IN GOOD HANDS Surgeon skill is important, but it's not the only factor in ensuring surgery goes as planned.

Nine times out of 10, cataract cases go off as planned, but your surgeons need to react to unexpected developments to ensure one of surgery's most routine procedures remains just that. Here's what 3 leading eye docs have to say about managing the rare, but potentially devastating, mishaps that can occur before, during and after surgery.

1Capsular tear
It's not overly difficult to tear the capsular bag, says Paul Rosenblum, MD, a cataract surgeon in Jupiter, Fla. He says capsular tear occurs in less than 1% of his cases, but it's involved in most of the complications he faces. When it occurs, the cataract drops into the back of the eye where it can't be reached with ordinary anterior segment techniques. A retinal surgeon must perform corrective surgery at a later date.

"If the complication is managed well, you can still achieve good outcomes," says Dr. Rosenblum. "But if not, secondary complications can occur, including retinal tears or detachments, infection and retinal swelling — although these complications are extraordinary rare."

Robert F. Melendez, MD, a cataract and refractive surgeon at Eye Associates of New Mexico in Albuquerque, says history of eye disease or past trauma are red flags of a loose capsular bag. Even in expected routine cases, he'll know something is amiss after he makes the first manual slice of the capsulorhexis — if a femtosecond laser is making the cut, you're not getting the same feel and feedback, says Dr. Melendez.

When the bag feels loose, he makes the incision slightly larger — approximately 6.25 mm instead of his standard 5.75 mm — to relieve stress on the zonules. He considers the larger capsulorhexis a safety measure that lets him prolapse the lens into the anterior chamber if necessary.

Is a small pupil more dangerous than a small capsulorhexis? "Experienced surgeons can operate successfully through a small pupil," says Dr. Melendez. "But it's extraordinarily difficult to perform surgery through a smaller capsulorhexis, especially when dealing with a really dense cataract."

Capsular rupture should occur in less than 1% of cataract patients, says Richard Hoffman, MD, clinical associate professor of ophthalmology at the Casey Eye Institute in Eugene, Ore. However, he says the risk of rupture jumps to as much as 30% in patients with posterior polar cataracts. Previous vitrectomy surgery or pars plana injections, especially when the cataracts develop soon after the injections, are other warning signs of a compromised posterior capsule, says Dr. Hoffman.

Patients with posterior cataracts often have a very thin, weakened, central posterior capsule that's more likely to rupture, so surgeons should avoid hydrodissection if they believe the posterior capsule is compromised, says Dr. Hoffman. To prevent the bag from rupturing, he also avoids rotating the lens in the capsular bag and polishing the capsule.

Don't ignore the importance of operating with the optimal visualization afforded by optics on the latest surgical microscopes. When Dr. Hoffman upgraded his scope, he was amazed (and sometimes distracted) by the incredible detail it provided. "Any time you achieve improved visualization, you're less likely to grab the posterior capsule and you're more likely to identify zonular weakness, which can help you avoid capsular rupture," he says.

TRIPLE CHECK Have hard stops in place to ensure the correct lens is being implanted in the correct eye.

2Floppy iris
Intraoperative floppy iris syndrome (IFIS) hinders a surgeon's access to the anterior chamber. Some docs pre-treat patients with atropine to help prevent the condition, but Dr. Hoffman uses a lidocaine-epinephrine solution. If the pupil still doesn't dilate well — to 5 or 6 mm — and looks like it's going to provide trouble during the procedure, he inserts an expansion ring or uses iris hooks to make the case routine. He also employs a bimanual microincisional technique, which keeps the irrigation flow above the iris plane for the majority of the case, meaning it's less likely to cause billowing of the iris and aggravate a floppy iris.

Dr. Melendez says 2% to 3% of his patients — typically those on Flomax — present with IFIS. When operating on these patients, he lowers the phacoemulsification's vacuum settings, lowers the bottle height and tries to stay anterior to the iris plane, because, he says, as soon as fluid gets under the posterior iris, IFIS gets significantly worse.

Should surgeons use iris hooks or expansion rings to expand floppy irises? That depends on the surgeon, says Dr. Hoffman, who says hooks are the better option in patients with very shallow anterior chambers, when there are adhesions between the iris and the cornea or a defect on the iris.

"My preference is to use a ring," he says. "But when it won't fit onto the pupil because of adherent leukoma of the iris or large defects, then the hooks are a better choice."

Dr. Melendez says his rate of using hooks has dropped significantly since using preservative-free enzymes to treat IFIS, but if the condition is severe, he often opts for hooks. He says rings are a bit faster going in and coming out, but the hooks are less expensive, add about 2 minutes to the typical case and provide more exposure than the ring if the capsular bag is loose.

3Wound leakage
Corneal incisions are often self-healing, but failing to achieve a tight wound seal can lead to post-op infections, including endophthalmitis, the potentially debilitating post-op inflammation inside the eye. Dr. Rosenblum explains, "Fluid can leak not only out of the eye, but tears carrying bacteria can leak back in through the wound."

He makes a very small "shelled" incision in the cornea by cutting at a 45-degree angle instead of a right angle, so the pressure from inside the eye pushes the inside flap against the outside flap to theoretically form a watertight seal.

"But I'm very risk-averse, so when I finish my case and put fluid back in, I make sure the eye is rock-hard and doesn't have a leak," says Dr. Rosenblum. "If there's a leak, I put in a stitch, which solves the problem."

Placing a stitch adds an extra 2 minutes to his procedure times and an extra $20 to his case costs. He's fine with that, based on his weekly caseload, but would a high-volume surgeon stand for spending an extra 30 to 40 minutes a week in the OR and shelling out hundreds more dollars to cover supply expenses?

Time- and money-conscious surgeons, and those who'd prefer to keep their suture rates down, might opt for a new wound sealant designed to prevent wound leakage. Although with today's surgeons making 2-point instead of 3-point incisions, the risk of leakage is lower, according to Dr. Melendez, who believes sealant or sutures play a small role in successful cataract outcomes.

Dr. Hoffman places a suture on the wound if he's worried about leakage, and won't hesitate to place a suture at the slit lamp during exams on post-op day 1, especially if the leak is significant or the anterior chamber is shallow. He expresses concern with the sealant. "It requires that the wound is not leaking in order to apply it," says Dr. Hoffman. So if the wound is self-sealing on the table, why should you place a sealant on it? "Well, yeah, exactly," he says.

4Infection and inflammation
Surgeons prescribe their own concoctions of antibiotic, steroidal and non-steroidal drops to prevent post-op inflammation and infection in the eye. Dr. Rosenblum says good surgical technique will likely prevent post-op inflammation, and says it might be overkill to prescribe steroid drops 4 times daily for a month, but he has had patients who've forgotten to take steroid drops after 2 days post-op. Their eyes were fine, but the incidences highlight the real risk of patient non-adherence. Wouldn't it be great if patients didn't have to worry about adhering to the multi-drop therapy?

Dr. Hoffman admits his week-long regimen of antibiotic drops probably isn't needed for patients who undergo routine surgery and leave with sealed incisions, but calls the possibility of replacing drops with a single injection "very interesting" and is intrigued by the option of eliminating patient compliance issues and lowering post-op care costs.

Although Dr. Melendez says more research and time are needed to ensure injections are the most effective and safest way to prevent post-op inflammation and infection, he's excited by the possibility. "I'd be all for that," he says. "It'd save patients money, reduce healthcare costs, improve efficiency in the clinic and result in fewer call-backs from patients about prescription issues."

THE RIGHT LOOK A sticker identifies the operative eye before the surgeon makes his mark.

PATIENT SAFETY
Mark the Correct
Eye Before Dilation

It's never too soon to ensure you're focusing on the correct eye before cataract surgery. When we dilate in pre-op, before the eye is marked by the surgeon, we verify the location of the procedure with the patient and put a sticky R or L dot above the operative eye. Even if another nurse needs to administer the drops, the site is readily identified to ensure accurate medicating.

Nancy Harla, RN, BA-C
Harper Hospital
Macomb Mich.
[email protected]

5Wrong-eye surgery

You'd think the blatant arrow above the correct eye would have indicated which eye should have been blocked. "You'd think," says Dr. Hoffman. "It was just a real boneheaded move."

He's referring to the time a nurse anesthetist injected local anesthetic around the wrong eye, even though it was properly marked. Luckily, the mistake was caught before surgery began, by one of the triple-checks employed by Dr. Hoffman' surgical team: The nurse anesthetist marks the correct eye before placing the block (oops!), Dr. Hoffman signs an "H" above the intended eye, and the team confirms the correct procedure and site with the patient and against the surgical schedule during the pre-op time out.

As Dr. Hoffman's near-miss shows, marking the right eye isn't 100% fail-safe, but having a multilayered plan in place to check and confirm the correct site will likely prevent a devastating conclusion to what should be a routine procedure.