COMPLICATED CASES

Planning for Unplanned Vitrectomy

When routine cataract surgery isn’t so routine, your preparedness, focus and foresight will see you through.

BY LISA BROTHERS ARBISSER, MD

We often emphasize that as we become better surgeons and perform higher volumes of surgery, we obtain better outcomes. We also encounter fewer complications, primarily because we anticipate problems prior to surgery. However, it’s still imperative that we’re prepared to change gears at the first sign of any complications to limit both the stage of complication and the collateral damage. Preparation and planning are the keys to successful outcomes.

Anticipate Problems

The best way to prevent complications is to identify the potential causes in advance. For example, when a patient has asymmetric anterior chambers, I consider padding the surgery schedule because I know there may be zonular issues, which may increase the length of time required to complete the procedure.

I also know there’s a greater chance patients will require vitrectomy if they have unilateral shallow chambers, pseudoexfoliation syndrome, loose lenses, post-traumatic cataract, cataract complications in the fellow eye or had prior vitrectomy surgery.

Preoperative surgical planning for these patients is important. I classify the case as having a higher level of difficulty, place it at the end of a long line of routine cases, consider peri-bulbar anesthesia and always keep vitrectomy instrumentation on standby. Preventive measures during surgery include recognizing zonular laxity, avoiding convexity of the lens dome, re-grasping the edge often to control the vector of tear, burping the bag to prevent tamponade of continuous curvilinear capsulorrhexis (CCC), maintaining nucleus mobility, respecting zonules during rotation, staying in the “safe zone” within the rhexis with the phaco tip and knowing where that CCC edge is at all times.

Recognize Early Signs

When performing repetitive cataract surgeries, you may slip into a comfortable, almost Zen-like state but each patient’s tissue and circumstances are different, so it’s necessary to be alert and observant at all times. Vigilance means problems will be detected and addressed early to help ensure the best outcome possible.

To stay focused, it helps to start with a quiet environment or soothing music in the OR. I invite each patient’s family to watch the surgery remotely through the microscope, and I explain what I’m doing to the patient and family throughout the procedure with a specific dialogue designed to inform and reassure. When I operate on 25 patients a day, I talk a great deal, but it keeps the patient calm, it keeps me focused, and it allows my scrub nurse, circulator and other staff to stay abreast of our progress.

If something unusual happens — I detect a little spidering of the capsule during phaco, for example — I say, “timing,” and then my staff knows it’s an atypical case. If I weren’t focused, I might miss that spidering or other subtle sign, miss the opportunity to use viscoelastic to stabilize the chamber, or continue with aspiration or phaco that would encourage vitreous prolapse and cause vitreoretinal traction.

Prepare Your OR

Before surgery, we usually know which cases will be challenging, but even straightforward cases sometimes surprise us. Therefore, we must be prepared in the OR. I suggest that surgeons use a mental flowchart approach to plan their strategies. For example, you might have in mind, “If there is iris prolapse, then perform steps a, b and c….” The flowchart should include steps you need to take, as well as instructions you need to give your staff so they can help you make the surgery a success.

A good way to initiate that plan in the OR is to call a “Code V.” Physicians use a code red or blue for emergencies, and it’s wise to prepare for a response to vitreous loss in the same way.

At the end of the day, after the last patient is wheeled out, randomly call a Code V and respond with your staff. They should know the location of the vitrectomy kit, know its setup and parameters and be ready with all of the other items you need at your disposal for the best outcome. You can use the Code V drills as an opportunity to practice your own timing and sequencing with the vitrectomy foot pedal.

Consider This Case

My first attempt at using the femtosecond laser for intumescent cataract was a difficult one. The patient was uninsured and the cataract had been profound for some time, to the point of becoming morgagnian. After ensuring the patient had a clear understanding of her poor prognosis, we proceeded.

Despite increasing femto parameters according to best advice at the time and a mere 1.5 second capsulotomy, on the table, I encountered an anterior chamber clouded with lens milk and, despite OVD and trypan blue staining, had to tap to find whether and where the capsule was perforated. For the first time in years, I defaulted to an extracapsular extraction as it was clear I didn’t have a complete capsulotomy and it was difficult to identify the integrity of the posterior capsule with this huge, free-floating, dense chip of a nucleus.

The patient required a limited anterior vitrectomy. Because she had a poor visual prognosis and experienced unexpected bleeding from the root of the iris during our surgical maneuvers, I left the eye aphakic. Postoperatively, a central retinal vein occlusion was diagnosed leading to cryotherapy and laser treatments for neovascularization. As there was no central potential for vision improvement, a secondary implant was never indicated and the eye healed uneventfully.

Even in this very rare situation, my focus and preparation as well as an informed staff helped me successfully complete this patient’s surgery under difficult circumstances. ■