SURGICAL PEARLS

Careful Planning Sets the Stage for Success in the OR

BY PETER A. RAPOZA, MD

Saving time in the OR can involve various approaches. When I think about saving time in the OR, I break the conversation down into four parts: (1) facility protocols designed to improve overall efficiency and efficacy; (2) preoperative technology to complete a thorough and systematic evaluation, which serves to expedite the surgical case; (3) intraoperative technology that can improve efficiency in a range of cases from routine to complex; and (4) surgical pearls I’ve learned that reduce intraoperative time while still ensuring an efficient procedure and safe and successful outcome.

LAYING THE FOUNDATION

Being efficient in the OR starts with careful planning and execution in the clinic. My practice, Ophthalmic Consultants of Boston, is a multi-subspecialty, private practice entity with academic affiliations with both Tufts and Harvard Medical Schools. We have tailored our philosophy of excellence in patient care, research, and teaching to serve the needs and demands of our specific patient population. Most of the physicians on staff have their own team. My clinical staff consists of six full-time technicians, four optometrists, and a surgical counselor who all know my preferences, including how I like to have a patient prepared and educated during the visit. This team travels with me to each of the three locations where I practice and we have worked hard to make our process seamless. I feel confident and comfortable that my team can answer most routine questions from patients.

We also add efficiency by using our website and the select use of marketing materials to address routine questions and concerns that could otherwise bog us down in clinic. Thus, when a patient is ready to undergo a procedure, there are few, if any, lingering questions that could serve as a distraction in the operating room. One of the more unfortunate situations I’ve experienced is when a patient shows up in the OR with numerous questions.

PRE-OP WORKUP

In my practice, we use dedicated technicians for all pre-op diagnostic testing. This level of specialization allows the technicians to build a strong knowledge of refractive and biometric principles, thus achieving a high level of competence in using the equipment and practiced efficiency in meeting pre-op requirements. We provide ample and ongoing training opportunities. We instruct technicians to alert us immediately if there are any abnormalities (i.e., high or irregular astigmatism that may warrant ocular surface imaging to rule out keratoconus) detected during testing, so further examination or testing can be performed while the patient is still in office.

We don’t rush patients into making decisions, especially when considering a premium IOL. I prefer to reschedule patients who are still weighing their options so that we’re all comfortable with the implant selected and the refractive goal. At the same time, it’s also important to know when to say “no” to a procedure or patient. I have, on occasion, asked patients with unreasonable expectations to seek services elsewhere, because if I’m not feeling positive about the patient-physician relationship or I can’t provide the desired result, then it’s not good for the patient or me to move forward with surgery.

On OR days, I want to make sure the correct lenses have been selected and are available for each patient on that day’s roster. Likewise, if we’re engaging in a second eye procedure, I review the results of the first eye in advance so I know the refractive outcome and can decide whether any adjustments in IOL power may be needed to optimize the outcome in the second eye.

IN THE OR

I always have one of my technicians present during OR sessions to field patient questions, interact with families, handle communication with staff who aren’t in the OR, complete our patients’ post-op medication schedule, and code diagnoses and procedures accurately for our billing department. The one situation in which I always talk with a patient is when there is a complication during the surgery. In those cases, I want to speak to the patient and the family. I’ve found this policy to provide courteous and high-quality patient care. It also helps our overall flow if I can take a few moments to explain what happened and how we plan to address the complication to continue with our goal of achieving an optimal result.

Appropriate scheduling of cases on OR days is another important element of maximizing efficiency. Cases must be scheduled realistically regarding their probable duration and recognizing that different times are required for simple versus complex cases. I always schedule my more complex cases with greater potential for complications (i.e., pseudoexfoliation or prior ocular trauma) at our Boston center when I know one of my retina colleagues can rapidly come to the OR if necessary.

INTRAOPERATIVE TECHNOLOGIES

We don’t currently use a femtosecond laser for cataract surgeries in our ASCs. Depending on the type of case, we operate on four to six eyes per hour on surgical days. Fortunately, we have an extremely low complication rate and a high premium implant utilization rate. Considering that femtosecond laser would add cost to the procedure and introduce some degree of disruption to our flow, we have made the decision that the technology upgrade isn’t currently necessary. As the technology matures, the optimal instrument(s) is (are) identified, and the usual price reduction occurs, we will continue to reevaluate adding femtosecond cataract surgery to our centers.

Another way I ensure consistent patient flow is by using a similar instrument tray from procedure to procedure so my surgical nurses and technicians know each instrument I typically utilize, what to pass and when. I also aim to perform each step of a surgical procedure efficiently and effectively to avoid unnecessary instrument exchanges and minimize the need to enter and exit the eye repeatedly.

If I suspect a patient may have an issue with inadequate pupillary dilation, I use preoperative atropine, which reduces the need for pupillary expansion devices. If the diameter of the pupil remains small or floppy iris syndrome is suspected, we employ a pupillary expansion device (hooks or rings), and we tell the patient in advance. In the past, I used iris hooks exclusively, primarily due to their low cost. More recently, I’ve found that my intraoperative experiences and post-op outcomes with the Beaver Visitec I-Ring have been phenomenal. I found deployment and removal of the I-Ring to be faster and easier than hooks, and it gives a round pupil intraoperatively and postoperatively. It’s also easier to use in topical cases compared with hooks, which have an externalized shaft protruding from the eye that can catch and snag on the eyelids or speculum, potentially leading to complications, such as iris tears or damage to the lens capsule.

I’ve used the I-Ring in a number of cases now, and I’d be interested to see how it might work with the WaveTec ORA intraoperative aberrometer as an adjunct in premium implant cases in rare instances when we confront pupillary challenges in this select group of patients. Intraoperative aberrometry gives me confidence in eyes with previous refractive surgery and in placing toric implants on the correct axis. I haven’t had a chance to use an I-Ring and intraoperative aberrometry in the same case, but I suspect the added efficiency of the I-Ring and ability to achieve greater accuracy with aberrometry could allow more patients to reap the benefits of a premium implant.

An anterior segment surgeon should have the ability to use various intraoperative adjuvants safely to achieve a successful outcome, especially in those more complex cases. In addition to pupillary expanders, use of various viscoelastics, capsular retractors, capsular tension rings, and having the ability to suture IOLs to the iris or sulcus are tools that will be very useful in the OR.

TIPS & PEARLS FOR EFFICIENT AND EFFICACIOUS SURGERY

The instruments we hold in our hands during surgery can aid us greatly in performing safe, efficient, and efficacious surgery. But these instruments are only as good as the hands that hold them. I believe the final piece of the puzzle in being efficient in the OR is learning the craft and being committed to continual learning to get better.

Perhaps the most important thing I’ve learned is to always be mindful of the task at hand when performing surgery. On the level of technique, I think every good cataract surgeon should be able to perform a well-centered anterior capsulotomy of a diameter appropriate for the selected IOL and achieving a successful hydrodissection of the cortex from the capsule (except in cases of posterior polar cataracts where hydrodelineation is more appropriate to minimize a central capsular discontinuity). If you can perform these steps well, the remainder of the procedure usually is straightforward. Lastly, I think every anterior segment surgeon should be able to perform a safe and efficient pars plana vitrectomy to personally manage many of the less complex instances of capsular tears, zonular dialysis with vitreous loss, and removal of readily reached lens fragments. I hope these suggestions help your efficiency and outcomes. ■