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Meticulous attention to detail can help prevent or manage surgical complications
Cataract surgeon outlines how to deal with perioperative and postop problems such as a capsular rupture or poor vision quality.
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Careful assessment of complications during and after surgery can assist physicians in treating problems such as broken capsules, vision quality and pupil size.
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Roger F. Steinert, MD, spoke at a symposium on managing complications at the American Society of Cataract and Refractive Surgery meeting. He outlined how to handle a capsule break and postoperative problems, including vision problems and pupil size.
The best management for complications is prevention, but problems arise perioperatively and postoperatively for even the most cautious surgeons, he said. Physicians should know the basics, including proper cortical clean-up, correct size of capsulorrhexis and correct power of the IOL implant to help in preventing mistakes and fixing them when they occur.
“The common denominator is the cornea – cornea health, corneal optics, the capsule, both the fixation and the clarity, and the pupil – is it at the wrong side, the wrong location, the wrong acuity? And then finally, the IOL optics themselves, our accuracy and the performance of the IOL itself,” he said.
Perioperative
When complications arise during surgery, Dr. Steinert said surgeons should stop, evaluate the situation and identify the problem.
If the capsule breaks during surgery, the first step is to evaluate exactly what has happened, he said. If the capsulorrhexis is “bad,” or an ineffective incision, but the posterior capsule is still intact, the surgeon must determine if haptic fixation is possible. If haptic fixation can be performed, most IOLs can still be implanted and the procedure can be completed as planned.
Before proceeding, however, Dr. Steinert recommended that surgeons incise the capsulorrhexis about 160° opposite the break to prevent a decentered capsule. He noted that when fixating in the capsule, accommodating IOLs cannot be used; multifocal IOLs that allow sulcus fixation can be used but are designed for smaller eyes.
If the capsule is broken and has vitreous loss, the capsulorrhexis could possibly still be fine, he said. In those cases, a multifocal lens can be used, but an accommodating lens cannot be used. It is important in such cases that the multifocal lens be centered because the capsulorrhexis will “drive” the centration to the implant.
If both the capsulorrhexis and posterior capsule are ineffective and broken, the safest option is to use a monofocal IOL, which is more forgiving regarding centration, Dr. Steinert said.
“If you are feeling adventurous, skilled and lucky, again, you can consider sulcus fixation of a multifocal lens,” he said.
He emphasized that when doing sulcus fixation in such cases, it is critical to “do it perfectly or not do it at all.” If the case is not centered, the procedure could be unsuccessful, Dr. Steinert said.
Postoperative
After surgery, Dr. Steinert said, a surgeon might think the procedure was successful, but the patient may have a different opinion. If a patient says he or she has visual problems, the first step is to take a careful patient history.
“Listen closely to the patient, and by that I mean, don’t ask leading questions,” Dr. Steinert said. “Patients are often prompted to say what you want [them to say], but there are moments when you have to hear what they’re saying. Given a chance, there are some patients who can articulate the loss of contrast sensitivity – you just have to tease that out.”
He said physicians need to ask questions to determine the exact problem. If a patient says that his or her vision is “not good,” a physician should ask for more specific answers, such as “Is your vision cloudy or blurry?” or “Do you have halo or glare?” Further questioning should determine the quality of near, intermediate and distance vision.
Physicians should do a careful manifest refraction using a defogging technique, especially in multifocal and accommodating patients. Surgeons should also immediately have a corneal topography taken, he said. The topography could assist in setting the refraction, in respect to cylinder. Testing for halo and glare by simulating it with light can assist in determining which eye is experiencing the side effects, Dr. Steinert said.
“The other thing is to go slow,” he said. “Although it’s tempting to say, ‘Well, it’ll get better if I implant the other eye,’ if you want an angry patient, do the wrong thing twice.”
If a second eye is being implanted, physicians should rethink their plans for the implantation, Dr. Steinert said. The mixing-and-matching technique could be effective at this stage. However, if the patient’s intermediate and distance vision are not adequate, there is a definite problem, he said. He recommended checking the posterior capsule and then doing a YAG capsulotomy.
Another possible postop complication could be that the pupil is too small, preventing good near vision, Dr. Steinert said. He said technicians in many offices automatically dilate the pupil as soon as there is a problem, but physicians should first exam the patient before dilation to detect problems with the pupil. Alphagan (brimonidine tartrate, Allergan) can help reduce some pupils with different lighting conditions and will not constrict, he said.
“Start with Alphagan, and if that doesn’t do the trick, we use pilocarpine, which you can get commercially at 0.5% and you can dilute it further if you need to,” he said.
For more information:
- Roger F. Steinert, MD, can be reached at Eye Institute at University of California, Irvine, 118 Med Surge I, Irvine, CA 92697-4375; 949-824-8089; fax: 949-824-4015; e-mail: steinert@uci.edu. Ocular Surgery News could not confirm whether Dr. Steinert has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.