A few key instruments, a trained staff, and preparation for the unexpected are all necessary components of a successful cataract surgery, experts say
Cataract surgery is one of the safest procedures in today’s environment, but in order to ensure the best possible outcome, certain mainstays are necessary. Beyond the mandatory phacoemulsification machine, EyeWorld asked leading surgeons what they must have in their cataract surgical suites to perform phaco successfully. While individual responses about particular instruments differed, one thing became clear: successful phaco surgery is equal parts surgeon comfort and patient comfort.
Before the first incision is made
Patient preparation is key, said James P. Gills, M.D., St. Luke’s Cataract and Laser Institute, Tarpon Springs, Fla. Without an operating suite where all the employees can talk to the patient, Dr. Gills said he is not comfortable.
“Cataract surgery with topical anesthesia is verbal anesthesia,” he said. “You have to have a staff who can communicate and are people-people. The most important purchase we make is who we hire.”
Proper patient positioning is equally important to Louis “Skip” Nichamin, M.D., medical director, Laurel Eye Clinic, Brookville, Pa., who said he’s “fussy and compulsive about how the head and eye are positioned and draped.” He prefers the patient to be slightly temporal to where he sits, and exposure must be optimized. “I have to be able to access the limbus and the patient’s chin has to be right,” he explained, mainly because 50% of his patients undergo limbal relaxing incisions.
The patient “has to be prepped properly, with good relaxation, well positioned, dilated and relaxed,” said Jay “J.E.” McDonald, M.D., editor of the ASCRS Cataract and Refractive Internet Forum and in private practice, Fayetteville, Ark. “Before we even start to think about the tools we use, we have to know the patient is still and quiet. The ambience my staff creates in the OR and what we’ve done as a team to establish patient confidence will dictate how the entire surgery is going to go.”
When there’s a nurse anesthetist on the case, “the nurse is going to get the patient in a comfortable position for me, and I don’t have to think about it. It’s a great comfort to me to know that,” he said.
Simplified, it comes down to ergonomics, said Samuel Masket, M.D., clinical professor of ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, Los Angeles. “Both the surgeon and the patient need to be in a physical position that’s comfortable,” he said, who prefers to position patients himself.
Along with patient positioning is draping, Dr. McDonald said. “If that’s done well, the next steps work easily,” he said. “You can’t go to the next step in any surgery until the previous one is conquered.”
Dr. Masket agreed. “I’ve trained the OR staff so they’re as efficient and effective as possible in terms of isolating lid lashes and margins. You have to protect the operative field from microbes. If you don’t have a cooperative patient, this is next to impossible,” he said. “A patient’s own flora are the primary source for microbial contamination, so draping properly is extremely important.”
Draping and patient preparation go hand-in-hand, Dr. Gills said. “It’s essential we have Betadine with a neutral pH so there’s no chance of keratitis or dry eye,” he said. “We use a diluted betadine that’s been neutralized so it’s not acidic.” Dr. Gills’ patented betadine formula is available at www.stlukeseye.com/professionals.
Always anticipating what might go wrong is what makes Nick Mamalis, M.D., director, Ophthalmic Pathology Laboratory, John A. Moran Eye Center, University of Utah, Salt Lake City, comfortable in the OR. At the VA hospital where he often works with residents, patients may not have complete histories, or may be unaware of their medications and this could lead to unforeseen problems.
“The first thing you have to have on hand is trypan blue dye [(VisionBlue, Dutch Ophthalmic Research Center International, B.V., Zuidland, The Netherlands)],” he said. “You need adequate visualization of the capsule to make a good capsulorhexis. Obviously, if it’s white you know that ahead of time. But something like a dark fundus, or red reflex, isn’t as obvious. I like to have it on hand for those ‘just in case’ scenarios.”
What’s needed next are pupil dilating or expanding devices, such as the Malyugin ring (MST MicroSurgical Technology, Redmond, Calif.). He said “it’s easy enough to have it preloaded and ready to go.” With the VA patients, some do not know if they’re on prostate cancer medication or they’ve sometimes forgotten.
“When there is the potential for an incomplete medical history, it’s important to have some kind of pupil expansion device available,” he said. In those cases, he also likes to have a high viscosity OVD on hand, “especially for those IFIS cases you didn’t know about before surgery,” Dr. Mamalis said. His OVDs of choice are Healon V (Advanced Medical Optics, Santa Ana, Calif.) or DisCoVisc (Alcon, Fort Worth, Texas). “Surgeons need to familiarize themselves with how to use these OVDs,” he said. “They’re different not only in how to inject them, but they’re different animals in how they function.”
Capsular tension rings (CTRs) should also be on hand, he said. “You just don’t know the focal areas of the weak zonules,” Dr. Mamalis said. “I prefer to use an injector instead of forceps, and we have both standard and Cionni rings on hand. If the zonule disruption is significant, you’re going to have to suture it.”
A CTR in the suite is “absolutely” necessary, said Lisa B. Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, University of Utah Moran Eye Center. “It’s inappropriate to go to surgery without the possibility of having to place a CTR,” she said. “You can predict some of them ahead of time, but you’re not going to really know until you’re in it.” She also has standard and Cionni CTRs on hand.
Dr. Nichamin uses a lid speculum “for 100% of my intraocular cases.” The Storz model (Storz, San Dimas, Calif.) that bears his name is made to “optimize a temporal approach, so the bulk of the speculum is not in the way when you go towards the limbus,” he said. “It locks so you can get as much exposure as you need.”
Also, pay attention to the patient’s age, Dr. McDonald said. “It’s going to be much easier to seal the younger eye. The sclera is more pliable, and your incision seal will be better,” he said.
“Incision is what really starts the case and defines in so many ways how the case is going to go,” Dr. McDonald said. “If you’ve made a poor incision, it’s going to be a struggle.”
For Dr. Gills, the incision is “the essence of clear corneal surgery.” He prefers to go through the sclera into the cornea, at 17 degrees or less.
Dr. Masket usually attempts a 2.2 mm square clear corneal incision. “I firmly believe that blade technology plays an important role in the success of an incision,” he said. He uses the Mastel 2.2 mm diamond blade (Mastel Precision, Rapid City, S.D.) for all of his incisions. “It’s a reproducible incision in my hands. I have my own specific technique where I make a groove and dissect the pocket into the cornea before piercing Descemet’s,” he said. “That’s critical from a standpoint of induced astigmatism and hermetic sealing at the end of surgery.”
Dr. McDonald also prefers a diamond blade. “I’m more consistent using the same amount of force with the diamond blade,” he said. He uses a trapezoid blade “because the incision is the most important part of the surgery.” In his premium lens channel patients, Orbscan and K readings will help define the angle of entry. Dr. McDonald also uses diamond blade for the second hand incision as well.
“The second hand incision is sometimes the one that’s harder to seal,” he said. “We’ve used tight, round instruments through the opening, and that gets fish-mouthed.” He’s working with a manufacturer on a second hand instrument that would be beveled on one side, flat on the proximal side.
“Nothing’s perfect,” he said. “You need to know your second hand instrument and its limitations. We need to be much warier in the periphery and that will limit what you can do ‘blindly.’ In a small pupil where the nucleus doesn’t rotate well, a smooth tip keeps me out of trouble.”
Dr. Arbisser “would not like to be without a micrometer diamond guarded blade for astigmatic keratectomy at a predictable depth.” She also routinely uses the Triamond blade (Mastel Precision) and a Rosen Splitter (Katena, Denville, N.J.) for vertical chops in any density cataract. Her Arbisser blade can make a 0.3-0.5 incision at “any length. With a little measuring, I can make very different size incisions,” she said.
Remaining portions of surgery
Dr. Arbisser also prefers to have a pair of intraocular scissors on hand. “Ideally, I like a pair that goes through a small incision,” she said. “It’s easier to enlarge the capsulorhexis when necessary.”
Dr. McDonald prefers a bent 25 gauge needle, and makes “the whole capsulorhexis with it.” His technique is a bit unique, in that when he uses the bent need, “I bend it backwards from what most people do, so the smooth part of the tip is the leading edge,” he said. With a 25- or 23 g needle, “there’s enough inertia in the tip to go ahead and make a full capsulorhexis without introducing forceps,” Dr. McDonald said.
Dr. Nichamin has “very few instruments on my tray … maybe 6 or 7, but those are direly important.” Among these instruments: the 21 g side-port cannula (Storz, San Dimas, Calif.). “Bringing a conventional infusion cannula into deeply set eyes at 6-12 o’clock is difficult,” he said. “This one allows for hydration to the side port incision. More often than not, the side port leads more than the main incision.” He also uses two choppers, one from Storz for routine cases, and one for rock hard cataracts (Rhein Medical, Tampa, Fla.)
“In routine cases, I like to have the Chang cannula on hand for hydrodissection,” Dr. Mamalis said. He prefers a vertical chopper as well. Dr. Gills’ patented single port cannula has a sleeve on the tip to keep fluid at bay, he said.
Dr. Masket uses an intraoperative tonometer to set intraocular pressure at physiologic levels (between 15-20 mm Hg) in “each and every case,” he said. “When I next test IOP with a Sidel test, I can ensure the wound is hermetically sealed.”
Dr. Arbisser keeps Healon V on hand for IFIS cases, and “like the availability of mixing intracameral epi in cases of IFIS,” she said. “There’s no substitute for Viscoat (Alcon) for endothelial cell protection and to protect the open capsule and chamber loss in the event of a complication.”
Dr. Nichamin agreed, stating that while he doesn’t use Viscoat for routine surgery, when faced with potential vitreous loss “there’s no OVD that works better to tamponade than Viscoat. It’s indispensable for complicated surgery.” For uncomplicated surgery, he prefers to use Amvisc (Bausch & Lomb, Rochester, N.Y.), and for IFIS, Healon.
Dr. Masket said his strategy for IFIS works “extraordinarily well.” He pre-treats patients with topical atropine for two days pre-surgery, and sometimes during the day of surgery.
“My strategy is to use atropine and intracameral epi and DisCoVisc,” he said. “That trio has made IFIS a routine cataract surgery for me.”
Intraoperatively, “antibiotics are absolutely essential,” Dr. Gills said. “Our center has 1/25th the national rate of endophthalmitis. I don’t think our way is the only way to go, cetafozine and vancomycin can be equally good.”
Dr. Masket instills 50 microliters of Vigamox directly from a fresh bottle. It’s been proven to be safe in terms of intraocular administration,” he said.
Additionally, Dr. Masket said it’s “very valuable on occasion to work through the pars plana and use an MVR blade (Escalon Medical, New Berlin, Wisc.) to work on the sclerata.”
Dr. McDonald uses a 30 g needle on a 1.5 cc syringe filled with vancomycin at a ratio of 1 mg/0.1 mL, he said.
“When you use the cannula to insulate the wound, you’re spreading the collagen fibrils apart,” he said. “You want the top and bottom fibrils to be the least deformed and to start drying to seal the incision. I take that 30 g needle and stick it into virgin cornea and inject vanco into stroma and seals from incision from above basically by compressing it.”
While she only sutures “every 1 in 500 or so cases,” Dr. Arbisser prefers to use Biosorb sutures (Alcon). “They’re easy to bury a 2-1-1 know and it dissolves in 90 days.”
Postoperatively, Dr. Gills recommends every surgeon check IOP 20-30 minutes after surgery completion “to make sure your seals aren’t leaking. You need to make sure you’re not sucking the conjunctiva back in.” In his clinic, he uses the neutralized Betadine formulation and an air puff tonometer.
The quality of a disposable blade “is quite good these days,” Dr. Mamalis said. “There are high quality disposable metal blades available if you don’t have access to a diamond blade.” For surgeons who use metal blades, he stressed the importance of having the staff trained properly on cleaning/sterilization techniques.
Cataract surgery involves “a plethora of incredible actions that are all incrementally done, and we all probably do each step a little differently,” Dr. McDonald said. “If you count the steps involved in cataract surgery, it’s mind-boggling.”
Patient positioning, draping, and those “few critical instruments” are indispensable in having efficient, reproducible cataract surgery and outcomes, Dr. Nichamin said.
Editor’s note: Dr. Gills has no direct financial interests related to his comments. Dr. Nichamin has designed most of the instruments he discussed, but has no direct financial interest with the affiliated companies. Dr. McDonald has financial interests with Bausch & Lomb (Rochester, N.Y.). Dr. Masket has financial interests with Alcon (Fort Worth, Texas), Othera (Exton, Pa.), and Visiogen (Irvine, Calif.). Dr. Mamalis has financial interests with Advanced Medical Optics (Santa Ana, Calif.), Alcon, Bausch & Lomb, and Calhoun Vision (Pasadena, Calif.), among other companies. Dr. Arbisser has no financial interest in her comments.
Arbisser: 563-323-2020, email@example.com
Gills: 727-938-2020, firstname.lastname@example.org
Mamalis: 801-581-6586, email@example.com
Masket: 310-229-1220, firstname.lastname@example.org
McDonald: 479-521-2555, email@example.com
Nichamin: 814-849-6547, firstname.lastname@example.org