There are perhaps no two greater fears among patients than blindness and a cancer diagnosis. According to the American Cancer Society, it is estimated that, this year, 3,140 new incidences of ocular cancers will be diagnosed in the United States and 490 deaths will occur related to cancers of the eye and orbit.1
When cancer is suspected, an optometrist, primary care physician, or general ophthalmologists will refer these individuals to someone with the training, expertise, and experience to deal with this complex diagnosis. This is where retina specialists and ocular oncologists enter the picture, offering those with an eye tumor the most innovative and effective surgical solutions.
At this critical juncture in the patient's journey, it is our responsibility to provide optimal care and be at the top of our surgical game. To do this, we must be aware of and ready to mitigate the most common complications as well as incorporating best practices and pearls into every stage of treatment.
Overcoming the top 3 challenges in ocular oncology surgery
Though ocular oncology presents a plethora of potential challenges and complications, today we will discuss the top three that residents/fellows should be most attuned to addressing.
Challenge 1: Getting the diagnosis right
Make the diagnosis, make it early, and from the diagnosis, everything flows. One of the most critical things for residents/fellows is getting the diagnosis correct, because everything flows from that.
In today’s practices, doctors and technicians are using ancillary technologies to great degree to help in making a diagnosis, but in ocular oncology, in particular, the gold standard for the diagnosis is the clinical examination with the indirect ophthalmoscope.
If you completely depend on imaging, without thoroughly examining the patient, you can be misled. If a patient comes in with a diagnosis of melanoma in the right eye, naturally, they will get a complete exam on that eye, but it's just as important to look at the left eye. First, looking at the “normal eye” can be invaluable for comparison and being secure in your diagnosis.
When utilizing ultrasound, residents/fellows should remember three things:
- Low internal reflectivity: Melanoma
- Medium internal reflectivity: Metastatic tumor
- High internal reflectivity: Vascular tumor (i.e., choroidal hemangioma)
Diagnostic pearls for ocular oncology:
- Remember the colors on Optos are not true colors: Keeping this in mind, be aware that what looks to be a melanoma could be a red lesion that is imaging as if it were pigmented.
- Avoid perception bias: Do not just attempt to support your initial assumption with imaging/testing; remain open to all potential conditions until you have a definitive diagnosis.
- Utilize all the tools available to you: In retina and ocular oncology, we are blessed to have virtually every test we need in our office; take advantage of wide-field photography, OCT, OCT-A, and, especially ultrasound.
Challenge 2: Avoiding vitreous hemorrhage
The most common complication when you biopsy a tumor is vitreous hemorrhage, but there are ways to minimize the risk of occurrence. One way you can control bleeding is to elevate the intraocular pressure (IOP).
If you're operating at 20 or 30mmHg, which is where most surgeons operate, when you are ready to biopsy, prior to inserting the needle through the retina and into the tumor, elevate the intraocular pressure, temporarily, to 60mmHg. Performing the biopsy under high IOP closes the tumor vessels.
Additionally, the use of valved cannulas stabilizes the pressure during instrument exchange and at the time of biopsy removal. If I'm worried extensively about bleeding, I immediately put the laser back in and ablate the site where the biopsy was taken. Once complete, I lower the pressure by stages, while I'm watching the eye to ensure there's no complication.
Challenge 3: Properly placing a brachytherapy plaque
Radiation therapy, either with a plaque or a proton beam, requires a surgeon to sew the material onto the eye. For a proton beam procedure, this entails sewing on tantalum rings to allow for imaging the tumor.
However, with brachytherapy, which is the procedure of choice for our institution, the radiation patch must be perfectly centered and attached to the wall of the eye outside of the tumor.
There are two complications that commonly occur during this process:
- Miscentering the material: The most common mistake made by junior surgeons is to miscenter the plaque. To avoid this, employ ultrasound. Use the ultrasound probe to visualize the plaque on the wall of the eye and the tumor inside the eye to confirm there is an appropriate margin.
- Suture situations: With our residents/fellows who are less experienced with buckling surgery, it is not uncommon to overpenetrate by sewing the sutures too deeply into the eye, thus causing bleeding, which can lead to leakage and cause a detachment.
7 general pearls for new surgeons
Pearl 1: Make certain you are treating the correct eye.
It seems like a no-brainer, but always make sure you have the correct eye; be 1,000% sure.
Pearl 2: Control the surgical field to avoid complications.
The most common issue I see with surgeons-in-training is controlling the surgical field to limit complications. So what does that mean? Make sure you get your instruments in the eye appropriately.
This seems relatively simple, but when a tumor comes into play, it is paramount to know exactly where those borders are so you can avoid tumor contact. This can also occur when the surgeon is unaware a melanoma existed until in the midst of operating.
Additionally, it is imperative to know the status of the retina, regarding detachment, so it can be avoided. If you can't physically examine the entire eye, you have to have an excellent ultrasound. The ultrasound is your eyes until you're in the OR.
Pearl 3: Do not let ego override patient care.
Understandably, younger surgeons are eager to prove themselves. However, if the ophthalmologist has any doubt on whether or not they can confidently and competently perform a specific procedure, they should feel no shame in referring the operation to a more experienced colleague.
To provide the best patient care, humility is sometimes required.
Pearl 4: To improve outcomes, take a good look at your results.
Set a standard for analysis and track surgical results over a span of time to gauge your effectiveness with different procedures. For example, if you're doing refractive surgery, measure how close you are to a perfect refraction.
Determine how many of your patients have 20/20 or, at least, better visual acuity. In the field of ocular oncology, you have to look a little deeper, but electronic health records are very good at tracking our data. Make use of this invaluable information.
Pearl 5: Commit to continuing education.
When I watch somebody operate and they report an incredible success rate, if my surgical success rate isn't as good as theirs, I ask myself, “What do they do better than I do? What can I do differently to get those results?”
The mindset should be one of how to increase the benefit to your patients by becoming a better diagnostician, imager, and surgeon. Becoming the best surgeon you can be requires a commitment to lifelong training.
Three ways you can continue your learning are:
- Surgical videos: One of the easiest ways you can continue your education is through reviewing surgical videos. Now, we have the video capability of capturing procedures in high quality in real time.
- When I hear or read about a surgeon doing something amazing with impressive results, I seek out a narrated video to witness exactly how they are performing the surgery, step-by-step.
- Conferences: If you have the opportunity to attend a conference where the surgeon is lecturing and you ask questions while watching their video or discuss the surgical protocol with a full panel of key opinion leaders, this is an even better option.
- One-on-one training: Do not be intimidated to reach out by phone or in-person and ask for guidance and advice. The majority of surgeons are dedicated to elevating the next generation of ophthalmologists.
Pro tip: Videos that reveal complications and mistakes and then demonstrate how the surgeon pivoted to address these issues are especially helpful and serve as a reminder that even the most seasoned surgeons face challenges.
Pearl 6: Identify your ideal surgical workflow.
As every ophthalmologist will be performing multiple surgeries of varying levels of difficulty each day, it can be beneficial to develop a surgical workflow that best fits your stamina, focus, and personality.
For example, I prefer to schedule my simpler cases throughout the morning, as a warmup of sorts, and finish the day on my more complicated cases. Other colleagues choose to do the opposite and perform their most challenging procedures early in the day.
However, with this option, you must weigh your ability to recover and regroup; if the first surgery of the day winds up being frustrating, riddled with complications, and yields less than satisfactory outcomes, will you be able to calm down, center yourself, and handle all of the procedures that follow?
Either way, be deliberate with surgical scheduling to optimize outcomes and avoid personal burnout.
Pearl 7: Know your own equipment.
As I do, you may operate at hospitals with teams that often shift, so know your equipment. Know how to troubleshoot if something goes awry. If the gas pressure is too low, know how to adjust it. Or if the electricity pops off and comes back, know how to reboot and manage.
Final thoughts
Though ocular oncology surgery has advanced tremendously over recent decades, complications still occur. Therefore, residents and fellows need to recognize possible complications and what factors influence patient outcomes to optimize surgical results.
Young surgeons must master the skills of being fluid and flexible, while realizing that they will improve year after year if they are humble in their approach and hungry to ever expand their proficiency.
