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Much of the ophthalmic surgical population is elderly and frail. Guidelines on perioperative care of elderly patients should be followed.^1,21

Services should be streamlined to make preoperative assessment, surgery and postoperative care as simple and effective as possible. Travel and repeated hospital attendance may be especially difficult for these patients.^1,21

Special care should be taken to assess social circumstances when discharging elderly patients into the care of an equally frail and elderly spouse. Home support from family or social services may be required; for instance, to ensure that postoperative eye drops are administered in an appropriate and timely fashion. These needs should be identified at preoperative assessment and support arranged...

Older patients should be assessed for risk of postoperative cognitive dysfunction and preoperative interventions undertaken to reduce the incidence, severity and duration. Hospitals should ensure that guidelines are available for the prevention and management of postoperative delirium and circulated preoperatively to the relevant admitting teams.³³

Postoperative cognitive dysfunction is a particular concern and can disrupt otherwise stable home circumstances. The risk should be reduced as far as possible by minimising interventions and using local anaesthesia alone when feasible.^1,21

Patients deemed to be lacking in capacity should have a best interest meeting involving relevant stakeholders prior to booking a date for surgery. Such patients often represent high risk for both surgery and anaesthesia, and careful consideration of the risks should be considered. Conclusions should be clearly documented in the medical records.^21,34

Patients with severely restricted mobility pose additional problems when attempting to position for surgery.³²Time should be spent preoperatively with these patients explaining the surgical requirements and assessing the patients’ ability to lie flat before a final decision to operate is taken. For patients unable to lie flat, a multidisciplinary discussion is recommended to consider alternative options for positioning...

Additional resources may be necessary at the time of surgery, and may include additional personnel, hoists, or extra time allocation on the operating list.

Complex ophthalmic surgical cases often require specialised anaesthetic input. This may include patients having repeated ophthalmic procedures, long and difficult cases, and those potentially requiring specialist intravenous drug therapy, such as intravenous steroids, acetazolamide or mannitol. An anaesthetist of appropriate experience should have dedicated responsibility for operating lists containing such complex cases.

Patients requiring anaesthesia who are systemically unwell should be optimised as far as reasonably practicable beforehand.³⁵It is extremely rare for ophthalmic surgery to be so urgent that remedial measures cannot be taken. Arrangements for appropriate perioperative medical care should be made, with specialist input from other services as required.