During the Spotlight on Cataract Surgery Symposium at the
2005 Annual Meeting, audience members anonymously responded to
speaker questions about complicated
cases and intraoperative
complications. Their candid answers follow.
This past October, the Spotlight on Cataract Surgery Symposium at
the American Academy of Ophthalmology’s Annual Meeting was entitled
New Pearls on Managing Complicated Cases and Complications.
My program co-chairman was Louis D. “Skip” Nichamin, MD, chairman of
the ASCRS cataract clinical committee. In all, 30 different speakers
addressed topics ranging from managing a descending nucleus to how
to inform patients when a complication has occurred. During the
symposium, an audience response poll was conducted. The 3,000
attendees could voice their opinions if they wished to do so by
using one of the 1,500 interactive rapid response units available
throughout the room. For each topic, two questions were posed, and
the audience used the keypads to respond. The answers were tabulated
and projected on a screen behind the speaker during his or her
talk.
The results, all of which are presented here, are
particularly interesting given the anonymous nature of this polling
method. Read on for the questions and answers, as well as a
commentary from each speaker.
Complicated Cases: 24
Questions
Managing the Abnormal Corneal
Surface
Speaker:
Edward J. Holland, MD
Q1: Your regimen for
preop cataract patients with
blepharitis:
Generally
disregard ............... 10%
Usually treat
aggressively...... 43%
Only treat worst
cases ......... 47%
Speaker
comment: As endophthalmitis is the most devastating
complication of cataract surgery and the organisms responsible for
this infection come from the ocular surface, it is surprising that
10 percent of the audience would disregard preoperative findings of
blepharitis. Aggressive treatment of blepharitis will not only
reduce the risk of endophthalmitis but also reduce some of the other
postoperative problems such as unstable tear film and ocular surface
findings that are associated with it.
Q2: Have you ever had a corneal melt with a topical NSAID
post
cataract?
Yes ........................................
12%
No, despite regular use ......... 51%
Don’t use them
regularly ....... 37%
Speaker comment:
Of interest is that 37 percent of the audience does not use
nonsteroidal anti-inflammatory drugs (NSAIDs) routinely in post
cataract surgery. Cystoid macular edema (CME) is the leading cause
of visual loss after cataract surgery. There are excellent studies
demonstrating the efficacy of topical NSAID use in preventing
CME.
Phaco in Highly Myopic
Eyes
Speaker: Robert J. Cionni,
MD
Q3: In your experience, the hyperdeep AC
during phaco:
Is not a significant problem
............................................................... 16%
Increases
the rate of PC rupture
....................................................... 13%
Makes
phaco difficult, but hasn’t increased my complication rate
...... 71%
Q4: For the hyperdeep AC, have you ever tried lifting the
iris off of the anterior capsule?
Yes ............
21%
No ............ 79%
Speaker
comment: Although most surgeons do not believe that a
hyperdeep chamber increases the risk for complications, most do feel
that it makes phaco more difficult. In addition, patients undergoing
phaco with topical anesthesia who develop a hyperdeep chamber will
experience more pain during surgery. Still, most surgeons were not
aware that simply raising the iris off of the anterior capsule will
restore the chamber to normal depth. Hopefully, more and more
surgeons will become aware of and begin to utilize this technique,
thereby making surgery easier and relieving the pain felt by these
patients.
Phaco in the Crowded Anterior
Chamber
Speaker: Samuel Masket,
MD
Q5: Your preferred viscoelastic for the
crowded AC:
Maximally cohesive .....
14%
Dispersive ................... 21%
Healon 5
..................... 35%
Duo Visc ......................
30%
Speaker comment: It is evident that a
plurality of respondents recognizes the benefit of a highly cohesive
viscoagent for space maintenance in the crowded anterior chamber.
Cohesive agents do not adhere well to ocular tissue; this helps
prevent iris prolapse during surgical maneuvers. An understanding of
the rheologic properties of the varied viscoagents is
useful.
Q6: Would you consider pars plana vitreous tap for a very
crowded AC?
Yes ..............
51%
No .............. 49%
Speaker
comment: Although roughly half of the respondents would not
consider prophylactic pars plana removal of vitreous to enhance
working space in the anterior chamber (AC), it is a valuable tool.
Although it is infrequently necessary, it is a skill that should be
acquired by most cataract surgeons.
Posterior Polar
Cataract
Speaker: Abhay R. Vasavada,
MD
Q7: Your estimate of PC defect incidence
in posterior polar cataracts:
Less than 5 percent
........ 27%
5 to 20 percent ............... 45%
20 to
50 percent ............. 19%
More than 50 percent
...... 9%
Speaker comment:
Seventy-three percent of poll respondents estimate that, in eyes
with posterior polar cataract, there is a 5 percent or greater
incidence of posterior capsular defect. This implies that it would
be desirable to postpone cataract surgery until the reduction of
vision is significant. When surgery is elected, the patient should
be informed of the possibility of intraoperative posterior capsular
rupture (PCR), dropped nucleus, prolonged operative time, secondary
posterior segment intervention and the possibility of delayed visual
recovery. This also should alert the entire surgical team to be
prepared for complicated surgery.
Q8: Your incidence of vitreous loss in posterior polar
cataracts:
Less than 1 percent ......... 34%
2
to 5 percent .................. 40%
6 to 10
percent ................ 15%
More than 10
percent ...... 11%
Speaker
comment: Because posterior polar cataracts are associated
with vitreous loss, the desirable strategy would be to adhere to the
principles of closed chamber technique and to retain an epinuclear
bowl that acts as a mechanical cushion to protect the posterior
capsule during subsequent maneuvers.
Management of Iris
Defects
Speaker: Kenneth J. Rosenthal, MD,
FACS
Q9: Have you ever suture repaired an
iris defect?
Yes ...............
71%
No ................ 29%
Q10: Number of patients in your practice who would be
candidates for artificial iris
implant:
None .................. 22%
1 to
2 ................. 55%
3 to 5 .................
16%
More than 5 .......
7%
Speaker comment: Until very recently the
repair of iris defects was a daunting task, and many patients, yet
untreated, continue to suffer from unwanted visual disturbances,
such as photophobia, glare, halos and degradation of visual quality.
With 10 years of experience in iris prosthetic implantation (three
of these in clinical trials), we have the experience and knowledge
to help this small but very visually needy patient population.
Judging from the audience response, most practices have a small
number of such patients. While iris repair will help some of these
patients, iris prostheses offer surgical solutions to those with
larger defects.
Diagnosing Zonular
Weakness
Speaker: Robert H. Osher,
MD
Q11: Number of times you’ve used a
CTR:
Never ..................... 49%
1 to
2 ..................... 18%
3 to
10 ................... 19%
More than 10 .........
14%
Speaker comment: For the half of
the surgeons who have never used a capsular tension ring (CTR), you
can be certain that eventually a case of undetected preexisting or
iatrogenic weakened zonules will be encountered. Have a CTR
available and know how to use it because it will give your patient a
better outcome.
Q12: Cases seen of delayed bag-IOL
dislocation:
None ................. 21%
1
to 2 ................ 46%
3 to
5 ............... 22%
More than
5 ....... 11%
Speaker comment:
The jury is still out on how often we will see this syndrome in
patients with pseudoexfoliation . . . my bet is very
infrequently.
Capsule Retractors vs.
CTRS
Speaker: Richard J. Mackool,
MD
Q13: Percent of your cataract population
with weak zonules:
Less than 1 percent ............
24%
2 to 3 percent ..................... 42%
4 to 7
percent ..................... 24%
More than 7
percent ........... 10%
Q14: Preferred strategy for very deficient
zonules:
Capsule retractors (the Mackool Cataract
Support System) ..... 13%
Iris retractors for
capsule ..........................................................
21%
CTR ............................................................................................
27%
Refer to someone
else ...............................................................
39%
Speaker comment: The audience poll
indicates that 25 percent of those responding to the “incidence of
zonular laxity” question did not answer the question regarding
strategy. It is personally encouraging to see that more surgeons use
retractors than CTRs; I designed the disposable capsule retractor to
be superior to the iris hook for this purpose, although it’s
slightly more difficult to insert and remove. I have found that
retractors provide far better support to the lens during phaco and
cortex removal than does a CTR, and that a CTR is best inserted just
prior to IOL insertion (with the retractors still in place).
CTR Pitfalls
Speaker:
Lisa B. Arbisser, MD
Q15: When do you insert
the larger-sized CTR?
Never have used a
CTR .......... 55%
Only in larger
eyes .................
34%
Always ....................................
11%
Speaker comment: It is a shame that it
took so long for the CTR to become FDA approved because 55 percent
of surgeons in this audience have not used one as yet. It is clear
that the CTR is a necessary part of our armamentarium, and I hope
the number [of users] will rapidly grow. The problem with sizing is
that we can’t accurately know the size of the capsular bag, as it
isn’t always proportional to the white-to-white measurement or the
axial length. This might be an argument for using the larger-sized
CTR, as overlap of the ends is not thought to be a problem. The
larger rings, however, are stiffer and more difficult to place
without zonular stress, so the balance of additional risk to benefit
needs to be considered.
Q16: Assuming you’ve used more than five CTRs, have you
ever torn the AC or PC with a CTR?
Yes ........
25%
No ........ 75%
Speaker
comment: Twenty-five percent of respondents have ruptured
the capsule with a CTR, which underscores the fact that this
technology is not entirely benign. One should develop a set of
criteria for when to use a CTR based upon the anatomy of each case.
The CTR is technically not approved to promote future stability of
the bag or lens but rather to prevent intraoperative complications
when the zonular complex requires support. It has been suggested
that the presence of a condition that may lead to zonular weakness,
like pseudoexfoliation syndrome, is indication enough. Although many
of us believe that there may be some ongoing protection, this has
not been proven and is an off-label use of the device. I therefore
choose to use the CTR when I judge there to be sufficient
intraoperative evidence of zonular laxity or dehiscence.
Subluxated Crystalline
Lens
Speaker: Ike K. Ahmed,
MD
Q17: For intact bag but large zonular
defects, I would favor:
AC
IOL .............................................................
15%
PC IOL in bag with sutured CTR or CTS ...........
42%
PC IOL in
sulcus ...............................................
43%
Speaker comment: Although most
respondents preferred either an endocapsular posterior capsule IOL
(PCIOL) with a sutured capsular tension device or a sulcus-supported
PCIOL in cases of large zonular defects, placement of a sulcus PCIOL
in the presence of significant zonulopathy risks postoperative
decentration. An anterior chamber IOL may also be appropriate in
some patients, although the use of sutured capsular tension devices
is gaining popularity in these complex zonular defect cases.
Q18: If it were FDA-approved in the United States, I
would most likely use:
Cionni
CTR ................................... 41%
Capsular tension
segment ..........
35%
Neither.......................................... 24%
Speaker
comment: When faced with profound zonulopathy, most
respondents would most likely use a Cionni-modified CTR, or a
capsular tension segment (CTS).
Intraoperative Floppy
Iris Syndrome
Speaker: David F.
Chang, MD
Q19: Percent of your Flomax
patients exhibiting IFIS:
Have never seen
IFIS .................. 20%
Less than 15
percent ................... 49%
15 to 85
percent ........................... 22%
More than 85
percent ..................... 9%
Speaker
comment: It is surprising that the respondents have not
experienced
a higher prevalence of intraoperative floppy iris
syndrome (IFIS) in Flomax patients. In my own experience, some
degree of IFIS is present in more than 95 percent of Flomax
patients. This can range from mild to severe, however, and the
wording of the question may have elicited only the severe cases of
IFIS.
Q20: Your preferred management for IFIS:
Iris
retractors ................ 46%
Pupil expansion ring
..... 5%
Healon 5 .......................
35%
Other ............................
14%
Speaker comment: Iris retractors and
Healon 5 are the most popular management techniques, which may
reflect the higher cost and longer learning curve associated with
expansion rings.
Capsular Staining: Indications
and Techniques
Speaker: Steve A. Arshinoff, MD,
FRCSC
Q21: Your preferred capsular
dye:
ICG ........................................................
13%
Vision Blue (DORC)
................................ 60%
Pharmacy-formulated
trypan blue .......... 27%
Speaker
comment: After the late approval of Vision Blue (commercial
trypan blue, DORC), surgeons have rapidly moved from the less-safe,
pharmacy-formulated sources to the FDA-approved, highly
quality-controlled formulation of Vision Blue. Indocyanine green
(which is not as safe and yields poor visibility) about which we
heard so much before Vision Blue was available in the United States,
has appropriately rapidly decreased in popularity.
Q22: Preferred dye technique:
Air
bubble ...............................................
67%
Underneath ophthalmic visco-device .......
15%
Direct
injection ........................................
18%
Speaker comment: Our collective
practices clearly demonstrate the impact of commercial promotion.
Trypan Blue is listed in the Merck Index as a potential carcinogen,
and all of us are cautious in introducing any foreign product into
the eye. Yetik et al. found successful capsular staining with as
little as 0.1 milliliters of 0.0125 percent trypan blue,¹ yet most
surgeons still use the air bubble technique. The Ultimate Soft Shell
Technique, a variation of the second procedure (underneath
ophthalmic visco-device (OVD)), above, confines minute amounts of
trypan blue to the anterior capsule, without getting any in the rest
of the anterior chamber. It is safer and yields better visibility of
the capsule.
____________________________
1 J Cat Refract
Surg 2002;28(6):988–991.
Rock Hard
Cataracts
Speaker: Roger F. Steinert,
MD
Q23: Preference for rock hard
cataracts:
Usually
phaco ................................ 55%
Usually do
ECCE ............................ 14%
Regularly do
both, depending ...... 31%
Speaker
comment: Only a few years ago, more than 80 percent of
respondents would have stated that extracapsular cataract extraction
(ECCE) was the correct choice. The current preferences reflect the
dramatic improvement in ultrasound technology and
phacoemulsification technique. Now many patients with highly
advanced cataracts can benefit from small-incision technology.
Q24: Will sharp-edged nuclear fragments puncture the
PC?
Very likely (has happened to me)
............ 38%
Very likely (has not happened to me)
...... 18%
Very unlikely
............................................. 40%
Not
sure ......................................................
4%
Speaker comment: Clearly this issue is
controversial. Few surgeons would doubt, however, the advantage of
stabilizing a nuclear fragment in order to effectively remove it.
Re-installation of a low molecular weight ophthalmic viscoelastic
device midway through nuclear emulsification is the best method to
stabilize a nuclear fragment while protecting the posterior capsule
and the endothelium.
Intraoperative Complications: 36
Questions
Anesthetic Complications
Speaker: R.
Bruce Wallace III, MD
Q25: Your anesthesia
preference for cataract surgery:
More than 90
percent topical ...................... 46%
More
than 90 percent retrobulbar ................ 17%
More than
90 percent peribulbar ................. 24%
Commonly use
both (topical or injection)....... 13%
Speaker
comment: It was interesting that despite the hype
associated with topical anesthesia, injection anesthesia is still
running a tight race with topical as a preferred method.
Q26: Globe perforations you’ve witnessed from anesthetic
injection:
Never .............
70%
1 .....................
21%
2 ..................... 3%
More than
2 ..... 6%
Speaker comment: It is
comforting to see the low incidence of globe perforations associated
with injection anesthesia. Topical anesthesia surgeons may prefer
their technique more because of the cosmetic benefits, rather than
the fact that the risk of ocular perforation is reduced.
Operative Causes of
TASS
Speaker: Nick Mamalis,
MD
Q27: Number of cases of TASS you’ve
seen:
None ............................
48%
Fewer than 2 ............... 32%
3 to
5 ........................... 13%
More than
5 ................. 7%
Speaker
comment: Toxic anterior segment syndrome (TASS) is much
more prevalent than surgeons realize as more than 50 percent of all
respondents have seen cases of TASS with 7 percent having seen more
than five cases.
Q28: Greatest risk for TASS is:
Irrigating
solution .................
35%
Medications............................ 33%
Sterilization
problems ............
30%
IOL .........................................
2%
Speaker comment: Respondents were equally
divided on the greatest risk for TASS between irrigating solutions,
medications and sterilization problems. These results mirror our
findings when analyzing outbreaks of TASS referred to our
center.
Complications of
Intracameral Drugs
Speaker:
James P. Gills, MD
Q29: I routinely use
intracameral antibiotics:
In the irrigating
bottle ............. 17%
Via direct injection into
AC ......
18%
Never .......................................
65%
Speaker comment: It is interesting that
only 35 percent of the respondents use intracameral antibiotics. We
conducted our own poll of high-volume surgeons, and more than 90
percent reported that they use intracameral antibiotics. I use them
because I feel that this provides a safer approach.
Q30: Regarding intracameral steroid:
I use
it ................................................ 6%
I
would consider using it ................... 29%
Risk
currently outweighs benefit ........
65%
Speaker comment: I am surprised that 6
percent of the respondents already use intracameral steroids and
another 29 percent would consider this. The fact that 65 percent
still think the risk outweighs the benefits is actually a low number
considering that intracameral steroids have only been used for a
short time. I think that many more would use this if there were a
commercially available, preservative-free steroid made for
intracameral use.
Incision Complications (Burns,
Leak and Infection)
Speaker: Randall J. Olson,
MD
Q31: Number of times you have had a
significant wound burn:
Never ..................
54%
1 ........................ 24%
2 to
3 ................... 17%
More than 3 ...........
5%
Speaker comment: A survey I recently
conducted suggests that severe wound burns had a 0.1 percent
incidence;¹ however, we also had many people who had no wound burns
with large volumes and others who have had quite a few. This
suggests that wound burns may, indeed, be clustered because with a
0.1 percent incidence I would expect more than 46 percent of the
respondents would have had a wound burn. Our work suggests there are
specific machine features and approaches related to wound burn and,
therefore, it would be interesting to expand our database to see if
there are combinations of factors that are protective against wound
burn creation and at the same time other combinations that are
likely to result in clustering, which is suggested by the audience
response.
________________________
1 Am J Ophthalmol
in press
Q32: Compared to scleral pocket, my incidence of
endophthalmitis with CCI
is:
Higher ....................
18%
Unchanged ...........
52%
Lower .................... 12%
I don’t do
CCI ....... 18%
Speaker comment:
This means 82 percent of the audience has at least partially been
doing clear corneal incisions (CCI), which is a dramatic change over
the last several years. Interestingly, the audience as a group does
not feel that, on average, clear corneal incisions are increasing
the risk of endophthalmitis. This is contrary to many studies,
including those that have looked at the CMS database, all of which
indicate that, in general, endophthalmitis has gone up in the era of
clear corneal incisions. One possible explanation for this
disconnect is that the database studies to date are not
representative of surgeons in general. A more likely explanation,
however, is that doubling the incidence of an uncommon event, such
as endophthalmitis, is not necessarily noticeable to the average
surgeon. I know at our institution no one felt that we had an
increased incidence of endophthalmitis even though we documented
that it had at least doubled during this period. This further shows
the importance of good studies to better ascertain what is happening
and to determine just what the causes and preventive measures might
be.
Managing the
Torn Capsulorhexis
Speaker: Mark
Packer, MD, FACS
Q33: My rate of radial CCC
tear:
Less than 1 percent ........... 64%
2 to
3 percent .................... 23%
4 to 5 percent
.................... 8%
More than 5
percent ............ 5%
Speaker
comment: While most surgeons experience radial tears
infrequently, more than one in 10 surgeons have to deal with them
once in every 20 to 25 cases. Those surgeons who find they often
tear the rhexis edge should videotape every case and review their
complications.
Q34: Following a radial tear to periphery and a dense
nucleus, I would:
Phaco with single radial
tear ..................... 51%
Make another tear 180 degrees
away ...... 16%
Convert to can opener and
phaco ............. 17%
Convert to
ECCE ........................................
16%
Speaker comment: A radial tear does not
generally require a conversion to ECCE in the hands of 84 percent of
surgeons. It is encouraging to see that the majority feel
comfortable completing phaco in the presence of a tear.
Intraoperative Capsular Block
Syndrome
Speaker: Kensaku Miyake,
MD
Q35: Number of times you’ve ruptured the
PC with hydrodissection:
Never
.................... 47%
1 ..........................
34%
2 to 4 .................... 16%
More than 4
.......... 3%
Speaker comment: The
incidence was larger than I would have expected in the United
States, where you have a lot of “California Cataracts,” which
are rarely associated with intraoperative capsular block
syndrome.
Q36: Before today, had you understood capsular block
syndrome?
Yes .............
73%
No .............. 27%
Speaker
comment: I am very happy to learn that my presentation
provided new information to 27 percent of the audience.
Complications of Bimanual
MICS
Speaker: Paul S. Koch,
MD
Q37: Your MICS
experience:
Never tried it
............................. 81%
Tried MICS, prefer
coaxial ........... 16%
Prefer MICS
................................ 3%
Speaker
comment: It’s hard to improve on standard
phacoemulsification. Not only have most surgeons never bothered to
try microincision cataract surgery (MICS), 84 percent of those who
did gave it up and went back to coaxial.
Q38: I think MICS is:
Significant step
forward ...................... 12%
Minor variation of
standard phaco ....... 71%
Step
backward ....................................
17%
Speaker comment: It is interesting that
while only 3 percent prefer MICS (see question 37), 12 percent feel
it is a significant step forward. Perhaps [those respondents in]
that 9 percent gap have phaco equipment not suited to MICS and would
perform it if they could. One wonders if this group did try it
whether they would embrace it, or be part of the 16 percent who
tried and went back to coaxial.
Fluid Misdirection
Syndrome vs. Choroidal
Hemorrhage
Speaker: William J.
Fishkind, MD, FACS
Q39: Times I’ve aborted
surgery due to flat/shallow AC:
Never
............................ 73%
1 to 2
............................. 23%
3 to 4
............................. 3%
More than
5 .................... 1%
Speaker
comment: A shallow anterior chamber during phaco is a
somewhat common occurrence. Seventy-three percent of respondents
have never terminated a case due to this problem. On the other hand,
suprachoroidal hemorrhages occur with regularity.
Q40: Times I’ve had a true suprachoroidal hemorrhage with
phaco:
Never ................
54%
1 ......................
29%
2 ...................... 10%
More than
2 ....... 7%
Speaker comment:
Forty-six percent of respondents have definitively identified this
diagnosis. Since shallow chambers occur commonly and suprachoroidal
hemorrhages rarely, the surgeon must be vigilant, possessing a high
index of suspicion for this problem when a shallow anterior chamber
is encountered.
Managing the Descending
Nucleus
Speaker: Richard B. Packard,
MD
Q41: Number of dropped nuclei in past 12
months:
None ........................
65%
1 .............................
27%
2 ............................... 5%
More than
2 ............... 3%
Speaker comment:
The descent of the nucleus is still considered a most unpleasant
event in our surgery. In this survey it is a complication that
occurred in the past year for 35 percent of the surgeons responding.
Of these, 8 percent had more than one such event.
Q42: How do you manage a descending
nucleus?
Close eye—refer to retina .......
33%
PAL with spatula .....................
22%
Viscoat levitation ....................
32%
Prayer ......................................
13%
Speaker comment: The answers to this
question indicated a variety of solutions; vitreoretinal surgeon
involvement as a primary management move is chosen by 33 percent. It
is interesting to see that nearly two-thirds have tried some
surgical maneuver to lift a dropping nucleus, 32 percent favoring
Viscoat levitation.
Kenalog Vitreous Staining: When and
How?
Speaker: Scott E. Burk, MD,
PhD
Q43: Number of times vitreous
incarceration discovered
postop:
Never ....................
18%
1 ......................... 25%
2 to 5
.................. 43%
More than 5 .........
14%
Speaker comment: It seems obvious
from the responses that the majority
of us have experienced some
difficulty identifying the vitreous. More than four out of five
ophthalmologists surveyed completed surgery only to find vitreous
incarceration at a postoperative visit. Clearly this emphasizes the
need for better vitreous visualization, especially because residual
vitreous plays a significant role in serious postoperative
complications.
Q44: For anterior vitrectomy, I use
triamcinolone:
Never
........................................ 86%
Less than 15
percent ................. 7%
15 to 50 percent
........................ 2%
More than 50 percent
................. 5%
Speaker comment: Given
the fact that triamcinolone-assisted vitrectomy has been published¹
and presented at all major meetings by myself or my colleagues since
2002, it is somewhat surprising that 86 percent of ophthalmologists
surveyed have never used triam- cinolone for enhancing vitreous
visualization. I believe this speaks to the need for widespread
commercial availability of a preservative-free
preparation.
_____________________
1 Burk, S. E. et al. J
Cataract Refract Surg 2003;29(4):645–651.
Pars Plana Anterior
Vitrectomy
Speaker: Louis D. “Skip” Nichamin,
MD
Q45: Your PC rupture
rate:
Less than 1 percent .......................
52%
1 to 2 percent ................................
33%
3 to 5 percent .................................
12%
More than 5
percent .......................
3%
Speaker comment: Most published reports
on the incidence of capsular rupture during modern phaco surgery
hover around the 1 to 3 percent mark. One would think that this type
of poll, given the target audience and anonymity associated with it,
would yield fairly accurate data regarding this complication.
Indeed, 85 percent of surgeons responded with a rate of less than 3
percent. With 12 percent reporting a capsular rupture rate of 3 to 5
percent, and 3 percent of surgeons at higher than 5 percent, I think
that it is safe to say that this complication remains the most
significant problem in the back of the cataract surgeon’s mind.
Q46: Pars plana anterior vitrectomy (PC
rupture):
Would never do
it ................................... 13%
Would consider
depending on case ....... 64%
Have tried it, not
my preference .............. 5%
Preferred
technique .................................
18%
Speaker comment: I must admit that I am
both surprised and pleased with these results. The message regarding
the benefits of a pars plana approach is now coming across; 18
percent of surgeons are currently employing this technique, and two
out of three are considering adopting this approach.
IOL Fixation After Capsule
Tears
Speaker: Howard V. Gimbel, MD,
MPH
Q47: Have you ever performed a posterior
CCC?
Yes ...............
36%
No ................
64%
Speaker comment: Only about
one-third of respondents have used posterior continuous curvilinear
capsulorhexis (PCCC). It seems that many surgeons judge the
difficulty in performing PCCC based on their experience in doing
CCC. This experience may have been while using a viscoelastic other
than the highly viscous ones now on the market. These add so much to
the control and may give more surgeons the confidence to use it to
avoid vitrectomy in pediatric cataract with IOLs and to surgically
remove dense plaques on the posterior capsule at the time of
cataract surgery.
Q48: Have you ever used CCC optic
capture?
Yes ................
53%
No ................ 47%
Speaker
comment: Optic capture is a technique used, for the most
part, to manage complications of anterior or posterior capsule
tears. The 47 percent of respondents who have never used it may not
have had an occasion to use it.
Injector Complications/
Explanting Damaged IOLS
Speaker: Stephen S. Lane,
MD
Q49: Number of IOLs damaged upon
injection (past year):
None
........................ 36%
1 to 2 ........................
48%
3 to 5 ........................ 11%
More than 5
............. 5%
Speaker
comment: The incidence of at least one IOL annually being
damaged during injection into the eye is roughly 64 percent. This
indicates a more widespread problem than I would have anti-cipated
and puts the onus on manufacturers to produce more reliable injector
systems and on surgeons to be more fastidious as they load and
inject these lenses. Perhaps IOLs preloaded in the injector by the
manufacturer will reduce this problem.
Q50: Preferred method of acrylic IOL
removal:
Refolding inside
AC ........................................
15%
Cutting IOL into pieces
................................. 60%
Enlarge incision—no
cutting or folding........... 25%
Speaker
comment: When damage is noted, cutting the IOL appears to
be the preferred method, as it is probably the simplest.
Surgical Causes of Corneal
Decompensation
Speaker: Richard L. Lindstrom,
MD
Q51: Your incidence of postcataract
corneal decompensation (last two
years):
Never ..............................
42%
Once ............................... 40%
2 to 3
times .................... 15%
More than 3
times............ 3%
Speaker comment:
These responses confirm that postcataract surgery corneal
decompensation is rare and decreasing in incidence vs. earlier
reports in the literature. Since the typical American cataract
surgeon performs approximately 300 procedures per year, this poll
suggests the incidence of postcataract surgery corneal
decompensation in routine practice may now be as low as one per
500.
Q52: Which best protects the
endothelium?
Dispersive
OVD ........................ 55%
Cohesive OVD
......................... 23%
Viscoadaptive (Healon
5) ......... 14%
Not much difference
................ 8%
Speaker
comment: Improved surgical skill, advances in
phacoemulsification machine technology and the almost universal use
of an OVD all play a role in the decreasing incidence of
postcataract surgery corneal decompensation. The published data and
these audience responses confirm that there is no consensus
regarding the preferred OVD for corneal endothelial
protection.
Intraoperative Retinal
Complications of Cataract Surgery
Speaker: H. Richard
McDonald, MD
Q53: Do you inject a
subconjunctival aminoglycoside?
Yes,
routinely ................ 13%
Only
occasionally .......... 21%
Never
.......................... 66%
Speaker
comment: Aminoglycosides should never be used for routine
cataract cases. They do not provide coverage for those organisms
most commonly associated with postcataract endophthalmitis and are
extremely toxic to the retina. Ten years ago, the number using
aminoglycosides in this setting would have been double or triple
these numbers. The numbers using these drugs are still too high.
Q54: Number of cases of endophthalmitis in past five
years:
None ..........................
52%
1 to 2 ........................ 40%
3 to
5 ......................... 7%
More than
5 ............... 1%
Speaker
comment: Whether or not the incidence of postcataract
extraction endophthalmitis has risen as a result of clear corneal
wounds cannot be answered by a survey. But there seems to be growing
evidence to suggest that may be the case.
Avoiding/Managing
Resident Complications
Speaker:
Douglas D. Koch, MD
Q55: Best approach for
training residents:
Begin with phaco
................. 35%
Begin with ECCE ..................
49%
Makes no
difference............... 16%
Speaker
comment: I found the responses to both my questions
to be interesting and a little surprising. When asked the best
approach for training residents, the majority indicated that
residents should begin with ECCE. In our program, we no longer use
this approach. Was the audience response based on their own
experience as residents, or is ECCE more commonly performed than I
suspect?
Q56: PC rupture with nucleus in the eye should be managed
by:
The operating resident ..............
29%
The attending surgeon ...............
71%
Speaker comment: Again, surprisingly, 71
percent of respondents indicated that the attending surgeon should
complete the case. This reflects, I believe, the view that the
patient’s well-being is the primary concern. In addition, this
permits the attending surgeon to demonstrate to the resident
appropriate steps for managing this type of potentially
sight-threatening complication. In our program, the attending may do
this
on one or two cases. Depending on the resident’s skill
level, subsequent cases (hopefully few arise) are managed by the
resident surgeon.
Patient Counseling Following
Complications
Speaker: David M. Dillman,
MD
Q57: After vitreous loss (IOL
successfully placed), I usually:
Immediately inform the
patient of the complication ................. 47%
Wait until
later to discuss the complication
............................. 24%
Don’t discuss this unless there
are further complications......... 29%
Speaker
comment: Of the “4 Rs” contained in an authentic medical
apology (recognition, regret, responsibility and remedy), Michael
Woods, MD, in his book Healing Words: The Power of Apology in
Medicine strongly observes that physicians struggle the most with
recognition. Our training to be perfect plus the deny-and-defend
mentality drilled into us, especially in the hospital setting,
simply often blinds us to the need for an authentic medical apology.
The responses to questions 57 and 58 underscore this.
Q58: Following complications, I believe an apology and
full disclosure:
Increases the chance of being
sued ................... 13%
Decreases the chance of being
sued .................. 70%
Isn’t a major factor in
likelihood of a lawsuit ...... 17%
Speaker
comment: While 70 percent feel apology and disclosure
actually decreases the risk of litigation, only 47 percent (from
question 57) would feel the need to immediately inform the patient
following vitreous loss with successful IOL implantation. Remember,
“If you have to eat crow, it’s best to do it while it’s
hot!”
And I think this is also a strong reflection that all
of us new to the concept of apology and disclosure in medicine have
to learn the fact that apology and disclosure does not necessarily
equal admitting wrongdoing or guilt.
Risk Management Pearls in
Cataract Surgery
Speaker: Richard L. Abbott,
MD
Q59: Number of times you’ve been sued for
a cataract claim:
Never ......................
79%
1 ............................ 15%
2 to
3 ..................... 4%
More than 3
........... 2%
Speaker comment:
The Ophthalmic Mutual Insurance Company (OMIC) data show
approximately one-third (32 percent) of all closed claims and suits
stem from cataract surgery. The audience indicated that only 21
percent had incurred at least one claim or suit from cataract
surgery. Hopefully, this reflects a positive trend in reducing
malpractice litigation for the future.
Q60: Which would make you the most nervous about being
sued:
Endophthalmitis .........................
43%
Wrong IOL power ....................... 29%
Dropped
nucleus ......................... 17%
ON damage from IOP
spike ........ 11%
Speaker comment:
The main reasons ophthalmologists are sued in cases of
endophthalmitis are failure to diagnose in a timely fashion and then
failure to refer. Most cataract claims and suits are based on
problems related to IOLs (i.e., wrong lens power, size, type).
Financial Disclosures
|
Financial interests are designated with an A,
C or O. A = Affiliation, which means that the
speaker or a member of the speaker’s family has membership on
the board of directors, officership, editorial position or
status as a paid employee or paid or nonpaid consultant in any
for-profit health-related or business concern, including any
health publishing, Internet or e-commerce
entity. O = Ownership, which means the
speaker or a member of his or her family has personal holdings
in any commercial entity, including any publishing, Internet,
e-commerce or other business interest that provides products
or services related to health care or to Academy
activities. C = Compensation, which means
the speaker or a member of the speaker’s family receives
support from commercial or other sources, including any
publishing, Internet or e-commerce organizations, related to
health care or to Academy activities. Income includes stock
options and/or warrants in, royalty arrangements with, or
dividends from the commercial entity.
Dr.
Holland: Advanced Vision Science, A; Alcon, A;
Allergan, A; Bausch & Lomb, A. Dr.
Cionni: Alcon, A; Morcher, C. Dr.
Masket: AMO, A; Medennium, A; Alcon, A; Visiogen, A;
Othera Pharmaceuticals, C; IntraLase, A. Dr.
Vasavada: None. Dr. Rosenthal: AMO,
C; Baxter Pharmaceuticals, C. Dr. Osher:
Alcon, C; AMO, C. Dr. Mackool: Alcon, A;
Impex, A. Dr. Arbisser: Alcon, C; AMO, C.
Dr. Ahmed: None. Dr. Chang:
AMO, A,C; Visiogen, A; Cataract & Refractive Surgery
Today, A; Slack, C; Alcon, C; Calhoun Vision, O.
Dr. Arshinoff: Alcon, A; AMO, A; Bausch &
Lomb, A. Dr. Steinert: Alcon, A,C; AMO, A;
IntraLase, A,C; Rhein Medical, C. Dr.
Wallace: AMO, C. Dr. Mamalis:
Visiogen, A; Medennium, A; Rayner Intraocular Lenses, C.
Dr. Gills: None. Dr. Olson:
AMO, A; Allergan, A; Calhoun Vision, A; Becton-Dickson, A.
Dr. Packer: AMO, A; Advanced Vision Science,
A; Visiogen, A; Carl Zeiss Meditec, A; Bausch & Lomb, A;
Medtronic Ophthalmics, A; iScience, A; Johnson & Johnson
Medical, A; VisionCare Ophthalmic Technologies, A; Staar
Surgical, A; Ethicon, A; Eyeonics, A; Alcon, A. Dr.
Miyake: None. Dr. Koch: Bausch &
Lomb, A; ThinOptx, O; Staar Surgical, A; iScience, A.
Dr. Fishkind: AMO, A; Thieme Medical
Publishers, C. Dr. Packard: None. Dr.
Burk: None. Dr. Nichamin: Bausch
& Lomb, A; Refractec, A. Dr. Gimbel:
None. Dr. Lane: Alcon, A,O,C; Bausch &
Lomb, A,C; Visiogen, A,O,C; Vision Care, A,C; Medennium, A;
Surgical Specialties, A. Dr. Lindstrom:
Bausch & Lomb, A,C; AcuFocus, A,C; AMO, A,C; C & C
Vision, A,C; VisiJet, A,C; Refractec, A,C; Santen, A,C; Slack,
A,C; TLC Vision, A,C; Visx, A,C. Dr.
McDonald: None. Dr. Koch: Alcon, C;
AcuFocus, C; Othera Pharmaceuticals, C; Visx, C. Dr.
Dillman: None. Dr. Abbott: Santen,
A,C; Ophthalmic Mutual Insurance Company (OMIC),
A,C. |
Enjoy the Spotlight Session at Home |
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