Extreme surgical challenges can spark creativity

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

As surgeons, we all have to deal with challenging cases. As we gain experience, we build our skills and become competent to the extent that we can handle them with ease. And yet, we might at some point be challenged with the unexpected, with uniquely awkward situations, in which there is no textbook and no previous experience that can help us. All we can do is be creative, think laterally and find our own unique solution to the problem. This month, we are going to discuss or rather narrate the unusual: Cathleen M. McCabe, MD, Lisa K. Feulner, MD, PhD, and Carlos Buznego, MD, will tell us how they navigated the unexpected, took the challenge and drove successful results.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Operating on a patient with kyphosis

The story I want to tell you is that of a patient with extreme kyphosis, whom I remember walking into my office, the torso bending down 90°, his head facing the ground.

“Nobody else has even allowed me to come in their surgery center before to try to help me, so I’m ever so grateful you have accepted to see me,” he said, and I immediately felt I had, and wanted, to do everything possible to solve his problem.

On the day we had scheduled for cataract surgery, we sat him back in Trendelenburg position, with the head of the bed as far down as it could go. However, the most we could get him to lie back would be with his head facing me as though he was sitting. I turned the microscope at 90°, which enabled me to direct the light straight ahead, and extended the oculars out toward me so that I was facing the patient as though we were sitting face to face. Of course, this is not the most comfortable of positions for surgery because your arms are outstretched and the working distance becomes longer. You also have to keep in mind that gravity is acting differently on all the fluids. It is not easy to wet the cornea, for instance, so we would use a dispersive viscoelastic on the cornea to keep it from becoming dry during the procedure. I had an assistant holding the patient’s head to try to keep it as upright as possible and to hold the lid speculum up because gravity wants to bring that down as well. Everything inside the eye moves differently in that position because gravity is inferior rather than posterior, but if you act accordingly, it is possible to do surgery that way.

I did the left eye first, and as a right-handed surgeon, that was relatively easy because I could come in temporally with my hand and the nose did not get in the way. Everything went well, and the patient was so grateful that he wanted me to operate on his right eye. This was an even bigger challenge because he was not just sitting straight towboard me, but his head was tilted slightly to the right and his chin pointed down, which meant that for me, as a right-handed surgeon, his nose was in the way. And he was so far down on his chest with his chin on the right side that the microscope was resting on his chest and could not just face straight ahead at a 90° angle but had to be pointed up. In that position, with the oculars pointing upward, you have to flex your neck a lot to look into them, still with a long working distance for your arms. However, I was able to complete the surgery, even with a complication that required vitrectomy.

It was difficult, awkward at times and tiring. We had to redrape many times, and I had to take a short break at some point. The good news is that today, with heads-up 3D viewing systems, a lot of these challenges are made much easier, something I have now experienced with another patient with extreme kyphosis. It was still difficult to position him on the bed, and the problems related to gravity effects were still there, but my neck during surgery was far more comfortable.

• For more information:
• Cathleen M. McCabe, MD, chief medical officer at Eye Health America and medical director at The Eye Associates in Sarasota, Florida, can be reached at cmccabe13@hotmail.com.

Operating standing on step stools

The case I am going to tell you about took place several years ago, when I was doing surgery in a hospital setting, and I had a patient who weighed more than 400 pounds, too heavy for the eye stretchers at the hospital.

I had to operate on him using a regular operating room bed, but these beds are much higher because our colleagues in other specialties mostly stand up to operate, and ophthalmologists are an exception. The bed could not be lowered enough for me to sit, and the size of the patient elevated him even higher. Even standing up, I could not reach the height that was needed for me to perform surgery, and the only option I had was to stand on separate stacks of rectangular, fairly large step stools placed side by side. They had to be stacked about four high in order for me to stand up high enough, with the microscope foot pedal on the step stool to the left and the phaco pedal on the step stool to the right. I had the microscope in front of me, so I had the option either to focus or to phaco, but I could not do both at the same time, and I did not have any way of bracing myself to stay steady because I was standing and leaning over the patient. At one point I almost fell off the stool, but I was able to successfully finish this case.

If you are an ophthalmologist, operating standing up is precarious at best, and that is if you are standing on the ground. But to stand on stacked step stools is pushing one’s luck. I was young at the time when I did this, and I am not sure whether I would take that risk today. The room was full of people watching me because word had spread in the hospital that I was propped up on all these step stools and operating standing up in a precarious way. But I think it was not a smart thing to do. In my youth, I thought I could do anything and told myself, “This man needs his cataracts out. This is the only way he’s having them out, so I’ll do what it takes.” I am aware that it could have ended in a disaster, but sometimes it is true that fortune favors the bold, and it ended up going well.

Once I did the first eye, I searched around the city to find an operating room that had an eye bed that could hold the patient’s weight. I found it, and I was able to do his second eye in an ASC on a bed that allowed me to operate in a much safer situation.

• For more information:
• Lisa K. Feulner, MD, PhD, founder of Advanced Eye Care & Aesthetics in Bel Air, Maryland, can be reached at lisa.feulner@vipeyes.com.

Standing up for a patient with COPD

My difficult case was that of a gentleman in his 60s who came to see me because of advanced, rapidly progressing posterior subcapsular cataract.

He was a barber, still active in his job, but within a short period of time, he had lost so much vision that he was no longer able to drive and had trouble performing his usual working tasks. We all would want a barber to see well so that the customer does not get injured. But many before me had refused to operate on this man because he had chronic obstructive pulmonary disease (COPD) and could not lie flat without having a hard time breathing. What could I do for this patient? In order to allow him to breath normally, the head of the operating bed had to stay up high at 45°, up around my chest height. In those circumstances, I could not sit in the usual position, so I proceeded to do the cataract surgery standing up. Most surgeries in medicine are done standing up, but ophthalmic surgeons need to have both feet on pedals, one to control the microscope and one to control the phaco machine. To operate both pedals while standing up, I had to improvise a sort of fast footwork dance, something like a Mexican huapango or an Irish jig, jumping from one foot to the other in an intricate interplay with my hands. The case was successful, I was able to remove the cataract, and the patient was able to go back to work, drive and have a normal life. He was happy and grateful, even more so because others had turned him down.

In the second case I want to tell you about, the unexpected was not in the premise but in the conclusion, in the first reaction a patient had the moment she regained vision after having been blind for nearly 10 years. She was a woman from Cuba, bilaterally blind from advanced mature cataracts. Her country did not have the resources to take care of her problem, and along the way, she had immigrated to another country but was too scared to have surgery. When she arrived in the United States, she was basically blind. She came to see me with her husband, whose face she had not seen for almost 10 years, and her daughter, who had immigrated to the U.S. about 20 years previously when she was still a teenager. I performed extracapsular cataract extraction, as we used to do in those days, and patched the patient overnight. The next morning, I was excited to uncover her eyes and see how she would react to seeing her husband’s face for the first time in nearly 10 years and her daughter, who in 15 years had turned from a teenager into an adult woman who had brought her mom over to the U.S. I expected a first statement such as, “My husband, I love you, and I haven’t seen you for so long!” or “My beautiful daughter, what a woman you’ve become!” When I removed her patch, the first thing she said was, “Dr. Buznego, you’re much fatter than I thought you would be!”

After a moment of awkward silence and a desperate attempt by the daughter to apologize, I looked at the patient and threatened to take the cataracts out of the garbage can and put them back in her eyes. Then we all laughed and were extremely happy.

• For more information:
• Carlos Buznego, MD, a founding partner of the Center for Excellence in Eye Care in Miami, can be reached at cbuznego19@gmail.com.

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Sources/Disclosures

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Source:
Expert Submission

Disclosures:
Buznego, Feulner and McCabe report no relevant financial disclosures.

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