American Academy of Ophthalmology Web Site: www.aao.org
Original URL:

 
Feature
60 Questions: Cataract Complications and Complicated Cases
By David F. Chang, MD, Program Co-Chairman
 
 

During the Spotlight on Cataract Surgery Symposium at the 2005 Annual Meeting, audience members anonymously responded to speaker questions about complicated cases and intraoperative complications. Their candid answers follow.

This past October, the Spotlight on Cataract Surgery Symposium at the American Academy of Ophthalmology’s Annual Meeting was entitled New Pearls on Managing Complicated Cases and Complications. My program co-chairman was Louis D. “Skip” Nichamin, MD, chairman of the ASCRS cataract clinical committee. In all, 30 different speakers addressed topics ranging from managing a descending nucleus to how to inform patients when a complication has occurred. During the symposium, an audience response poll was conducted. The 3,000 attendees could voice their opinions if they wished to do so by using one of the 1,500 interactive rapid response units available throughout the room. For each topic, two questions were posed, and the audience used the keypads to respond. The answers were tabulated and projected on a screen behind the speaker during his or her talk.

The results, all of which are presented here, are particularly interesting given the anonymous nature of this polling method. Read on for the questions and answers, as well as a commentary from each speaker.

Complicated Cases: 24 Questions

Managing the Abnormal Corneal Surface
Speaker: Edward J. Holland, MD

Q1: Your regimen for preop cataract patients with
blepharitis:
Generally disregard ...............  10%
Usually treat aggressively......  43%
Only treat worst cases  .........  47%

Speaker comment: As endophthalmitis is the most devastating complication of cataract surgery and the organisms responsible for this infection come from the ocular surface, it is surprising that 10 percent of the audience would disregard preoperative findings of blepharitis. Aggressive treatment of blepharitis will not only reduce the risk of endophthalmitis but also reduce some of the other postoperative problems such as unstable tear film and ocular surface findings that are associated with it.

Q2: Have you ever had a corneal melt with a topical NSAID post cataract?
Yes  ........................................ 12%
No, despite regular use  ......... 51%
Don’t use them regularly  ....... 37%

Speaker comment: Of interest is that 37 percent of the audience does not use nonsteroidal anti-inflammatory drugs (NSAIDs) routinely in post cataract surgery. Cystoid macular edema (CME) is the leading cause of visual loss after cataract surgery. There are excellent studies demonstrating the efficacy of topical NSAID use in preventing CME.

Phaco in Highly Myopic Eyes
Speaker: Robert J. Cionni, MD

Q3: In your experience, the hyperdeep AC during phaco:
Is not a significant problem ............................................................... 16%
Increases the rate of PC rupture  ....................................................... 13%
Makes phaco difficult, but hasn’t increased my complication rate  ...... 71%

Q4: For the hyperdeep AC, have you ever tried lifting the iris off of the anterior capsule?
Yes  ............ 21%
No   ............ 79%

Speaker comment: Although most surgeons do not believe that a hyperdeep chamber increases the risk for complications, most do feel that it makes phaco more difficult. In addition, patients undergoing phaco with topical anesthesia who develop a hyperdeep chamber will experience more pain during surgery. Still, most surgeons were not aware that simply raising the iris off of the anterior capsule will restore the chamber to normal depth. Hopefully, more and more surgeons will become aware of and begin to utilize this technique, thereby making surgery easier and relieving the pain felt by these patients.

Phaco in the Crowded Anterior Chamber
Speaker: Samuel Masket, MD

Q5: Your preferred viscoelastic for the crowded AC:
Maximally cohesive  ..... 14%
Dispersive  ................... 21%
Healon 5  ..................... 35%
Duo Visc  ...................... 30%

Speaker comment: It is evident that a plurality of respondents recognizes the benefit of a highly cohesive viscoagent for space maintenance in the crowded anterior chamber. Cohesive agents do not adhere well to ocular tissue; this helps prevent iris prolapse during surgical maneuvers. An understanding of the rheologic properties of the varied viscoagents is useful. 

Q6: Would you consider pars plana vitreous tap for a very crowded AC?
Yes  .............. 51%
No   .............. 49%

Speaker comment: Although roughly half of the respondents would not consider prophylactic pars plana removal of vitreous to enhance working space in the anterior chamber (AC), it is a valuable tool. Although it is infrequently necessary, it is a skill that should be acquired by most cataract surgeons.

Posterior Polar Cataract
Speaker: Abhay R. Vasavada, MD

Q7: Your estimate of PC defect incidence in posterior polar cataracts:
Less than 5 percent  ........ 27%
5 to 20 percent  ............... 45%
20 to 50 percent  ............. 19%
More than 50 percent  ......   9%

Speaker comment: Seventy-three percent of poll respondents estimate that, in eyes with posterior polar cataract, there is a 5 percent or greater incidence of posterior capsular defect. This implies that it would be desirable to postpone cataract surgery until the reduction of vision is significant. When surgery is elected, the patient should be informed of the possibility of intraoperative posterior capsular rupture (PCR), dropped nucleus, prolonged operative time, secondary posterior segment intervention and the possibility of delayed visual recovery. This also should alert the entire surgical team to be prepared for complicated surgery.

Q8: Your incidence of vitreous loss in posterior polar cataracts:
Less than 1 percent ......... 34%
2 to 5 percent .................. 40%
6 to 10 percent ................ 15%
More than 10 percent ......  11%

Speaker comment: Because posterior polar cataracts are associated with vitreous loss, the desirable strategy would be to adhere to the principles of closed chamber technique and to retain an epinuclear bowl that acts as a mechanical cushion to protect the posterior capsule during subsequent maneuvers.

Management of Iris Defects
Speaker: Kenneth J. Rosenthal, MD, FACS

Q9: Have you ever suture repaired an iris defect?
Yes ............... 71%
No  ................ 29%

Q10: Number of patients in your practice who would be candidates for artificial iris implant:
None .................. 22%
1 to 2 ................. 55%
3 to 5 ................. 16%
More than 5 .......    7%

Speaker comment: Until very recently the repair of iris defects was a daunting task, and many patients, yet untreated, continue to suffer from unwanted visual disturbances, such as photophobia, glare, halos and degradation of visual quality. With 10 years of experience in iris prosthetic implantation (three of these in clinical trials), we have the experience and knowledge to help this small but very visually needy patient population. Judging from the audience response, most practices have a small number of such patients. While iris repair will help some of these patients, iris prostheses offer surgical solutions to those with larger defects.

Diagnosing Zonular Weakness
Speaker: Robert H. Osher, MD

Q11: Number of times you’ve used a CTR:
Never ..................... 49%
1 to 2 ..................... 18%
3 to 10 ................... 19%
More than 10 .........  14%

Speaker comment: For the half of the surgeons who have never used a capsular tension ring (CTR), you can be certain that eventually a case of undetected preexisting or iatrogenic weakened zonules will be encountered. Have a CTR available and know how to use it because it will give your patient a better outcome.

Q12: Cases seen of delayed bag-IOL dislocation:
None .................  21%
1 to 2 ................  46%
3 to 5 ...............   22%
More than 5 .......  11%

Speaker comment: The jury is still out on how often we will see this syndrome in patients with pseudoexfoliation . . . my bet is very infrequently.

Capsule Retractors vs. CTRS
Speaker: Richard J. Mackool, MD

Q13: Percent of your cataract population with weak zonules:
Less than 1 percent ............ 24%
2 to 3 percent ..................... 42%
4 to 7 percent ..................... 24%
More than 7 percent ........... 10%

Q14: Preferred strategy for very deficient zonules:
Capsule retractors (the Mackool Cataract Support System) ..... 13%
Iris retractors for capsule .......................................................... 21%
CTR ............................................................................................ 27%
Refer to someone else ............................................................... 39%

Speaker comment: The audience poll indicates that 25 percent of those responding to the “incidence of zonular laxity” question did not answer the question regarding strategy. It is personally encouraging to see that more surgeons use retractors than CTRs; I designed the disposable capsule retractor to be superior to the iris hook for this purpose, although it’s slightly more difficult to insert and remove. I have found that retractors provide far better support to the lens during phaco and cortex removal than does a CTR, and that a CTR is best inserted just prior to IOL insertion (with the retractors still in place).

CTR Pitfalls
Speaker: Lisa B. Arbisser, MD

Q15: When do you insert the larger-sized CTR?
Never have used a CTR .......... 55%
Only in larger eyes ................. 34%
Always .................................... 11%

Speaker comment: It is a shame that it took so long for the CTR to become FDA approved because 55 percent of surgeons in this audience have not used one as yet. It is clear that the CTR is a necessary part of our armamentarium, and I hope the number [of users] will rapidly grow. The problem with sizing is that we can’t accurately know the size of the capsular bag, as it isn’t always proportional to the white-to-white measurement or the axial length. This might be an argument for using the larger-sized CTR, as overlap of the ends is not thought to be a problem. The larger rings, however, are stiffer and more difficult to place without zonular stress, so the balance of additional risk to benefit needs to be considered.

Q16: Assuming you’ve used more than five CTRs, have you ever torn the AC or PC with a CTR?
Yes ........ 25%
No  ........ 75%

Speaker comment: Twenty-five percent of respondents have ruptured the capsule with a CTR, which underscores the fact that this technology is not entirely benign. One should develop a set of criteria for when to use a CTR based upon the anatomy of each case. The CTR is technically not approved to promote future stability of the bag or lens but rather to prevent intraoperative complications when the zonular complex requires support. It has been suggested that the presence of a condition that may lead to zonular weakness, like pseudoexfoliation syndrome, is indication enough. Although many of us believe that there may be some ongoing protection, this has not been proven and is an off-label use of the device. I therefore choose to use the CTR when I judge there to be sufficient intraoperative evidence of zonular laxity or dehiscence.

Subluxated Crystalline Lens
Speaker: Ike K. Ahmed, MD

Q17: For intact bag but large zonular defects, I would favor:
AC IOL ............................................................. 15%
PC IOL in bag with sutured CTR or CTS ........... 42%
PC IOL in sulcus ............................................... 43%

Speaker comment: Although most respondents preferred either an endocapsular posterior capsule IOL (PCIOL) with a sutured capsular tension device or a sulcus-supported PCIOL in cases of large zonular defects, placement of a sulcus PCIOL in the presence of significant zonulopathy risks postoperative decentration. An anterior chamber IOL may also be appropriate in some patients, although the use of sutured capsular tension devices is gaining popularity in these complex zonular defect cases.

Q18: If it were FDA-approved in the United States, I would most likely use:
Cionni CTR ................................... 41%
Capsular tension segment .......... 35%
Neither.......................................... 24%

Speaker comment: When faced with profound zonulopathy, most respondents would most likely use a Cionni-modified CTR, or a capsular tension segment (CTS).

Intraoperative Floppy Iris Syndrome
Speaker: David F. Chang, MD

Q19: Percent of your Flomax patients exhibiting IFIS:
Have never seen IFIS ..................  20%
Less than 15 percent ...................  49%
15 to 85 percent ........................... 22%
More than 85 percent ..................... 9%

Speaker comment: It is surprising that the respondents have not experienced
a higher prevalence of intraoperative floppy iris syndrome (IFIS) in Flomax patients. In my own experience, some degree of IFIS is present in more than 95 percent of Flomax patients. This can range from mild to severe, however, and the wording of the question may have elicited only the severe cases of IFIS.

Q20: Your preferred management for IFIS:
Iris retractors ................ 46%
Pupil expansion ring  .....   5%
Healon 5  ....................... 35%
Other ............................  14%

Speaker comment: Iris retractors and Healon 5 are the most popular management techniques, which may reflect the higher cost and longer learning curve associated with expansion rings.

Capsular Staining: Indications and Techniques
Speaker: Steve A. Arshinoff, MD, FRCSC

Q21: Your preferred capsular dye:
ICG ........................................................  13%
Vision Blue (DORC)  ................................  60%
Pharmacy-formulated trypan blue ..........  27%

Speaker comment: After the late approval of Vision Blue (commercial trypan blue, DORC), surgeons have rapidly moved from the less-safe, pharmacy-formulated sources to the FDA-approved, highly quality-controlled formulation of Vision Blue. Indocyanine green (which is not as safe and yields poor visibility) about which we heard so much before Vision Blue was available in the United States, has appropriately rapidly decreased in popularity.

Q22: Preferred dye technique:
Air bubble  ...............................................  67%
Underneath ophthalmic visco-device .......  15%
Direct injection ........................................   18%

Speaker comment: Our collective practices clearly demonstrate the impact of commercial promotion. Trypan Blue is listed in the Merck Index as a potential carcinogen, and all of us are cautious in introducing any foreign product into the eye. Yetik et al. found successful capsular staining with as little as 0.1 milliliters of 0.0125 percent trypan blue,¹ yet most surgeons still use the air bubble technique. The Ultimate Soft Shell Technique, a variation of the second procedure (underneath ophthalmic visco-device (OVD)), above, confines minute amounts of trypan blue to the anterior capsule, without getting any in the rest of the anterior chamber. It is safer and yields better visibility of the capsule.
____________________________
1 J Cat Refract Surg 2002;28(6):988–991.

Rock Hard Cataracts
Speaker: Roger F. Steinert, MD

Q23: Preference for rock hard cataracts:
Usually phaco ................................ 55%
Usually do ECCE ............................ 14%
Regularly do both, depending  ...... 31%

Speaker comment: Only a few years ago, more than 80 percent of respondents would have stated that extracapsular cataract extraction (ECCE) was the correct choice. The current preferences reflect the dramatic improvement in ultrasound technology and phacoemulsification technique. Now many patients with highly advanced cataracts can benefit from small-incision technology.

Q24: Will sharp-edged nuclear fragments puncture the PC?
Very likely (has happened to me)  ............  38%
Very likely (has not happened to me)  ......  18%
Very unlikely  .............................................  40%
Not sure ......................................................  4%

Speaker comment: Clearly this issue is controversial. Few surgeons would doubt, however, the advantage of stabilizing a nuclear fragment in order to effectively remove it. Re-installation of a low molecular weight ophthalmic viscoelastic device midway through nuclear emulsification is the best method to stabilize a nuclear fragment while protecting the posterior capsule and the endothelium.

Intraoperative Complications: 36 Questions

Anesthetic Complications
Speaker: R. Bruce Wallace III, MD

Q25: Your anesthesia preference for cataract surgery:
More than 90 percent topical  ......................  46%
More than 90 percent retrobulbar ................ 17%
More than 90 percent peribulbar  ................. 24%
Commonly use both (topical or injection)....... 13%

Speaker comment: It was interesting that despite the hype associated with topical anesthesia, injection anesthesia is still running a tight race with topical as a preferred method.

Q26: Globe perforations you’ve witnessed from anesthetic injection:
Never ............. 70%
1 ..................... 21%
2  .....................  3%
More than 2 .....  6%

Speaker comment: It is comforting to see the low incidence of globe perforations associated with injection anesthesia. Topical anesthesia surgeons may prefer their technique more because of the cosmetic benefits, rather than the fact that the risk of ocular perforation is reduced.

Operative Causes of TASS
Speaker: Nick Mamalis, MD

Q27: Number of cases of TASS you’ve seen:
None ............................ 48%
Fewer than 2 ............... 32%
3 to 5 ........................... 13%
More than 5 .................   7%

Speaker comment: Toxic anterior segment syndrome (TASS) is much more prevalent than surgeons realize as more than 50 percent of all respondents have seen cases of TASS with 7 percent having seen more than five cases.

Q28: Greatest risk for TASS is:
Irrigating solution ................. 35%
Medications............................ 33%
Sterilization problems ............ 30%
IOL .........................................  2%

Speaker comment: Respondents were equally divided on the greatest risk for TASS between irrigating solutions, medications and sterilization problems. These results mirror our findings when analyzing outbreaks of TASS referred to our center.

Complications of Intracameral Drugs
Speaker: James P. Gills, MD

Q29: I routinely use intracameral antibiotics:
In the irrigating bottle .............  17%
Via direct injection into AC  ......  18%
Never .......................................  65%

Speaker comment: It is interesting that only 35 percent of the respondents use intracameral antibiotics. We conducted our own poll of high-volume surgeons, and more than 90 percent reported that they use intracameral antibiotics. I use them because I feel that this provides a safer approach.

Q30: Regarding intracameral steroid:
I use it  ................................................ 6%
I would consider using it  ................... 29%
Risk currently outweighs benefit ........ 65%

Speaker comment: I am surprised that 6 percent of the respondents already use intracameral steroids and another 29 percent would consider this. The fact that 65 percent still think the risk outweighs the benefits is actually a low number considering that intracameral steroids have only been used for a short time. I think that many more would use this if there were a commercially available, preservative-free steroid made for intracameral use.

Incision Complications (Burns, Leak and Infection)
Speaker: Randall J. Olson, MD

Q31: Number of times you have had a significant wound burn:
Never  .................. 54%
1   ........................ 24%
2 to 3 ................... 17%
More than 3 ........... 5%

Speaker comment: A survey I recently conducted suggests that severe wound burns had a 0.1 percent incidence;¹ however, we also had many people who had no wound burns with large volumes and others who have had quite a few. This suggests that wound burns may, indeed, be clustered because with a 0.1 percent incidence I would expect more than 46 percent of the respondents would have had a wound burn. Our work suggests there are specific machine features and approaches related to wound burn and, therefore, it would be interesting to expand our database to see if there are combinations of factors that are protective against wound burn creation and at the same time other combinations that are likely to result in clustering, which is suggested by the audience response.
________________________
1 Am J Ophthalmol in press

Q32: Compared to scleral pocket, my incidence of endophthalmitis with CCI is:
Higher .................... 18%
Unchanged  ........... 52%
Lower .................... 12%
I don’t do CCI .......  18%

Speaker comment: This means 82 percent of the audience has at least partially been doing clear corneal incisions (CCI), which is a dramatic change over the last several years. Interestingly, the audience as a group does not feel that, on average, clear corneal incisions are increasing the risk of endophthalmitis. This is contrary to many studies, including those that have looked at the CMS database, all of which indicate that, in general, endophthalmitis has gone up in the era of clear corneal incisions. One possible explanation for this disconnect is that the database studies to date are not representative of surgeons in general. A more likely explanation, however, is that doubling the incidence of an uncommon event, such as endophthalmitis, is not necessarily noticeable to the average surgeon. I know at our institution no one felt that we had an increased incidence of endophthalmitis even though we documented that it had at least doubled during this period. This further shows the importance of good studies to better ascertain what is happening and to determine just what the causes and preventive measures might be.

Managing the Torn Capsulorhexis
Speaker: Mark Packer, MD, FACS

Q33: My rate of radial CCC tear:
Less than 1 percent  ........... 64%
2 to 3 percent  .................... 23%
4 to 5 percent  ....................   8%
More than 5 percent ............   5%

Speaker comment: While most surgeons experience radial tears infrequently, more than one in 10 surgeons have to deal with them once in every 20 to 25 cases. Those surgeons who find they often tear the rhexis edge should videotape every case and review their complications.

Q34: Following a radial tear to periphery and a dense nucleus, I would:
Phaco with single radial tear ..................... 51%
Make another tear 180 degrees away ...... 16%
Convert to can opener and phaco ............. 17%
Convert to ECCE ........................................ 16%

Speaker comment: A radial tear does not generally require a conversion to ECCE in the hands of 84 percent of surgeons. It is encouraging to see that the majority feel comfortable completing phaco in the presence of a tear.  

Intraoperative Capsular Block Syndrome
Speaker: Kensaku Miyake, MD

Q35: Number of times you’ve ruptured the PC with hydrodissection:
Never  .................... 47%
1   .......................... 34%
2 to 4 .................... 16%
More than 4  ..........  3%

Speaker comment: The incidence was larger than I would have expected in the United States,  where you have a lot of “California Cataracts,” which are rarely associated with intraoperative capsular block syndrome.

Q36: Before today, had you understood capsular block syndrome?
Yes  .............  73%
No   .............. 27%

Speaker comment: I am very happy to learn that my presentation provided new information to 27 percent of the audience.

Complications of Bimanual MICS
Speaker: Paul S. Koch, MD

Q37: Your MICS experience:
Never tried it  ............................. 81%
Tried MICS, prefer coaxial ........... 16%
Prefer MICS  ................................  3%

Speaker comment: It’s hard to improve on standard phacoemulsification. Not only have most surgeons never bothered to try microincision cataract surgery (MICS), 84 percent of those who did gave it up and went back to coaxial.

Q38: I think MICS is:
Significant step forward ...................... 12%
Minor variation of standard phaco ....... 71%
Step backward ....................................  17%

Speaker comment: It is interesting that while only 3 percent prefer MICS (see question 37), 12 percent feel it is a significant step forward. Perhaps [those respondents in] that 9 percent gap have phaco equipment not suited to MICS and would perform it if they could. One wonders if this group did try it whether they would embrace it, or be part of the 16 percent who tried and went back to coaxial.

Fluid Misdirection Syndrome vs. Choroidal Hemorrhage
Speaker: William J. Fishkind, MD, FACS

Q39: Times I’ve aborted surgery due to flat/shallow AC:
Never   ............................ 73%
1 to 2  ............................. 23%
3 to 4  .............................   3%
More than 5 ....................   1%

Speaker comment: A shallow anterior chamber during phaco is a somewhat common occurrence. Seventy-three percent of respondents have never terminated a case due to this problem. On the other hand, suprachoroidal hemorrhages occur with regularity.

Q40: Times I’ve had a true suprachoroidal hemorrhage with phaco:
Never ................ 54%
1  ...................... 29%
2  ...................... 10%
More than 2 .......  7%

Speaker comment: Forty-six percent of respondents have definitively identified this diagnosis. Since shallow chambers occur commonly and suprachoroidal hemorrhages rarely, the surgeon must be vigilant, possessing a high index of suspicion for this problem when a shallow anterior chamber is encountered.

Managing the Descending Nucleus
Speaker: Richard B. Packard, MD

Q41: Number of dropped nuclei in past 12 months:
None ........................ 65%
1  ............................. 27%
2  ............................... 5%
More than 2  ............... 3%

Speaker comment: The descent of the nucleus is still considered a most unpleasant event in our surgery. In this survey it is a complication that occurred in the past year for 35 percent of the surgeons responding. Of these, 8 percent had more than one such event.

Q42: How do you manage a descending nucleus?
Close eye—refer to retina  .......  33%
PAL with spatula  .....................  22%
Viscoat levitation  ....................  32%
Prayer ......................................  13%

Speaker comment: The answers to this question indicated a variety of solutions; vitreoretinal surgeon involvement as a primary management move is chosen by 33 percent. It is interesting to see that nearly two-thirds have tried some surgical maneuver to lift a dropping nucleus, 32 percent favoring Viscoat levitation.


Kenalog Vitreous Staining: When and How?
Speaker: Scott E. Burk, MD, PhD

Q43: Number of times vitreous incarceration discovered postop:
Never .................... 18%
1   ......................... 25%
2 to 5  .................. 43%
More than 5 ......... 14% 

Speaker comment: It seems obvious from the responses that the majority
of us have experienced some difficulty identifying the vitreous. More than four out of five ophthalmologists surveyed completed surgery only to find vitreous incarceration at a postoperative visit. Clearly this emphasizes the need for better vitreous visualization, especially because residual vitreous plays a significant role in serious postoperative complications.

Q44: For anterior vitrectomy, I use triamcinolone:
Never   ........................................ 86%
Less than 15 percent  ................. 7%
15 to 50 percent  ........................  2%
More than 50 percent  ................. 5%

Speaker comment: Given the fact that triamcinolone-assisted vitrectomy has been published¹ and presented at all major meetings by myself or my colleagues since 2002, it is somewhat surprising that 86 percent of ophthalmologists surveyed have never used triam- cinolone for enhancing vitreous visualization. I believe this speaks to the need for widespread commercial availability of a preservative-free preparation.
_____________________
1 Burk, S. E. et al. J Cataract Refract Surg 2003;29(4):645–651.

Pars Plana Anterior Vitrectomy
Speaker: Louis D. “Skip” Nichamin, MD

Q45: Your PC rupture rate:
Less than 1 percent .......................  52%
1 to 2 percent  ................................ 33%
3 to 5 percent ................................. 12%
More than 5 percent .......................    3%

Speaker comment: Most published reports on the incidence of capsular rupture during modern phaco surgery hover around the 1 to 3 percent mark. One would think that this type of poll, given the target audience and anonymity associated with it, would yield fairly accurate data regarding this complication. Indeed, 85 percent of surgeons responded with a rate of less than 3 percent. With 12 percent reporting a capsular rupture rate of 3 to 5 percent, and 3 percent of surgeons at higher than 5 percent, I think that it is safe to say that this complication remains the most significant problem in the back of the cataract surgeon’s mind.

Q46: Pars plana anterior vitrectomy (PC rupture):
Would never do it ................................... 13%
Would consider depending on case .......  64%
Have tried it, not my preference ..............  5%
Preferred technique ................................. 18%

Speaker comment: I must admit that I am both surprised and pleased with these results. The message regarding the benefits of a pars plana approach is now coming across; 18 percent of surgeons are currently employing this technique, and two out of three are considering adopting this approach.

IOL Fixation After Capsule Tears
Speaker: Howard V. Gimbel, MD, MPH

Q47: Have you ever performed a posterior CCC?
Yes  ............... 36%
No  ................  64%

Speaker comment: Only about one-third of respondents have used posterior continuous curvilinear capsulorhexis (PCCC). It seems that many surgeons judge the difficulty in performing PCCC based on their experience in doing CCC. This experience may have been while using a viscoelastic other than the highly viscous ones now on the market. These add so much to the control and may give more surgeons the confidence to use it to avoid vitrectomy in pediatric cataract with IOLs and to surgically remove dense plaques on the posterior capsule at the time of cataract surgery.

Q48: Have you ever used CCC optic capture?
Yes  ................ 53%
No   ................ 47%

Speaker comment: Optic capture is a technique used, for the most part, to manage complications of anterior or posterior capsule tears. The 47 percent of respondents who have never used it may not have had an occasion to use it.

Injector Complications/ Explanting Damaged IOLS
Speaker: Stephen S. Lane, MD

Q49: Number of IOLs damaged upon injection (past year):
None  ........................ 36%
1 to 2 ........................ 48%
3 to 5 ........................ 11%
More than 5  .............   5%

Speaker comment: The incidence of at least one IOL annually being damaged during injection into the eye is roughly 64 percent. This indicates a more widespread problem than I would have anti-cipated and puts the onus on manufacturers to produce more reliable injector systems and on surgeons to be more fastidious as they load and inject these lenses. Perhaps IOLs preloaded in the injector by the manufacturer will reduce this problem.

Q50: Preferred method of acrylic IOL removal:
Refolding inside AC ........................................  15%
Cutting IOL into pieces  .................................  60%
Enlarge incision—no cutting or folding...........   25%

Speaker comment: When damage is noted, cutting the IOL appears to be the preferred method, as it is probably the simplest.

Surgical Causes of Corneal Decompensation
Speaker: Richard L. Lindstrom, MD

Q51: Your incidence of postcataract corneal decompensation (last two years):
Never .............................. 42%
Once ............................... 40%
2 to 3 times .................... 15%
More than 3 times............  3%

Speaker comment: These responses confirm that postcataract surgery corneal decompensation is rare and decreasing in incidence vs. earlier reports in the literature. Since the typical American cataract surgeon performs approximately 300 procedures per year, this poll suggests the incidence of postcataract surgery corneal decompensation in routine practice may now be as low as one per 500.

Q52: Which best protects the endothelium?
Dispersive OVD ........................ 55%
Cohesive OVD  ......................... 23%
Viscoadaptive (Healon 5) ......... 14%
Not much difference  ................   8%

Speaker comment: Improved surgical skill, advances in phacoemulsification machine technology and the almost universal use of an OVD all play a role in the decreasing incidence of postcataract surgery corneal decompensation. The published data and these audience responses confirm that there is no consensus regarding the preferred OVD for corneal endothelial protection. 

Intraoperative Retinal Complications of Cataract Surgery
Speaker: H. Richard McDonald, MD

Q53: Do you inject a subconjunctival aminoglycoside?
Yes, routinely ................ 13%
Only occasionally ..........  21%
Never  ..........................  66%

Speaker comment: Aminoglycosides should never be used for routine cataract cases. They do not provide coverage for those organisms most commonly associated with postcataract endophthalmitis and are extremely toxic to the retina. Ten years ago, the number using aminoglycosides in this setting would have been double or triple these numbers. The numbers using these drugs are still too high.

Q54: Number of cases of endophthalmitis in past five years:
None ..........................  52%
1 to 2  ........................  40%
3 to 5 .........................   7%
More than 5 ...............   1%

Speaker comment: Whether or not the incidence of postcataract extraction endophthalmitis has risen as a result of clear corneal wounds cannot be answered by a survey. But there seems to be growing evidence to suggest that may be the case.

Avoiding/Managing Resident Complications
Speaker: Douglas D. Koch, MD

Q55: Best approach for training residents:
Begin with phaco  ................. 35%
Begin with ECCE  .................. 49%
Makes no difference............... 16%

Speaker comment:  I found the responses to both my questions to be interesting and a little surprising. When asked the best approach for training residents, the majority indicated that residents should begin with ECCE. In our program, we no longer use this approach. Was the audience response based on their own experience as residents, or is ECCE more commonly performed than I suspect?

Q56: PC rupture with nucleus in the eye should be managed by:
The operating resident  .............. 29%
The attending surgeon ............... 71%

Speaker comment: Again, surprisingly, 71 percent of respondents indicated that the attending surgeon should complete the case. This reflects, I believe, the view that the patient’s well-being is the primary concern. In addition, this permits the attending surgeon to demonstrate to the resident appropriate steps for managing this type of potentially sight-threatening complication. In our program, the attending may do this
on one or two cases. Depending on the resident’s skill level, subsequent cases (hopefully few arise) are managed by the resident surgeon.

Patient Counseling Following Complications
Speaker: David M. Dillman, MD

Q57: After vitreous loss (IOL successfully placed), I usually:
Immediately inform the patient of the complication ................. 47%
Wait until later to discuss the complication  ............................. 24%
Don’t discuss this unless there are further complications.........  29%

Speaker comment: Of the “4 Rs” contained in an authentic medical apology (recognition, regret, responsibility and remedy), Michael Woods, MD, in his book Healing Words: The Power of Apology in Medicine strongly observes that physicians struggle the most with recognition. Our training to be perfect plus the deny-and-defend mentality drilled into us, especially in the hospital setting, simply often blinds us to the need for an authentic medical apology. The responses to questions 57 and 58 underscore this.

Q58: Following complications, I believe an apology and full disclosure:
Increases the chance of being sued ................... 13%
Decreases the chance of being sued .................. 70%
Isn’t a major factor in likelihood of a lawsuit ......  17%

Speaker comment: While 70 percent feel apology and disclosure actually decreases the risk of litigation, only 47 percent (from question 57) would feel the need to immediately inform the patient following vitreous loss with successful IOL implantation. Remember, “If you have to eat crow, it’s best to do it while it’s hot!”

And I think this is also a strong reflection that all of us new to the concept of apology and disclosure in medicine have to learn the fact that apology and disclosure does not necessarily equal admitting wrongdoing or guilt.

Risk Management Pearls in Cataract Surgery
Speaker: Richard L. Abbott, MD

Q59: Number of times you’ve been sued for a cataract claim:
Never  ...................... 79%
1  ............................  15%
2 to 3  .....................   4%
More than 3  ...........   2%

Speaker comment: The Ophthalmic Mutual Insurance Company (OMIC) data show approximately one-third (32 percent) of all closed claims and suits stem from cataract surgery. The audience indicated that only 21 percent had incurred at least one claim or suit from cataract surgery. Hopefully, this reflects a positive trend in reducing malpractice litigation for the future.

Q60: Which would make you the most nervous about being sued:
Endophthalmitis  ......................... 43%
Wrong IOL power .......................  29%
Dropped nucleus ......................... 17%
ON damage from IOP spike ........  11%

Speaker comment: The main reasons ophthalmologists are sued in cases of endophthalmitis are failure to diagnose in a timely fashion and then failure to refer. Most cataract claims and suits are based on problems related to IOLs (i.e., wrong lens power, size, type).

 

Financial Disclosures
Financial interests are designated with an A, C or O.
A = Affiliation,
which means that the speaker or a member of the speaker’s family has membership on the board of directors, officership, editorial position or status as a paid employee or paid or nonpaid consultant in any for-profit health-related or business concern, including any health publishing, Internet
or e-commerce entity.
O = Ownership, which means the speaker or a member of his or her family has personal holdings in any commercial entity, including any publishing, Internet, e-commerce or other business interest that provides products or services related to health care or to Academy activities.
C = Compensation, which means the speaker or a member of the speaker’s family receives support from commercial or other sources, including any publishing, Internet or e-commerce organizations, related to health care or to Academy activities. Income includes stock options and/or warrants in, royalty arrangements with, or dividends from the commercial entity.

Dr. Holland: Advanced Vision Science, A; Alcon, A; Allergan, A; Bausch & Lomb, A. Dr. Cionni: Alcon, A; Morcher, C. Dr. Masket: AMO, A; Medennium, A; Alcon, A; Visiogen, A; Othera Pharmaceuticals, C; IntraLase, A. Dr. Vasavada: None. Dr. Rosenthal: AMO, C; Baxter Pharmaceuticals, C. Dr. Osher: Alcon, C; AMO, C. Dr. Mackool: Alcon, A; Impex, A. Dr. Arbisser: Alcon, C; AMO, C. Dr. Ahmed: None. Dr. Chang: AMO, A,C; Visiogen, A; Cataract & Refractive Surgery Today, A; Slack, C; Alcon, C; Calhoun Vision, O. Dr. Arshinoff: Alcon, A; AMO, A; Bausch & Lomb, A. Dr. Steinert: Alcon, A,C; AMO, A; IntraLase, A,C; Rhein Medical, C. Dr. Wallace: AMO, C. Dr. Mamalis: Visiogen, A; Medennium, A; Rayner Intraocular Lenses, C. Dr. Gills: None. Dr. Olson: AMO, A; Allergan, A; Calhoun Vision, A; Becton-Dickson, A. Dr. Packer: AMO, A; Advanced Vision Science, A; Visiogen, A; Carl Zeiss Meditec, A; Bausch & Lomb, A; Medtronic Ophthalmics, A; iScience, A; Johnson & Johnson Medical, A; VisionCare Ophthalmic Technologies, A; Staar Surgical, A; Ethicon, A; Eyeonics, A; Alcon, A. Dr. Miyake: None. Dr. Koch: Bausch & Lomb, A; ThinOptx, O; Staar Surgical, A; iScience, A. Dr. Fishkind: AMO, A; Thieme Medical Publishers, C. Dr. Packard: None. Dr. Burk: None. Dr. Nichamin: Bausch & Lomb, A; Refractec, A. Dr. Gimbel: None. Dr. Lane: Alcon, A,O,C; Bausch & Lomb, A,C; Visiogen, A,O,C; Vision Care, A,C; Medennium, A; Surgical Specialties, A. Dr. Lindstrom: Bausch & Lomb, A,C; AcuFocus, A,C; AMO, A,C; C & C Vision, A,C; VisiJet, A,C; Refractec, A,C; Santen, A,C; Slack, A,C; TLC Vision, A,C; Visx, A,C. Dr. McDonald: None. Dr. Koch: Alcon, C; AcuFocus, C; Othera Pharmaceuticals, C; Visx, C. Dr. Dillman: None. Dr. Abbott: Santen, A,C; Ophthalmic Mutual Insurance Company (OMIC), A,C.

Enjoy the Spotlight Session at Home
The entire four-hour Spotlight on Cataract Surgery symposium is available on DVD-ROM. To order the disc, please visit www.dbpub.com/store. Under “Ophthalmology,” click “American Academy of Ophthalmology.” The first product displayed will be the 2005 Spotlight on Cataract Surgery DVD. Price is $159 for members, $209 for nonmembers.