JUL 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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22 EW CATARACT July 2013 Device focus Planning the complicated cataract surgery by Michelle Dalton EyeWorld Contributing Writer Iris hooks, used here, should be on hand for complicated cases, surgeons say. Source: Steven G. Safran, MD Performing complicated surgery is much easier if you're prepared, experts say I deally, every patient presents with a grade 1 or 2 cataract, has no other systemic or ocular disease, and surgery takes no more than 15 minutes. Unfortunately, a good number of patients do not fall into that category, and for those predicted difficult surgeries, fully preparing yourself as a surgeon and your staff will only enhance patient outcomes, experts say. "There's a saying that 'failure to plan is planning to fail,' and that's true for complicated cataract surgery," said Peter Heiner, MD, associate professor and trustee, Bond University, Gold Coast, Queensland, Australia. Among the many reasons cataract surgery can be difficult: ocular issues (small pupil, bound down pupil, floppy iris syndrome, corneal pathology, corneal scarring, dense cataracts, hypermature cataract, pseudoexfoliation, weak or deficient zonules, or a posterior pole cataract), anatomic difficulties (including deep set eyes or a protruding brow), or general health problems, including chronic obstructive pulmonary disease, the use of anticoagulants, or dementia, Dr. Heiner said. "There are also difficult cases due to age," said Alan S. Crandall, MD, professor of clinical ophthalmology, vice chair of clinical services, and director of glaucoma and cataract, John A. Moran Eye Center, University of Utah Health Sciences Center, Salt Lake City. Pediatric cases involve a "guesstimation of the anesthesia and the amount of time the A-scan will take under anesthesia. Other disorders, such as Marfan's, take me about 45 minutes if they're not fixating, so surgeons need to build in that time as well as the wake-up time in pediatric cases," Dr. Crandall said. In preparation for these kinds of cases, Audrey Talley-Rostov, MD, in practice, Northwest Eye Surgeons, Seattle, said she includes in her notes what she thinks she may need—ranging from different retractors to capsular tension hooks to preferences for a peribulbar block. Dr. Crandall also suggests scheduling these cases for later in the day. "I prefer to run through my easy cases first and do the complicated ones later," but "it's safer for the kids if those cases are done earlier in the day." Dr. Talley-Rostov tends to reserve the longer cases for later in the day, and reviews with the staff those cases she feels may be more difficult. Dr. Heiner believes all difficult cases "begin in the consultation room. First, the surgeon should ask himself whether or not he wants to do the case or refer it out. If you're doing the case yourself, warn the patient of the possible complications and likelihood of delayed healing or the possibility for a second procedure." He is also an advocate of discussing the case with surgical partners "who may be prepared to assist you if it's one of your first cases." The first time Dr. Talley-Rostov glued an IOL, "I used videos and I had my OR staff review the videos with me. We went over the steps, made sure the staff understood the order we expected things to happen during the surgery, made sure the necessary tools were on hand." Patients with narrow angles, pseudoexfoliation, or who use tamsulosin aren't dilated because "I think they have a risk of going into angle closure before you start your case," Dr. Crandall said. "I'll use intracameral lidocaine instead and dilate them on the table." He also recommends trypan blue dye for easier visualization and both the Malyugin rings (MicroSurgical Technology, MST, Redmond, Wash.) and Grieshaber iris hooks (Alcon, Fort Worth, Texas) for harder cataracts, noting the latter comes in two sizes and he has both on hand as "sometimes miotic eyes are easier with the bigger hooks." If the nucleus is hard, "you might want to consider a little bit larger rhexis to be able to manipulate the pieces easier when you're bringing them up," Dr. Crandall said, but acknowledged others may prefer smaller incisions as they are planning to place the iris devices. "If things look a little floppy, I'll put in MST hooks or a Mackool hook [Bausch + Lomb/Storz, Rochester, N.Y.] to stabilize the nucleus," he said. He also recommends having a bimanual setup since the I/A is more difficult. "I always ask for vitreous stain so that at the end of the case you can ensure there are no loose strands of vitreous that can come around," he said. Getting staff involved Dr. Talley-Rostov is a firm believer in having staff involved in the planning and having videos available for referencing during the surgery itself. "We've even had videos loaded onto someone's iPhone," she said. Drs. Heiner and Crandall agree that the best way to prepare is to watch and learn from those who have done the surgery before. And, if possible, go visit a surgeon who has more experience with the type of challenging case, Dr. Crandall said. Books are also helpful. Dr. Crandall recommends Roger Steinert, MD, David Chang, MD, and Jason Jones, MD (Randall Olson, MD, is the subeditor) as three go-to authors for explaining complicated cases. Helpful hints "Review tapes, do your homework, and review the case with your staff the morning of surgery," Dr. TalleyRostov said. "Use what's available— the ASCRS clinical videos, YouTube, call a colleague. Make sure the OR is prepped that morning, from the particular suture to the specific hook, blade, or needle." Schedule these cases when time does not matter, Dr. Heiner said. "These are not the types of cases to be training new staff on," he said. "Check and ensure your capsular dyes, iris hooks, Malyugin rings, vitrectomy instruments are all in the room." And ensure there are backup IOLs available for times you discover the initial lens is not suitable. "Take your time and approach the case with your usual technique (chop or divide and conquer, etc.)," Dr. Heiner said. "At the end of the day the surgeon could reflect on what went well or otherwise and consider how to manage these difficult cases next time." One last pearl—"Make sure that if things start to go sour, you have the instruments necessary to shut it down quickly," Dr. Crandall said. "You should have a chamber maintainer ready to go in cases where a suprachoroidal hemorrhage starts. And since we don't suture often, make sure there's some 10-0 nylon in the room in case you do need to shut down quickly." EW Editors' note: The physicians have no financial interests related to this article. Contact information Crandall: alan.crandall@hsc.utah.edu Heiner: pheiner77@hotmail.com Talley-Rostov: ATalleyRostov@nweyes.com

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