During the past 2 decades, I’ve been fortunate to train about 150 ophthalmology residents while performing thousands of ocular surgeries. One of the biggest challenges is teaching surgical judgment, which is more difficult to grasp than learning a surgical technique. Traditionally, judgment is built slowly by years of experience. That means making some mistakes, and realizing that some patients should not have had surgery.

The best situation is when you can determine ahead of time which patients should not have surgery. While it is easy to refer a patient to a colleague who practices a different subspecialty, such as referring a patient with an orbital tumor to an oculoplastic surgeon, it is often more difficult to refer a patient to someone in your area of expertise. It is also important to differentiate between an elective surgery and one that is urgently required. Cataract or refractive surgery can be postponed for years and even glaucoma, corneal, and eyelid surgery can be delayed. However, cases such a macular-threatening rhegmatogenous retinal detachment need to be treated promptly.

For elective cases, the most important issue is to feel confident that your skills will allow you to give the patient a good outcome with a very favorable benefit-risk ratio. I’ve learned that while I enjoy learning new techniques and mastering them, sometimes it’s better to refer an unusual case to a colleague who has more experience using this new or different technique. A recent case involved a patient who needed a scleral sutured intraocular lens using polytetrafluoroethylene and a lens with 4 loop haptics to ensure great long-term stability. I’ve done these cases a few times with good success, but I’ve often wished for posterior segment instrumentation to clean up prolapsed vitreous and provide a pars plana infusion to keep the eye inflated. I began sending these patients to a trusted retinal surgeon who has written extensively about these types of sutured lenses; I was amazed by his beautiful outcomes and also relieved that he was taking care of a patient who developed a retinal break at the pars plana entry site.

The eye is very delicate and there are a limited number of procedures that can be performed on the same ocular tissue. A patient with prior radial and astigmatic keratotomy can have cataract surgery with success, but then choosing to perform additional procedures, such as LASIK or PRK to chase emmetropia, can be risky. The cornea is about half a millimeter thick and can only take so much surgical manipulation. Sometimes the saying, popularized by Voltaire, that perfect is the enemy of good applies perfectly to ocular surgery.

Another important group of patients who should probably not have elective surgery are those for whom the expectations are greater than the anticipated outcome. Patient happiness can sometimes be defined as the difference between the surgical results and patient’s expectations. By increasing this delta, we can help ensure patient satisfaction with the outcome of surgery. We’ve all had the cataract patients who are willing to pay for any lens and any technology as long as they can regain the perfect vision of youth. Or the prebyopic low myope who wants you to perform refractive surgery to improve her distance vision, but wants the near vision to remain the same because she doesn’t need glasses for near work now. While you and I know that these desires are unreasonable, the patients genuinely do not understand this. You can educate the patient and temper expectations, or you can simply choose not to operate.

Finally, when performing elective ocular surgery, you should be certain that the patient is in a stable state of mind and actually wants the surgery. Sometimes people who are under significant medical or psychological stress, such as from a diagnosis of cancer or an ongoing divorce, desire elective procedures to improve their lives and take their minds off the other stresses. This should be approached with caution, because anything less than a perfect outcome may be seen as a catastrophic failure and an additional source of stress.

Surgery causes permanent, irreversible change to our patients’ most precious sense, their sight. It’s a big responsibility and, in a sense, we accept ownership of these patients for the rest of their lives. And likewise, these patients own us forever too. Choose wisely!

 

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