SIDE OF SAFETY Cataract surgery is one of the safest surgical procedures, yet complications can still occur.

Cataract surgery is already one of the safest procedures around, but it never hurts to improve. Here are 8 advances that will boost the safety of your patients, surgeons and staff members.

Dropless and less drop surgery
Dropless and less drop procedures improve patient compliance with an otherwise tedious post-op drop regimen. In dropless surgery, the surgeon gives the patient an intraocular antibiotic injection before surgery, eliminating the need for pre- and post-op drops.

Not only does this mean you don't have to rely on patients placing their own drops perfectly to ward off infection, but it also saves your patients money, says Denise Carpenter, BSN, RN, director of nursing at the Surgery Center of Northern California in Redding. "Patients pay about $500 per eye for drops, though Medicare covers part of this," she says. "Patients don't pay for the dropless. Instead the facility covers the cost."

This can mean, though, that you'll have to weigh the costs vs. the advantages. "I love the product, and it is only $20 a patient, but that would cost us around $70,000 a year in overhead," adds Ms. Carpenter. Because of that, her center currently only offers dropless surgery to those with trouble applying drops after surgery, like nursing home patients, rheumatoid arthritis patients and others likely to forget their discharge instructions.

For facilities that want to simplify their patients' drop regimen without making the commitment of going fully dropless, there are "less drop" compounded medications that include the steroid, anti-inflammatory and antibiotic a patient must use post-operatively in a single solution. This reduces the number of drops patients have to remember to use, says Mary Radke, RN, manager of the Dakota Eye Surgery Center. "It's less expensive for the patient," she says. "It's only about $60 a bottle, compared with several hundred for standard drops. And it makes a big difference in their compliance. After all, you only have 1 drop to remember."

MORE COMFORT T. Hunter Newsom, MD, says surgeons should work with their OR teams to find the best patient position for enhanced ergonomics.

Laser cataracts
Not only is offering laser cataract surgery a way to attract patients who want cutting-edge technology, but it also can come with tangible benefits to patient care. "The surgeons believed it was a promising new technology that offered more precision, surgical efficiency and improved, predictable outcomes," says Annamarie York, MBA, executive director of the Hoffman Estates (Ill.) Surgery Center.

And now that her docs have used the laser for more than 3 years, they say they've seen its advantages firsthand, including less post-op inflammation and fewer complications. "It decreases overall phaco time and the ultrasonic energy dissipated into the eye," says Mark Rosanova, MD, a surgeon at Hoffman Estates. "Plus, it makes a perfect capsulorhexis, which prevents peripheral capsular tearing."

However, T. Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa, Fla., warns that the evidence thus far that the laser's increased precision translates to improved outcomes is anecdotal. "It's definitely more precise than a surgeon's hand," he says, "but there's not any significant peer-reviewed data showing that using a laser for cataract surgery improves safety."

Eye marking
For patients receiving specialty toric or multifocal lenses, it's imperative that the surgeon insert the lens at the correct angle. Otherwise, the patient may have poor outcomes and require future corrective procedures. To make accurate marks indicating where surgeons must place the lens, Ms. Carpenter's center recently started using a self-leveling corneal marker that's pre-inked and comes with sterile disposable tips.

"The marker really helps get an accurate placement of the lens," says Ms. Carpenter. "It saves time and is more accurate. Some surgeons mark the eye with it, but it's easy enough that most trust our nurses to do it for them."

Another option is digital marking systems, says Ms. York. In these systems, the surgeon takes a digital photo of the patient's eye pre-operatively, which is then used to create a map overlay. This map shows the surgeon information on the patient's astigmatism, axial length, lens choice and toric correction during the surgery, boosting the doctor's overall accuracy when making cuts and inserting the lens.

Pre-loaded IOLs
Hands-free, pre-loaded IOL injection systems provide predictable and safe lens insertion. Ms. York's center recently began trialing the options, noting that the no-touch, disposable system helps minimize the risk of infection and standardize the lens loading practice. "Because they are uniformly loaded, it decreases the chance of damage to the lens as a result of manual loading," adds Dr. Rosanova. "You're eliminating the risk of human error."

Dr. Newsom notes that though higher-volume surgeons likely have techs who are proficient at loading the lenses, smaller or multi-specialty centers may see improved overall efficiency and a reduced risk of lens damage. "Where you don't have a consistent scrub tech, or if you don't have techs that specialize in cataract surgery, these can be good to have," he says.

Pupil maintenance
When it comes to opening up a tough pupil, most surgeons' first instinct is to turn to pharmaceutical options, says Dr. Newsom. "The easiest thing is to use eye drops before surgery," he says. "Then, if the pupil still won't open up, in surgery you can use an intracameral injection."

While Shugarcaine, a compounded solution of epinephrine and lidocaine, has traditionally been a popular injection choice, there's a new option on the market called Omidria, a phenylephrine and ketorolac injection that is added to the standard irrigation solution used during cataract surgery. The manufacturer of Omidria claims it keeps the pupil open without needing additional mechanical methods, like Malyugin rings, which it says can increase complication rates.

While patients who receive Malyugin rings versus pharmaceutical dilation systems may have a higher complication rate, Dr. Newsom says this is because these patients are at an overall higher risk. "I always say, if the pupil is not dilating normally, it's not a normal eye," he adds.

CATARACT DISASTER
Bad Blocks Blind 5 Cataract Patients

MISSED SHOT? Did a Massachusetts anesthesiologist accidentally pierce the retinas of 5 cataract patients?

An anesthesiologist's first day administering blocks at the busy cataract surgery center was a disaster, with patients screaming in anguish as the needles missed their mark and pierced their eyeballs and retinas. Tzay Chiu, MD, reportedly blinded 5 patients in one morning at Cataract & Laser Center West in West Springfield, Mass., while trying to administer peribulbar and/or retrobulbar blocks.

Four of the 5 patients were left completely blind in their affected eyes, and the fifth was left with a crescent-shaped blind spot that severely limits his vision. Two of the patients have filed lawsuits and all 5 have hired lawyers.

Dr. Chiu, who could not be reached for comment, later signed a practice restriction agreement with the state medical board in which he agreed to no longer perform peribulbar or retrobulbar blocks (he reportedly can continue to practice anesthesia while under investigation). Rebecca Capozzi, his lawyer, did not return a call from Outpatient Surgery.

Dr. Chiu had been assigned to the facility by D&G Associates, an anesthesiologist broker in Massachusetts. The center believed Dr. Chiu was competent, based on 2 letters of reference from colleagues and on the word of the anesthesiologist usually assigned to the center, who has disputed that account in a recent deposition, according to reports. Both the surgery center and D&G Associates declined to comment.

— Jim Burger

Reprocessing tools
One of the key aspects of safe cataract surgery is thorough reprocessing. At Ms. Radke's center, staff take advantage of ultrasonic washers, which help ensure that delicate instruments like diamond knives are thoroughly cleaned after each case. Ms. Radke also looked into lumen-flushing devices, which automatically push pressurized water through tiny lumens to better remove bioburden from phaco handpieces, needles and other ports.

DRUG DECISIONS If a patient's pupil won't dilate after using drops, try pharmaceutical intracameral injection maintenance systems.

Ergonomics
Surgeons bent over microscopes day in and day out can develop sore necks and backs. There are several ways to improve their comfort, including adjustable microscopes, heads-up displays, and ergonomically designed chairs and stools.

Heads-up displays broadcast the images of the microscope on flat-panel screens — much like those used in endoscopic cases — to give the surgeon a more comfortable view of the eye. Ms. Carpenter says that her surgeons like using microscopes with adjustable ocular lenses "so they can sit straight up and look forward instead of having to bend their neck to look through the microscope."

How a surgeon sits also makes a huge difference. Because of that, Ms. Carpenter suggests letting your surgeons pick out their own stools or chairs that are most comfortable for them. For example, she says that one of her surgeons had back surgery previously, so he chose a chair specifically designed to help those with back problems. "He says it really makes a difference," she says.

Positioning the patient correctly is also important. Surgeons need to work with their team to find a standard patient position that's going to be comfortable, no matter how complex the case, says Dr. Newsom. Since this is different for every surgeon, he suggests looking for beds, microscopes and other positioning devices that are simple and quick to adjust. The surgeon should work with staff members to find a standard position that is most comfortable for him. "If you start to have a complication or problem during surgery, all of a sudden a 5-minute procedure becomes a 25-minute one," he says. "You might think you can easily tolerate an odd position for 5 minutes, but if it goes to 20 or 25, then that's when it's going to put a strain on your body."

Safety sharps
Safety sharps aren't always an easy sell to surgeons, but they can have a major impact on staff safety. Though Ms. Carpenter's surgeons still use conventional diamond blades, they have started transitioning to safety scalpels for other eyelid and corneal transplant procedures after a staff member was cut while cleaning up a case. Seeing the risks in real life hastened the transition, she says.

Ms. Radke's center uses safety scalpels and needles for cataract procedures. After the surgeon is finished with the diamond knife, he covers the blade with the safety shield and safely passes it off to the surgical tech. She says that getting surgeons to make the switch was relatively simple once she explained the risks to the surgeons. "We just told them that they had to use it for the benefit of our staff," says Ms. Radke. "They're very conscientious about sharps injuries, and whatever we need them to do to keep everyone safe, they go along with."

On the safe side
While cataract surgery is already one of the safest procedures, you want to do all you can to ensure that your patients have excellent outcomes with no complications. Incorporating these 8 advances is a good place to start. OSM