Dr. Steve Charles is a pioneer of modern vitreoretinal surgery. A mechanical and electrical engineer as well as a surgeon, he has developed many of the techniques and devices currently used by retinal surgeons worldwide. During his 47-year career, Dr. Charles has performed over 45,000 vitreoretinal surgeries and published numerous articles as well as the textbook Vitreous Microsurgery, now in its sixth edition. He has consulted with Alcon in research and development (R&D) for more than 30 years and has over 190 patents issued or pending. His many honors include the 2018 Laureate Recognition Award, the highest award given by the American Academy of Ophthalmology, and the first Founders Award given by the American Society of Retina Specialists. During our conversation, which has been edited for length and clarity, Dr. Charles provided his observations on efficiency in the operating room.

You still perform about 60 surgical procedures each month, most of them in an ambulatory surgery center (ASC). Can you talk through your typical day of surgery?

I average about 16 procedures a week, but I haven’t been on vacation since 1996, so I work 52 weeks a year. I’ve had block time on Tuesdays and Thursdays ever since the surgery center opened. Before that, I had block time on Tuesdays and Thursdays at a hospital outpatient department. I’ve been in practice since July 1975 and I’ve always operated basically all day on Tuesdays and Thursdays. I start at 7:30 AM, I do around eight cases and sometimes nine, and finish up at 4:30 or 5 PM. In the old days, it used to be much longer; I’ve finished up sometimes at 9 or 10 o’clock at night, but that hasn’t been the case for many, many years.

How is your surgical day planned or organized? Are there certain cases you prefer to do earlier, or later, in the day, and why?

 When I see patients, I have a scribe that’s been with me since 1984. We also have an experienced surgical coordinator in the office. So there’s not a lot of discussion about the order of cases unless somebody’s extremely anxious or has some high pressure and pain in their eyes so you want to expedite them. You also want to get kids done first. But for most cases it’s just scheduled as first come, first served, in terms of filling those operating room days.

What about emergency cases? How do you incorporate those into your surgery days?

 My associate, Dr. Stephen Huddleston, operates on different days than I do, so we’re usually able to cover those cases. If a patient comes in at 3 o’clock in the afternoon, but they just ate a slab of ribs, their detachment can wait until the next day, when they’re NPO. But let’s say somebody comes in early, or a case is referred from an optometrist or ophthalmologist the night before as a possible retinal detachment. We tell them, “Come in at 7:30 AM to the office, don’t eat breakfast, and somebody in the office will evaluate you right away,” and then they’ll send the patient over for surgery. So I might book six cases for a surgery day, and the afternoon before that day another case will be added so now it’s seven, and then in the morning another case might show up to make it eight. That works for Monday through Thursday in the ASC. We do have some hospital access on Fridays when necessary. Most people I know that are high volume and organized have a schedule somewhat like mine. They’re not doing weekend or nighttime surgery.

There are certain cases that must be done at the hospital, not in the ASC, such as when the patient weighs over 300 pounds. You need to have a hospital backup for patients that are too sick for the surgical center—over 300 pounds, on dialysis, or with diseases like sickle cell that can cause problems with anesthesia. You’ve got to have a good relationship with the hospital and treat them well, but you’re going to find your schedule less than flexible at the hospital.

It sounds as though you prefer operating in the ASC, is that right?

 I prefer the ASC. Clearly, we’re faster in the surgical center than when we operate in hospitals. One of the reasons is architectural: In the ASC, the distance from the autoclave to the operating room is usually just a few feet. In some of the hospitals they literally take the instruments to central supply, which is down five floors, with people who’ve never seen the kind of cases we do.

The key elements of efficiency are staffing and supply chain management, not necessarily that you’re in an ASC. If you have consistent staffing and high-quality supply chain management, it is possible to be efficient in a hospital. The problem is that unless you operate all day, every day, five days a week in the hospital, you’ve got to share people that have many other important functions—heart surgery and neurosurgery and orthopedic surgery and abdominal GI surgery.

Can you tell me a little more about how your staff contributes to surgical efficiency?

 Consistent staffing is a big deal. We have three people that scrub for us in the ASC that are all employees of our office and are extremely experienced. My associate and I pay our scrub techs, even though the surgery center is supposed to supply them. To have the very best surgical techs, pay them yourself. Does that decrease your profitability from surgery? Absolutely, but it pays off in greater efficiency and better outcomes. Good people are expensive and worth it.

You want to train the operating room staff yourself and explain every step. You can’t pass off training to someone who doesn’t understand the intricacies of the procedure. I’ve found that using Ngenuity, the 3D heads-up display from Alcon, provides a big advantage. You have a 55-inch screen showing the surgery, so now the anesthesiologist, the circulator nurses, and the scrub techs see exactly what you’re doing and they’re able to anticipate your next move. I rarely ask for something during regular cases. My hand lifts ever so slightly, and somebody takes an instrument out and puts another one in without a word being spoken.

If you work with rotating staff in an ASC or hospital, it’s even more important to tell them what you’re going to do, and why you’re doing it, ahead of time so they understand the steps. These people work very hard and they’re multifunctional—they do orthopedics on Monday and gallbladders on Tuesday afternoon and neurosurgery on Wednesday, then they do your retina case on Thursday. As the complexity of our equipment increases, they can’t be expected to know every nuance of what you’re going to do.

In terms of supplies, tell your team exactly what you want ahead of time. Say, “For this case, I’m going to use this, this, and this. Bring this one into the room but don’t open it. I might need it and we don’t want to delay, but I don’t want to open it and waste $100 if it turns out we don’t need it.” That preparation and game planning is an important aspect of efficiency.

You’ve helped to develop many of the advances in surgical instrumentation over the past few decades. Can you speak about these innovations, and how newer systems contribute to surgical efficiency?

 I’m the principal architect of Alcon’s Accurus and Constellation systems. The concept came from my experience flying jets for 40 years. In the cockpit you don’t want 10 different types of radios and radars and flight management systems that have compatibility issues, you want to have an integrated suite of systems that work together. So I came up with the idea of having so-called “smart keys,” push buttons around the perimeter of the display for different tasks, while other things are “global functions,” meaning they are always ready, like infusion, illumination, or diathermy. These things operate without you having to cognitively think about it and that’s an important deal. When you have a single console that supports every function—laser, illumination, silicone oil injection, gas, phaco, vitrectomy, fragmenter—all these functions in one box with one foot pedal and one power cord and one pack and one vendor, that makes it much more efficient.

There are some details that speed up turnover time. The Constellation has the first push-prime system, so instead of sucking fluid up to the vitreous cutter and fragmenter and extrusion cannula system to prime them with fluid, it pushes it, which is much faster and also allows it to calibrate the fluidic resistance in the infusion system, which does what’s called flow compensation. Secondly, I have a patent on RFID [radio frequency identification]. RFID is built into so-called smart connectors, so when you plug something into the console, it configures the console. It’s plug and play, so RFID saves a lot of time. That’s a huge advantage.

What advice would you share with a vitreoretinal surgeon who is just starting out?

 First, younger retinal surgeons should learn how the equipment works. I know surgeons who can’t turn the equipment on. They have no idea how to turn on the laser, change the illumination, or change settings on the console. If their nurse is out sick that day or has a family emergency, which happens, they get upset.

Second, sit down with your scrub tech and carefully decide what should be included in your custom surgical packs. Don’t count on someone else to do this. Evaluate each item and ask yourself, “Is this something I really don’t use anymore?” Every single disposable should be there for a reason, not just because your attending once told you to include it, even though he/she didn’t use it either. Think through your pack and be engaged in that process.

Third, understand how the supply chain works. You never want your nurses saying, “Oh, we don’t have that, we’ve got to order it,” or “We ran out of this, we ran out of that.” There’s such variability in retinal surgery about what you need for each case. There should always be a cache of critical items available in a cabinet in the operating room, so if that you find something you didn’t expect—which happens not infrequently in retinal surgery—you’ll have everything you need. If you have almost no inventory except for basic pack and everything else is special order, you’re going to be markedly inefficient and you’re going to have lower-quality patient outcomes. ■