Complicated Cases: Part 1

Marguerite McDonald, MD, invites two surgeons who specialize in difficult cases-Brandon Ayres, MD, and Zaina Al-Mohtaseb, MD-to explain how they educate patients about the expectations and risks associated with a surgical procedure. Listen to gain insight into pre- and postoperative conversations with patients in complicated cases.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: Welcome again to Informed Consent: Getting to Yes, the podcast where leading eye surgeons share the fair and balanced words they use to get their patients to say yes to the treatments they recommend. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York.

The topic of this edition is complicated cases, or cases with complications—whichever you prefer.

I’m honored to have this conversation with two great eye surgeons who specialize in these difficult cases. The first is Dr. Brandon Ayres, who is with the Cornea Service at Wills Eye Hospital in Philadelphia. It’s great to have you, Brandon.

BRANDON: Hi, thanks for having me.

MARGUERITE: The second is Dr. Zaina Al-Mohtaseb, who is an assistant professor and cornea and anterior segment cataract specialist at Baylor College of Medicine in Houston, Texas. Welcome, Zaina.

ZANIA: Thank you. Happy to be here. And really it's amazing that you have this podcast because one of the most important things is the more time I spend preoperatively talking about potentially the expectations and the risks, the less time that is needed to talk postoperatively. And I think the patients are happy and they understand there always is a risk of complications and theirs might be higher, but if you have that discussion at the beginning, it becomes more of a give and take postoperatively instead of “what do I do now?”

MARGUERITE: I agree completely.

So Brandon, when it comes to complicated cases, it's all about setting expectations. Most of us know going in when we're probably going to encounter some trouble, some hurdles. So suppose I'm Mrs. Smith, and I've got a pseudoexfoliation in a 4+ nuclear sclerotic cataract. What would you say to me pre-op?

BRANDON: Well, these are always difficult situations. Now, the one advantage that we're going to have is, most of the time, these patients were sent to us because they know they have an issue. So they come in understanding that they have to see a specialist because their eye is not the same as their neighbor's.

And I think what patients really want to know is that you're there to do the best job that you can, and you're not going to leave them hanging if there's an issue. So I would typically say, "You know, Mrs. Smith, you know this is a very bad cataract, and you have a preexisting condition called pseudoexfoliation, which increases your risk for complication during this surgery."

"Our job is to anticipate every potential complication and make sure that we are ready to deal with that complication in the operating room, but sometimes things can happen. The support system in the eye can be too weak to hold the implant. Sometimes the cataract can displace itself into the back of the eye, and that may take an additional specialist to remove. We'll do the best that we can for you, and no matter what happens, we're going to make sure you get through this as safely and quickly as possible."

And then, I'll also go over the more typical adverse reactions or complications that can happen during cataract surgery, like infection or bleeding or posterior capsule rupture and things of that nature. I also tell them that because of the condition of their eye, they're at risk of higher complications down the road. And they may or may not be good candidates for some of the other implants that their neighbors may have had, such as a multifocal or toric or whatever the case may be.

ZANIA: I actually have an eye model that I use when I'm explaining this. So kind of imagine that I have an eye model as I'm talking to Mrs. Smith. So Mrs. Smith, you have a cataract and the lens, which is in the middle of the eye, instead of being clear, is filled with a chocolate like material. Sometimes that material's very hard and dense, as in your case. And the lens itself is held onto the eyeball through these zonules that you can see in this picture here. So there's always a risk of complications any time we touch the eye. There's a risk of infection, retinal detachment, inflammation and need to do another surgery in the future.

For you, your risk of complications is a little bit higher than the normal patient who has a regular cataract and the reason for that is because that lens itself is not necessarily stable. And when it's very, very dense like that, it makes it a little bit tougher. But these are the kinds of cases I do all the time and I'm very happy to take care of you in this case. And I really want to tell you that there is a chance that you might need to do another surgery in the future if we're not able to put the lens in the right place that we would like. Tell me what questions you have for me.

MARGUERITE: The second surgery, what would that be about if I need it?

ZANIA: So it's important to know that I will do my best to be able to take out that cataract and put that lens in the shell itself, like the M and M shell that you have. And if I'm not able to at times, that's when it would denote maybe doing another surgery in the future if it's unsafe because that shell breaks during the surgery, then we would sometimes leave the lens and be able to put it later in the future. And if anything like a retinal detachment, which is like the film in the back of the eye, which is a little bit of a higher risk in your type of cataract, I would talk to my colleagues, who we work together and we could potentially need another surgery in the future. But we'll make sure you're very well taken care of.

MARGUERITE: So on the rare occasion when a piece of nucleus does hit the optic nerve and you have to chat with them one day post-op, how do you explain that sort of thing?

BRANDON: Well, I'll actually start doing that right there at the hospital before they go home. I don't think that it's a good idea to try and play with words or say, "This happened. That happened."

I definitely do not blame the patient for what happened, but I just simply say, "Look, we talked about this beforehand. The support system in the eye wasn't able to support the cataract surgery. There's still some cataract left, but I'm going to get you in to see one of my colleagues, and as quickly as we can, we'll get this taken care of." And that's the same story I tell them the next day, and I'll talk to the family that day as well.

ZANIA: So in that case, if you've spent that time, and they're prepared, patients come out of the surgery and they tell me "Were you able to put the lens in the bag?" So if you have that discussion, it's really much easier to discuss afterwards. So Mrs. Smith, unfortunately, like we talked about previously, because the lens was very dense, we actually weren't able to put the lens in the correct place. We did have a little bit of a break in that shell that I was talking about and part of that material in the lens actually fell back to the retina. So just like we discussed previously, in this case, I'm going to have you see my partner so that she is able to remove that lens material and be able to stitch up a lens and put it in the right place for you. And I'm going to actually make that happen for you today so that you're able to go talk to her and discuss.

MARGUERITE: In a case like this, Zaina, do you do a block for surgery?

ZANIA: Oh definitely. First of all, not just for the surgeon's comfort, but I definitely think for the patient's comfort. Some of these cases, no matter how much you prepare, no matter how much you know this is going to be a complicated case, sometimes there are surprises. And you really want the patient to be calm and comfortable when you're doing these cases. And it just gives you much more of a confidence going in when you're not dealing with the patient moving during a complicated case. So I definitely think I would block these cases.

MARGUERITE: So you have a referral practice. In comes the patient referred by one of your colleagues and friends in the community, dropped nucleus, with or without IOL, and they're agitated and upset. So how do you speak to them? How do you tell the agitated Mrs. Smith that things are going to be okay?

ZANIA: Right. Well, first of all, it's very important to never say anything negative about the referring physician, for multiple reasons. We're all humans. If you operate, you're going to have complications. So this can definitely happen to you.

BRANDON: So that's the difficult patient because they're already a little angry or afraid or a combination of the two because of what's going on. I'll often take a look at the eye, do my exam and sit down and say, "Hey, look, this is a really difficult situation. Your eye is more complex than average, and you've got a complicated problem, but we're going to work through that."

I'll often pick up the phone, right in front of the patient, and call one of my retina colleagues and say, "Hey, look, this is the situation. I've got a patient here who is going to need attention in the near future. Can you see this patient for me today, tomorrow or the next day?"

That way, I think it really leaves in the patient's mind the sense that, "Hey, you know what, they're doing something for me. They're not hanging me out to dry, and I've got this kind of white glove service and a doctor who really cares and is going to watch over me as I go through this."

ZANIA: Mrs. Smith comes in I say "Unfortunately, you had one of the potential complicated cases of cataract surgery and this happens to the best of surgeons. And what's great is that your surgeon has the confidence in me to take care of this second operation and this is my practice. I get a lot of cases like this and I will make sure to take care of you. And let me just explain to you what's happened. Again, that lens is not in the correct position. And unfortunately, the shell has broken and there's a small piece in the back of the eye. So I'm going to work with my retina colleague. She's going to clean up the remaining material and I'm going to go in and stitch up or put in a lens that can be held onto the eye wall so that you can see very well. And I know it's hard to believe right now, especially because I know you're not seeing very well, but just give it some time and once we do the procedure, you'll be seeing much better and much happier and you'll almost forget about this experience."

MARGUERITE: So are you going to scrub with the retina specialist, Dr. Al-Mohtaseb?

ZANIA: So we have a great team at Baylor and any time there's a lens fragment or a nuclear piece, of course we include our retina colleagues to remove the actual lens material. I've been, for the past year and a half, been doing the double needle Yamane technique from Japan for sclera fixation so a retina colleague ends up cleaning up the vitreous and I come in and I do that sclera fixation using that technique. So it's really a great combination where we try to decrease the risk of retinal tears, retinal detachments by cleaning up the vitreous and then I go in with that technique to sclerally fixate that lens.

MARGUERITE: So you scrub together. That's great.

ZANIA: Correct.

MARGUERITE: Do you ever find that it's hard to calm the referred patient down and they're pressing you "Did my first doctor make a mistake?" Do you ever find yourself in that situation?

BRANDON: Every time. What happened? Why didn't they? Shouldn't they have? And I really try and diffuse that situation, and my classic thing is, "Listen, I really don't know, but I see problems from some of the best eye doctors. Sometimes, I have problems with surgery, and this is what I deal with every day. All we can do is move on from here and make sure you get the best care possible."

ZANIA: They just want to feel that someone did wrong and that's why they're having this trouble. And I think it's really important to re-guide them back that any surgeon can have these complications and everybody's human and it's not that someone necessarily made a mistake that was on purpose. And so just really guiding them. If you tell them what you're going to do and what this entails and really giving them that confidence that I do this all the time, I've seen this, you're not the only patients that have through this. Because they'll start giving you stories. My best friend, the next day woke up and could see well. And you'll tell them "You'll get to that point and it takes time."

BRANDON: I do not try and pass blame on the other surgeons. It's likely not their fault, but in the patient's eyes, it is. And so, not only is it my job to treat that patient and make sure they get excellent care, but it's also to try and protect the reputation of the referring doc, who is relying on me to get their patient through this and maintain a good doctor-patient relationship with the initial doctor.

ZANIA: I think the most important thing is always be honest and communicate with the patient. The worst thing you can do is not have a complication, is try to cover up a complication, or not actually involve the patient and discuss things with them. We are all human and the key is just as soon as it happens, right after, spend that time, explain what happened and provide a plan. If you're not comfortable doing the complications or the scleral fixation, make sure you have someone that you can refer these to, someone you trust.

MARGUERITE: Well, this has been extremely useful. Thank you both so much.

BRANDON: Any time. Thanks for having me.

ZANIA: Thanks again for having me.

MARGUERITE: You’re both welcome. It has been my pleasure, and I trust our listeners’ as well. Please watch out for our next Informed Consent: Getting to Yes podcast.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.