Publication Exclusive: Case selection important when learning new techniques, trying novel devices

There is a range of difficulty that we encounter during cataract surgery, with some cases being significantly more difficult than others. At the beginning of our careers when we are learning the basics, it is important to select patients who are anticipated to have a straightforward surgery so that we can hone our skills while minimizing complications. Because surgery constantly evolves, learning is a life-long pursuit for experienced surgeons as well, with new techniques, devices and instrumentation coming every year. When trying these new ideas for the first time, we must choose appropriate cases so that we can learn while maintaining a margin of safety for our patients.

An easy phaco case vs. a difficult case is usually determined by a few key factors: patient cooperation, exposure to the cataract, density of the nucleus, condition of ocular structures and patient healing ability. A softer nucleus in a younger patient with great dilation tends to be easier to perform than a dense nucleus in an older patient with poor dilation.

Uday Devgan

Key factors of surgery

Patient cooperation means ability to tolerate the surgical procedure as well as the willingness of the patient to accept the risks of surgeries and to have reasonable expectations. A patient with ocular comorbidities must understand that the cataract surgery may only correct part of the vision, that the rate of complications is higher and that another surgery may be needed. In addition, the patient should be able to lie flat and endure the procedure while holding still under light sedation. Patients with orthopnea or spinal lordosis may be mentally cooperative but physically unable to lie flat and therefore pose additional challenges.

Exposure to the cataract is important for safe and comfortable surgery. A patient with a prominent brow or a tight pupillary fissure makes it difficult to access the eye during surgery, particularly from a superior approach. Within the eye, a poorly dilating eye makes access to the cataract more difficult and may necessitate the use of hooks or rings to provide further exposure.

The condition of ocular structures relates to the health and stability of the cornea, iris, capsular bag and zonular apparatus. A patient with a weak or irregular cornea, particularly one with a low endothelial cell count, is more likely to have postoperative complications from surgery. If the iris musculature has been adversely affected by drugs such as tamsulosin, it is more likely to be floppy and prolapse during cataract surgery. The capsular bag and zonular structures are critical to hold the nucleus in place during phacoemulsification as well as to accept the IOL.

The condition of ocular structures also relates to the posterior segment of the eye. The vision in patients with retinal disease or optic nerve pathology will be limited, and cataract surgery alone may not improve their vision sufficiently enough. Patients with retinal breaks or weakness may be more prone to developing a retinal detachment after an uneventful cataract surgery. And those with advanced glaucomatous damage to the optic nerve can experience irreversible damage from the phaco surgery.

Patient healing relates to the ability to recover good vision quickly after surgery with an uneventful postop period. Patients with concomitant health issues such as diabetes can have poor wound healing, worsening of their retinopathy and cystoid macular edema after even a well-performed cataract surgery. Patients with a history of uveitis can have a prolonged course of inflammation and more potential complications than others. Even compliance with postoperative eye drops plays a role in the patient’s healing process.

Click here to read the full publication exclusive, Back to Basics, published in Ocular Surgery News U.S. Edition, June 25, 2015.