Though, in the United States, cataracts are not the leading cause of blindness, the condition still affects more than 20.5 million Americans over age 40.1 Furthermore, 6.1 million Americans have already undergone cataract surgery and, with the aging population, those numbers will continue to rise.2
Since Sir Howard Ridley performed the first cataract surgery utilizing an intraocular lens (IOL) in 1949, there have been myriad advancements in both surgical techniques and IOL technology.3
The evolution of IOLs and modern cataract surgery
The progress from the original polymethylmethacrylate (PMMA) IOL to the latest full visual range (FVR) IOLs and femtosecond laser-assisted surgery (FLACS), have made cataract procedures more precise and predictable. However, it is inevitable that, if you perform enough procedures, you will encounter complex cases and unexpected situations.3,4
In this article, Eric Rosenberg, DO, addresses how to mitigate intraoperative challenges during cataract surgery.
Case background
Here we present a case of an 88-year-old female with a history of pseudoexfoliation, poor dilation, 4+ NS lens, and 20/200 vision who is undergoing cataract surgery. Typically, when I book these cases, I consent to pars plana vitrectomy (PPV) along with a planned complex cataract extraction with intraocular lens due to the increased possibility of complications secondary to poor visualization.
As this patient presented with a small pupil unresponsive to mydriatrics, I needed to improve my visualization. Therefore, I elected for a Malyugin ring to help assist in my approach.
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Surgical Video of Complex Cataract Surgery with Complications
This surgical video demonstrates Dr. Rosenberg performing complex cataract surgery while managing complications in real time with narration.
Pearls for surgical success during a difficult capsulorhexis
1. Always operate with two hands.
If you restart the video, you will see I ALWAYS operate with two hands. Sometimes this can be easy to forget because you are at the mercy of the incisional fulcrum. Even if maneuvers are not as commonplace for you, having another approach angle or assist device helps to expedite and improve the safety of any approach.
2. Be open to augmenting your approach.
My second pearl comes into play at the one-minute mark. Do not get fooled into thinking you have to do everything one way. As ego-shattering as something may be, always be evaluating and reevaluating situations.
Here I lost the subinicisional loop of the Malyugin ring under this floppy iris. Realizing it may be more dangerous to fish it out, I elected to augment my approach to this case instead of forcing my will by employing only my initial approach.
3. Challenge yourself.
Challenge yourself when challenges don't exist. For example, let's say you have a patient who dilates extremely well, instead of making a 5+mm rhexis, try a 4.5. If you learn how to maneuver in good eyes, challenging ones will be less of an issue when the time comes.
4. Titrate your light.
Operating under dim settings helps save maculas; always titrate your light once you become comfortable with your surgical approaches.
Words of wisdom to young surgeons
Remember, you are the captain of the ship, and no one is timing you. Approach each iceberg carefully, and you will live to see the next day. In closing, I would like to offer some advice to young surgeons on how to remain calm in the face of unexpected complications when conducting surgery.
First, when you realize the procedure is not going as planned—stop—no more movements, no switching of instruments, nothing. Now, take a deep breath and step back from your preprogrammed checklist.
Moving forward, consider the repercussions of each next movement. Ask yourself questions such as, “If I take out this instrument, what will happen next?” and “If X is likely to happen, then should I do Y to prevent X from happening?”
Once you find a way out of the woods, then the fun begins. It is why you are a surgeon. If all that was required of us was to repeat the same 10 steps day in and day out, then we would not be needed. Our job has and will always be to think first and then act to produce the best possible surgical results for our patients.
Stay level-headed, never panic, and approach any problem like you would any other problem in your daily life.
In closing
Cataract surgery complications are inevitable in some cases, but their impact can be minimized through understanding the underlying causes, recognizing what factors influence patient outcomes, and then taking the proper steps to optimize surgical results.
Young surgeons can navigate these challenges by being fluid and flexible, while realizing that they will improve year after year if they are humble in their approach, eager to expand their proficiency, and committed to becoming the epitome of a calm and confident surgeon.
