Pearls for Reducing the Risk of Adverse Surgical Outcomes
Long before a patient is under the surgical drape and you are about to insert the first cannula into the eye, it is important to consider criteria for who is a good surgical candidate. The foundations of a good surgical outcome are laid in the clinic. To follow are critical pearls toward successful surgery.
Remember that you will never regret the surgery you didn’t perform. I am not advocating putting off a maculaon retinal detachment or fixing a macular hole, both of which are obvious conditions that require surgical repair. This statement, rather, is referring to those cases in which you feel conflicted whether the patient would notice any improvement in his or her vision with the surgical procedure. In other words, you want to perform surgery that will make a difference to the patient, preferably improving vision, or at the very least, reducing the risk for visual loss.
Know the situations in which to think twice (or 3 times) before signing a patient up for surgery. The first is the patient with an epiretinal membrane (ERM) and good visual acuity. In these patients, it is critical to elicit symptoms consistent with macular disease (particularly distortion). The second patient for whom you should pause before recommending surgery is the diabetic with a tractional retinal detachment and good vision. This type of scenario is a setup for failure. In the past (prior to the practice of using preoperative bevacizumab [Avastin, Genentech]), it was critical to use as much panretinal photocoagulation laser as possible to ensure that the neovascularization was quiescent before attempting surgery. Bevacizumab, however, has helped with that issue. Despite the benefits of bevacizumab, patients can still develop posterior breaks during surgery that can result in a progressively downhill slide into hand motions vision in an oil-filled eye. It is critical to be sure that tractional changes are progressing into the foveal area before considering surgery. Some of the most ominouslooking tractional retinal detachments can be stopped just short of the losing central vision and remain stable for years with the help of modern anti-VEGF therapies.
Understand the patient’s chief concern. This is particularly important prior to taking a patient to surgery for macular surface problems (ERM and vitreomacular traction [VMT]). If the patient has good vision, be sure that his or her symptoms are consistent with the optical coherence tomography (OCT) findings. I have often found that patients with good vision and an ERM present with symptoms of dry eye or presbyopia and no metamorphopsia, or other symptoms consistent with macular disease. ERMs are not emergency cases, and often a follow-up visit can help build a relationship between the patient and the surgeon. If the ERM is worsening on OCT, it will be evident to the doctor, the patient, and the patient’s family on a follow-up visit. This tincture of time also gives the patient an opportunity to critically assess his or her symptoms for those specific to a macular problem and also offers better insight to patient expectations.
Prior to consenting anyone for a vitreoretinal procedure, look at the optic nerve. One of my most regrettable cases involved a patient with an ERM and 20/60 visual acuity. Her OCT and exam findings along with her visual acuity prompted me to perform a vitrectomy and membrane peeling. When her visual acuity did not improve beyond 20/200 postoperatively, I began to scrutinize her optic nerve only to discover that it was glaucomatous (in a very gradually sloping manner). Fortunately, the patient was very understanding as I explained to her what occurred, which leads to a pearl that should not need to be stated: always be forthright and honest about complications or errors. Every retina specialist has access to an OCT. Almost all OCTs can perform optic nerve and/or nerve fiber layer analysis. Look at the optic nerve, and if there is a question, obtain a nerve fiber layer OCT scan.
Establish a routine for discussing risks and benefits. I believe this is important, as having a routine can help prevent important points from being left out of the discussion that may influence the patient’s expectations or understanding of the risks of surgery. A good routine involves ensuring the patient understands what is happening in their eye, followed by a discussion of the procedure that is needed to address the problem (without going into too much technical detail). The most important part of the discussion should be the extent to which the patient will see a noticeable improvement in his or her vision as well as any chance that he or she will lose a noticeable amount of vision. Next, the discussion of possible severe complications (typically infection or severe intraoperative hemorrhage) that could result in substantial or complete vision loss should be mentioned to the patient and his or her family. In certain cases (such as a macular hole, ERM, or retinal detachment), the odds of a recurrence of the problem should be mentioned. The fact that visual recovery following retinal surgery is often slower and less noticeable than in cataract or refractive surgery should also be noted.
Document your discussion. Adverse outcomes often result from miscommunication. It is good to have a set routine that will prevent omitting critical facts from the doctorpatient discussion. As important as the discussion itself is the documentation of the discussion. The old adage of “if you didn’t document it, you didn’t do it” applies to the preoperative discussion with patients as much as any other point in a patient encounter. Often days or weeks will go by between the preoperative visit and the actual surgery. and it is important that the surgeon understands the expectations set forth for the patient prior to surgery. For example, a patient with a history of a chronic macular hole and 20/400 preoperative vision should have a different level of expectations than a patient with a new, small hole and 20/60 vision. The expectation level set by the surgeon must remain consistent.
Pay attention to the details. This is particularly important to new surgeons. Every detail matters when it comes to surgery. You need to know the details about the patient such as the preoperative diagnosis, visual acuity, lens status, prior history of surgery, and status of the fellow eye (monocular patients should be of utmost concern). It is also important to know the patient’s medical history including allergies, prior experience with anesthesia, medical problems such as diabetes or hypertension, and use of anticoagulant medications. The details of the bed position, position of the wrist rest, and the height of the surgeon’s and assistant’s seats are also important. Proper prepping of the patient’s eye and periorbital area is key to reducing the risk of infection, and a properly prepped and dried periorbital region will allow the drapes to be applied properly. One detail worth special attention is that of draping the patient. An improperly draped patient can result in fogging of the lens that can be frustrating and distracting even to the most keen surgeon. Placement of the cannulas is important to give the surgeon the best access to the entire vitreous cavity while reducing the risk of iatrogenic trauma to the crystalline lens. One practice that has been helpful for me is to visualize the surgery while scrubbing for the case I am about to perform. Surgical skill may seem like a gift that some are born with, but it is not. What is often not seen or quantified is the amount of time, thought, and training that the surgeon has put into preparing to perform the surgery.
Be a good decision maker. One of the areas in which many young surgeons struggle is decision making. Vitreoretinal surgery is so diverse, and there is often more than one “right way” to approach a problem in the OR. Experience and excellent training can help ease this transition. A general rule is that not making a decision on how to deal with an intraoperative problem is paramount to making the wrong decision. In other words, you must deal with the problem encountered rather than spending too much time contemplating the problem. Another way of phrasing this is the following mantra: the first stage of any surgical complication is denial. It is normal to not want something bad to happen to your patient (particularly if you were directly responsible for it occurring). The key is to acknowledge the misstep and work to correct it as efficiently as possible.
Dictate details from start to finish. Mitigating adverse outcomes does not end once a procedure has been performed properly. Dictation is an area fraught with the potential for misunderstanding. In general, most medical records are difficult for anyone other than the physician reviewing the records to decipher. This leaves a large amount of variability for interpretation by patients, other health care providers, lawyers, judges, and juries. Any part of the record that is dictated is exempt from handwriting or scribe interpretation. Often, the letter to the referring physician and the operative report are the only dictated items found in the medical record. The dictated letter should include the rationale for intervention and the options discussed. This letter should also avoid statements such as “this membrane peel should only take me 15 minutes” which can only come back to haunt the overly “ambitious” surgeon. The operative report is a key part of the medical record and certainly will be scrutinized in the case of an adverse outcome. Set dictation templates should not be used in any situation because in retina, each case is unique. A talented plaintiff’s attorney will scrutinize whether a template was used with any surgical complication. If something did occur and it was not noted in the operative report because a “standard” template was used, the physician has 1 strike against him. Also, be sure to dictate the rationale for surgery before dictating the actual procedure itself. The rationale for surgery should include the patient’s presenting concern, visual acuity, and preoperative exam findings. It should then include a brief summary of the discussion with the patient in regard to the potential for improvement/loss of vision, as well as the chances of a recurrence of the problem and the major risks of the procedure. This ties back to the preoperative discussion with the patient about expectations. If you have not had this discussion or have not documented your discussion with the patient, then this portion of the operative note cannot be completed.
Call and check on your patients the night after surgery. This not only helps a young retina surgeon build a practice, but it can be one of the most rewarding experiences of the entire process. Calling to check on my patients ensures that they have access to me should they have a problem or issue. Many young specialists worry about patients having access to their cell phone number; in my experience, this has never been abused by a postoperative patient, and the good will that this builds is nothing short of remarkable.
The final key is to understand your patient’s financial situation. A properly educated patient will understand that no surgery is 100% guaranteed. Showing an understanding for their financial situation is a level beyond just caring for a patient’s eye. An example is a recent patient of mine who developed a retinal detachment that was initially repaired with a primary scleral buckle, cryotherapy, needle drainage of subretinal fluid, and C3F8 gas injection. His inferior retina never reattached due to a focal area of proliferative vitreoretinopathy that I did not support adequately (I should have added a 287WG segmental element and positioned the buckle more posterior). When talking with the patient and his wife about the persistent retinal detachment, the patient informed me that he was considering not undergoing additional surgery to “fix” the detachment again. It would have been understandable for a discouraged patient after a somewhat uncomfortable postoperative period to consider not having surgery. It is also understandable that he may want to weigh all of his options after I had disclosed that he probably should have gotten a larger element to support the scar tissue in his eye (I had hedged my bets that a 41 band would be sufficient). Despite his maculaoff status, I felt he had potential for a good outcome with another surgery. When I inquired about his rationale behind not wanting surgery, he informed me that his insurance would only cover 2 surgeries per year (he had undergone a successful retinal detachment repair in his fellow eye several months prior). This additional surgery was going to cost him out-of-pocket money, which he simply did not have. It was easy to remedy this situation and write off a significant portion of the surgery. A 5-minute phone call to the hospital billing administrator also alleviated a portion of his hospital bill for the second surgery.
Every vitreoretinal surgeon will encounter adverse outcomes in his or her career. The key is dealing with them with integrity and grace, which are learned traits that can be practiced and perfected. You and your patients will benefit from developing these skills. I would love to hear of any other practice pearls that you may have in regards to avoiding adverse outcomes. Please feel free to email me your tips at firstname.lastname@example.org.
John W. Kitchens, MD, is a Partner with Retina Associates of Kentucky in Lexington. He is a member of the New Retina MD Editorial Board. He can be reached at email@example.com.
Brandon G. Busbee, MD, is with Tennessee Retina, which is based in Nashville. He is a member of the New Retina MD Editorial Board. Dr. Busbee may be reached at firstname.lastname@example.org.
Omesh P. Gupta, MD, MBA, is with the Retina Service of Wills Eye Institute, Mid Atlantic Retina, and is an Assistant Professor of Ophthalmology at Thomas Jefferson University Hospital in Philadelphia. He is a member of the New Retina MD Editorial Board. Dr. Gupta may be reached at 215 707 3346; or via e-mail at email@example.com.