I’ll always remember the sage advice of a mentor who told me, “Any surgeon can operate, but it takes a surgeon with sound judgment to know when not to operate.” It sounded catchy at the time, but little did I know how much influence those words would have on my future career.
This advice is particularly true for reoperations. Surgery on virgin tissue tends to be the easiest. No scar tissue, no prior incisions, better healing response, more robust tissue. A reoperation requires more time and is higher risk, with outcomes that are not always as good. Communication is critical to set appropriate patient expectations and to inform patients of the added risks involved.
I recently saw a patient who had undergone uncomplicated cataract surgery more than a decade ago. She had great results for many years, but recently she was noticing a decline in vision in both eyes. Her pseudoexfoliation syndrome had progressed and zonular laxity was causing displacement of the entire capsular bag and intraocular lens (IOL) complex. In her right eye she was able to see the 20/60 letters looking through her decentered IOL, but her left eye was functionally aphakic with an uncorrected acuity of counting fingers.
Looking at her right eye, it seemed like the IOL was just behind the iris and that I could help her with a revision surgery. Because she had a single piece IOL in the capsular bag with severe zonular laxity and loss, I determined it would be best to remove the entire IOL and bag, and replace it with a new IOL. The new lens could be an anterior chamber IOL or it could be a posterior chamber IOL fixated to either the sclera or the iris. Her corneal endothelial cell count was on the low side, so perhaps avoiding the anterior chamber IOL would be better in the long term. For the left eye, the lens/bag complex was at the inferior ora serrata and appeared stable without any induced reaction. Perhaps it would not need to be removed and simply placing a new IOL could be sufficient.
I’ve been doing IOL exchange surgery and fixated IOL procedures for many years and I enjoy the challenge of solving a difficult puzzle. I believe my results have been excellent and patients have been satisfied. And the reason I suspect I have had this level of success is that I try to be careful to know when not to operate.
In the clinic, I placed the patient in the supine position and examined her eyes using the indirect ophthalmoscope, both as a way of seeing her posterior segment, but also using the 20 diopter lens as a way of magnifying my view of her anterior segment. What I saw next caught me off-guard. In her right eye, the IOL which was just behind the iris when examined at the slitlamp microscope, fell far back into the mid-vitreous due to severe zonular laxity. In the left eye, the IOL bag complex which I thought was stable at the inferior ora serrata, fell back towards the macula.
This patient needs a vitreoretinal surgeon to safely remove the dislodged IOLs. Any attempt to remove these IOLs from an anterior segment approach would pose a very high risk of iatrogenic retinal damage. I referred the patient to a vitreoretinal colleague who will do a proper pars plana vitrectomy, IOL removal, and fixation of a 4-loop acrylic IOL to the sulcus using a flexible, monofilament, biomaterial suture. This likely will give the patient better long -erm results than my attempt to remove these IOLs from an anterior segment approach.
The patient was disappointed that I would not be doing her surgery, but when I told her that it was for the best, she agreed to see my retinal colleague. Now that I’m squarely at the midpoint of my career, I find that surgical judgment is as critical as surgical dexterity. The sage advice I received from a mentor in medical school has made me a better surgeon. (Thanks, Dad.)