During my training, one of my mentors explained to me that, “Any surgeon can operate, but it takes a surgeon with good judgment to know when not to operate.” As a young resident in training, this pearl went against the flawed thinking of maximizing the number of surgeries performed in order to increase experience in the operating room. The mark of a great surgeon is sound intraoperative surgical judgment as well as the ability to decide when not to operate.
Patients must have realistic expectations regarding the potential results of surgery. They must understand that all surgery, no matter how safe or seemingly simple, carries some degree of risk. Although it sounds obvious, we must remember that we are operating on our patients’ eyes — their most precious sense. Patients will see the world every waking moment for the rest of their lives through our surgery. Surgical procedures that I routinely perform, such as cataract and refractive surgery, have limitations. We have advanced technology IOLs, but none of them perform as well as the natural human lens in a young person. There are no manmade body parts, whether lens implants or heart valves, that perform as well as young, healthy human tissue. When patients expect surgical results that are beyond what we can deliver, it is best to avoid performing surgery.
Ocular tissue is delicate, and for reoperations, every subsequent surgery is more difficult than the previous and the tissue is less able to handle the procedure. A good example of this is the corneal endothelium, which tends to lose cells with each intraocular surgery. For a patient with a borderline endothelial cell count and increased corneal pachymetry, we should be cautious about performing another surgical procedure. We must balance the potential benefit of our proposed surgery with the risks, which are now quite high due to the condition of the cornea. The same could be applied to retinal surgery, glaucoma surgery and even strabismus surgery, in which the tissues can only take a limited amount of surgical intervention before deteriorating.
Figure 1. This patient has a weak cornea with a low endothelial cell count and increased corneal pachymetry. Any future surgery has a high risk of inducing corneal failure, and that would necessitate a future corneal transplant. The potential benefits of another surgery must be weighed against the increased risks.
Images: Devgan U
Figure 2. This patient has a posterior polar cataract and an iris coloboma. Many surgeons could successfully perform the cataract part of the procedure, but the use of a prosthetic iris implant, which is not FDA approved, is available with a device exemption at only a few sites. It may be best to refer this patient to one of the limited number of surgeons who have experience in its use.
Consider the future
We must remember to look at the whole patient, not just their eyes. Although our intentions may be good, sometimes performing ocular surgery in patients with grave medical issues may not be in their best interests. Recently I saw a patient in consultation with advanced cataracts that had rendered him 20/400 in both eyes. He wanted surgery badly, but he had a number of serious systemic medical issues so we made a decision to defer his ocular procedure until after he was declared stable by his primary care doctor. While the eyes are certainly important for daily functioning, a perfect result from ocular surgery is not useful if the patient expires from severe systemic medical illnesses.
While cataract surgery can reasonably be expected to last the duration of the patient’s life, the same cannot be said for other procedures such as glaucoma surgery or complex procedures such as sewn-in IOLs. The longevity of our surgical result is an important consideration, especially for younger patients. Using a technique such as intrascleral haptic pocket (the Agarwal glued IOL technique) may be a better choice for long-term IOL fixation when compared with a sewn-in technique. A procedure that is expected to have limited functional years can still be appropriate as long as the patient understands the likely need for a reoperation in the future.
Learn when to refer
Surgeons tend to gravitate toward fields that interest them, and with time, this becomes a narrower focus with a deeper breadth of knowledge and experience. When we are in training as resident surgeons we know a little bit about many different surgical subspecialties, but as we mature as surgeons we tend to super-specialize so that we know a tremendous amount about a narrower range of surgical procedures. There are times when patients present with an ocular condition that is outside my area of expertise and comfort level. It is far better to refer this patient than to attempt to do a procedure that is beyond my level of surgical experience.
Patients must be involved in the decision to operate, and they must actually want to have surgery. Patients who reluctantly agree to surgery are the ones who tend to be the most difficult to please after the surgery. Once you do a surgery on a patient, in a sense, you own that patient for life. And the converse also holds true — the patient owns you for life. Any future ocular issues may be perceived as occurring due to the effect of your surgery, although that may not be the case. Depending on the situation, sometimes the best surgery may be no surgery at all.
Uday Devgan, MD, is in private practice at Devgan Eye Surgery and Chief of Ophthalmology at Olive View UCLA Medical Center. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; 800-337-1969; email: firstname.lastname@example.org
; website: www.DevganEye.com
Disclosure: Devgan has no relevant financial disclosures.