1195: when you should not operate

Any surgeon can operate, but it takes a surgeon with good judgment to know when not to operate.

During my training, one of my mentors, Brad Straatsma MD, explained to me that, “Any surgeon can operate, but it takes a surgeon with good judgment to know when not to operate.” As a young resident in training, this pearl went against the flawed thinking of maximizing the number of surgeries performed in order to increase experience in the operating room. The mark of a great surgeon is sound intra-operative surgical judgment as well as the ability to decide when not to operate.

coloboma text
Figure: This patient has a posterior polar cataract (yellow arrow) along with iris coloboma and absence of zonular support for at least 2 clock hours (blue arrow). This will not be an easy surgery and asking for help or referring the patient are both reasonable options.

1.  When Patients have Unrealistic Expectations

Patients must have realistic expectations regarding the potential results of surgery. They must understand that all surgery, no matter how safe or seemingly simple, carries some degree of risk. Though it sounds obvious, we must remember that we are operating on our patients’ eyes – their most precious sense. Patients will see the world every waking moment for the rest of their lives through our surgery. Surgical procedures that I routinely perform, such as cataract and refractive surgery, have limitations. We have advanced technology IOLs, but none of them perform as well as the natural human lens in a young person. There are no man-made body parts, whether lens implants or heart valves, that perform as well as young, healthy human tissue. When patients expect surgical results that are beyond what we can deliver, it is best to avoid performing surgery.

2. When the the Risks outweigh the Benefits, especially in a Re-Operation

Ocular tissue is delicate and for re-operations, every subsequent surgery is more difficult than the previous and the tissue is less able to handle the procedure. A good example of this is the corneal endothelium which tends to lose cells with each intra-ocular surgery.  For a patient with a borderline endothelial cell count and increased corneal pachymetry, we should be very cautious about performing another surgical procedure. We must balance the potential benefit of our proposed surgery with the risks, which are now quite high due to the condition of the cornea. The same could be applied to retinal surgery, glaucoma surgery, and even strabismus surgery where the tissues can only take a limited amount of surgical intervention before deteriorating.

fuchs K dys
This patient has Fuchs’ Corneal Dystrophy, a low corneal endothelial cell count, increased corneal pachymetry, but now desires an IOL exchange procedure. The risks are just too high and another procedure should be avoided if spectacles can sufficiently improve the vision.

3. When Patients have Unstable and Serious Systemic Medical Issues

We must remember to look at the whole patient, not just their eyes. Though our intentions may be good, sometimes performing ocular surgery in patients with grave medical issues may not be in their best interests. Recently I saw a patient in consultation with advanced cataracts which had rendered him 20/100 in both eyes. He wanted surgery badly, but he was having issues with a number of serious systemic medical issues so we made a decision to defer his ocular procedure until after he was declared stable by his primary care doctor. While the eyes are certainly important for daily functioning, a perfect result from ocular surgery is not useful if the patient expires from severe systemic medical illnesses.

man old depressed headache
If the general health is unstable, an elective procedure like cataract surgery should be deferred.

While cataract surgery can reasonably be expected to last the duration of the patient’s life, the same cannot be said for other procedures such as glaucoma surgery or complex procedures such as sewn-in IOLs. The longevity of our surgical result is an important consideration, especially for younger patients. Using a technique such an intra-scleral haptic pocket (the Agarwal “glued IOL” technique) or the four-point fixation with Gore-Tex (see this video from Dr. Pradeep Prasad) may be a better choice for long term IOL fixation when compared to a sewn-in technique using delicate 10-0 polypropylene suture. A procedure which is expected to have limited functional years can still be appropriate as long as the patient understands the likely need for a re-operation in the future.

4. When Patients would fare better with other Sub-Specialists

Surgeons tend to gravitate towards fields that interest them and with time this becomes a narrower focus with a deeper breadth of knowledge and experience. When we are in training as resident surgeons we know a little bit about many different surgical subspecialties, but as we mature as surgeons we tend to super-specialize so that we know a tremendous amount about a narrower range of surgical procedures. There are times where patients present with an ocular condition that is outside my area of expertise and comfort level. It is far better to refer this patient than to attempt to do a procedure that is beyond my level of surgical experience. An example of this is a four-point scleral fixated IOL using Gore-Tex suture in an eye with extensive vitreous prolapse. I have stopped doing many of these surgeries, particularly when there is vitreous traction, and instead refer them to a retina colleague for the procedure. The patients do better with a complete and thorough pars plana vitrectomy.

akreos goretex post-op
post-op day 1 after four-point scleral fixation of an IOL

Patients must be involved in the decision to operate and they must actually want to have surgery. Patients who reluctantly agree to surgery are the ones who tend to be the most difficult to please after the surgery. Once you do a surgery on a patient, in a sense, you own that patient for life. And the converse also holds true – the patient owns you for life. Any future ocular issues may be perceived as occurring due to the effect of your surgery though that may not be the case. Depending on the situation, sometimes the best surgery may be no surgery at all.

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  1. Would you push the patient to have surgery if she sees counting fingers due to dense cataracts, still driving but reluctant to have surgery?

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