Knowing your limitations—that is, knowing when to stop and to not do more—was one of the many surgical pearls that emerged during this year’s Cataract Spotlight session, “M&M Rounds—Learning From My Mistakes.” All told, 18 experienced surgeons presented cases that took an unexpected turn, and a group of 18 panelists provided expert commentary. The symposium concluded with the 17th annual Charles Kelman Lecture.
Learn from your first mistake. “We never learn from our first mistake; we repeat it again several times before we learn,” said Mitchell P. Weikert, MD, who operated on a patient who had a white cataract and had previously undergone a pars plana vitrectomy. Complications encountered during the case included 4 to 5 clock hours of zonular dialysis and a capsular tension ring (CTR) stuck in the anterior chamber.
Similarly, in her comments on a different case, Susan M. MacDonald, MD, quoted the late Alan Crandall, MD: “Why do you keep doing something if it doesn’t work?” In this case, presented by Naveen K. Rao, MD, the patient had a dense brunescent traumatic cataract. Dr. Rao ran into trouble when he tried to use the miLoop (Zeiss), and a cascade of problems ensued, including a large posterior capsular tear and vitreous prolapse.
Trust your gut. The patient of Brandon Ayers, MD, had a dislocated multifocal IOL and wanted to save it. Dr. Ayers’ first instinct was that this wasn’t the right approach, but he allowed the patient to talk him into it—and he had cause to regret his decision. The initial outcome was fine, but the patient’s vision changed postoperatively. “I could not for the life of me figure out what was going on,” Dr. Ayers said. As it turned out, the haptic had twisted in the optic. The final outcome was successful, but as panelist Michael E. Snyder, MD, commented, “Trust your gut.”
Get all the details of the patient’s history. Eliciting a full patient history—even long-ago details that a patient may overlook—remains essential, as illustrated by a case of zonular loss and AC shallowing that led to aqueous misdirection during surgery. In this case, the patient forgot to mention that, some years earlier, he had been in a terrible car accident, which deployed the airbag and broke the patient’s nose and orbit. “This case only took about a week off of my life,” said Uday Devgan, MD.
Schedule difficult cases at the end of the day. The patient of Marjan Farid, MD, had a dense brunescent cataract and a history of blunt trauma. It was the second case of the day, and it should have been one of the last. As it turned out, the patient had diffuse zonulopathy, and Dr. Farid felt “less and less comfortable” as the complications mounted up. Her take-home message: use an AC maintainer to keep the globe formed, stay calm and take time to improve your visibility—and schedule these cases at the end of the day so you’re not feeling any pressure to rush.
Remain cool, calm, and collected. The 81-year-old patient of Thomas W. Samuelson, MD, had exfoliation glaucoma and age-related macular degeneration. Dr. Samuelson found himself in a race against the clock when the patient became uncomfortable and agitated—and, apparently, moved. The anterior chamber shallowed suddenly, and the eye became rock-hard with hardware (a CTR) still in the eye. “I was worried everything was going to come at me any minute,” said Dr. Samuelson. In a first for him, he cut the ring. The case also involved a suprachoroidal hemorrhage and iris prolapse.
In discussing this case, panelist Sumitra S. Khandelwal, MD, said, some complications are “so rare that our normal checklist goes out the window.” And in acknowledging both the patient’s and the surgeon’s discomfort, panelist Thomas Kohnen, MD, PhD, advised his fellow cataract surgeons that, when significant complications occur, “You, yourself, must remain stable.”
You can’t treat unhappiness. In a case of a posterior polar cataract, the capsule ruptured when the IOL was inserted. Following multiple maneuvers, including a reverse optic capture, “the patient ended up doing well, with uncorrected 20/25 vision, but she’s still unhappy with me,” said John P. Berdahl, MD. “You can’t treat unhappiness,” commented cochair Nicole R. Fram, MD.
But honesty can carry the day. When you make a mistake, step up and own it, said Robert Osher, MD. In his case, everything went perfectly during surgery, except for one detail: he inadvertently implanted the wrong IOL. The mistake was revealed when the patient, a young woman with high myopia, had trouble reading following her surgery. Dr. Osher presented the patient and her mother with a number of options, and the patient chose contacts, which Dr. Osher paid for.
Kelman Lecture. The symposium concluded with the Charles Kelman Lecture, presented by Liliana Werner, MD, PhD. Dr. Werner, who gave an overview of 25 years of IOL innovations, is the first woman to present the Charles Kelman Lecture in its 17-year history. She noted that she felt added responsibility “not only in being the first woman but also in being the first member of an under-represented minority group” to accept the award.
—Jean Shaw
Financial disclosures: Dr. Ayres: Alcon: C,L; Allergan: C,L; Bausch + Lomb: L; Carl Zeiss: C; CorneaGen: C; Dompé: C,L; Glaukos: C; New World Medical : C; Novartis, Alcon: C; Rayner Intraocular Lenses: C; Sun Ophthalmics: C,L; Dr. Berdahl: Abbvie: C,L; Aerie Pharmaceuticals: C; Aerpio: C; Alcon: C; Aldeyra: C; Aurion Biotech: C; Bausch + Lomb: C; Carl Zeiss : C; Elios Vision: C; Equinox Ophthalmic: EO,C,EE,PS,P; Expert Opinion MD: C,EO,EE; Glaukos: C,L; Gore: C; Iacta Pharmaceuticals: C; Imprimis: C,P; iRenix: C; Johnson & Johnson: C; Kala: C; Kedalion: C; MELT Pharmaceuticals: C; MicroOptx: C; New World Medical : C; Ocular Surgical Data: C,EO; Ocular Theraputix: C; Omega Ophthalmic: C,PS; Orasis: C; Oyster Point: C; Rx sight: C; Sight Sciences: C; Surface: C,PS; Tarsus: C; Tear Clear: C; Verana Health: PS; Versea Biologics: C; Vertex Ventures: C; ViaLase: C; Visionary Ventures: C; Visus: C; Vittamed: C; Dr. Devgan: Advanced Euclidean Solutions IOLcalc.com: EO; CataractCoach.com: EO; Centricity: C; LensGen: SO,C; Dr. Farid: Alderya Therapeutics: C; Allergan: C; Bausch + Lomb: C; Bio-Tissue: C; CorneaGen: C; Dompé: C; Johnson & Johnson Vision: C; Kala Pharmaceuticals: C; Novartis, Alcon: C; Orasis: C; Sun Ophthalmics: C; Tarsus: C; Zeiss: C; Dr. Fram: Alcon: C; Avellino Labs: C; Beaver-Visitec International: L; CorneaGen: C,L,SO; Glaukos: L; Johnson & Johnson Vision: L,C; LENSAR: C; Ocular Science: SO,C; Ocular Therapeutix: S; Orasis Pharmaceuticals: C,SO; OysterPoint: C; RxSight: L,C; Vital Tears: L; Zeiss: C,L,S; Dr. Khandelwal: Alcon: C; Bausch + Lomb: C; Carl Zeiss Meditec: C; Dompe: C; Kala Pharmaceuticals: C; Ocular Therapeutix: C; Dr. Kohnen: Allergan.: C; Avedro: C; Bausch + Lomb: C; Carl Zeiss Meditec: C,S; Dompé: C; Geuder: C; Johnson & Johnson Vision: C,S; LensGen: C; MedUpdate: C; Nevarkar: C; Novartis (Alcon): C,S; Oculentis: C,S; Oculus Optikgeräte: C,S; Presbia: C,S; Santen: C; SCHWIND eye-tech-solutions: C,S; STAAR Surgical: C; TearLab Corp.: C; Thieme Compliance: C; Zeiss: C,S; Ziemer: C; Dr. MacDonald: AXA Prime Impact Fund: C; CXLO: US,C; Global Health Funds: C; Iantrek: C,PS; perfect lens: PS,C; Z Optics: PS,C; Dr. Osher: Bausch + Lomb Surgical: C; Carl Zeiss Meditec: C; Microsurgical Technology: C; Video Journal of Cataract & Refractive Surgery: EO; Dr. Rao: Calyx: C; Tarsus: C; W.L. Gore: C; Dr. Samuelson: Aerie Pharmaceuticals: C; Alcon Surgical: C; Allergan: C; Avellino Labs: C; Bausch + Lomb/Valeant: C; Belkin Vision: C,SO; Elios: C,SO; Expert Opinion: C; Glaukos Corporation: C; Imprimis: C; Johnson & Johnson Vision: C; MicroOptx: C; New World Medical: C; Ocuphire: C,US; PolyActiva: C; Ripple Therapeutics: C; Santen: C; Sight Science: C,US; Tear Clear: C,SO; Vialase: C,SO; Zeiss Meditec: C; Dr. Snyder: Alcon: S; Alnivo: C; Glaukos Corporation: S; Haag-Streit USA: C; HumanOptics: C,P; Johnson & Johnson Vision: S; Rayner Intraocular Lenses Ltd: S; Trefoil: S; VEO Ophthalmics: PS; W. L. Gore: C; Dr. Weikert: Alcon: C; Avellino Labs: C; Carl Zeiss Meditec: C; Dr. Werner: Adaptilens: S; Alcon: C,S; Anew Optics: S; Bausch + Lomb: C,S; Carl Zeiss Meditec: S; Cristalens Industrie: S; Hoya: C,S; HumanOptics: S; LensGen: S; Long Bridge Medical: S; Mediphacos: S; Ocumetics: S; Perfectlens: S; Shifamed/Atia: S; Spyglass: S.
Disclosure key: C = Consultant/Advisor; E = Employee; EE = Employee, executive role; EO = Owner of company; I = Independent contractor; L = Lecture fees/Speakers bureau; P = Patents/Royalty; PS = Equity/Stock holder, private corporation; S = Grant support; SO = Stock options, public or private corporation; US = Equity/Stock holder, public corporation For definitions of each category, see aao.org/eyenet/disclosures.
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