Eyeworld

EW CATARACT 33 Steven Siepser, MD, Siepser Laser Eyecare, Wayne, Pennsylvania, thinks Dr. Miller is shortchanging himself a bit in his assessment of the repair. "He hit this one out of the park—it was a home run," Dr. Siepser said. "There is no doubt about it. Anyone casually looking at the eye would never notice anything had happened." The only criticism Dr. Siepser offered is that he might have used a little bit of cautery on the iris to round it out a bit more, but other- wise "he did a magnificent job with the Siepser sliding knot, getting the eye repaired," he said. As for Dr. Siepser's thoughts on how this situation could have been avoided from the beginning, he, like Dr. Miller, suggested a pharmaceuti- cal iris stiffener or use of an iris di- lating ring, though he said he rarely needs the latter in such cases. Dr. Siepser suspects that the pa- tient's primary surgeon had perhaps placed his incision a little too far posterior and likely didn't quite un- derstand that the patient had floppy iris due to tamsulosin. "It's obvious the surgeon didn't know how to get this iris out of the way. He just got the eye closed, which is good, but he amputated a lot of the iris there. You can usually get the iris back in," Dr. Siepser said, explaining that instead of trying to push it back in, the physician should pull from the opposite side of the cornea. In the end, Dr. Siepser said situations like this can occur due to a lack of experience and/or limited exposure to complications because such complications are rarer today. "There is tremendous variability [in surgical skill], but you only really see the variability of skills during difficult situations," Dr. Siepser said. "[Most surgeons] are usually rela- tively skilled but run out of options when things go wrong." Dr. Siepser said that he and his team prepare ahead of time for the inevitable problem or complication that could occur with each specific patient. He also said that gain- ing experience with complication management is why he recommends observing more senior surgeons at work. "I always say that's the advan- tage and value of a senior surgeon. He's got a lot of backup stuff in his armamentarium. When something happens, it's no big deal because he's already seen it 100 times and he knows just what to do. That's why I encourage young surgeons to go see other surgeons operate," Dr. Siepser said. Dr. Miller said there is some- thing to be said for surgeons know- ing their own limitations as well and having the sense to refer a patient from the get-go if they think they cannot handle the case. In this case, for example, the patient went back to the primary surgeon to have his second eye done and found himself back in Dr. Miller's office with a sec- ond round of similar complications. "We assume that a patient who had a problem in 1 eye, they're very likely to have a problem in the second eye," Dr. Siepser said. "In a patient who has had a problem in the first eye, you've got to say 'May- be you'd do better with Dr. Miller or so-and-so in the next town over.'" While Dr. Miller said he respect- ed the primary surgeon for realizing he was in over his head with the first eye, deciding to refer the patient rather than attempt a fix at that time, he did not think it was wise for this surgeon to agree to do the second eye. "He should have said, 'We had a bad outcome on the first eye and I think I can do the second eye, but I don't want you to have any regrets so you should go back to Dr. Miller or go to someone else.' That's what he should have done," Dr. Miller said. EW Editors' note: Drs. Miller and Siepser have no financial interests related to their comments. Contact information Miller: miller@jsei.ucla.edu Siepser: ssiepser@siepservision.com

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