When a complication happens intraoperatively, it can be devastating to both the patient and the surgeon. The result may be limited visual potential, a need for more surgery, issues with cosmesis, and more problems down the line. The surgeon can suffer feelings of anguish, disappointment, and even guilt. Teaching young surgeons how to deal with these issues and how to help the patient deal with a complication is an important part of any residency, including an ophthalmology residency.
The first instinct when a complication occurs might be denial. That’s what natural human instinct may tell us to do. We have a hard time believing that something untoward is actually happening. Early in our careers we may not even notice complications as they occur, but rather notice the sequelae after some time has passed. Learning to recognize a complication as it happens is a skill that takes time, and it is why even master surgeons continue to hone their talents after tens of thousands of cases. Once we see the complication and accept it, we must stay calm.
“Equanimity under duress,” was what the trauma surgeons would recite when I was a medical student as yet another gunshot wound or blunt force injury patient would be rushed into the operating room. In ophthalmology, we are not often dealing with this type of catastrophic injury, but the truism still applies. Staying calm and assessing the situation is paramount. In cataract surgery, for example, when the capsule breaks, the reflex “to suddenly pull out of the eye” must be blocked. Staying in the eye with the infusion on will limit the vitreous prolapse and negative effects of the complication. Thinking about what comes next is more important: keep the infusion on, inject viscoelastic to form a barrier, keep vitreous posterior, elevate any remaining cataract fragments, and don’t let the anterior chamber collapse.
Once the eye has been stabilized, there is usually time to think. Stop operating, put down the instruments, and look carefully through the microscope. What should the next step be? How can the damage be minimized? Are there remedies that will help restore good vision to our patient? And should we make the decision to refer the patient to a colleague? This is also an opportune time for the anesthesiologist to administer more sedation if required.
With a new game plan, now start the process of recovering from the complication. In the example of the ruptured capsule during cataract surgery, determine the extent of vitreous prolapse by injecting dilute triamcinolone. Set up the anterior vitrector, close the main incision, and instruct the staff to open a lens implant suitable for sulcus placement. Be meticulous and purposeful in finishing the case and take extra precautions to ensure a smoother postoperative recovery, including suturing the incisions and injecting antibiotics and steroids.
In the postoperative period, explain to the patients and the family members what happened during the surgery and what will happen next. I am truly sorry when a complication happens and I want patients to know that I will stand by them and do whatever it takes to aid in their recovery from surgery and to maximize their visual results. These are patients that I hold closer and see frequently in the postoperative period. I let them know that we did everything possible but complications can occur unpredictably. That is the nature of our work, because of the variability in patient tissues, and the life of a surgeon. Fortunately, in most cases, the patient can recover beautifully and achieve good vision.
Thirty years ago, the same trauma surgeon also reminded me that only 2 types of doctors never have surgical complications: those who don’t operate and those who aren’t truthful.