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Is 99% success considered a failure?

Advanced technologies help premier surgeons reach even higher levels of success.

Issue: November 10, 2014

ByMitchell A. Jackson, MD

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How many times does a premium surgeon ask himself, “I wish I could be wrong ___% of the time and keep my job” and, more importantly, avoid a major malpractice lawsuit.

As for percentages and success, Kevin Durant was the NBA MVP and shot only 50.3% from the field, meaning he missed half his shots. Philip Rivers, one of the league-leading NFL quarterback passers, had a 69.5% completion percentage, but he still missed 30.5% of his passes. In 2013, Miguel Cabrera of the Detroit Tigers led the league in hitting at .348, which meant he got a hit 35% of the time. Ty Cobb, considered the best hitter of all time at .366, had only a 37% success rate. Actually, all of these hall of famers and/or future hall of famers are only successful 35% to 50% of the time at what they do best professionally.

Although the definition of success for these high-caliber athletes is “the attainment of popularity or profit,” the meaning changes when it comes to being a premier surgeon and is “the accomplishment of an aim or purpose.” Every day a surgeon tackles the surgical schedule of simpler and more challenging cases, a 100% success rate is expected by both the patient and surgeon. Anything less than 100% is considered a failure, and premium surgeons are not even going to the hall of fame when less than 100% success is achieved. Rather, they are probably going to a deposition in the near future.

Corneal topography devices, guidance systems

So how do we assure that our surgical success approaches the 100% mark every day in the OR? As an anterior segment surgeon, our armamentarium has increased dramatically in the last 2 years. Corneal topography devices have evolved into separating out corneal from lenticular astigmatism with devices such as OPD III (Marco Ophthalmics) and iTrace (Hoya), and devices such as the Cassini (i-Optics) and Galilei (Ziemer) calculate total corneal astigmatism accounting for posterior corneal effect, as published by Koch et al in 2012 and 2013. Devices such as the Cassini also allow for iris registration and toric axis guidance at the time of cataract surgery with femtosecond laser technology, either with astigmatic incisions and/or toric IOL alignment. Cassini can be linked with the Lensar system (Lensar), specifically when coupled with TrueVision. Other guidance systems include Verion (Alcon) and Callisto (Carl Zeiss Meditec), the latter linked with the IOLMaster used preoperatively. These newer guidance systems create digital overlays that allow for a markerless approach to toric IOL placement, astigmatic incision steep axis placement, and improved centration and alignment guidance even in the case of multifocal IOLs.

Femtosecond laser technology

Femtosecond laser technology has evolved with several U.S. Food and Drug Administration-approved platforms including Lensar, Victus (Bausch + Lomb), Catalys (Abbott Medical Optics), LenSx (Alcon) and Femto LDV Z6 (Ziemer). All of the platforms except for Ziemer have approval for anterior capsulotomy and lens fragmentation, and all of the platforms have approval for clear corneal and arcuate incisions. All of the systems utilize optical coherence tomography for digital imaging except for Lensar, which uses its patented Augmented Reality system with Scheimpflug 3-D high-definition imaging and biometric measurements of the cataract in up to 16 different locations regardless of nuclear density. OCT-based systems have a limitation in that they typically only display one sagittal and one transverse scan of the lens. In the end, with all these femtosecond laser systems, fragmentation of the lens can be optimized to allow for phaco energy reduction, with potential corneal endothelial insult minimized and faster visual recovery. I found that the use of Lensar has essentially eliminated my need for epinucleus removal at the time of the phaco portion of the cataract procedure, minimizing another risk of posterior capsule tear/rupture. Astigmatic arcuate incisions have especially impressed me with femtosecond laser technology due to their precise placement and depth accuracy as compared with manual limbal relaxing incisions in my hands. The Scheimpflug imaging with the Lensar allows for reimaging of the cornea just seconds before creating the incisions, thus minimizing the risk of an inadvertent corneal perforation. Precise sizing of the anterior capsulotomy with all these systems ultimately aids in the proper effective lens position for most posterior chamber IOLs used today and is especially helpful with accommodating IOLs such as the Crystalens and Trulign toric (both Bausch + Lomb).

Intraoperative aberrometry

The final hurdle to truly achieving improved outcomes and trying to surpass the success percentage of most hall of fame athletes has come, in my experience, with intraoperative aberrometry. The ORA system with VerifEye (Wave-Tec Vision) and Holos IntraOp (Clarity Medical Systems) allow for real-time aberrometry, which is especially useful in aphakic spherical power selection and pseudophakic toric IOL alignment in post-refractive cataract cases. Since my inception of femtosecond laser creation of arcuate incisions, I have also used the pseudophakic limbal relaxing incision mode to determine if my arcuate incisions need to be opened intraoperatively or if I should wait to titrate a response postoperatively at the slit lamp. My data series in a subset of post-LASIK cataract patients utilizing preoperative Haigis-L software analysis from the IOLMaster 500, as presented at the 2013 European Society of Cataract and Refractive Surgeons meeting, yielded 83% predictability within ±0.5 D postoperatively. With the addition of ORA intraoperatively to this same subset of patients after my Haigis-L analysis preoperatively, my data improved to a level approaching the desirable 93%+ predictability seen with LASIK outcomes.

The good news for premier surgeons: In 2014, we are approaching success rates in the 90% range with all of the newer advanced technology as part of our armamentarium, and although we are not being inducted into the hall of fame for 30% to 50% success, we are bringing great outcomes to our patients and hopefully avoiding medicolegal risk.

Stay tuned for next month’s Premium Channel column — a top 10 femtosecond laser fact vs. fiction analysis for today’s premium surgeon.