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What happens after cataract surgery?

June, 2022

Cataract surgery has evolved to become a day case surgery, ensuring same day discharge back home.

Cataract surgery involves the removal of a clouded lens, with the replacement artificial lens being implanted. This is not an absolute as on occasions the cataract may be removed without implanting an artificial lens. The aim is always to improve the vision and improve the quality of life of our patients.

In this article, Gurjeet Jutley explains what happens after cataract surgery and what the post-operative management entails.

After the surgery

After your surgery, your vision should begin to improve. This will usually happen within a few days. It is important to bear in mind that the improvement is not immediate and may take some to time to see appreciable change. Healing is variable and as such an exact timeframe for improvement can never be given.

To note the full impact of surgery, it may take some weeks. It’s normal to feel some mild discomfort and itching after surgery, considering that metallic objects were placed inside the eye, the healing time being so short is rather remarkable. This discomfort should ease within a few days. If it continues for any length of time, seeking medical help is important.

Normally, patients are discharged with a patch or a clear shield to discourage you from rubbing it. Eye drops are imperative to reduce the risk of inflammation and infection, hence it is critical that these are used exactly as directed. Pressure reducing drops or tablets may be administered at the same time.

A follow up is usually arranged with the same team for optimal safety, within a few weeks from surgery. Until then, swimming and heavy lifting should be discontinued. Activities such as reading or watching TV may be challenging, but not harmful. A pair of readers over the counter may be sensible, until a full refraction is undertaken after the second eye has been operated on.

Complete healing from cataract surgery should take place within eight weeks. Some people may recover quicker, others may take slightly longer.

Activity after surgery

Any medical procedure will have an impact on your energy levels for a few days and you may feel more tired so resting is usually a good idea.

Initially, you may have some trouble judging distances which could impact your spatial awareness. While it’s possible to begin driving again after around 24 hours, it can be prudent to wait for a few days. Shortly after surgery, you should also take extra care going up and downstairs and pouring hot liquids.

Activities such as running or cycling should be avoided for a couple of weeks while your eyesight has a chance to adjust. Equally, you should avoid other strenuous activities such as weightlifting or aerobic exercise. Swimming, hot tubs, gardening and dusting should also be avoided for 1 to 2 weeks.

If you have cataracts in both eyes, your second surgery will be scheduled after careful assessment that the first eye has settled.

When to contact for help

After surgery, you will be assessed regularly to monitor recovery. You should contact a professional immediately if you experience any of the following;

Pain that persists despite using painkillers
Swelling to your eyelid.
Vision loss.
Multiple new spots or light flashes in front of your eye.
Increased eye redness.

If you have any questions or concerns about your cataract surgery contact Dr Jutley today.

The risk factors associated with glaucoma patient falls

March, 2022

What are the risk factors associated with glaucoma patient falls?

Glaucoma impacts the visual fields of patients, so it’s perhaps unsurprising that it can increase a patient’s risk of falling. It has been described, that patients can have up to three to four times greater risk of falling, with ensuing risks of injuries.

The most significant factor associated with glaucoma patients is their decreased visual field, particularly inferiorly. This means they can be particularly vulnerable in environments with which they are unfamiliar, as well as their own home. Furthermore there is a huge economic impact on the nation as a whole, with a study in 2018 extrapolating costs from a regional Hospital to nationwide level suggesting £29 million over six years attributed to patients admitted with falls and glaucoma.

In this article, Gurjeet Jutley discusses falls/accidents in patients with glaucoma.

Decreased Visual Field

The visual field is the complete area of what one can perceive around oneself. Visual field loss occurs when an individual experiences damage to any part of their visual pathway, from the eye to the brain.

For all kinds of reasons, people can experience a reduction in their visual field. The causes are varied, and the type of visual field loss will depend on the exact part of the pathway that was damaged. Regardless of the causes of visual field loss, the most common symptoms are blurriness or a blind spot. However, in many cases, the sufferer may not be aware that they are experiencing visual field loss until it is advanced. This increases the risk of falls because the individual isn’t aware that they need to take extra precautions.

This lack of awareness, particularly in the early stages, can increase the risk of falls and accidents. Glaucoma is a disease that initially impacts your peripheral vision, and its insiduous nature ensures that can be difficult to recognise its evolution. The changes can initially be subtle, with one eye compensating for the other.

Symptoms of visual field deficit can include bumping into objects on the affected side, trouble reading, falls and trips and even car accidents. As glaucoma progresses, more of the peripheral vision will be lost and can even impact central vision. Early diagnosis and treatment of glaucoma are essential if some of the potential risks of a reduced field of vision are to be avoided. Hence, visual field testing and nerve assessment is important diagnostically and prognostically at the early stages of glaucoma.

The importance of visual field testing

As glaucoma develops, VF enables clinicians to evaluate stability versus progression of disease, with the speed of deterioration of the latter influencing the treatment merited. If the VF defect is more suggestive of a neurological cause, neuro-imaging such as a MRI may be necessary.

Early treatment for glaucoma reduces the risk

Glaucoma treatment aims to control the pressure in the eye, through medicine, conventional surgery or minimally invasive surgery. Early diagnosis, awareness and management is key to prevent the vicious cycle.

Top tips for better eye health this winter

January, 2022

Can the winter have an impact on one’s eyes?

As the days get shorter, can there be an effect on ocular health? In this article, Gurjeet Jutley looks at the typical eye problems associated with the winter months and offers hints and tips on how to cope.

Winter eye problems

A range of specific issues can create problems for our eyes during the winter months. These include:

● Dry eyes – central heating and being indoors can lead to our eyes becoming dry and itchy.
● Teary eyes – cold winds and low temperatures can all irritate our eyes and make us overproduce tears.
● Digital eye strain – as we spend more time indoors we can spend even more time looking at screens.
● Contact lenses in the winter – Harsh winds and cold temperature and with the lack of moisture in the air, wearing contact lenses can become uncomfortable and lead to irritation.

Ways to look after your eyes during the winter

As always, general health endeavours reap multiple rewards for all the tissues of the body.
For example:

Drink plenty of water

During the colder months, many of us drink more hot drinks. These are not always hydrating and, in some cases, can dehydrate us further, particularly in the case of caffeinated drinks. Drinking plenty of fresh water helps to keep our eyes, skin and the rest of our body adequately hydrated. This is as essential to our body’s vital functions through the winter as much as it is in the summer.

Look after your diet

We are all human and during the festive months we reach out for carbohydrate and sugar-heavy foods! While there’s nothing wrong with this in moderation it’s important to ensure you eat plenty of fresh fruit and vegetables.

Various vitamins are beneficial in maintaining good eye health:

● Vitamin A protects the cornea and it may lower the risk of cataracts and macular degeneration. Found in cheese, eggs, oily fish and yoghurts.
● Vitamin E is an important antioxidant, that helps to protect your body’s cells, including those in your eyes. Soya, corn and olive oil are great sources of Vitamin E.
● Vitamin C is required to make collagen a protein that provides structure to your eyes. Oranges, broccoli and red and green peppers can help you get enough.

As well as vitamins, Omega-3 fatty acids help to form the cells of the eyes and also contain anti-inflammatory properties.

Use a dehumidifier

Heaters and radiators can make the air in your home dry which can lead to eye irritation. To help keep your eyes moist it can be helpful to use a dehumidifier in the home. Also, reducing the radiator temperature can be helpful.

Use eye drops

Lubricating eye drops can help to protect your eyes generally. They can help reduce the drying impact of wind and cold air but are also helpful if you’re spending time in a centrally heated home or workplace. If you’re a contact lens wearer make sure that they’re suitable for lenses, particular emphasis to preservative free.

Wear your glasses

If you’re a glasses wearer the good news is that they offer excellent protection for your eyes against the impact of winter cold and drying winds. Those of us who enjoy skiing, sunglasses can give UV protection and avoid photokeratitis.

How lifestyle factors such as diet and exercise can affect people living with glaucoma

December, 2021

We are often asked by our patients if any lifestyle modifications can help manage glaucoma. This is an interesting topic and is worth exploring, as some evidence does exist that
lifestyle factors may exert an influence on eye pressure.

In this article, Gurjeet Jutley explores how lifestyle choices can impact your condition.

Food and drink

Caffeine

Large amounts of caffeine can have the effect of raising the pressure in your eyes, as well as having systemic detriment to the body as a whole. Where possible, aim to reduce caffeine intake, particularly if more than five strong cups are consumed daily.

Alcohol

Excessive alcohol drinking can damage the optic nerve, so called toxic neuropathy. We also see instantaneous optic nerve damage with methanol ingestion. Clearly, moderated alcohol consumption promotes better health all round.

Smoking

The health risks of smoking are well-documented, and while there are no specific links between smoking and glaucoma, older smokers may a higher risk of developing increased intraocular pressure (IOP) compared to non-smokers. Furthermore, smoking can directly damage the optic nerve also.

Diet

While there is no strong evidence about aspects of diet or dietary supplements that can have a positive impact on the development and management of glaucoma, omega oils have been found to be helpful for general eye health. These can be found in fish and seeds, and as well as promoting eye health, they also have a range of other benefits, such as lowering cholesterol.

Gingko Biloba extract has been shown to have neuro-protective effects, improving perfusion and general well-being to the optic nerve. It is always advusable to seek help from a GP prior to starting any treatment, to ensure there is no interaction with existing medication.

Exercise

Excerise is crucial for all aspects of life, however one should be cautious with an existing diagnosis of diagnosis. For example, whilst yoga is generally safe, any positions requiring the head being lower than the heart can increase eye pressure so should therefore be avoided, such as the downward dog.

Other activities that can potentially transiently increase eye pressure include lifting heavy weights, using swimming goggles, and even playing wind instruments.

Does Cataract Surgery Last a Lifetime?

August, 2021

Cataracts occur when the natural lens in the eye becomes cloudy. This can cause gradual visual disturbance, affecting colour perception, night driving and quality of life.

Although it most commonly occurs after the age of 40, it can also be caused by a variety of factors. This includes infections, nutrition, eye trauma, smoking and diseases such as diabetes.

Commonly asked is how cataract surgery is carried out and will it last a lifetime? In this article, Gurjeet Jutley, Cataract Surgeon Oxford, explores the subject in more detail.

What is cataract surgery?

The nursing team assess each patient carefully, ensuring the full pupil dilation with drops. Within the operating room, the surgical team numb the eye before proceeding to make 2.4mm incisions that self-seal upon conclusion of the surgery. The cataract is ‘hoovered’ out before an acrylic lens is inserted to replace the previous one. Recovery usually takes 2-6 weeks and a protective eye shield is likely to be required at night.

If both eyes need treatment, surgery is usually undertaken weeks apart, although in some circumstances bilateral surgery may be considered. The new clear lens implants for cataracts are permanent and should last a lifetime. However, other condition affecting your eyes, such as diabetes or glaucoma, may mean limited vision irrespective of successful cataract surgery.

Risks and complications of cataract surgery

As with any other surgical procedure, risks of complications exist, varying depending on the eye and the type of cataract. Assuming that surgical complications are avoided, what is the natural lifespan and course of the lens. Well, approximately 20% of patients develop a posterior capsule opacification (PCO). This is a type of ‘scar tissue’ forming behind your lens implant. It’s caused when residual cells from the natural lens grow and migrate behind the lens and become sight impairing. Sight can often become blurred and cloudy, and you may experience issues with bright lights and glare.
Hence, affectively the impact of PCO can be fairly similar to the changes experienced when cataracts first came on, i.e. the ‘after-cataract’. Clearly, PCO can affect both eyes following bilateral surgery. This is not however absolute and the time gap between both eyes being affected may be large.
Certain factors may predict progression of PCO, such as: younger age at cataract surgery, inflammation and pre-existing ophthalmic conditions. However, it can occur in the setting of no other morbidities.
Fortunately, it is managed in an outpatient setting with treatment that is non-invasive and extremely effective.

Summary

The lens implant is inert and lasts a lifetime. Clouding of the capsule can occur in up to twenty percent of patients and is treatable in the outpatient setting.

Consultant Ophthalmologist, Gurjeet Jutley explains the treatment of posterior capsular opacification.

What is Telemedicine and Can it Help with Glaucoma Management

July, 2021

Telemedicine has evolved rapidly as a result of the pandemic and can be innovative way of delivering health care to select groups of patients from a distance virtually. Technology can be utilised for the benefit of patients, ensuring safety and regulations are upheld.

Healthcare professionals can aid each other for advice and opinions worldwide, particularly enabling global teaching webinars to disseminate ideas and experiences.

Hence, telemedicine a rapidly growing field that offers a multitude of potential benefits to patients and medical professionals alike. In this article, Gurjeet Jutley, Glaucoma Surgeon Oxford and team, discuss how telemedicine can benefit glaucoma patients.

Evolution of Telemedicine post pandemic

The pandemic has challenged ophthalmic services to maintain delivery of timely, high quality care with restrictions including upholding safe distancing and COVID-safe santisation. Telemedicine and creating virtual clinics are excellent modalities to supplement face-face care.

The concept of the virtual clinic can help to provide extra capacity for unmet demand within a subset of stable patient cohort. Proof of concept studies have revealed that patients do not always require a face-to-face interaction with a doctor at every hospital visit, with safe and effective service being delivered in a “virtual clinic”.

How does telemedicine work?

The concept of telemedicine is very straightforward, whereby a consultation or appointment with a Doctor is made over the phone or using a platform like Zoom/Teams. This of course enables real-time communication, i.e. ‘interactive medicine’.

Multiple models exist which have some evidence supporting them. For example, the ‘store and forward’ model allows doctors to share patient information with other physicians. Remote Patient Modelling is a step beyond this model where mobile medical devices are used to collect data such as intraocular pressure and then to monitor the patient status.

Of course, caution must be upheld as telemedicine can never be a complete substitute for face-to-face healthcare.

How can telemedicine benefit glaucoma management?

Currently, virtual clinics whereby technicians have accrued the dataset of pressures, vision, fields and OCT work extremely well in the low-medium risk patients. Future innovations should include:

Opinions from further afield
Remote Management of allergic symptoms
With time patients could benefit from a continuous flow of information regarding the patient’s disease status.
In other words, glaucoma care becomes easier and more efficient.

Conclusion

Telemedicine is evolving, with an acceleration post pandemic. With improving technology, it can be a dynamic way to help all patients. It can be postulated that telemedicine will continue to be a prominent model to help deliver healthcare. Of course, it will be interesting to see what new technological developments will emerge to facilitate this.

Top Tips For Travelling and Holidays When You Take Glaucoma Medications

June, 2021

Safely taking glaucoma medications whilst travelling and holidays

Of course, a break from life can ensure slackening of rituals, which should be avoided with respect to ocular medications.

We can attempt to ensure compliance to medications utilizing the following practical suggestions:

Keep Glaucoma Medication In Your Hand Luggage
Fortunately, medications are allowed to be carried on whilst flying, which is invaluable to ensure long flights are not a hindrance to instilling drops. In the current situation passengers are still required to wear face masks (unless exempt), which of course exacerbates dry eyes. Lubricant medications should be used to ensure the eyes are comfortable.Whilst glaucoma surgery is not an absolute contra-indication for flying, it would mean follow-up will be compromised. Hence it is sensible to avoid flying until a degree of stability is reached.
Ensure That You Travel With Plenty Of Glaucoma Medication
Negotiation with physicians and pharmacists is important to ensure adequate medication is available for the duration of the holiday. It is also extremely sensible to know how and where to seek ophthalmic help in the country being visited.
Set Alarms and RemindersIrrespective of whether you have been taking Glaucoma medication for weeks, months or years, it’s recommended to set alarms and reminders when travelling and going on holiday. Doing so will ensure that consistency is achieved ensuring the drops are affective during the day.
Determine Whether Your Glaucoma Medication Is Suitable For The Climate You Are Travelling To
Importantly, some medications must be refrigerated and kept at a certain temperature. Some patients carry cool boxes with them to achieve this, which is an excellent adjunct to have.
Be Mindful Of New Symptoms
Be mindful of any new symptoms and be aware of red flag symptoms requiring an assessment. These can include: nausea, intense eye pain, headaches, blurred vision, red eyes or haloes.

Gurjeet Jutley
Consultant Ophthalmic surgeon

Cataract surgery after lockdown - is it safe?

May, 2021

Unfortunately, due to restrictions owing to the pandemic, many patients have suffered poor quality of life and increasing risk of falls due to cataracts. Increased isolation from lockdown, compounded with worsening vision, can have a significant impact on the mental well-being of patients, which as clinicians we are seeing regularly. Hence, as a profession we have recognised the importance of cataract surgery services recommencing to help our patients.

Cataract surgery

Since the visual impact from cataracts is gradual, quite often an individual will not recognise the impact they can have. The natural clear crystalline lens becoming opaque, whilst gradual, ultimately requires surgical intervention.

The impact post-operatively will be improved ability to focus on objects, improved clarity of vision and significant reduction in glare.

Transition post pandemic

Considerable effort has been undertaken to ensure that us as a population transition to a safe dawn, with the vaccination programme at the epicentre of this. Safety precautions are likely to remain in place for some time and all health care professionals will continue to follow the most rigorous safety protocols during all of their treatments.

Measures to minimise transmission pre, intra and post surgery have been implemented, including:

Swabs in the pre-assessment phase
Isolation and shielding
Strict PPE
Shielding post-operatively

Full details of Covid-19 protocols will be made clear heading into the surgical period, ensuring a smoother journey and allevaiting anxiety.

This blog is contributed by Gurjeet Jutley.

Glaucoma management plans after lockdown

May, 2021

Sadly, the Covid-19 pandemic has had profound repercussions on all aspects of life. In ophthalmology for instance, glaucoma patients have suffered a lack of continuity, with many appointments being cancelled or postponed.

Due to the immense effort of specialists, the vaccine program is helping drive a recovery stage, to achieve some semblance of normality. This gives great hope to clinicians and patients alike.

The impact of Covid-19 on glaucoma treatment

Glaucoma UK have suggested what we have seen in clinical practice: sadly lengthy delays were noted for surgical procedures which have inevitably contributed to sight loss.

Furthermore, it has been seen that the number of referrals from optometry into hospitals for glaucoma was reduced by around 70% in 2020, compared to the previous year. Hence, patients were neither receiving diagnoses nor early management plans.

Whilst, doctors have used innovative approaches, including virtual assessments, it is clear clinical assessments are required.

How will glaucoma treatments be managed

Clinical prioritisation is key: effective triage and stratification will enable the medics to assess those at highest risk of sight loss first. Maximising face to face consultations, whilst respecting guidance about social distancing in waiting room is the challenge we are all working towards.

New patients?

Currently, the majority of services are triaging referrals and those with ‘red flags’ of sight loss are expidited into ‘screening clinics’. This is key in ensuring patients are managed safely to stop propogation of pathology. We are slowly transitioning to seeing new referrals into the correct components of the multi-disciplinary team, whether it be ophthalmologists or optometrists.

It is clear that the progress we are achieving is through great team work, evolving and improving in nature, under the most toughest of circumstances.

This blog is contributed by Gurjeet Jutley.

The day of surgery: Information for patients

November, 2020

Considerations pre-operative on the day of surgery

In the outpatient clinic, the discussion is made on the type of anaesthesia that is required. To be absolutely safe if general anaesthesia or sedation is required, refrain from having a meal for six hours prior to surgery. Small sips of fluid are acceptable.

It is important not to stop your systemic medications. For example, having a raised blood pressure on the day of surgery is hugely undesirable, hence medications to control this should not be stopped on the day of surgery.

Unless specified, do not stop your usual eye drops on the day of surgery

The nursing team will instil drops in the pre-operative setting. These will be broadly categorised as:

Mydriatics
- Make the pupil bigger to access the part of the eye to operate on
- The bigger the better! It aids in helping with surgery
  - Hence at least four lots of drops are instilled
- Typically the pupil dilation is required for surgeries such as cataract and posterior segment surgery
- Some mydriatics such as phenylephrine 10% may have an impact on systemic hypertension. Hence steps to avoid this can include:
  - Punctal occlusion immediately after instillation
  - Using phenylephrine 2.5%
Miotics
- Make the pupil smaller
- This may be necessary in certain glaucoma surgeries such as trabeculectomy or putting in secondary lenses

Considerations post operatively
The type of surgery that is undertaken dictates the drop regime given. General principles include:

Surgeries that are reliant on conjunctiva (such as glaucoma surgeries) will require preservative free drops. These will be minims.
– Broad categories of drops include:
- Mydriatics
  - These will make the pupil bigger
  - Hence the vision will be blurry and not overly clear
- o Antibiotics
  - Often these are stored in the fridge
- Steroids
  - To reduce the inflammation
The regime will be variable, depending on the type of surgery and surgeon choice
For example, for cataract surgery a typical regime could be:
- Antibiotic four times a day for two weeks
- Steroids four times a day for two weeks, tapering to two times a day for two weeks

Typical do’s and don’ts:

Use the clear shield on overnight for the first week or so
If there is a opaque pad, take it off when you get home unless specified conversely. Ensure the shield is used at night-time (avoiding inadvertent rubbing of the eyes)
Pre-existing eye drops should not be discontinued, unless specified
- A caveat to this is most types of glaucoma surgery, which will require stopping of pre-existing drops. This is the case for surgeries like trabeculectomy.
Avoid heavy lifting for a week or so after surgery
- Bending over is acceptable
Avoid swimming for a month or so after surgery

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