November 2008

 

CATARACT/ IOL

 

When it’s “in the family”


by John D. Sheppard, M.D.

 

The problem confronting all surgeons of all levels of skill arises on occasion and that is should this patient be referred to another ophthalmologist or should I perform the surgery myself? Certainly, we can almost always find someone that we think of as somewhat more skilled than we are; however, the inconvenience of directing patients to distant locations can compromise their care. In addition, we tend to have an emotional attachment to our patients that may affect our judgment and our mental equanimity. Finally, when patients have multiple disease entities within the same eye, the staging of procedures becomes an issue. All of these are viewed with the expert consideration on the part of Dr. Sheppard in this month’s column. I think everyone will find this interesting reading and a cause for concern.

I. Howard Fine, MD, Column Editor

 
DSEK with gas bubble

Cortical cataract Source: John D. Sheppard, M.D.

Imagine this scenario. A one-eyed patient comes to you for treatment. In her only good eye she has a cataract, ocular surface disease, and Fuchs’ dystrophy … and, she has known you for 10 years. Maybe you’d flinch. Let’s just say, yes, this patient raised my adrenaline because she was such a delightful lady and deserved the best outcome, in my mind. I also provided eye care for her children, and she was from my hometown in Pennsylvania, which again added to her familiarity. Some things are beneficial, though, about patients one is familiar with, which I found to be the case here. The patient is calmer in the operating room if he or she knows the surgeon well. The patient is more likely to be compliant with instructions. And, the patient is less likely to litigate. It’s good to know that when an acquaintance comes to you for surgery, you’ll be able to help them out—and doing so has its own benefits. On the other hand, there are times when I believe surgeons should refer their patients to other eye care providers. I can remember taking a skin lesion off my mother when I was a medical officer in the navy. It was the simplest of things, but I imagined that as a result of my surgery, she was going to experience a pulmonary embolism. It’s amazing how a surgeon can lose objectivity when operating on a family member. So now, I defer even routine cases of family members to others, and recommend others do the same when it comes to operating on parents, siblings, spouses or children.

Otherwise, I’m willing to take on the toughest of one-eyed cases, which is what I did in this situation. This case was psychologically challenging. One-eyed patients are more on edge and have supreme faith in the doctor This patient’s right eye was horribly diseased from cranial neuropathy and a brain tumor, leaving her blind in that eye. Her left eye needed serious attention as a result of the cataract and decompensating Fuchs’ dystrophy. I operated on the cataract first, which itself wasn’t easy, as it was a 4+ brunescent one. These dense cataracts are never easy because zonules and the capsule are weaker, and they take more phaco energy. At least I didn’t have to worry about destroying endothelium, because I took out the endothelium during the following DSEK procedure anyway. Further, this patient had corneal edema, making the view quite difficult. The patient also had a shallow chamber and a deep orbit.

But performing the cataract operation first yielded much more room in the eye. I also performed a laser iridotomy before DSEK surgery to allow an air bubble in the eye. Because of her somewhat shallower anterior chamber, I was concerned. That iridotomy did the trick though, eventually allowing the air bubble for the DSEK surgery to be larger, which prolonged the time I could take to perform the DSEK, and also facilitated corneal adhesion. Further, with the technique we use, I was able to constrict the pupil. By constricting the pupil, I was able to have better control in the chamber and not damage the plastic lens.

Generally I prefer to do cataracts and see how patients fare and then perform DSEK at a later date. But she already had corneal edema. There was no way she was going to see better without a transplant at the same time.

I think I made the right call, as she soon attained 20/30 UCVA from 20/400 preoperatively. She was delighted with the result. She was expecting and planning for the worst, which is the right psychology given her situation, but her outcome was indeed very good. In challenging situations, you have to know yourself. Know your own responses to stress. Know your own capabilities. Experience pays dividends, and those without lots of patients under their belt need to examine and then re-examine their worst-case-scenario strategies.

Sometimes, when something goes wrong during surgery, the hardest thing to do is wait to execute a planned strategy to deal with the complication.

The problematic patient may not even be what causes stress in such a situation. It may be that there are seven patients behind him or her awaiting surgery. You always have an obligation to keep the surgical practice moving. No matter what, you’ve got to keep your cool. Talking in a calm voice calms the talker down. “Oh, I’ve noticed a change in the pressure of the eye that I’ll take care of with viscoelastic” is better than “Oh no, the prognosis is horrible, I’ve blinded this guy.”

Overall, successfully operating on a one-eyed patient with lots of challenges was emotionally rewarding, especially since I knew her well … but not too well.

Editors’ note: Dr. Sheppard is professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk, Va. He has no financial interests related to his comments.

Contact information:

Sheppard: 757-622-2200, docshep@hotmail.com

       
When it’s “in the family” When it’s “in the family”
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