April 02, 2016
4 min read

Checklists vs. checkmate: Reproducibility key to premium surgery success

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Every day we are challenged as premium surgeons with an unusual preoperative diagnostic measurement, intraoperative unexpected complex situation and/or a postoperative unrealistic expectation. There are many scenarios throughout the refractive cataract surgical experience that can potentially bring the premium surgeon into a “checkmate” position.

Traditionally, checkmate is a position in the game of chess in which a player’s king is in check, without a way to remove the threat. The king cannot be captured, so the game ends when the king is checkmated. As a premium surgeon, no one ever wants to be checkmated at any stage of the surgical process, from preoperative to intraoperative to postoperative. Other forms of etymology have suggested checkmate to signify being “ambushed,” a feeling many of us have experienced in our surgical careers. A means to avoiding being a checkmated surgeon is creating “checklists” from the time of the first patient encounter until the final postoperative visit. The process of checklists can bring reproducibility to a surgical process that already yields successful outcomes in a premium surgeon’s practice.

Preoperative checklist

The diagnostic armamentarium that is available to premium surgeons today, especially for refractive cataract surgery, is enormous. In my opinion, it is important to keep the preoperative process consistent in order to determine if a patient even qualifies for an advanced intraoperative technology and/or advanced IOL, to determine what type of advanced technology and/or advanced IOL, and to determine what data are used from such technology and/or what power of IOL is to be used.

In my practice, we start every refractive cataract surgical evaluation with the patient answering a lifestyle questionnaire to determine, for example, the patient’s desire to wear or not wear glasses postoperatively, how many hours the patient works on a computer, the type of work the patient does for a living, and the most frequent hobbies a patient does routinely. The additional diagnostic tests performed in my preoperative checklist include brightness acuity/glare testing and objective scatter index (AcuTarget HD, AcuFocus) to assess a patient’s visual function; corneal topography (Cassini) to assess a patient’s anterior, posterior and total corneal astigmatism; OPD III (Marco) analysis to distinguish corneal vs. lenticular astigmatism, angle kappa magnitude and spherical aberration measurement; OCT analysis of the macula to rule out epiretinal membrane or other macular pathology; IOL power calculation (IOLMaster 500, Carl Zeiss Meditec); ocular surface assessment with tear osmolarity (TearLab); Dynamic Meibomian Imaging (TearScience); and MMP-9 (InflammaDry, RPS).

If there is any ocular surface abnormality at the preoperative visit, treatment is initiated and certain diagnostic tests such as corneal topography and IOL power calculation measurements are repeated to confirm accuracy at the patient’s scheduling visit, on average 2 weeks later. Another good reason to perform preoperative ocular surface testing is to show patients that cataract surgery is not the cause of their postoperative dry eye-induced visual fluctuations.

Intraoperative checklist

Again, the premium surgeon is spoiled with a vast array of intraoperative advanced technologies to perform first-class refractive cataract surgery. In my practice, the intraoperative checklist starts preoperatively with my interpretation of all the diagnostic data obtained above to create the proper surgical plan intraoperatively.

Despite having electronic medical records, I still print out each patient’s IOLMaster IOL power sheet and highlight what is the surgical eye, what power of IOL is to be used for my primary IOL and for my “backup” sulcus or optic capture IOL, whether femtosecond laser and/or intraoperative aberrometry will be utilized, whether other pharmaceuticals will be used (trypan blue, intracameral antibiotics, Omidria from Omeros and/or intravitreal antibiotic-steroid combinations), and whether additional surgical devices such as capsular tension hooks/segments, pupillary expansion devices such as the Malyugin ring (MST) or Assia pupil expander (APX Ophthalmology), and/or surgical glue (ReSure sealant, Ocular Therapeutix) will be used.


If I am simultaneously treating corneal astigmatism, I determine if I will be performing manual limbal relaxing incisions guided by ORA-based intraoperative aberrometry (Alcon) post-IOL implantation or performing femtosecond astigmatic incisions utilizing iris registration captured by Cassini images preoperatively and then using Lensar (Alphaeon) Streamline technology to adjust for cyclorotation errors intraoperatively.

I typically perform astigmatic incisions for corneal astigmatism correction up to 1.5 D of correction and reserve toric IOL correction greater than 1.5 D of astigmatic correction. If performing presbyopia-correcting IOLs, I typically reserve the use of Crystalens (Bausch + Lomb) for patients with prior refractive surgery and/or mild macular changes and/or for patients with high angle kappa. I use the Trulign toric version (Bausch + Lomb) for correction of corneal astigmatism in these same scenarios. In patients with more demanding near vision needs and low angle kappa, I will typically select the low-add Tecnis multifocal IOLs (ZKB00 and ZLB00, Abbott Medical Optics) and perform femtosecond astigmatic incision correction if corneal astigmatism exists.

Postoperative checklist

Once perfect diagnostic testing and surgery have been performed, the healing response does not always follow suit. Pre-existing ocular surface disease (dry eye, epithelial basement membrane dystrophy) can cause visual function havoc postoperatively and needs to be addressed preoperatively to set appropriate patient expectations. Nevertheless, a postoperative checklist always needs to be employed, starting with positive patient communication with each postoperative surgical visit. Other helpful steps to take are appropriate diagnostic testing such as OCT to detect macular edema earlier, tear osmolarity to reinforce patience compliance with dry eye treatment, performing laser vision correction when needed for residual refractive error and/or opening femtosecond laser astigmatic incisions at the slit lamp for enhanced astigmatic effect, and performing YAG laser capsulotomy earlier to avoid capsular contraction changes.

In the end, checklists should be implemented preoperatively, intraoperatively and postoperatively to avoid being that king — the premium surgeon — who is checkmated or ambushed by the surgical process or the patient.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb, Cassini, Lensar, TearLab, TearScience, Ocular Therapeutix, Marco, APX Ophthalmology and Omeros and an investor in RPS.