Did you hear the one about the eye doctor who went into stand-up comedy?
He made a real ‘spectacle’ of himself . . .
While ophthalmology jokes may elicit a giggle or two, complications in posterior segment surgery are no laughing matter . . . in fact, they can permanently affect vision if not managed efficiently. Therefore, to mitigate these adverse events, surgeons must improvise and act quickly to deliver the optimal patient outcomes.
Funnily enough, this is one area where eyeballs and comedy intersect: Improvisation. In delivering a stand-up routine, or in repairing a detached retina, there are times when unplanned instances occur, requiring off-the-cuff thinking for success (be it applause or visual).
In this issue’s Cover Story, we delve deeper into improvisation in vitreoretinal surgery – including tales from complicated cases, pre-planning for adverse events, technology that helps reduce improv in the OT . . . and finally, tips for younger surgeons.
Stand-up cases in improvisation
Case #1. Our first act is Dr. Andrew Chang, a vitreoretinal ophthalmologist and surgeon in Sydney, Australia. He comes to the stage with a case of extensive retinal detachment, using vitrectomy for the repair. In this instance, the surgery was progressing until they noticed the retinal detachment was worsening, rather than flattening – the BSS infusion line tip was underneath the retina, and therefore, infusing fluid underneath it.
Dr. Chang immediately stopped the infusion . . . and the improvisation began. He removed the infusion line from the cannula and placed it into another cannula, then inserted heavy liquid to stabilize the posterior retina. The subretinal fluid was then pushed back out through the original infusion line. He replaced the cannula with a longer 6mm cannula to ensure the tip was in the vitreous and proceeded with the surgery as planned.
This improvisation by Dr. Chang not only led to a reattached retina, but the patient’s vision was recovered, too.
Case #2. The next headliner is Dr. Diva Kant Misra, a vitreo-retina, ocular oncology and ROP consultant, at Eye Q Super Speciality Eye Hospital in Lucknow, India. His case in improvisation begins with a 55-year-old male patient with a vitrectomized eye, who received phaco for cataract in that same eye.
Dr. Misra recalled that the surgery was very challenging: “When the trypan blue dye was injected, it seeped through the zonules (or through some area of zonular weakness) into the vitreous cavity and immediately comprised the red glow.”
This complicated the surgery . . . and the improv began. Dr. Misra says that during this surgery, his mentor Dr. Ronel Soibam, senior consultant at Sri Sankaradeva Nethralaya, Guwahati, India, improvised by suggesting the use of 25-gauge chandelier-assisted retroillumination to proceed with phacoemulsification.
“This technique has been previously described for combined cases of phacoemulsification and posterior segment surgeries, when there is a poor glow because of posterior segment pathologies,” explained Dr. Misra, noting a 2018 study published in the Indian Journal of Ophthalmology.*
In this prospective observational study, Dr. Manish P. Nagpal and co-authors found that while cases with a poor red reflex pose a challenge, “chandelier-assisted retroillumination proves to be a safe and effective tool in combined phacovitrectomy surgeries”.
The authors explained that during surgery, the “sclerotomy port for chandelier tip was made in the inferotemporal or superonasal quadrant, based on the incision site for phacoemulsification. Later, it was replaced with infusion cannula or endoilluminator”.
This method markedly enhanced the red reflex in all cases during phacoemulsification. The investigators reported that visual acuity (VA) in all patients improved, and the median best-corrected visual acuity (BCVA) was 20/60 at 6 months. In addition, there were no intraoperative or postoperative complications.
Continuing the case from Dr. Misra, he explained that a single sclerotomy was required in the inferotemporal quadrant, 3.5mm from the limbus – then, using a valved cannula, the chandelier tip was introduced. He says that important steps (like capsulorhexis, cortex removal, capsular bag polishing and IOL implantation) were done under chandelier retroillumination, with the operating microscope and room lights turned off.
“Xenon light source, which comes with the Constellation Vision System (Alcon, Geneva, Switzerland) was used for chandelier illumination [during this procedure],” said Dr. Misra. “We were able to achieve a red reflex during the crucial steps of phacoemulsification – which resulted in an uneventful phacoemulsification and an excellent outcome.”
Anticipating complications: keep calm and carry on
Sometimes, things just go wrong during surgery. In some instances, recognizing risk factors can help surgeons anticipate potential complications, ensuring preparation rather than improvisation.
In the case of a worsening retinal detachment, Dr. Chang says the complication can be anticipated if the retina detachment is extensive and the eye has low intraocular pressure (IOP). “These cases may be associated with choroidal thickening due to choroidal effusions, which poses a risk that a standard 4mm-long cannula for infusion may be too short to ensure that the tip is in the correct position within the vitreous cavity,” said Dr. Chang, adding that surgeons should check the tip of the infusion line carefully.
In addition, he says clinical examination for choroidal effusions or using B-scan ultrasounds of the globe (to image choroidal effusions) can also help anticipate this complication preoperatively. Intraoperatively, if the retina detachment increases during the vitrectomy, then doctors should suspect a subretinal position of the infusion line. Moreover, Dr. Chang says that in anticipation of this complication, he advises surgeons to have longer 6mm cannulas available in the OT, while heavy liquid can be used to stabilize the retina posteriorly during the subretinal infusion.
Dr. Misra says that a surgeon should always be ready for complications: “There is no surgical step that cannot lead to a possible complication . . . and the success of each and every step guarantees the ultimate success of the surgery,” he explained.
Like comedians performing onstage, surgeons should conduct a mental ‘dress rehearsal’ prior to hitting the OT, which should include preparedness for possible complications. “Before a surgery, I mentally go through all the steps of the surgery,” said Dr. Misra. “This helps me to be mentally prepared for all possible complications and reminds me to keep the instruments ready for these possible complications.”
Thankfully, there are ophthalmic ‘props’ that can help prevent and mitigate complications when they arise. According to Dr. Misra, there have been various advances that have helped reduce complications in retina practice. Innovations like 25- and 27-gauge vitrectomy systems, newer designs in forceps and cutters, as well as intraoperative OCT (iOCT), have allowed surgeons to lower the rate of iatrogenic breaks, while improving the ability to identify and peel membranes.
“All surgical advances in ophthalmology are targeted towards making it less invasive and reducing the overall complication rate,” said Dr. Misra.
Keep learning: tips for beginners
When complications occur, surgeons often rely on previous experience to overcome any challenges. However, newer surgeons might not have that backlog of prior cases to draw from.
“Even a beginner can perform all the steps of the surgery easily – but what sets apart an experienced surgeon [from a beginner], is his ability to gauge impending complications and swiftly take measures to mitigate the problem,” said Dr. Misra. He added that beginners should keep in mind that complications are part of the learning process – and they can occur in the hands of the most experienced surgeons, too.
“One should accept their complications and use them as steppingstones to greater surgical conquests in the future. Though unfortunate, a complication will teach more than many uneventful surgeries,” continued Dr. Misra. “The single most important factor in managing complications is to keep calm once a complication occurs, pause for a moment, rethink your strategy and go ahead.”
In addition, he suggests that younger surgeons should always be in ‘learning mode’. “As they say, ‘life is too short to learn from your own mistakes’,” said Dr. Misra. To optimize the learning of surgical procedures, he suggests using the REPEAT strategy: Read, Observe and Assist, Perform, Audit and Teach.
Final curtain call
Following a stand-up comedy routine, success is measured in laughter and applause – and while vitreo-retinal surgeons often deserve a standing ovation following complicated procedures, visual outcomes are simply not measured by clapping.
Like comedians interacting with an audience, surgeons can find themselves in situations where quick-thinking is required to deliver the punch line (or successfully complete the surgery). And sometimes improvisation during complications, like in the cases described by Drs. Chang and Misra, is vital to patient satisfaction and outcomes.
Of course, improvisation in comedy is unplanned . . . but in surgery, every element must be carefully considered. Therefore, through preparation, planning and continued learning, there can be less improv in the OT and more efficient management of complications.
*Nagpal MP, Mahuvakar SA, Chaudhary PP, et al. Chandelier-assisted retroillumination for phacoemulsification in phacovitrectomy. Indian J Ophthalmol. 2018;66:1094-1097.
