgery, night before and immediately after surgery? Most diabetic patients are on multiple drugs. In general, they should take their BP medicine on day of surgery. Usually, patients need to take all medicines for BP, Asthma, Fits (if epileptic) etc. However, whether surgery is under General anaesthesia or local anaesthesia and the type of surgery patient has to undergo, will decide answer to this question. Hence very clear information of which other medicines to take or not take on day of surgery should be counselled to patient and attendant in detail.
  8. Based on point 6, diabetic patients should always get their recent drug chart and all reports of all tests done before surgery (like ECG/ X-ray/ consultations with cardiologist etc) to the hospital along with stock of all medications patient uses daily or in emergency. Running around for this information and drugs wastes a lot of time and creates harassment for all concerned in the team. It is the responsibility of the patient and attendant to ensure this point. Even if the hospital staff or eye doctor sometime due to lack of anticipation say ‘ no need to get this’ it is wise planning to have these ready in the hospital in case needed at any point of time.
  9. Diabetic patients, while awaiting surgery can land into problems if they get dehydrated or the BP or sugar levels fall because as they may eat/drink less or be fasting on day of surgery. Most eye surgeries do not need patient to be fasting and they can continue their routine of diet etc. However, in case diet restrictions have been informed, such as patients undergoing General anaesthesia or major surgeries, the patient and attendant should be vigilant about remaining hydrated (dehydration increases chances of strokes and some infections) and preventing low BP or sugar. They should report immediately to the nurse/ OT in-charge or doctor if they feel symptoms like shivering, weakness, lethargy, sweating, dizziness, slowing of speech etc.
  10. Most important information to diabetic patients is that they should remain positive about good outcomes after surgery. Most diabetics do very well after surgery and only few get problems. The number of diabetic patients who get these types of problems is low overall, but amongst patients who get such rare problems, diabetics are a larger group. If Planning is thorough, and all the team members are on board and alert, all preparations will be in place to prevent and also handle any untoward events. These will ensure in most cases gratifying outcomes and great surgical experience. Most of the concepts presented here are also applicable to many other surgical scenarios and even for non-diabetics.