Presbyopia surgery, floppy iris syndrome, endophthalmitis are hot topics in cataract surgery

In this report from the OSN Section Editor Summit, David Dillman, MD, discusses trends from the past year and the concept of “humanitarian risk management.”

Issue: June 1, 2006

ByDavid Dillman, MD

A note from the editors:
Ocular Surgery News convened its annual Section Editor Summit in Las Vegas in March. In this third installment of reports from the OSN Section Editor Summit, Cataract Surgery Section Member David Dillman, MD, gives an update on his subspecialty.

The May 2005 ruling by the Centers for Medicare and Medicaid Services, allowing doctors to bill and patients to pay outside of the Medicare system for accommodating and multifocal IOL surgery, introduces new factors into the presbyopia surgery equation. As I report on this topic, I am going to borrow heavily from the thoughts of OSN Cataract Surgery Section Editor William F. Maloney, MD.

Establishing and documenting appropriate patient expectations are important, and that is going to take a lot more preoperative counseling. A good way to approach this is through Dr. Maloney’s zones of vision (see Table). Patients also are paying for you to meet their expectations for daytime needs, nighttime needs, indoor needs and outdoor needs.

Once we have selected a proper patient, the surgeon must meet those expectations, and a big part of that is having proper IOL calculation with proper biometry. Dr. Maloney feels that this requires use of the IOLMaster (Carl Zeiss Meditec). Not every surgeon may agree with that, but certainly excellent biometry is important. Dr. Maloney also feels that the surgeon — especially with the IOLMaster – should be doing the biometry because he feels, “It’s as skill-specific as the surgery itself.”

Proper IOL selection

Meeting those expectations also means picking the proper IOL. Some surgeons believe that the crystalens (eyeonics) works best for distance, the ReZoom (Advanced Medical Optics) is best at intermediate, and the ReSTOR (Alcon) is best at near. If that is true, then does it make any sense to try to combine these technologies? Can you combine an accommodating lens with a diffractive multifocal lens? Can you combine an accommodating lens with a refractive multifocal lens? Can you combine a diffractive and a refractive multifocal lens? Are these technologies compatible? Do they enhance binocular summation, or do they negate binocular summation? The jury is still out on those issues.

Another area that we have to be able to justify in the reimbursement equation is enhancing and refining. This takes on two separate forms. The first is what I call “verbal enhancing and refining.” This is the extra chair time it takes to talk to these patients postoperatively to both counsel them and to coach them on how to use their new vision.

The second form of enhancing and refining is further surgical intervention. What if we miss our spherical or astigmatic target and we need to do a second procedure? That is going to incur additional costs, both for equipment and for the operating room.

Dr. Maloney is passionate about this form of surgery. He has stated, “The surgeon first becomes an architect and designs this surgery before the ground is broken. He then builds the surgery according to his blueprints.”

Intraoperative floppy iris syndrome

Another big issue facing cataract surgeons is intraoperative floppy iris syndrome, described by David Chang, MD, and John Campbell, MD. It relates to the adverse, intraoperative events that can occur in cataract surgery with patients taking Flomax (tamsulosin HCl, Boehringer Ingelheim), a drug for benign prosthetic hyperplasia. In January 2005, the American Society of Cataract and Refractive Surgery sent a warning out to its members about intraoperative floppy iris syndrome.

There is a triad of symptoms with this that occur intraoperatively during cataract surgery. The iris becomes floppy and unstable. The floppy iris billows in response to normal irrigation currents in the anterior chamber. It tends to prolapse through all incisions, even the side-port incision. The pupil tends to get much smaller as the surgery progresses. In my experience, this is a real phenomenon, and it makes cataract surgery extremely difficult.

If we need to alter our surgical technique, what are the surgical options? The first option is to discontinue Flomax use. It is important for ophthalmologists to know that Flomax is sometimes prescribed for women off-label for urinary retention. In our practice we ask everybody if they are taking Flomax prior to cataract surgery. If so, we ask them to try to stop it 2 to 4 weeks beforehand, but we never tell them to stop using it without first consulting with the doctor who prescribed if for them. What you need to understand is, even if they do stop, it still may not have much of a positive effect on the surgery. Other strategies to use in dealing with floppy iris syndrome include low flow and low vacuum settings, iris retractors, and the Healon5 (sodium hyaluronate 2.3%, Advanced Medical Optics).

Endophthalmitis increasing

Another important trend in cataract surgery to discuss is the apparent increase in the incidence of endophthalmitis. A study by Emily West, PhD, and colleagues of Johns Hopkins from June 2005 reviewed a 5% sample of Medicare claims from 1994 to 2001. They looked at a little more than 1,000 cases of endophthalmitis in a large number of cataract surgery cases. Dr. West found an endophthalmitis incidence of about 2.15 per 1,000 cases, which sounds relatively reasonable to me. The study also showed that from 1998 to 2001 there was a significant increase in the rate of endophthalmitis, but they made no attempt in this study to address why.

The troubling question in all of this is, if the incidence is rising, is it because of the clear corneal incision? There are some studies that would indicate that maybe this is true. In 2000, a study in Canada showed that when they went from scleral-based incisions to clear corneal incisions there was a 2.5-fold increase in endophthalmitis. That’s not 2.5%; that’s a 250% increase.

A study in Japan showed a 600% increase in endophthalmitis when they went to clear corneal incisions.

Learning curve

If indeed there is a correlation between the advent of clear corneal incisions and an increased incidence of endophthalmitis, I think it is from a clear corneal incision that is not properly constructed. There is a learning curve to this, much as when we all made the transition from extracap to phaco, and we had a higher incidence of broken posterior capsules, which is now no longer the case.

Another explanation is that there is antibiotic resistance now; however, we have not seen an increase in endophthalmitis in penetrating keratoplasty, trabeculectomies or other intraocular surgeries. I am putting my money on the learning curve.

I think those of us who have been performing clear corneal incisions for a long time believe that there is not an increase in endophthalmitis; those who are newer to it might believe that there is.

Humanitarian risk management

I do not think anybody would argue that there is a medical malpractice crisis in our country. I think one of the reasons for this is the traditional risk management approach to complications and undesired outcomes, which is to deny and defend. A newer approach that has been espoused is called humanitarian risk management, and this is what apology and disclosure are all about.

One of the main organizations involved with this movement I am currently aware of is called Doctors in Touch, led by Michael Woods, MD. The Web site for Doctors in Touch is www.doctorsintouch.com.

The other organization that works more with institutions rather than individual doctors is called Sorry Works, headed by Doug Wojcieszak, MD, and the Web site is www.sorryworks.net.

Whenever there are complications or unexpected outcomes it can be for a variety of reasons. Regardless of the reason, instead of denying and defending, we should be apologizing and disclosing. Keep in mind there is a huge difference between apologizing and admitting wrongdoing or admitting guilt. Dr. Woods, in his book "Healing Words: The Power of Apology in Medicine,” really takes a hard look at these two ideas in medicine.

Patients want to know what happened, how will this affect their vision now and in the long run, why did this happen, what is being done to make them better, who is going to pay for all of this, and what the doctor is going to do to make sure this does not happen to someone else.

There are the four R’s of apology. The first is recognizing the need for apology. I am starting to think that if I wish this hadn’t happened then I probably should apologize for it. The second “R” is regrets, which is simply to honestly inform the patient that you are sorry that this happened and you recognize that this is troublesome for them. The third “R” is for taking responsibility. We are going to accurately disclose to the patient everything we know that happened, and we say “I,” not “We.” Basically, you are making sure that everybody, the patient, staff, and family stays informed. And then the last “R” is remedy. “Plan A, here is what I’m doing now. Plan B, here is what the options are in case Plan A doesn’t work.” We discuss who is paying for what, and then again what’s being done to prevent this from happening to another patient.

Next issue

Jack T. Holladay, MD, MSEE, FACS, OSN Optics, Refractive and Contact Lenses Section Editor, discusses the latest in optics as it pertains to cataract and refractive surgery.

For more information:

David Dillman, MD, can be reached at Dillman Eye Care Associates, 600 N. Logan, Danville, IL 61832; 217-443-2244; fax: 217-443-6779; e-mail: dadomer@aol.com.

References:

Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery. Can J Ophthalmol. 2000;35(7):373-378.

Nagaki Y, Hayasaka S, et al. Bacterial endophthalmitis after small-incision cataract surgery: effect of incision placement and intraocular lens type. J Cataract Refract Surg. 2003;29(1):20-26.

West ES, Behrens A, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare population increased between 1994 and 2001. Ophthalmology. 2005;112(8):1388-1394.