What medications need to be flagged on a pre-operative medication review?

Key medications to flag before eye surgery: (1) Anticoagulants (aspirin, clopidogrel/Plavix, warfarin, newer anticoagulants like rivaroxaban) -- affect bleeding risk and may need to be temporarily stopped per the surgeon's and prescribing physician's guidance. (2) Tamsulosin (Flomax) and other alpha-1A blockers -- cause intraoperative floppy iris syndrome (IFIS) in cataract surgery. (3) Sildenafil (Viagra) and similar agents -- interact with certain intraocular agents. (4) Topical steroid drops that might mask a corneal infection post-operatively.

Why is a 'time out' required before ophthalmic surgery?

A time out is a standardized safety pause performed immediately before starting a surgical procedure in which the surgical team verbally confirms: patient identity (name and date of birth), the specific procedure to be performed, and the correct anatomical site (right or left eye). Wrong-site surgery (operating on the incorrect eye) is a sentinel event -- rare but preventable. The time out is required by Joint Commission standards and most surgical accreditation bodies and must not be skipped, even for brief or routine procedures.

What written information must be included in post-operative discharge instructions for cataract surgery?

Comprehensive post-cataract discharge instructions include: (1) The name, frequency, dose, and duration of each prescribed eye drop, ideally in a written schedule chart. (2) Activity restrictions (no swimming, no heavy lifting, no rubbing the eye) and their duration. (3) Hygiene guidance (how to wash the face, whether showering is permitted). (4) Expected normal symptoms (mild redness, gritty sensation, sensitivity to light). (5) Urgent warning signs requiring same-day contact (sudden severe pain, rapid vision loss, increasing redness, hypopyon). (6) Follow-up appointment dates.

What should the CPOA do if a post-op patient calls complaining of increasing eye pain and decreasing vision?

Increasing pain and decreasing vision after eye surgery -- especially cataract surgery -- are red flag symptoms that may indicate endophthalmitis (intraocular infection) or another serious complication. The CPOA should take this call seriously, avoid reassuring the patient that 'this is probably normal,' and immediately communicate the complaint to the supervising doctor for triage. Most practices have protocols requiring the patient to come in the same day for urgent evaluation. Do not schedule a routine follow-up appointment for these symptoms.

Why should a post-op drop schedule be provided in writing?

Post-cataract surgery patients typically take 3-4 different eye drops on staggered schedules (e.g., antibiotic 4x/day, steroid 4x/day tapering over weeks, NSAID 3x/day) for weeks after surgery. This is complex and difficult to remember verbally, especially for older patients who may be managing multiple systemic medications simultaneously. A written schedule chart with drug names, frequency, time of day, duration, and which eye significantly reduces medication errors, improving surgical outcomes and reducing preventable complications.

Pre-Op and Post-Op Care for the CPOA Exam

The CPOA's Role in Surgical Care

Eye care practices performing surgical and laser procedures depend on the CPOA to prepare patients thoroughly before procedures and to support their recovery afterward. Thorough pre-operative preparation reduces complications, and clear post-operative communication improves outcomes and reduces avoidable return visits for manageable concerns.

Pre-Operative Preparation

Pre-Op Checklist

Before any surgical or laser procedure, the CPOA typically ensures the following are complete:

Measurements and diagnostics: Biometry, corneal topography, specular microscopy (as applicable) are in the chart and verified for accuracy.
Consent: Signed informed consent for the specific procedure is in the chart.
Medical clearance: Any required medical evaluation (cardiac clearance, blood work) is completed and documented.
Medication review: Current medication list is reviewed and flagged for the surgeon. Particular attention to: anticoagulants (aspirin, warfarin, clopidogrel), alpha-blockers (tamsulosin -- floppy iris risk), and any drugs that affect healing or anesthesia.
Allergies documented: Drug allergies are listed in the chart, especially sulfa (affects CAIs), penicillin, anesthetics, and iodine.
Pre-operative drop protocol: Correct pre-op drops administered and time documented (antibiotic, NSAID, mydriatics, anesthetic).
Fasting instructions (if general anesthesia is used): Typically nothing by mouth for 6-8 hours. For topical anesthesia only, fasting is generally not required.

💡 Clinical Tip: A standardized pre-op checklist reduces the risk of a preventable surgical complication from missed information. Use the checklist systematically for every surgical patient, even familiar patients -- familiarity can lead to complacency and errors.

Pre-Op Patient Communication

Explain what will happen during the procedure at a level appropriate for the patient's understanding.
Confirm the patient has arranged a ride home -- all patients receiving sedation or topical anesthesia with sedation cannot drive.
Confirm the patient knows what to do if they have a question or concern before the procedure day.

Intraoperative Support

Confirm patient identity and procedure site (right vs. left eye) before the procedure begins -- a critical safety step required by most accrediting bodies.
Confirm the correct IOL (model, power, and laterality) is available before starting a cataract procedure.
Provide reassurance and communication during the procedure to keep the patient calm and cooperative.

⚠️ Common Mistake: Failing to perform a formal patient and procedure-site verification. Wrong-site surgery (operating on the wrong eye) is a sentinel event. The "time out" -- a moment before starting the procedure when the team confirms patient name, procedure, and eye -- is mandatory and must not be skipped under any circumstances.

Post-Operative Care

Immediate Post-Op

Apply any ordered post-op drops (antibiotic, steroid, NSAID) while the patient is in the recovery area.
Check vital signs if anesthesia was used.
Apply a patch or shield if ordered.
Confirm the patient is alert and comfortable before discharge.

Discharge Instructions

All post-op patients receive written discharge instructions that include:

Drop schedule: Name of each drop, how many drops, how often, how long, and in which eye. Provide a written schedule chart if the patient takes multiple drops on different frequencies.
Activity restrictions: No swimming, no heavy lifting (raises IOP), no rubbing the eye, no bending over forcefully. Duration varies by procedure (typically 2-4 weeks).
Hygiene instructions: How to wash around the eye, whether showering is permitted, and whether make-up can be worn.
Expected symptoms: What is normal (mild redness, some grittiness, sensitivity to light, mild discharge, floaters after injection).
Warning signs: When to contact the office urgently (severe pain, sudden vision loss, worsening redness, discharge that increases rather than decreases).
Follow-up appointments: Day 1, week 1, and month 1 post-cataract surgery. Specific schedules for other procedures as ordered.

Post-Op Follow-Up Coordination

Schedule all required follow-up appointments before the patient leaves.
Verify the patient can reach the office by phone if they have post-op concerns.
Call the patient the following business day if clinic policy requires a post-op check-in call.

Key Takeaways

Pre-op: verify measurements in chart, confirm consent, review medications (flag anticoagulants and tamsulosin), administer pre-op drops, confirm ride home.
Intraoperative: verify patient identity and correct eye (time out) before starting; confirm correct IOL is available for cataract procedures.
Post-op: administer ordered drops, provide written discharge instructions (drop schedule, activity restrictions, warning signs), schedule all follow-up appointments.
A written drop schedule is essential -- verbal-only instructions are insufficient for multi-drop post-surgical regimens.
The time-out (patient and site verification before the procedure) is mandatory -- never skip it.