Every cataract surgeon has experienced it — that moment during surgery when you hold your breath and hear your heartbeat as if it may have relocated to your ear. Complications during cataract surgery, though uncommon, happen to the best of us, and when they occur in a patient undergoing refractive cataract surgery, the surgeon must pivot in new and different ways.

Several years ago, when I was just starting to use premium IOLs, I had a case in which I planned to use a new multifocal IOL. I meticulously performed all the preoperative testing and calculated the power of the lens, carefully consulting with colleagues to make sure I chose the best target to give my patient an optimal result.

Despite all my careful planning, I was still not prepared for what happened. I removed the dense cataract, but in doing so a capsular tear occurred. With this complication, I realized that placing the multifocal lens I had spent so much time selecting in the bag was no longer the best option for this patient. Mid-surgery, I decided to adjust my surgical plan and place a monofocal three-piece lens in the sulcus.

However, with so much emphasis on this new, special multifocal IOL, we had neglected to have a backup lens ready! Fortunately, things turned out well, as I was able to do the necessary calculations on the fly in the operating room and the patient ended up 20/20.

This complication taught me several important lessons in performing refractive cataract surgery that have served me well. In this article, I’ll share my top five considerations in managing complications in refractive cataract surgery.

1. PREPARE BEFORE YOU EVEN GET TO THE OPERATING ROOM

Managing complications starts well before the patient enters the operating room. Addressing patient-specific risk factors early on that may predispose a patient to complications, such as a history of trauma, previous vitrectomy or even a very dense lens, can be very useful in deciding whether a patient is an appropriate candidate for refractive cataract surgery even before complications occur. Once you have identified and documented any specific risk factors, take time to explain to the patient what these risks mean in terms of their surgery and set the stage for adjustments you may need to make should a complication occur. I make a point to let the patient know what the plan is for refractive cataract surgery, but I will modify the plan if needed during surgery to do what is best for their eye.

If a patient understands the risks of a potential complication, you’ll minimize their surprise should one occur. Also, in considering the risks of a complication, you as the surgeon are more likely to think through the steps needed to address it and consider what you can do preemptively.

2. HAVE YOUR BACKUP PLAN READY

Intraoperatively, it goes without saying that you need an intact capsular bag with enough zonular support to align a multifocal lens in proper position. However, if the bag becomes compromised during surgery, a lens may need to be placed in the sulcus instead. You may also need to perform optic capture or reverse optic capture depending on the bag’s status. But these options may affect the correction of the refractive error. Making sure that you have done these calculations ahead of time and having the correct backup lens available will make things much easier on you and your staff during surgery should these complications occur. Having a well-thought-out “Plan B” will help you manage the natural adrenaline rush that may occur if a complication arises so you can execute your backup plan.

3. CONSIDER OTHER REFRACTIVE OPTIONS TO ACHIEVE VISUAL GOALS

A lot of patients choose refractive cataract surgery to correct their astigmatism. But what if a complication occurs and you cannot place a toric lens? Or if your femtosecond laser malfunctions and you cannot place an astigmatic keratectomy incision?

Recall that outside of refractive cataract surgery, you may employ many refractive options to achieve the desired visual goals of a patient (ie, LASIK, PRK, SMILE). As these procedures may add cost, build these options into the agreement with the patient prior to surgery. In an ideal world, each refractive cataract surgeon would have access to their own laser or be able to perform these enhancements themselves. However, if that is not possible, develop a relationship with a refractive surgeon in the community who can help you on these rare occasions.

You should always discuss the option of traditional lens placement if you can’t perform refractive cataract surgery because of a complication. Build this into your understanding with the patient, and make this part of your informed consent package.

4. THINK OUTSIDE THE BOX

With a plethora of new treatments available, it is worthwhile to “think outside the box” when an unexpected complication arises to see what adjustments can be made to achieve a comparable outcome to the original plan. For example, if you cannot place the multifocal of choice in the first eye, that doesn’t mean the second eye may be precluded from having a multifocal lens. I have many patients that I have “mixed and matched” for various reasons who have done quite well.

Monovision also works well in many patients and can be simulated with a contact lens trial prior to second eye surgery if there is any question. Further, with the FDA approval of VUITY (Allergan) and soon other presbyopic drops, even monofocal lens patients can potentially have freedom from spectacle correction.

5. REASSURE THE PATIENT

Telling a patient that they suffered a complication in refractive cataract surgery is never entirely comfortable. But clear communication and reassurance that you will continue to provide optimal care can ease the path.

For example, if you had to make an adjustment during surgery, explain to the patient that you had to choose a different lens than what was discussed initially based on what was best for the patient’s eye and the complication that occurred. Reassure the patient that they had the best possible treatment. Be honest and straightforward without being alarming.

On a practical note, be sure that they receive a prompt refund of any payment for an unused multifocal lens. Postoperatively, don’t hesitate to consult with another specialist if you’re dealing with a complication. Generally, most patients understand that surgery involves risks and that complications can occur. They just want to understand what happened and know that you will be there to help them along the way.

CONCLUSION

With these points in mind, handling refractive cataract surgery complications does not have to be much different from managing other complications. For younger surgeons who have not dealt with many complications, having a mentor to discuss issues and options can reduce their stress.

Refractive cataract surgery is rewarding for both patients and surgeons and something I would encourage all ophthalmologists to incorporate into their practice. OM

Lisa Nijm, MD, JD, is a board-certified corneal, cataract and refractive surgeon at Warrenville Eyecare & LASIK, Warrenville, Ill., and an assistant clinical professor of ophthalmology at the University of Illinois Eye and Ear Infirmary in Chicago. She is also the founder of the educational resource, RealWorldOphthalmology.com , helping young ophthalmologists succeed in early practice. Email her at LNijm@RealWorldOphthalmology.com. Relevant disclosures: Dr. Nijm is a consultant for Allergan.