Cataract surgery may be the least complication-prone procedure performed at your facility; but, as you know, challenges do arise. To help you handle - and prevent - potential problems, we asked several surgeons and surgical team members to share their best advice. Their insights touch on a broad range of timely topics, including basic safety, anesthesia, intraoperative complications and achieving the highest quality of post-op vision for their patients.
1 Anticipate IFIS
Earlier this year, David F. Chang, MD, and John R. Campbell, MD, identified a new small-pupil syndrome that can significantly increase the risk of complications during cataract surgery. Intraoperative floppy iris syndrome is characterized by repeated incisional iris prolapse and progressive intraoperative miosis, which increase the risk of posterior capsule rupture and iris trauma. It is caused by tamsulosin hydrochloride (Flomax), a systemic alpha-adrenergic blocker commonly prescribed for male patients with benign prostatic hyperplasia (BPH, enlarged prostate). The medication relaxes the smooth muscle in the bladder neck and prostate, improving urinary flow. According to Drs. Chang and Campbell, Flomax is highly selective for the alpha-1A receptor subtype found in the prostate, which is the same subtype present in the iris dilator smooth muscle. Based on their first two studies of IFIS, which involved 1,600 eyes, they concluded that the syndrome occurs in two percent to three percent of cataract patients.
"Flomax is by far the most commonly prescribed medication for BPH in the United States," explains Dr. Chang. "In addition, we are seeing IFIS in patients who have been off of the drug for as long as two to three years, so there seems to be a semi-permanent loss of iris rigidity due to this drug."
Interestingly, common small pupil techniques such as sphincterotomies and pupil-stretching aren't effective for managing this syndrome. It requires alternative strategies, so your facility should have the right tools available in the OR in anticipation of IFIS cases, depending on your surgeon's preferences. Dr. Chang recommends that you
- question all male patients pre-operatively about current and past Flomax use;
- consider stopping the medication for one week to two weeks before surgery (keep in mind that this does not eliminate IFIS, but does mitigate it in many cases)
- pay close attention to proper wound construction;
- be aware that in some cases of IFIS, even if capsulorhexis creation is uneventful, problems may still occur during the hydrodissection and phaco stages of the procedure;
- consider using Healon 5 viscoelastic with decreased aspiration flow and vacuum settings during phaco; and
- particularly if the pupil is small, consider using an iris expansion ring or iris hooks, inserted before creating the capsulorhexis, to maintain pupil diameter.
"These cases are very challenging, and in the past seemed to arise without warning," says Dr. Chang. "Now that we can anticipate when IFIS will occur by eliciting a history of Flomax use, we can use alternative methods of small-pupil management that should decrease the complication rate."
2 Use capsular tension rings
Capsular tension rings should be available in every OR where cataract surgery is performed, says Richard J. Ruckman, MD, FACS, medical director of The Center For Sight in Lufkin, Texas. "Capsular tension rings can reduce the chance of complications, and should complications occur make them more manageable," he says.
It's also key that surgical personnel be able to quickly find a CTR when it is needed. "In our surgery center, we keep them with our other backup instruments, readily available between our two operating rooms," says Dr. Ruckman.
Different styles of capsular tension rings are now available, but they all to some degree serve the same purpose, which is support the capsular bag when the zonules are weak or otherwise compromised. Supporting the bag in these cases, which include pseudoexfoliation syndrome, traumatic cataract and high myopia, can prevent vitreous loss, lens subluxation into the vitreous, capsular tears and nucleus dislocation.
The surgeon can insert the ring at any time after creating the capsulorhexis as long as the capsulorhexis is intact. "If I think the cataract is going to be particularly dense or if I think something about the case will put undue stress on the zonules, I will go ahead and place a ring immediately following the capsulorhexis," says Dr. Ruckman. "Be aware that once the ring is in place, removal of residual cortex will become more difficult. In general, it is best to insert the ring when you first recognize the need for it but after completing as much of the case as possible."
Dr. Ruckman recommends a gentle insertion to prevent pushing the ring through the capsule. Proper orientation is also necessary. "Don't insert the ring directly toward the capsule," he says. "Let it follow the natural curvature of the capsular bag. If some intact zonules are present, start your placement in that area and then move toward the compromised area."
3 Use topical anesthesia safely
At the Eye Surgery Center of Augusta in Augusta, Ga., cataract surgeons find that the most efficient and patient-friendly way to deliver the necessary medications to the eye is via a combination of lidocaine gel and dilating, antibiotic and anti-inflammatory drops. "In addition to IV sedation, rather than using several doses of dilating and antibiotic drops followed by gel, our protocol is to instill one dose of our combination gel," says Wallace N. McLeod, Jr., MD. "This provides ideal anesthesia and dilation in well over 95 percent of our patients. Occasionally we need to supplement poor dilators with additional dilating drops, or give them some extra time, but the vast majority of our patients are ready to go to the OR 15 minutes after application of the gel."
Dr. McLeod warns not to use this combination approach for patients who are allergic or overly sensitive to any of the ingredients. He also stresses the importance of avoiding contamination by following hand-washing standards and using a separate syringe of gel for each patient. The ingredients and protocol for the combination gel:
- 1.5cc phenylephrine 2.5%,
- 2cc cyclopentolate 1%,
- 1cc diclofenac 0.1% or 1cc ketorolac 0.3%,
- 4cc lidocaine jelly 2% and
- 1cc moxifloxacin 0.5% or 1cc gatifloxacin 0.3%.
Each dose is equivalent to 3.5mg lidocaine jelly, 1.1mg cyclopentolate, 8.8mg phenylephrine, 58mcg diclofenac or 75mcg ketorolac, and 281mcg moxifloxacin or gatifloxacin. Surgical staff mix the solution in a sterile container, from which a syringe for each patient can be drawn. They instruct the patient to tilt his head slightly back and look upward toward the forehead. They instill 0.3cc to 0.5cc of the gel to cover the cornea, tape the lid closed, check progress in 15 minutes and instill additional dilating drops if necessary.
4 Consider IV prep for all patients
Dr. Ruckman notes the current cataract surgery trend toward topical or topical with p.o. anesthesia, and adds, "We realize that each patient is different and may need different levels of sedation and analgesia."
His facility has created an anesthesia protocol that is uniform, cost-effective and still allows for additional medication as needed. In pre-op, patients first receive 1mg to 2mg midazolam IV, followed by lidocaine gel placed in the cul-de-sac. Every patient has IV access using a saline lock. Having the lock in place means that midazolam or fentanyl can be infused quickly if the patient becomes anxious, uncomfortable or uncooperative during the procedure, says Dr. Ruckman.
"Furthermore, in the event of a complication, we don't want the patient to experience a complication and be hurting at the same time," he says. "That is a recipe for an unhappy patient."
The cost to start IV access? Less than a dollar per patient, says Dr. Ruckman. "Even if we only need additional IV access for two or three patients over the course of the day, this is a significant cost savings when compared to losing five minutes to 10 minutes of OR time as we try to start an IV and give medication," he says.
On the worksheet for each surgery day, when relevant, Dr. Ruckman includes notes about a patient's first cataract procedure, such as whether the patient was tense and how much midazolam he required. The sheet is posted in the pre-op area and also in each OR. "Patients do have more pain and awareness the second time around," says Dr. Ruckman, who proved as much in a study he presented at the 2004 meeting of the American Society of Cataract and Refractive Surgery. His advice: Anticipate the need for additional IV sedation rather than waiting until patients say they hurt. "Knowing a patient required a certain amount of sedative during the first case and allowing for a little bit extra during the second case reduces the discomfort and helps the surgery team complete the case efficiently and safely," says Dr. Ruckman.
5 Demystify vitrectomy
Even when the need for a vitrectomy interrupts the flow of a cataract procedure, your surgical team can take steps to keep the case and its outcome routine. First among those steps is rehearsing how to set up the equipment efficiently. At the Oregon Eye Surgery Center in Eugene, Ore., staff use practice vitrectomy sets and tubing to walk through the process on each of their machines. "Where does the vitrector plug in? How does the tubing fit onto the handpiece? Is the infusion bottle lowered? What if the surgeon wants to perform a bimanual vitrectomy? These are the types of things we solidify in our minds during our practice sessions," says operating room manager Cheri Van Bebber, RN, BSN.
"It's also beneficial to fine-tune and reprogram your machine's default vitrectomy settings before you need them," she says. "Different situations require different settings. For example, if you're removing vitreous only, you want a high cut rate. If you need to remove cortex or lens material, you want a lower cut rate. The machine needs time to bring the pieces in and cut them. A high cut rate tends to push them away. It can be helpful to consult with your instrument manufacturer's representatives for fine-tuning because they know what works best for their machines in a given situation." The center also keeps hard copies of each surgeon's preferred settings on hand in case they need them.
Adopting new approaches and techniques can also improve your outcomes. For example, performing vitrectomy bimanually, with infusion and cutting separated, can be more controlled and effective. "Another technique that can be very helpful is using a triamcinolone stain for better visualization of the vitreous," says Ms. Van Bebber. "Our surgeons use a cannula, not a filter needle, to inject the solution, which is 0.1cc triamcinolone to 0.9cc BSS. As they're gaining experience with it, they're asking for it more and more. The solution tends to want to separate, so staff should be sure to mix it well."
Another piece of advice from Ms. Van Bebber: Even if you have to do a vitrectomy, the capsular bag may still be able to sustain implantation of the IOL optic. "You would place your IOL haptics in the sulcus, but keeping the optic in the bag fosters lens stability and may allow you to use the originally planned power."
6 Create an IOL emergency kit
While many IOL explantations are scheduled secondary procedures, others are not. A number of IOL-related complications can occur intraoperatively, including the tearing of a lens. To avoid losing time in these situations, Ms. Van Bebber's center has put together a specific backup instrument set. It contains a snare for cutting silicone, a chopper and scissors that cut acrylic, a foreign body forcep and an indirect lens in case the surgeon needs more visibility than he can get with the microscope.
"The kit is sterile and ready to go," she says. "Everyone on the surgical team knows that the box is kept in OR 1 on a certain shelf. The more serious the complication, the less time you want to lose getting these instruments into the surgeon's hands."
7 Implement a fail-safe system for operating on the correct eye
At the top of I. Howard Fine, MD's, list of necessities for running a safe cataract OR is following a system for ensuring the correct eye is operated on. At the Oregon Eye Surgery Center in Eugene, Ore., where he performs his cases, the system is initiated in the admitting area. There, a staff member checks the chart and confirms with the patient which eye is scheduled for surgery. Before the patient enters the surgery suite, a piece of tape bearing OS or OD is placed on his forehead above the correct eye. As another precaution, only the eye to be operated on is dilated. Before the surgeon enters the room, the circulator greets the patient by name and repeats which eye is to be operated on. When the scrub is draping the eye, she verifies again with the patient which is the correct eye.
When Dr. Fine enters the OR, an assistant reads aloud from the surgery schedule, which contains all of the relevant details about the case, and is posted in four places, including on the microscope. "This final check begins, for example, with 'This is Mr. Smith, and we'll be operating on his left eye,'" explains Dr. Fine. "The patient is awake and along with the rest of us hears that one more time."
8 Perform LRIs on the correct axis consistently
If the surgeons in your facility perform limbal relaxing incisions during cataract surgery for the correction of astigmatism, they know the importance of making the incisions on the correct axis. But do they have a method for achieving repeatable accuracy? According to Dr. Fine, it's necessary to account for cyclorotation of the eye that can occur when the patient moves from the sitting-up to the lying-down position. "It's not infrequent that 90 degrees looks like it's off by 15 degrees once the patient reclines," he says.
To guarantee that he's properly oriented, Dr. Fine marks the 90-degree meridian on the sclera while the patient is sitting at the slit lamp prior to surgery. When it's time to make the LRIs, he uses a marker that he designed, which consists of two concentric rings. The outer ring is set at 90 degrees, and the inner ring is rotatable. Dr. Fine positions the 90-degree marks on the marker directly over the 90-degree marks made previously at the slit lamp. Then, he rotates the inner ring to the steep axis, pressing down to mark it. As he explains further, "If I'm going to make two 30-degree cuts, instead of setting the caliper at 30 degrees and straddling the steep axis, I set the caliper at 15 degrees and mark it off from the steep axis in both directions. If you straddle the steep axis, it's possible to do it eccentrically."
9 Follow an IOL power verification protocol
After five years and several thousand cases at his Sun Valley, Calif., surgery center, Uday Devgan, MD, FACS, has never implanted an IOL of the wrong power. Dr. Devgan performs his own IOL calculations, but that's not enough to eliminate all of the possibilities for error. In addition, Dr. Devgan types his own OR list for each day. Using that list, a nurse labels the IOL boxes to be used. No numbers are transcribed at this stage because that would be a possible source of error. A copy of the OR list is posted on the wall near the scrub technician and the surgeon. When the technician hands the loaded IOL to Dr. Devgan, she says the power out loud.
Ms. Van Bebber agrees that it's important to say the power, rather than just look at the list and the box. That final verbalization to the surgeon is also part of her center's lens verification routine. The night before surgery, a nurse checks the IOL boxes against what the surgeon ordered and what the technician pulled, then initials them. In the OR, the scrub nurse and the circulator check again - the chart, the order and the lens.
10 Keep critical-care readiness top-of-mind
On the rare occasion you need the crash cart during a cataract surgery case, the last thing you want the situation to be is a crash course for your personnel. That's why the NovaMed Surgery Center of Richmond requires its entire nursing staff, including RNs and LPNs, to be ACLS-certified, and why director Patricia Lampman runs mock codes at least once a year at the Virginia facility. "The advanced education and training is especially beneficial for a small outpatient facility, which doesn't have immediate access to resources such as a hospital code team," she says.
The center experienced those benefits firsthand when a cataract patient suffered respiratory distress shortly after administration of IV sedation. Staff members, assuming the roles they had been assigned during previous mock codes, successfully reversed the medication and intubated and manually ventilated the patient until her breathing returned to normal.
ACLS certification courses, which are available through many organizations, including hospitals and the American Heart Association, cost about $100. Certification is maintained for two years. "Our center pays for the courses, and staff members are paid for the hours they spend at class," says Ms. Lampman.