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BLOG: Do you really expect me to open the posterior capsule?
In this issue of OSN, our cover story tackles a very challenging subject: posterior capsule buttonholing and posterior optic capture during cataract surgery. For those unfamiliar, this involves posterior capsule rhexis after lens removal. To keep vitreous at bay, viscoelastic is injected into Berger’s space after the initial nick is made in the posterior capsule. The implant is placed in the bag as usual, but the optic is prolapsed through the posterior capsulotomy to secure it.
Right. And every surgeon is going to embrace that?
I believe we should try, but getting there will require us to answer some uncomfortable questions about the realities surgeons face.
1. Can we overcome our fear? What’s the one complication every resident dreads? What single statistic separates great surgeons from others? What one event during cataract surgery raises blood pressure because of a suddenly uncertain outcome? And now we want surgeons to do that on purpose? Will all of us consistently be able to maintain the anterior hyaloid face, avoiding increased risk of retinal detachment, cystoid macular edema and possibly glaucoma? In a world of continuous data collection on surgeons and outcomes, will we be “dinged” for rupturing the capsule even though we did so on purpose? Will plaintiffs’ attorneys find fault with us in the event unrelated complications arise? Some of these fears are easier to dispel than others, but all create inertia for the status quo.
2. What techniques and instruments will ensure success? To overcome fears, we need a clear set of steps and tools for every surgeon. The pioneers of this technique, such as Menapace, Tassignon, Arbisser and others, have standout surgical skill, but we are a field of individuals, each with varying abilities. And not every facility can afford a femtosecond laser. The only way forward is a technique with instruments and methods that can be taught to and consistently performed by a second-year resident.
3. How will this be reimbursed? Payments for surgery are declining, and we will likely eventually move toward bilateral same-day in-office surgery. Any added time or steps must earn their place inarguably in the streamlining world of cataract surgery. Many surgeons quietly appreciate the YAG capsulotomy procedure as a “second bite at the apple” of reimbursement. If we eliminate PCO, what will fill that void? A separate billing code for primary posterior capsulotomy might just be needed.
4. Will vision and results be better? Probably so. Primary posterior capsulotomy, particularly if it can be performed with high precision and reproducibility, opens a world of refractive options for new implants, such as the “bag-in-the-lens” design. The posterior capsule’s axial position varies minimally, so effective lens position is much easier to predict. But we need approval of new lenses to take advantage of this procedure to drive motivation. How can we expedite this?
5. Is it the right thing to do? I have addressed practical considerations first, but this is really the most important question, and the answer is probably yes. How many patients suffer with years of declining vision before getting a YAG laser? Is that really necessary? Shouldn’t the most commonly performed surgery — cataract surgery — be “one and done?” And how much pride will we feel when we’ve adopted a successful new technique motivated solely by the benefit of the patient? Prioritizing our patients’ well-being may not always be the easy thing to do or the profitable one, but it honors the reason most of us went into medicine, and through a less obvious path this usually leads to practical rewards as well.
With many of my colleagues, I share a lazy comfort with the current standards in cataract surgery. Still, I genuinely hope there will be cooperation among innovators to devise techniques, industry to create technologies and CMS to propose a financial pathway for primary posterior capsulotomy to become an easy reality for our future patients.