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Give the first surgeon the benefit of the doubt

Ocular surgery, particularly phacoemulsification, is delicate, challenging and often unforgiving. The margin between a success and a complication can be narrow, and while we do our best for our patients, we cannot give an absolute guarantee as to the outcome.

If you see a patient with a less than optimal outcome from a surgery performed elsewhere, make an effort to obtain the prior records and contact the first surgeon. There is a lot to be learned, including the limitations of the patient’s anatomy that contributed to the complication. Patients who encounter complications from surgery, whether mild or severe, are often best served by seeking a second opinion. Having a second or third ophthalmologist examine the eye in detail can often turn up subtle findings that can help explain the issues and lead to a resolution.

I performed cataract surgery on a patient who had a seemingly normal preoperative examination. The biometry was accurate, the corneal mapping was regular, and the macular function and anatomy were good. The surgery went beautifully with implantation of a toric IOL in the capsular bag. Postoperatively, the autorefractor showed that the eye was within a quarter diopter of plano for both sphere and cylinder — a great refractive outcome. But the patient was not so pleased and only managed 20/30 vision on Snellen testing. We followed her in the postop period, and her visual acuity improved mildly but still was not correctable to 20/20. She asked if the surgery went well and if it would be helpful to get a second opinion.

First surgery
Figure 1. It is important to give the first surgeon the benefit of the doubt.

Source: Uday Devgan, MD

In this situation, the patient’s instincts were right: A second opinion by a local colleague showed that she had mild cystoid macular edema on OCT testing. This resolved over the course of the next few months using topical NSAIDs and steroids. When it came time for the second eye to have cataract surgery, she asked if it was reasonable to have surgery with my colleague who gave the second opinion. She completed the procedure with my colleague, and everything went well during surgery. She also developed cystoid macular edema in the second eye, and it ended up having the same course as the first eye. Clearly, the patient’s anatomy and healing response played the major role in the development of macular edema in the postop period. And studies have shown this to be the case: If the first eye has cystoid macular after cataract surgery, then the second eye has a 50% chance of the same complication in the future.

prior cataract surgery was complicated
Figure 2. The patient needs cataract surgery in the right eye, but examination of the left eye shows that the prior cataract surgery was complicated.

Sometimes you will examine a patient who had surgery elsewhere, and there will be obvious clinical signs that there were challenges and complications. You must avoid thinking that the first surgeon had issues solely because he or she did not have enough surgical skill. This is a critical lesson: Always give the first surgeon the benefit of the doubt — assume that he/she had good skills and judgment but the patient’s tissues were the true challenge (Figure 1). It is the combination of the patient’s anatomy and tissue limitations, as well as the surgeon’s technique, that determine the outcome of the case.

A patient (Figure 2) had a complicated course for her first cataract surgery that was done elsewhere a few years ago. There was a sulcus IOL, surgical corectopia and a prolonged inflammatory reaction that lasted months. Ultimately, the first eye achieved good vision. When I saw the patient in consultation, I immediately thought that there must be significant tissue limitations and that I would encounter these same challenges and potential risks when doing a future surgery for her other eye.

Upon review of her old records, the first surgeon was one of my professors from two decades prior when I was doing my ophthalmology residency. I knew firsthand that he was skilled and possessed excellent judgment. This made me even more focused on the challenges that would await for cataract surgery in her other eye.

I talked extensively with the patient, letting her know that the first eye was done by a skilled surgeon and that the complications of surgery were in large part due to challenges with her tissues and anatomy. She understood that, despite our best efforts, similar types of issues could arise with the cataract surgery that we were planning.

Sure enough, her cataract surgery was a challenge. Extensive cortical opacities made visualization of the capsulorrhexis difficult. The capsule felt thin and the zonular attachments somewhat weak. The dilation was less than ideal, and the iris was floppy. The case turned out well, but it was stressful because of her tissues and also because of her expectations and nervousness.

patient achieved a good outcome
Figure 3. After a challenging cataract surgery, the patient achieved a good outcome in the right eye. The left eye, despite having a sulcus IOL and iris damage, sees almost as well as the right eye.

The patient healed well in the postop period and achieved excellent vision (Figure 3). The patient’s other eye, despite having a sulcus IOL and iris damage, sees almost as well. This case highlighted the take-home lesson: Always give the first surgeon the benefit of the doubt. Keep this important message in mind the next time you see a patient with complications from surgery done by another surgeon.

Video of this challenging case can be seen at cataractcoach.com/2018/12/14/critical-lesson-giving-the-benefit-of-the-doubt.

Disclosure: Devgan reports he owns CataractCoach.com, which is a free teaching website.

Ocular surgery, particularly phacoemulsification, is delicate, challenging and often unforgiving. The margin between a success and a complication can be narrow, and while we do our best for our patients, we cannot give an absolute guarantee as to the outcome.

If you see a patient with a less than optimal outcome from a surgery performed elsewhere, make an effort to obtain the prior records and contact the first surgeon. There is a lot to be learned, including the limitations of the patient’s anatomy that contributed to the complication. Patients who encounter complications from surgery, whether mild or severe, are often best served by seeking a second opinion. Having a second or third ophthalmologist examine the eye in detail can often turn up subtle findings that can help explain the issues and lead to a resolution.

I performed cataract surgery on a patient who had a seemingly normal preoperative examination. The biometry was accurate, the corneal mapping was regular, and the macular function and anatomy were good. The surgery went beautifully with implantation of a toric IOL in the capsular bag. Postoperatively, the autorefractor showed that the eye was within a quarter diopter of plano for both sphere and cylinder — a great refractive outcome. But the patient was not so pleased and only managed 20/30 vision on Snellen testing. We followed her in the postop period, and her visual acuity improved mildly but still was not correctable to 20/20. She asked if the surgery went well and if it would be helpful to get a second opinion.

First surgery
Figure 1. It is important to give the first surgeon the benefit of the doubt.

Source: Uday Devgan, MD

In this situation, the patient’s instincts were right: A second opinion by a local colleague showed that she had mild cystoid macular edema on OCT testing. This resolved over the course of the next few months using topical NSAIDs and steroids. When it came time for the second eye to have cataract surgery, she asked if it was reasonable to have surgery with my colleague who gave the second opinion. She completed the procedure with my colleague, and everything went well during surgery. She also developed cystoid macular edema in the second eye, and it ended up having the same course as the first eye. Clearly, the patient’s anatomy and healing response played the major role in the development of macular edema in the postop period. And studies have shown this to be the case: If the first eye has cystoid macular after cataract surgery, then the second eye has a 50% chance of the same complication in the future.

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prior cataract surgery was complicated
Figure 2. The patient needs cataract surgery in the right eye, but examination of the left eye shows that the prior cataract surgery was complicated.

Sometimes you will examine a patient who had surgery elsewhere, and there will be obvious clinical signs that there were challenges and complications. You must avoid thinking that the first surgeon had issues solely because he or she did not have enough surgical skill. This is a critical lesson: Always give the first surgeon the benefit of the doubt — assume that he/she had good skills and judgment but the patient’s tissues were the true challenge (Figure 1). It is the combination of the patient’s anatomy and tissue limitations, as well as the surgeon’s technique, that determine the outcome of the case.

A patient (Figure 2) had a complicated course for her first cataract surgery that was done elsewhere a few years ago. There was a sulcus IOL, surgical corectopia and a prolonged inflammatory reaction that lasted months. Ultimately, the first eye achieved good vision. When I saw the patient in consultation, I immediately thought that there must be significant tissue limitations and that I would encounter these same challenges and potential risks when doing a future surgery for her other eye.

Upon review of her old records, the first surgeon was one of my professors from two decades prior when I was doing my ophthalmology residency. I knew firsthand that he was skilled and possessed excellent judgment. This made me even more focused on the challenges that would await for cataract surgery in her other eye.

I talked extensively with the patient, letting her know that the first eye was done by a skilled surgeon and that the complications of surgery were in large part due to challenges with her tissues and anatomy. She understood that, despite our best efforts, similar types of issues could arise with the cataract surgery that we were planning.

Sure enough, her cataract surgery was a challenge. Extensive cortical opacities made visualization of the capsulorrhexis difficult. The capsule felt thin and the zonular attachments somewhat weak. The dilation was less than ideal, and the iris was floppy. The case turned out well, but it was stressful because of her tissues and also because of her expectations and nervousness.

PAGE BREAK
patient achieved a good outcome
Figure 3. After a challenging cataract surgery, the patient achieved a good outcome in the right eye. The left eye, despite having a sulcus IOL and iris damage, sees almost as well as the right eye.

The patient healed well in the postop period and achieved excellent vision (Figure 3). The patient’s other eye, despite having a sulcus IOL and iris damage, sees almost as well. This case highlighted the take-home lesson: Always give the first surgeon the benefit of the doubt. Keep this important message in mind the next time you see a patient with complications from surgery done by another surgeon.

Video of this challenging case can be seen at cataractcoach.com/2018/12/14/critical-lesson-giving-the-benefit-of-the-doubt.

Disclosure: Devgan reports he owns CataractCoach.com, which is a free teaching website.