I wish I hadn’t done that: Oops, I did it again
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This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
Recently, I had a day in the operating room in which not only did I break two posterior capsules, but in both cases, I dropped nuclear pieces into the back of the eye. Believe it or not, this is not even the bad part of the story.
The bad part comes next and relates to how I completely flubbed the postoperative management of one of these patients. Both patients had the same problem on the same day as a result of my surgery, but one of the patients thinks I hung the moon, and the other thinks that I butchered her. This difference of opinion has absolutely nothing to do with the surgery itself and everything to do with how I handled the complication after the operation.
The first patient was a gentleman with high myopia being operated on for a mild cataract. The surgery was going fine until — upon video review, I discovered — I blew the posterior capsule out during hydrodissection. Immediately after the phaco handpiece was placed into the eye, the entire lens fell into the posterior segment. This shocked me to no end, of course, because I had not suspected any problem with the case up to this point. Seeing this, I immediately placed a three-piece IOL into the sulcus with reverse optic capture, removed a few cortical remnants and concluded the case. Then I explained to the patient: “During your surgery, a defect was discovered in the posterior capsule that contains your natural lens. As a result, when trying to remove your lens, it descended into the back part of the eye, where it was unsafe for me to remove. I was able to place a new lens into your eye, but removing your old lens will require the assistance of a retina specialist.”
I called a retina specialist that morning and sent the patient over for an immediate same-day consultation. Our friendly neighborhood retina specialist was extremely reassuring and upbeat and, 1 one week later, removed the retained nucleus from the eye in a second operation. Three weeks after that, I saw the patient back in clinic — 20/20 uncorrected and thrilled, not only with me, but also completely charmed by the retina specialist. Somehow, I got the distinct impression that he was happier with the surgery as a result of the extra attention.
Later this same surgical day, however, I was performing a second cataract operation on a different patient. This was a significantly more challenging situation: a dense cataract in an eye with a previous vitrectomy, actually referred by this same neighborhood retina specialist. After a lengthy surgery, I observed a defect in the posterior capsule after my phacoemulsification was complete. This, of course, was my second posterior capsule rupture of the day, and my heart sank when I observed it. Very carefully, I removed the lingering cortical remnants and again placed a three-piece lens in the sulcus with reverse optic capture. This time, when I concluded the operation, I told the patient about the defect in the posterior capsule but nothing about any pieces dropped into the back, chiefly because I did not see any. I thought maybe we got lucky.
I saw the patient the next day. Everything looked fine. The lens was in place, the eye was quiet, and vision was good. But over the course of the next few weeks, things got worse. The eye became more uncomfortable. Vision worsened. Inflammation increased. Pressure went up. Repeat dilated exams did not show any nuclear fragments in the back of the eye. As a result, I tried to remain upbeat and encouraging: “Things are going to get better. You’re going to do OK.” Meanwhile, the patient was objectively getting worse and subjectively feeling much worse. The gap between her experience and what she was hearing from me widened. Three weeks after the procedure, she returned to see her retina specialist who indeed did discover a piece of nucleus in the vitreous, and she was scheduled for vitrectomy to remove it. Naturally, the patient was irate — a problem was discovered that had been missed by me, and in fact, she had never been told that there was a piece of lens in the back of her eye. Quite reasonably, she concluded that the surgery was botched, and she was being managed by a doctor who did not know what he was doing. She was not wrong to feel this way.
The key difference in these patients who experienced basically the same problem on the same day was that one was sent immediately to a retina specialist and the other was not. I was so embarrassed to be sending one retina doctor two posterior capsule ruptures in the same day that I held onto the second patient. Maybe if this second complication had happened on a different day, I might have behaved differently. This means, of course, that I am making medical decisions on the basis of something other than what is in the best interest of the patient.
Several of these recent columns have centered on the subject of denial, which, in my own personal case, seems to be a common factor in my worst outcomes. In this particular case, the specific lesson is to refer patients with posterior capsule ruptures promptly to a retina specialist, regardless of whether you think any fragments have fallen into the back of the eye or not.
Another point that could be gleaned from this misadventure is that it is so important to be comfortable having difficult conversations with patients and referring doctors. We are all trained on how to manage a posterior capsule rupture surgically, but we are less often trained on how to manage the problem socially or interpersonally — that is, what to say to everybody. What you say has a drastic impact on how the patient experiences life after the operation. If you are not comfortable having these conversations, then you will not do a good job, and you will be less likely to initiate them, leaving everyone worse off. Ultimately, I think you can rehearse these conversations in advance. The alternative is rehashing the conversation in your mind, over and over, after the mistake, thinking to yourself for weeks or months about what you should have said differently.
- For more information:
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
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