New M.D.

The Attending Was Too Impatient

By Lauren A. Eckstein, M.D., Ph.D.

The case wasn't going badly, but it was taking an awfully long time. The patient in question had recently been referred to our clinic. Unfortunately, we did not have a complete set of past medical records. Indeed, most of what we had to go on for preoperative planning was relayed by the patient himself. He had a long history of glaucoma bilaterally and had endured numerous IOP-lowering procedures and surgeries in both eyes. The exact details were, of course, unavailable. In addition, he had suffered a central retinal vein occlusion a few years prior, and he was now monocular.

What we knew for certain was that his better eye — the eye upon which I was now operating — had badly scarred conjunctiva, extensive iris synechiae, a diffuse paracentral corneal scar, prominent arcus and a dense white cataract. What we merely suspected was that he also had advanced cupping of his optic nerve (based on B-scan analysis), and that despite maximum tolerated medical therapy his IOP remained above his target pressure. We therefore planned for a combined phacoemulsification and trabeculectomy.

The Attending Grows Restless

The surgery started smoothly, but as we turned our attention from the initial steps of the trabeculectomy to the phacoemuslification, our progress slowed considerably. Stymied by extensive anterior segment scarring and restricted by limited visualization, the cataract extraction was proving very difficult. And very time-consuming. As mere minutes stretched into a half-hour and beyond, and as I used tube after tube of viscoelastic, my attending became restless. Although uninterested in taking over this difficult case, he suggested instead that I abandon the phacoemulsification and instead proceed with anterior vitrectomy to remove the remaining cataract. Shocked by this suggestion, I refused to heed his advice and continued with my measured (if slow) removal of the cataract by phacoemuslification.

It is plainly evident that not all cases will proceed as smoothly as we might like. Indeed, this is true even in the absence of complications. As was the situation with this particular case, both preoperative and intraoperative conditions may interfere with the routine progress of a surgery. Just as we must be prepared to handle surgical complications, we must also be ready to handle surgeries that challenge our patience (as well as that of the patient and of the operating room staff ).

Because my patient had been booked for a combined procedure, and because I also anticipated a prolonged surgery, my preop planning included performing a retrobulbar block. Moreover, I had alerted the anesthesiologist and other members of the operating theater staff preoperatively that I expected the surgery to be both difficult and time-consuming. Thus assembled, all essential parties involved in the surgery had been alerted and were prepared for a complex and protracted procedure.

Staying With the Plan

Sadly, what I was unprepared for was the impatience of my attending. Despite this unexpected stressor, I proceeded with the surgery as originally planned. Although progress was slow, I could visualize the intact posterior capsule, and I was making measurable progress in my attempts to remove the remaining cataract. Most importantly, the patient was comfortable and his vital signs were stable. There was no identifiable medical imperative that necessitated concluding the case urgently. Absent such a mandate, I could not be swayed from my predetermined course, and I certainly could not be coerced into opening the vitrector and potentially compromising my patient's surgical outcome. To paraphrase a famous credit card company advertisement: five tubes of viscoelastic, $350; 40 extra minutes of operating room time, $600; placing the IOL in the bag, priceless.

Although the case took substantially more than an hour to finish, the trabeculectomy was completed, the cataract was removed in its entirety, the capsule was intact and the lens was implanted in the bag. Ultimately, the patient did very well — his pressure was well controlled postoperatively, and although he did indeed have advanced optic nerve changes due to his glaucoma, his central vision improved dramatically following removal of the cataract. He was thrilled with the results and grateful for my intraoperative patience and diligence. OM