The last several years have seen a remarkable growth in interest in complex ophthalmic surgery. This trend is likely due to a multitude of factors: advances in surgical instrumentation, the increased reach of platforms such as YouTube to share exciting surgical content, social media facilitating communication among surgeons around the globe, and demographic change that has brought more and more patients into our clinics and operating rooms.

So, the need for formal training in complex anterior segment surgery within our field is paramount — yet it’s often underappreciated in conventional training schemes. While residents typically receive extensive education in general eye care and basic surgical techniques, the intricacies and nuances of complex anterior segment procedures demand a specialized and structured approach. The trouble is, there is not yet consensus on what that structured approach looks like. A broad understanding of complex surgery demonstrates that success lies in stringing fundamental, basic steps together in a logical path — in Dr. Ike Ahmed’s words, “Complexity is simplicity, multiplied.”

Therefore, it is imperative that comprehensive training programs focus on the fundamental underpinnings of our surgical techniques. Further opportunities for continuing education can build off these fundamentals and equip graduates with the proficiency needed to navigate the intricacies of complex anterior segment surgery.

In considering an approach to complex surgery, it is important to prepare oneself in a series of ways. We will delve into each of those topics below.

FIRST PRINCIPLES

The purpose of complex surgery is to address complex problems. By definition, these surgeries are not straightforward in presentation or management. A good surgical journey begins with a thorough history and examination. Details count when the potential for variability is so high.

Understand the patient’s complaints, symptoms and concerns first and foremost. That may sound painfully basic, but it is very easy for surgeons to focus only on obvious problems as opposed to the associated factors. So, define the etiology and all associated comorbidities and potential complications. Make sure to manage patient expectations and to explain the ideal as well as alternative outcomes. Close attention to detail is the name of the game here. Also, the contralateral eye must always be taken into consideration.

Our first principles: We are here to help this patient lead a better life by making this eye work better in a specific set of ways to match our patient’s expectations (which, admittedly, sometimes have to be lowered preoperatively). Take every opportunity to live up to that ideal.

PLOT A FLIGHT PLAN

As we stated previously, complex surgery is nothing more than a series of simple steps executed well. Beyond having a firm grasp of fundamentals that allow a surgeon to perform a simple step, a complex case requires some additional planning to strategize and navigate the long road ahead. In creating a plan, consider some of the following features:

1. Anesthesia type. Is this going to be a case under local or topical anesthesia, or will a regional block be preferred? Recognize that these cases are generally longer, so extra care is often required. However, there are situations in which the added posterior pressure of a retrobulbar block can make surgical access more difficult.
2. Adjunctive surgery or standalone. Based on preoperative considerations and comorbidities, are multiple procedures required? Could the assistance of a second surgeon from the same or a different subspecialty make this procedure safer or easier? The order of steps can matter here. Considerations such as anterior vitrectomy before a pupilloplasty (not the other way around) are extremely important.
3. Incision construction. Consider that all incisions have multiple variables that can be augmented to achieve your goals. Incision size is an obvious variable that we all entertain when performing anterior segment surgery — using a smaller paracentesis incision for small instruments and a larger incision for our phacoemulsification handpiece, for example. This concept can be extended beyond just size. Consider clock hour location, as well as direction in the X, Y and Z plane to optimize microincisional access to specific structures. There may be situations where a purely radial, iris plane incision will not be sufficient to reach a desired part of the anterior segment. As such, a uniquely oriented and directed microincision can improve surgical access and optimize ergonomics, taking full advantage of microinstruments without inducing unnecessary forces on the globe.
4. Backup plans. A good surgeon not only has a plan A but also several backup plans. As a case progresses, these backups emerge in the surgeon’s mind as potential forks in the road. Safe and smooth surgery is contingent on having all backups accounted for, with appropriate implant and instrumentation needs available at a moment’s notice.
5. Bring the right tools. The rapid progression of complex anterior segment surgery techniques during the last 15 years would not have been possible without the development of anterior segment-specific microinstrumentation and devices. Understanding which tools are available in your health-care setting will allow you to offer better solutions to patients. Having them ready before the case (and making sure your OR staff know where to find them and how to prepare them) will ensure success. In addition to the basic “intraocular surgery tray,” we recommend having a preoperative checklist with the following categories:
   • Specific or special-order surgical instruments (micrograspers, micro-tyers, micro-scissors, IOL cutting scissors, etc.)
   • Sutures (GORE-TEX CV-8, 10-0 prolene, 9-0 Vicryl, etc.)
   • Plan A devices (IOL, capsular tension rings, capsular tension segments, etc.)
   • Plan B devices (backup IOL, vitrectomy pack, etc.)
   • Drugs (triamcinolone acetate, Trypan blue, acetylcholine, etc.)

For devices and IOLs, our preference is to order two of each (one as backup) in preparation for a human error such as dropping or breaking a device.

6. Review surgical techniques and patient-specific studies the day before surgery. This includes anterior segment OCT, ultrasound biomicroscopy, biometry and photographs. List the steps and approaches one by one. Some of us prefer to make drawings, while others like to visualize the steps or a combination of both.
7. Explain the plan and order of materials to staff. Surgeons are only as good as their team, so make sure fellows, scrub nurse and circulating staff know the plan.

ERGONOMICS ARE ESSENTIAL

Once it’s time to go to the OR, keep in mind that complex surgery is a marathon, not a sprint. The single most important fundamental skill set a surgeon can develop is an understanding of how to position their body in space relative to the surgical field. Recognizing that complex surgeries often take longer than a routine cataract extraction, surgeons should position themselves in a comfortable and biomechanically optimized way for the duration of the procedure. While surgical ergonomics is a large topic, some key points and concepts can be easily highlighted.

First, ensure that the patient is positioned at a height that allows the seated surgeon to have an appropriate angle of flexion at the ankles, knees, hips, elbows and shoulders. Movement at all these points should be optimized to allow for comfortable work at the mid-range of motion, not at an end-range where sensitivity is reduced and joint stress can occur.

A comfortable and functional surgical chair can be a powerful surgical instrument in your toolkit, but it does not substitute for good posture, which is influenced by the processes of proprioception (unconscious) and body awareness (conscious). The good news is both are trainable and modifiable. Good habits and prophylactic exercises can both prevent and treat bad posture and inadequate biomechanics. These two are important for surgical success (precision, accuracy of movements) and in preventing musculoskeletal injuries commonly seen in surgeons (for example, herniated cervical discs, osteoarthritis of the wrist and hand).

The cervical spine should be held upright when addressing the surgical microscope — the scope should serve the surgeon, not the other way around. This is often best managed by tilting the surgical microscope about 10-15 degrees towards the surgeon, thus extending the oculars back towards the surgeon’s eyes. By making this rotational adjustment, the surgeon does not need to extend their neck towards the microscope (neck flexion), a position that can put significant strain on the lower cervical spine.

To ensure a coaxial view of the anterior segment, the patient’s head can be slightly turned towards the surgeon by the corresponding amount. This has the added benefit of ensuring that fluid on the ocular surface will run off temporally.

DON’T NEGLECT PHYSICAL FITNESS

Beyond intraoperative positioning of the surgical chair, the patient, the microscope and the surgeon, all ophthalmologists should consider a long-term strategy of ensuring appropriate strength and mobility of the spine, shoulders, neck, back and core. Mobility is as important as strength training. We highly recommend consulting with a team of physiotherapists and strength trainers for an individual assessment of your posture (in and out of the OR). Dr. Shah worked with a personal trainer for a year, focusing on his core, back and neck. The result was feeling much better at the end of a long day in the OR.

CONCLUSION

Tackling complex cases requires preparation and a multi-perspective preoperative evaluation of the eye and patient in turn. Preoperative assessment must be given appropriate emphasis. Having the right instruments and devices makes a big difference. Ergonomics, hand positioning and incision placement are key for case success and surgeon longevity. Teamwork is essential. OM

Manjool Shah, MD, is associate professor of ophthalmology and program director of the glaucoma fellowship program at NYU Langone Health Department of Ophthalmology in New York.

Xavier Campos-Möller, MD, has been the head of the Glaucoma and Advanced Anterior Segment Surgery division of the Department of Ophthalmology at Western Memorial Regional Hospital in Corner Brook, Newfoundland, since 2016. He runs a practice in Corner Brook, Newfoundland, focusing mostly on cataract, complex anterior segment and glaucoma surgery.