Patients often ask us, “What happens if I have to sneeze or cough during cataract surgery?” And it’s a valid question because a sudden movement of the patient’s head while we are inside the eye can cause significant damage to the delicate ocular structures. As a surgeon, how do you minimize this risk and if a sudden sneeze or cough does happen, what is the best reaction for the surgeon? And how do you detect any damage and then proceed with the remainder of the surgery?
Delay surgery if the patient is sick, coughing, or sneezing. With an elective procedure like cataract surgery, there is no harm done by delaying the surgery by a week or two until the upper respirator infection has cleared.
Tape the patient’s head to the operating room table before starting the surgery. I use paper tape to gently hold the patient’s head in place during the procedure. Place it over the forehead and use a tape that is gentle and will not damage delicate skin. Do not ever place tape over the eyebrows since they could be partially removed and they tend not to grow back so well in our elderly cataract patients.
Rest your hands on the patient’s face or head during the surgery. By coupling your hands to the patient’s head, any movement of the head will also move your hands and hopefully keep the instruments relatively immobile in relation to the eye.
Take the surgery seriously and devote 100% of your attention to the patient. I do not play music in my operating room and I do not talk about anything other than issues directly pertaining to the surgery being performed. If you’re singing along to music, talking about your weekend plans, and laughing with the staff, are you giving the patient your best? If you’re highly alert during the surgery, you will be able to react very quickly and a fraction of a second can certainly make a difference in the visual outcome.
Have the anesthesiologist administer appropriate intra-venous medications. Cough suppressants and medicines to dry out mucous membranes can be given in the pre-op area before bringing the patient into the operating room. Sometimes a deeper level of sedation can be useful as well to prevent involuntary coughs and sneezes.
Tell the patient to alert you if possible. Often the patient will know when the urge to cough or sneeze is building and can notify you a second or two before the event. This can be as simple as the patient saying, “I’m going to sneeze” or simply, “sneeze!” The surgeon can then quickly withdraw the instruments from the eye before the sneeze occurs. In the video below, the sneeze came suddenly and the patient was not able to notify me in advance.
As soon as you detect the sneeze or cough happening, pull out of the eye. You want your instruments out of the eye because they can do serious harm with the sudden, jerky movement from the cough or sneeze. Pull straight out immediately and then take your time examining the eye to determine if any damage has occurred. Also ask the patient to get the coughing or sneezing process finished before resuming surgery.
Proceed carefully and assume that there was some damage. In the case presented here, I assume that the 27ga cannula has penetrated the lens capsule and we proceed with caution. I avoid rotation of the lens nucleus and avoid stress on the capsular bag. The cataract is chopped into two halves, which are then removed, to avoid having multiple smaller cataract pieces which could fall into the vitreous cavity if the capsule has been violated.
Take a moment to re-focus and then continue the surgery. We move to cortex removal when it becomes clear that we fortunately did not have any damage occur during the sneeze. If there is a complication, deal with it carefully. In our case, all looks good so we finish the case as planned and the patient gets a great result.
*What if the surgeon has to sneeze or cough? Well, that’s much easier. Put down the surgical instruments, step away from the patient, and go ahead. Just be sure not to contaminate yourself. And if there is any doubt, just re-scrub and put on a new pair of gloves and a new gown.
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If you’re a patient who is reading this, choose your surgeon wisely!