Recovering and learning from your surgical complications

Everyone eventually falls off the horse and has a complication. The key is to recover and learn from it, be there for your patient, and ensure the best visual outcome.

There are two types of doctors who never have surgical complications: those who do not operate and those who are not quite fully truthful. This humorous adage emphasizes that no matter how rare, all surgeons have complications. Even master surgeons, with decades of experience over tens of thousands of surgeries, will occasionally encounter an intra-operative or postoperative complication. When a surgical complication happens, we need to appropriately deal with it to restore a good visual outcome to our patient and we need to learn from it so that we can minimize the risk of future occurrence.

Preoperative evaluation

The preoperative evaluation is important because it can alert us to risk factors for potential complications. A dense cataract may mean more ultrasound time and a higher risk for corneal edema and decompensation. Weak zonular structures can mean a greater risk for vitreous prolapse and capsular compromise. Even taking systemic medications such as tamsulosin (Flomax) can mean a higher risk for iris damage and visual loss for patients.

Explaining the increased risks to the patient before surgery is an important part of the informed consent process. Surgeons who explain the risks of a complication ahead of time are seen as wise for seemingly predicting it, whereas surgeons who fail to inform the patient may even be perceived as causing the complication.

Knowing about the preoperative status of the patient can also help surgeons prepare for the surgery by having additional equipment ready, such as trypan blue dye to improve visualization or iris hooks and rings to facilitate mydriasis.

Intraoperative techniques

When a complication happens during surgery, it can come as a surprise. There are often subtle clues ahead of time that may alert the surgeon to an impending complication. In cataract surgery, anterior chamber instability can mean that surge is more likely, and this could lead to a ruptured posterior capsule. A radialized capsulorrhexis can threaten to extend posteriorly during the case, leading to vitreous prolapse.

Once the complication happens, surgeons must act efficiently and carefully to control the situation and prevent further problems. The earlier the complication is detected, the sooner rescue maneuvers can be started. For a posterior capsule rupture, a sudden but slight deepening of the chamber or difficulty rotating the nucleus may be the first sign.

Surgeons should also pay attention to their gut instinct because if you get an uneasy feeling about the case, it is for a reason. The thousands of surgeries under your belt have alerted you to something being not quite right. Do not ignore that feeling. Stay calm, assess the situation carefully and react accordingly. One of the biggest mistakes during a cataract surgery complication is abruptly withdrawing the phaco probe or irrigation/aspiration handpiece from the eye. This depressurizes the anterior chamber and allows vitreous to prolapse in the event of a ruptured posterior capsule.

With the complication identified, the surgeon needs to judiciously get through the case without doing further harm. In cataract surgery, this means removing as much of the cataract as possible and securing the IOL implant. Remember, however, that the key is to do no harm. If the cataract pieces are already in the mid-vitreous, the better part of judgment is to leave it alone, clear the vitreous from the anterior segment, place a secure sulcus IOL, and refer the patient to a trusted retinal colleague for a pars plana lensectomy. How do you know when to pull back and refer? Use the golden rule: give the same treatment that you would want for yourself. In this case, a second surgery is much better than fishing in the vitreous for nuclear pieces and causing a giant retinal tear and detachment.

Keep in mind that often a surgical complication can be due to the patient’s tissues. Sometimes we encounter a situation with weak ocular structures, poor zonular apparatus, a thin capsule and aged tissues. In particular, patients who have had a surgical complication in the first eye may fall into this category and may have the same outcome for the second eye no matter how skilled the surgeon.

Postoperative management

Immediately after surgery, the patient should be informed of the complication, and this should be repeated the next day because any systemic sedation can impair the patient’s ability to understand your explanation. Even if a surgeon did not directly cause the complication, it is fine to apologize that the complication occurred. The patient just wants to know that the surgeon truly cares and will do everything possible to ensure the best possible recovery. Patients with complications are not looking to blame anyone; they just want to avoid being abandoned and they want help on their road to recovery. Keep these patients closer, see them more often for follow-up care, and make it easy for them to contact you if need be.

Patients who have had intraoperative complications can be at risk for more issues in the postoperative period. For example, with a ruptured posterior capsule the risk for endophthalmitis is many times greater compared with a case completed without complications. Cystoid macular edema is also more common in this situation, and healing in general can be delayed for these patients.

On occasion, we all will have a surgical complication. Patients at increased risk for complications should be identified, when possible, during the initial consultation and counseled appropriately. Intraoperatively, the keys are to identify complications as early as possible, take measures to prevent further issues, complete the case carefully and refer as needed for further procedures. After surgery, patients should be given a detailed explanation, and the surgeon should continue to help the patient throughout the prolonged recovery period. These patients can still have an excellent visual outcome and be quite pleased with their resultant vision.