Not all cataract surgeries go smoothly, and surgeons must be prepared for the inevitable complications that can occur. During the ASCRS meeting Sunday morning, a program entitled “Cataract Surgery Crisis Management 101” featured a panel of surgeons who discussed some of their problem cases and shared insights into how they effectively managed these crises. Moderated by Abhay R. Vasavada, FRCS, MS, the panel included Robert H. Osher, MD; Gerd U. Auffarth, PhD, MD; Nicole R. Fram, MD, ABO; Michael E. Snyder, MD, ABO; and Kevin M. Miller, MD.
Effective and compassionate communication is a critical element of patient satisfaction, especially when things go wrong, said Dr. Osher, a professor of ophthalmology at the University of Cincinnati College of Medicine and medical director emeritus of the Cincinnati Eye Institute. “The main way surgeons get in trouble is when they try to hide something. Patients can sense when something’s wrong. It’s better to admit what happened, reassure the patient, and offer them loads of help.”
Dr. Osher recounted a case many years ago during which he accidentally implanted the wrong lens in a female patient. He quickly acknowledged that the mistake was his fault, proposed options, ended up paying for the solution that she wanted, and still follows up with that patient periodically. “Patients don’t care how much you know until they know how much you care,” he said.
Dr. Miller, the Kolokotrones Chair in ophthalmology at the David Geffen School of Medicine at UCLA and chief of the Cataract and Refractive Surgery Division of the Stein Eye Institute, discussed the timing for this sort of conversation, contending that it’s better not to get into a detailed discussion in the moment that a complication occurs, as this is more likely to agitate the patient. “I firmly believe that at the end of the case, you have to tell them that things didn’t go exactly as planned,” he said. “But arrange time for them to come back and discuss it the next day. By then, they’ll see that they’re not going to go blind, and you can have that conversation.” Plan to take as much time as the patient needs, and use neutral words like “challenge,” rather than “complication.” “You always want to use neutral terminology,” he says. “The whole goal is communication.”
Dr. Snyder, a professor of ophthalmology at the University of Cincinnati, described a case in which a patient referred for cataract surgery had an odd-looking iris and a “vague history” of possible eye trauma as a child. Wanting to know what he was dealing with, he ordered an iris biopsy, which showed epithelial ingrowth involving several clock-hours of the iris. He decided the best approach would be to excise the growth surgically, so he performed a partial lamellar sclerokeratouvectomy. Six months after this procedure, he was able to successful perform cataract surgery and place a custom iris implant. “The patient ended up doing very well,” he said, with 20/25 vision, reduced glare and light sensitivity and no recurrence of epithelial downgrowth at five-year follow-up.
Dr. Miller narrated a video showing his challenging case, which occurred while he was performing cataract surgery on a 73-year-old woman who previously had a vitrectomy. Everything was going smoothly as he injected the single-piece IOL into the capsular bag, but as he carefully removed the ophthalmic viscoelastic device (OVD), he had an “uh-oh” moment — a wrap-around tear that left the IOL trapped between the two halves of the capsule with no OVD. Fortunately, the haptics remained properly oriented, the lens was centered, and it appeared to be in a stable position. “I decided to close up and take my chances the lens would stay there,” he said. He explained that he did not want to subject the patient to the trauma of removing the lens and exchanging it for a three-piece IOL. Fortunately, the lens remained perfectly positioned a year later, and her vision was excellent.