Practice makes … surgery go easier

A resident shares his interactive approach for inserting the Glaukos iStent; it has made surgery much more efficient.

By Michael Patterson, DO

Athletes understand the importance of practice. Physicians can liken rehearsal to conducting wet labs for a specific procedure before going live.

This is a story about the importance of involving your patients in the pre-implantation rehearsal of a Glaukos iStent.

In trouble already

The iStent, approved for use with cataract surgery, is a glaucoma implantation device that, truth be told, involves getting the patient in the right spot at the right angle and for enough time to have the micro-stent put in.

It doesn’t always happen that way. “Learning to insert an iStent was initially challenging and humbling to say the least,” says Larry Patterson, MD* of Eye Centers of Tennessee in Crossville.

As a third-year resident in Columbia, S.C., I knew I was in trouble when I saw my experienced program director, Bethany Markowitz, MD, spend more than a few minutes trying to coax an iStent patient to “Please, keep your head just so,” and “Please, keep your eye like this, for just a few minutes.”

If she couldn’t coax a patient, with all of her experience, how could I? I figured there had to be a better way.

Practice while they wait

I thought that developing a method for practicing with our patients prior to surgery made sense.

While patients are in the pre-operative area, they are typically just waiting. Almost all surgeons have at least one to two minutes they could spare before taking a patient back.

A perfect time to practice, I say.

This is the procedure:

1. Position the patient’s head for cataract surgery and tell her where her eyes will be focused. Explain to the patient that this is the position in which she will hold her head throughout that surgery. Unless staff has told them, patients usually don’t know this ahead of time.

2. Position the patient’s head for iStent implementation. Explain that you will rotate her head to the appropriate position to allow visualization under the microscope.

3. Position the patient’s eyes. I typically tell the patient to look at my hand and explain to her that while she won’t see my hand during surgery, I want her to remember this exact eye position so she can replicate it once we are in the OR and there are drapes covering her face.

4. PRACTICE! After you successfully position her head and her eyes, it’s time to have the patient practice (without any physical contact) so she knows exactly where her head and eyes need to be. Once we have two or three successful practice routines, and the patient says she understands the procedure, I proceed to the operating room.

Perfect grades, all around

Before we started this method, our Glaukos iStent insertion rates typically ran 10 to 15 minutes; since implementing this system, we have become extremely efficient.

Most of the saved time was spent trying to coach the patient to get his head positioned appropriately. “Having the patient practice prior to the procedure has made inserting the Glaukos iStent a much safer and efficient process,” says Dr. Markowitz. Adds Dr. Patterson, chief medical editor for Ophthalmology Management: “My best iStent case came directly after you spoke with me about your method to help with visualization and patient positioning.”

Real appreciation

The most rewarding part of this process is that patients appreciate that we have taken the time to help them understand what we are going to do to them — prior to placing pounds of medical drapes on their face and insisting they look somewhere they can’t see while a very bright light shines on them. These time-savings are due to the patient starting in the right position, eyes in the proper place and the patient’s less overall movement.

“It sounds like a very intriguing protocol,” says Chris Calcaterra, chief commercial officer of Glaukos.

He added, “We are very pleased to see this new generation of ophthalmologists thinking of ways to improve the procedure.”

I have used this protocol successfully on 30 patients; I have never had to reinsert the iStent on any of them. A meta-study on the iStent found that a common reported issue was its malposition.¹

Would a simple but vital activity like practice have helped the surgeon position the stent correctly?

Remember Allen Iverson?

The infamous basketball player once debated with a Philadelphia reporter about the importance of practice. “I’m supposed to be the franchise player, and we here talking about practice. Not a game … that I go out there and die for … We talking about practice, man. I mean, how silly is that?²

Maybe AI has since changed his mind about the importance of the P word. OM

*Larry Patterson, MD is the author’s father.

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