Viewpoint FROM THE CHIEF MEDICAL EDITOR

When Bad Things Happen to Good Patients

Larry E. Patterson, M.D.

It was Tuesday, just a few weeks ago. That's my day for cataract surgery. Things were going very well, as they usually do for most of us. The next patient, John, was still happy with the results we achieved in his first eye a month earlier. He'd elected to have a Crystalens implanted, and now wanted the same procedure in his second eye.

The surgery was going off without a hitch… until the end of the phacoemulsification. I have no idea how it happened, why it happened, or exactly when it happened, but there I was staring into the abyss of a moderately large posterior capsular opening. There was minimal but definite vitreous prolapse into the wound. Not only did I have a complication to deal with, I knew John wasn't going to get a Crystalens in his second eye.

My dismay about John's prognosis jogged my memory of an encounter I had years ago, soon after building my first surgery center. It was a multi-specialty center, which gave me the opportunity to interact with colleagues in other disciplines. One of the surgeons, whose first name is "Reb" (I live in the South, you know), once commented on the way hospitals and other agencies fixate on complication rates and numbers. He wondered if it wouldn't be more helpful instead to focus on how well surgeons handle complications.

I've had complications that, in hindsight, I could have prevented. Maybe this was one of them, but I couldn't explain it. The chamber never shallowed and my phaco tip, to my knowledge, never came anywhere close to the capsule. I did a careful anterior vitrectomy and placed a monofocal implant into the ciliary sulcus. The eye looked beautiful at the end of the case, almost pristine.

Now came the really hard part. What do I tell John, and his family, about what happened? I've always been very open and honest with patients when they had a complication, but explaining in lay terms exactly what happened and why has been less than satisfactory for me, and maybe them as well. I tried to explain that there was a tear in the back side of the cataract and, in limited detail, I described how we'd done our best to fix the situation, why we needed to change the type of implant, and how that would affect his final outcome.

John and his wife nodded in understanding, but I could tell the explanation was still incomplete. Then it came to me. "John, it's like this," I explained. "We took off in the airplane and everything was going great. But then we unexpectedly hit a flock of birds. It was obvious we'd be in trouble if we didn't act quickly. I couldn't land the plane where I wanted to, and my only option was to land in the Hudson river. While we didn't end up at the exact destination we planned, we did make it out safe and sound, and I'm very thankful for how it turned out."

John and his wife both smiled, and understood.