Is this common?

[KHE]

http://www.courant.com/health/connecticut/hc-botched-eye-operation-0628-20110627,0,3561787.story

Is this a common complication of surgeons in training or is this just the case of a center fielder dropping a routine pop-up?

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[Visionary]

http://www.courant.com/health/connecticut/hc-botched-eye-operation-0628-20110627,0,3561787.story

Is this a common complication of surgeons in training or is this just the case of a center fielder dropping a routine pop-up?

Yikes! No, this is not common, at all. Sounds like she injected the whole (or most of the) retrobulbar block into the globe. It's a theoretical risk, but I've never actually heard of it happening, until now. Wow. Even if you do engage the globe with the needle, you should feel something is wrong, especially before you "explode" the globe! Injecting anesthetic into the globe is not, in itself a vision-threatening issue. Intracameral anesthetic is pretty common nowadays. I have also heard of a small amount of anesthetic being accidentally injected into the globe from below during a dental block. The person administering the block quickly realized something was wrong, though. Patient ended up fine.

 

[bucknut101]

During my residency one of my fellow residents perforated the globe during a retrobulbar block. However the globe did not explode. The patient did however have a retinal tear that had to be barricaded with laser. He ended up doing fine. Thankfully, as Visionary stated, this complication is not common.

I love the lawyer's comment "It is clear that Dr. Wang's training was seriously inadequate". Last time I checked when you're a resident you are currently in the process of training.

 

[JMK2005]

This is a retrobulbar block complication. I'm happy the Associated Press is able to report these issues in a balanced and unbiased fashion.

Cataract surgery has risks. It's an unfortunate complication, but the tone of that article is was uncalled for.

 

[KHE]

This is a retrobulbar block complication. I'm happy the Associated Press is able to report these issues in a balanced and unbiased fashion.

Cataract surgery has risks. It's an unfortunate complication, but the tone of that article is was uncalled for.

What is the frequency of that complication?

How often does a globe perforation from a misdirected retrobulbar block result in that much damage to the eye?

 

[bucknut101]

What is the frequency of that complication?

How often does a globe perforation from a misdirected retrobulbar block result in that much damage to the eye?

Like Visionary stated its not that common at all. I've heard of it happening but never to the extent the globe "blows up". With the number of retrobulbar blocks done on a daily basis for eye surgery the percentage of this complication occuring has got to be extremely low.

Personally, I've probably done over a thousand blocks and never have this happen to me. I've had a few retrobulbar hemorrhages but never perforated the globe. With proper technique this really should not happen. A couple of things to look out for that could lead to an increased risk of globe perforation include a long axial length and a posterior staphyloma.

 

[speyeder]

What is the frequency of that complication?

How often does a globe perforation from a misdirected retrobulbar block result in that much damage to the eye?

Not common. I've never heard of this happening before.

 

[MstaKing10]

Repaired someones peforated globe with associated RD a few months back after botched peribulbar performed by inexperienced CRNA. Turns out pt had a staphyloma in the area. Incidence is rare, maybe .1% or less? Pt did not do so well unfortunately with multiple RD surgeries, PVR etc...

The worst part of the whole thing is the articles one sided coverage of the story. Fair and balanced my @$$.

 

[MR1]

Incidence probably 1/1000 at the most, have seen old globe perfs, some do well others not if it gets the macula. Have heard the the globe theorectically can explode with that much volume but would think there would be obvious signs to stop injecting b\f that happened.

 

[Zorro12]

Is rare, and I would guess much less than 1/1000. Higher chance with longer eyes or staphylomas. Usually you can feel if you are engaging sclera. Most people typically use retro-bular needles which probably are less prone to perforate the globe, esp if you use a larger diameter needle. Death can also result from a RBB being placed in the CNS, hence there are one or two large universities that no longer perform them and use only peri-bulbar blocks. Of course I know retinal specialists who block everybody getting laser for a tear or PRP which translates into alot of blocks without complication.

 

[Visionary]

Of course I know retinal specialists who block everybody getting laser for a tear or PRP which translates into alot of blocks without complication.

That's interesting. I never block anymore. I blocked for cataracts in residency, until I was adept enough for topical clear cornea. I blocked for a PRP once in residency, because the attending du jour demanded it. I blocked once in fellowship for a VHL tumor thermal ablation (now, I use PDT for those). Haven't blocked once in private practice. For standard retina lasers, such as PRP and retinopexy, you can usually adjust the burn duration and energy to minimize discomfort, while still getting in a good treatment. Then, you can completely avoid the risks of a block.

 

[orbitsurgMD]

http://www.courant.com/health/connecticut/hc-botched-eye-operation-0628-20110627,0,3561787.story

Is this a common complication of surgeons in training or is this just the case of a center fielder dropping a routine pop-up?

Fortunately it is not a common complication, but the reality of retrobulbar blocks is that they are a blind stick. Peribulbar is safer, but not risk-free either.

The article is crappy bush-league local reporting, nothing more than a press conference from the plaintiff's attorney and his own showboating interview. The writer ought to be ashamed of the product.

 

[OMD]

As others have said, it is thankfully very rare, especially to this degree. The risks of this blind stick are just not worth it to me even though I've never perforated or seen one. I just hate doing things blindly (which is why I don't really like the fairly popular horizontal chop method of phaco either). That being said, I can empathize with a resident not knowing what it's supposed to "feel" like. It doesn't say if she was in July at the beginning or June at the end of her 3rd year. I know I did plenty of things that I felt uncomfortable with and had no idea if that was what it was supposed to be like or not (muscle reattachments, retrobulbars, cutting the nerve in enucleations, lacrimal system surgeries, etc) and that's what residency is for. I cannot imagine the scene in the OR when the complication finally occurred though. I think I would have completely soiled myself. The article may as well have been written by the plaintiff's attorney. I understand the stereopsis issues and working as a roofer and the need for compensation. No question. But he can't watch TV or movies? Tell that to the millions of old people with AMD that has robbed their sight in one eye.

 

[Mirror Form]

This is a pretty bad story all around. On one hand, the resident should have known to pull back on the syringe before injecting the anesthetic. And even if they didn't, if the needle is positioned even remotely correctly then it would be pretty tough to cause this amount of eye damage.

On the other side, this quote from the prosecution is BS: "He is unable to drive except for short distances. Reading, watching television and going to movies are difficult because the undamaged eye tires so quickly, Bernard said." I guess that's our medico-legal system though, just lie and get rich!

 

[OjoCinco]

http://www.courant.com/health/connecticut/hc-botched-eye-operation-0628-20110627,0,3561787.story

Is this a common complication of surgeons in training or is this just the case of a center fielder dropping a routine pop-up?

KHE, I've seen you post a lot here. You're a smart guy. Do you really think this could be a common occurence?

That story is a tragedy, and like some of the above posters said, fortunately the complication was not death, which could happen. The only crime that could have happened here is if the resident did not do a good job consenting the patient, informing him of many of the possible complications that could occur as a result of a surgical procedure.

Otherwise, this sucks. Re-iterate the importance of explaining the consent for surgery or a procedure to a patient.

Article is written like ****, but nothing to be surprised about.

 

[WhatNEyeTem]

Can you imagine her next phaco case? I bet you it was a very nervous one.

I really don't understand why anyone, including residents, do retrobulbar blocks anymore. If you want good anesthesia and akinesia, subTenon blocks are efficacious and much safer. Even in retina surgeries, I would think a subTenon block would be sufficient.

I also feel bad that they actually published her name in the article. That is like kicking a dead horse square in the teeth!

 

[orbitsurgMD]

KHE, I've seen you post a lot here. You're a smart guy. Do you really think this could be a common occurence?

That story is a tragedy, and like some of the above posters said, fortunately the complication was not death, which could happen. The only crime that could have happened here is if the resident did not do a good job consenting the patient, informing him of many of the possible complications that could occur as a result of a surgical procedure.

Otherwise, this sucks. Re-iterate the importance of explaining the consent for surgery or a procedure to a patient.

Article is written like ****, but nothing to be surprised about.

Not really a "crime," but a significant liability if things go badly. The most exhaustive informed consent will not get you away from a bad outcome, sorry to say. Plaintiff's lawyers always say adequate consent was not given, otherwise their client would not have agreed to the surgery (after the fact, of course.)

 

[KHE]

KHE, I've seen you post a lot here. You're a smart guy. Do you really think this could be a common occurence?

That story is a tragedy, and like some of the above posters said, fortunately the complication was not death, which could happen. The only crime that could have happened here is if the resident did not do a good job consenting the patient, informing him of many of the possible complications that could occur as a result of a surgical procedure.

Otherwise, this sucks. Re-iterate the importance of explaining the consent for surgery or a procedure to a patient.

Article is written like ****, but nothing to be surprised about.

I never thought it was a common occurrence, I was asking if it was common in residents who are still training. Certainly the concept of an "exploding eye" is terrible over the top. That's not what I was asking. Is perforating the globe common in residents learning retrobulbar blocks. The answer seems to be NO.

So then the next question was is this just a case of a center fielder dropping a routine pop up?

 

[Visionary]

I never thought it was a common occurrence, I was asking if it was common in residents who are still training. Certainly the concept of an "exploding eye" is terrible over the top. That's not what I was asking. Is perforating the globe common in residents learning retrobulbar blocks. The answer seems to be NO.

So then the next question was is this just a case of a center fielder dropping a routine pop up?

Having no specific knowledge of the case, I would be more inclined to say this occurred because the combination of inadequate oversight and resident inexperience. As has been stated, it should never have gotten to that point. There are obvious signs of incorrect needle placement before and during retrobulbar injection. Very unfortunate.

 

[Meibomian SxN]

I love the lawyer's comment "It is clear that Dr. Wang's training was seriously inadequate". Last time I checked when you're a resident you are currently in the process of training.

Having no specific knowledge of the case, I would be more inclined to say this occurred because the combination of inadequate oversight and resident inexperience....

It was a 3rd year resident, I thought that's beginning of the end of the training process? Very unfortunate mistake for the resident.

At least she wasn't sued, although they did publish her entire name!

So then the next question was is this just a case of a center fielder dropping a routine pop up?

Seems more like the catcher trying to catch a foul ball! Not common but definitely should be comfortable in catching it!

 

[Visionary]

It was a 3rd year resident, I thought that's beginning of the end of the training process? Very unfortunate mistake for the resident.

At least she wasn't sued, although they did publish her entire name!

Honestly, it's hard to get specifics from the article. Was she truly a 3rd year resident in ophthalmology or was she a PGY-3 (or 2nd year resident in ophthalmology). Was she at the beginning or end of that year's training? How often are blocks given at that program? When are the residents first allowed to block? How many supervised blocks before they can perform them solo? How many had she done? Was she solo, or was there an attending guiding her? She may have been about to graduate from residency, but I sincerely doubt it.

In my program, the 1st years would start doing blocks for the senior residents about halfway through the year. The 2nd years would sometimes do their own blocks. The 3rd years would almost never do blocks, as they had become proficient enough for the topical clear cornea approach. I'm sure there is some variation from program to program.

As has been stated, this is fortunately a rare occurrence.

 

[bucknut101]

KHE, I've seen you post a lot here. You're a smart guy. Do you really think this could be a common occurence?

That story is a tragedy, and like some of the above posters said, fortunately the complication was not death, which could happen. The only crime that could have happened here is if the resident did not do a good job consenting the patient, informing him of many of the possible complications that could occur as a result of a surgical procedure.

Otherwise, this sucks. Re-iterate the importance of explaining the consent for surgery or a procedure to a patient.

Article is written like ****, but nothing to be surprised about.

You can talk to a patient till your blue in the face about the potential complications of cataract surgery and they really won't listen to any of it. I've heard from many patients that come in for cataract evals "Well I heard cataract surgery is just as simple and easy as getting your teeth cleaned!" Yeah right.

Most of them know friends and family that have had it done and everything has went fine with their surgeries. This sets expectations extremely high for cataract surgery. So when something does go wrong people are generally pretty upset and angry. So my point is that even if you tell them every single thing that can go wrong it's not going to change that mindset.

 

[MstaKing10]

You can talk to a patient till your blue in the face about the potential complications of cataract surgery and they really won't listen to any of it. I've heard from many patients that come in for cataract evals "Well I heard cataract surgery is just as simple and easy as getting your teeth cleaned!" Yeah right.

Most of them know friends and family that have had it done and everything has went fine with their surgeries. This sets expectations extremely high for cataract surgery. So when something does go wrong people are generally pretty upset and angry. So my point is that even if you tell them every single thing that can go wrong it's not going to change that mindset.

Kind of off topic, but there is a lot of truth to this statement. The unfortunate thing is that to some degree, we as ophthalmologists are doing this to ourselves. If you see some of the advertisements from some of these high volume guys/gals doing 5 minute phacos, showing the surgery on TV in the waiting room etc, they are partly to blame for the increase in patients expectations and an associated downplaying of the potential risks. Even more unfortunate is that this is usually directly associated to financial interests.

Personally, I run through all the risks I can think of when I discuss surgical options with patients, but I perform vitreo-retinal surgery, thus expectations are often much different and more realistic than cataract or refractive surgery.

 

[KHE]

You can talk to a patient till your blue in the face about the potential complications of cataract surgery and they really won't listen to any of it. I've heard from many patients that come in for cataract evals "Well I heard cataract surgery is just as simple and easy as getting your teeth cleaned!" Yeah right.

Most of them know friends and family that have had it done and everything has went fine with their surgeries. This sets expectations extremely high for cataract surgery. So when something does go wrong people are generally pretty upset and angry. So my point is that even if you tell them every single thing that can go wrong it's not going to change that mindset.

Should expectations NOT be high for modern cataract surgery?

I wonder what the complication rate for teeth cleanings is and how that compares to cataract surgery.

 

[Mirror Form]

Should expectations NOT be high for modern cataract surgery?

Many patients have very unrealistic expectations. They assume that b/c their friend saw 20/15 sc on POD #1, that they should too. Furthermore, all surgeons have complications.

 

[WhatNEyeTem]

Should expectations NOT be high for modern cataract surgery?

I wonder what the complication rate for teeth cleanings is and how that compares to cataract surgery.

Ummm, please never compare cataract or any other eye surgery to "teeth cleaning" again. I know you post here alot KHE, and I would hope you would know the difference between these two, vastly-different, procedures. But perhaps you really don't appreciate the difference between scraping tartar and maneuvering in a <3 mm enclosed space.

Or should we turn this into yet another optom vs. eye surgeon battle?

Look, complications happen to every surgeon. It doesn't matter if you're doing 5 phacos a week vs. 100 phacos a week. Like the old adage says: the only people who don't have complications either don't operate or are liars. The fact of the matter is that having complications is actually a good thing for a resident to experience...so that he or she understands how to manage them appropriately. I am not saying that "exploding" an eye with a RB block is necessary to the learning process, but having some complications is actually not such a terrible thing.

I have patients who seek my opinion because they have had complications from extremely-prominent eye surgeons (think: the guys you always see speaking at every meeting). These complications can range from "real" ones like ruptured posterior capsules to "soft" ones like -0.25 to -0.50 diopters of leftover refractive error or a little "glow" at night.

I agree with a previous poster who says that expectations are out-of-control when it comes to cataract/refractive surgery. A lot of it us Ophthalmologists have brought onto ourselves... and a lot of it is because a patient expects a lot if they are shelling out $3500 for a Crystalens or $5000 for an ICL. (You never hear (I hope) a vitreoretinal surgeon saying..."You're definitely going to see 20/20 after your PPV/MP/gas surgery!!")

I routinely downplay expectations specifically so there is a "WOW" factor after surgery. I always say, "these intraocular lenses will likely reduce your dependency on glasses, but are not a guarantee toward eliminating them... but they are definitely better than nothing in terms of helping your reading vision."

I wonder if any of these stories will start arising in Kentucky... (sorry, I just had to stir up the pot!)

 

[MR1]

To defend KHE, he did not compare teeth cleaning to phaco, someone before him said their patients thought they were similar in difficulty.

To KHE, patient expectation should be high with modern surgery but not unrealistic. Probably 98% will see 20/20-25 WITH glasses in the hands of a compentent surgeon. That means though 2% don't and probably about 1/100 have some significant complication or difficult post op course. We have brought this on ourselves though as others have said, promising glasses free, multifocal, etc. It is called refractive cataract surgery now by some.

 

[KHE]

Ummm, please never compare cataract or any other eye surgery to "teeth cleaning" again. I know you post here alot KHE, and I would hope you would know the difference between these two, vastly-different, procedures. But perhaps you really don't appreciate the difference between scraping tartar and maneuvering in a <3 mm enclosed space.

Huh? When do I ever try to "start" anything?

The point I'm trying to make is that you can go to the dentist, get your teeth cleaned, get some weird infection and die. Or get some crazy abscess that requires facial reconstruction. Obviously, there's potentially crazy complications in any medical intervention

MR1 is saying that the rate of serious complications or difficult post op course is 1/100.

WHat is the rate of "difficult post op course" for teeth cleanings?

 

[OjoCinco]

Not really a "crime," but a significant liability if things go badly. The most exhaustive informed consent will not get you away from a bad outcome, sorry to say. Plaintiff's lawyers always say adequate consent was not given, otherwise their client would not have agreed to the surgery (after the fact, of course.)

I hear you. I didn't mean that in a legal sense.

I meant that the the patient should be well aware of the risks of a surgery. Then they make the decision to go ahead with it and sign their form. It's important from the standpoint of patient's rights. If they forget all about it after the fact, oh well.

I know the lawsuits happen despite the above full disclosure consents. Patients and families are obviously going to be emotionally invested after a complication. To say that I have issues with the legal system in regards to dealing with issues like that is unnecessary in this forum. We're all in the same boat.

 

[Meibomian SxN]

I wonder if any of these stories will start arising in Kentucky... (sorry, I just had to stir up the pot!)

No need to do that. It was already stated that there have been NO complaints or lawsuits for 15 years in Oklahoma. Proof is in the pudding....

 

[WhatNEyeTem]

It was already stated that there have been NO complaints or lawsuits for 15 years in Oklahoma. Proof is in the pudding....

Wow! The ODs in Oklahoma are doing better surgically than 99.9% of the ophthalmologists out there if they have zero complaints or lawsuits.

Please reference the adage I quoted above in a previous post.

It's time I eat your pudding.

 

[Shnurek]

HERE WE GO AGAIN

 

[200UL]

WhatNEyeTem's long post above is spot on.

Delivery of the contents of a retrobulbar block into the eye does occur. The eye rupturing sounds unusual to me - especially if it had not seen previous surgery - perhaps it was a long eye or an eye with a history of glaucoma with thin sclera.

Bob Osher recently presented a recent case of his at a national meeting where he did this same thing. The eye did not explode but it did cloud the cornea immediately and the patient was in intense pain with NLP vision. With the immediate cloudy cornea, I estimate the IOP was likely >120 mm Hg. He performed an immediate paracentesis even before prepping the eye and proceeded with surgery after his retina friend came in and noted no retinal breaks (not sure if going ahead with phaco was the correct move). The anesthesia of the retina wore off the next day. The patient had an excellent visual outcome.

 

[Mirror Form]

Huh? When do I ever try to "start" anything?

The point I'm trying to make is that you can go to the dentist, get your teeth cleaned, get some weird infection and die. Or get some crazy abscess that requires facial reconstruction. Obviously, there's potentially crazy complications in any medical intervention

MR1 is saying that the rate of serious complications or difficult post op course is 1/100.

WHat is the rate of "difficult post op course" for teeth cleanings?

Your choice of analogy is very strange. There isn't much comparison b/w teeth cleaning and cataract surgery. The fact that you're using that analogy is annoying b/c it seems to indicate that cataract surgery is easy. I really don't think there are many complications to getting your teeth cleaned. It's not like some otherwise healthy person is just going to get an abscess after teeth cleaning.

Complications do occur in cataract surgery, but most surgeons are smart enough not to discuss their complications publicly. Supposedly there is a 2-3 percent rate of "reported" complications. That is a lot of people when you consider how common cataract surgery is.

 

[bucknut101]

No need to do that. It was already stated that there have been NO complaints or lawsuits for 15 years in Oklahoma. Proof is in the pudding....

Hate to burst your bubble, but I did my fellowship at Dean McGee in Oklahoma City and know of at least two instances of optometrists running into some problems.
One of the cornea faculty from Dean McGee was an expert witness for the prosecution in a lawsuit against a Dr. Melton for peforming PRK on a patient with know dry eye disease. Shockingly the dry eye symptoms worsened after the procedure.
Also there was a grand rounds presentation from the glaucoma fellow regarding a 5 year kid with a traumatic hyphema that was referred for high IOP. Not an unusual problem right? But what complicated things is the fact the optometrist had decided to do a A/C paracentesis. At the slit lamp. On a 5 year old kid. And inadvertently hit the lens with the needle. Resulting in a cataract. That required removal a few days later. I would consider that a complication.
So I guess there hasn't been zero complications or lawsuits as you have stated.

 

[JaggerPlate]

No need to do that. It was already stated that there have been NO complaints or lawsuits for 15 years in Oklahoma. Proof is in the pudding....

Hate to burst your bubble, but I did my fellowship at Dean McGee in Oklahoma City and know of at least two instances of optometrists running into some problems.
One of the cornea faculty from Dean McGee was an expert witness for the prosecution in a lawsuit against a Dr. Melton for peforming PRK on a patient with know dry eye disease. Shockingly the dry eye symptoms worsened after the procedure.
Also there was a grand rounds presentation from the glaucoma fellow regarding a 5 year kid with a traumatic hyphema that was referred for high IOP. Not an unusual problem right? But what complicated things is the fact the optometrist had decided to do a A/C paracentesis. At the slit lamp. On a 5 year old kid. And inadvertently hit the lens with the needle. Resulting in a cataract. That required removal a few days later. I would consider that a complication.
So I guess there hasn't been zero complications or lawsuits as you have stated.

What a shocker!!!!!

 

[200UL]

Hate to burst your bubble, but I did my fellowship at Dean McGee in Oklahoma City and know of at least two instances of optometrists running into some problems.
One of the cornea faculty from Dean McGee was an expert witness for the prosecution in a lawsuit against a Dr. Melton for peforming PRK on a patient with know dry eye disease. Shockingly the dry eye symptoms worsened after the procedure.
Also there was a grand rounds presentation from the glaucoma fellow regarding a 5 year kid with a traumatic hyphema that was referred for high IOP. Not an unusual problem right? But what complicated things is the fact the optometrist had decided to do a A/C paracentesis. At the slit lamp. On a 5 year old kid. And inadvertently hit the lens with the needle. Resulting in a cataract. That required removal a few days later. I would consider that a complication.
So I guess there hasn't been zero complications or lawsuits as you have stated.

Depending on the amount of treatment, I am pretty much ok with the PRK story if proper informed consent was obtained as LASIK on this patient would have been a bigger disaster, but the second story with the 5 year old actually is due to much more negligence than the exploding eye that started this thread. When you sign up for cataract surgery with a retrobulbar block there is a SMALL chance that needle could enter the eye - the rate goes up with certain ocular anatomy. There is no way proper informed consent was reached on this child with the hyphema. I am left wondering what the pressure actually was (tough to get an accurate pressure on a 5 year old)? I was obviously not there and do not know the "maturity" level of this 5 year old, but in general making a virgin paracentesis at the slit lamp is a bad idea in the setting of high pressure, attempting to do it on a 5 year old is likely a bad idea in 99.99999% of cases. Having cataract surgery at age 5 is also a less than optimal outcome for a billion reasons - wonder if the actual surgeons were wimps and performed this cataract surgery with an actual eye prep and under general anesthesia (in optometric “surgical” training, they must go straight to topical clear cornea surgery no matter what the situation – betadine prep optional)?

 

[KHE]

Your choice of analogy is very strange. There isn't much comparison b/w teeth cleaning and cataract surgery. The fact that you're using that analogy is annoying b/c it seems to indicate that cataract surgery is easy. I really don't think there are many complications to getting your teeth cleaned. It's not like some otherwise healthy person is just going to get an abscess after teeth cleaning.

Complications do occur in cataract surgery, but most surgeons are smart enough not to discuss their complications publicly. Supposedly there is a 2-3 percent rate of "reported" complications. That is a lot of people when you consider how common cataract surgery is.

I'm not trying say cataract surgery is "easy." I'm talking about the public's expectations. People have high expectations of cataract surgery and some on this forum are bemoaning that fact.

My question is....should the public NOT have high expectations?

If not, why not? You're saying there is a 2-3% REPORTED complication rate but most docs are smart enough to not discuss their complications publicly. Does that mean that they're smart enough to not report them?

If that's the case, then what's the TRUE rate of complication? 3X higher? 5X higher? Does cataract surgery have a 20% complication rate?

What SHOULD the public's expectations be of modern cataract surgery?

 

[Zorro12]

I'm not trying say cataract surgery is "easy." I'm talking about the public's expectations. People have high expectations of cataract surgery and some on this forum are bemoaning that fact.

My question is....should the public NOT have high expectations?

If not, why not? You're saying there is a 2-3% REPORTED complication rate but most docs are smart enough to not discuss their complications publicly. Does that mean that they're smart enough to not report them?

If that's the case, then what's the TRUE rate of complication? 3X higher? 5X higher? Does cataract surgery have a 20% complication rate?

What SHOULD the public's expectations be of modern cataract surgery?

In the words of a former president, "it depends what your definition of "is" is".
My definition of a complication is a retrobulbar hemorrhage, suprachoroidal hemorrhage, endophthalmitis, dropped lens and vitreous loss. You really can't predict the first 3, and they are very rare. Endophthalmitis is around 1:2000 I think, for all comers. It has been a long time since I have had "unplanned" vitreous loss. Meaning eyes that did not have trauma or phacodynesis. In other words, the chance of me slipping and nailing the posterior capsule and it is completely my fault is pretty low. I think the rate of the V loss, dropped lens in my hands is still well under 1%. Now, there are other "complications". If a rhexis runs out a little (not to the zonules) and the rhexis is oval, but the lens is centered is that a complication? I think not. Negative dysphotopsia for a month? FB sensation for a month? IOL master gets you + or - 0.25, complication?

It is all about patient expectations, and perceptions of what a "botched" surgery or complication really is. If I told you pre-op one million times your near sighted self will not be able to see up close if we are aiming for plano and you are upset DVa sc is 20/15 but can't read a book is that a complication? If your friend doesn't wear glasses after CE (they have no cyl), but you have -3.00 Diopters of cyl and you don't want to pay for a toric IOL, you will need glasses to see 20/20. That is not a botched surgery, that is someone not realizing limits of their eye. I cannot fix your ARMD or OAG with cataract surgery so there is no need to compare your post op VA with someone who has a healthy retina or nerve. It is even worse throwing multifocal IOLs into the mix. Our informed consent is extremely inclusive and is even longer with the mulifocals.

After this, the answer is no the rate of complications is not 20%, but probably closer to 1.0% all causes and all surgeons in practice more than 2 years (keeping in mind vit loss with sulcus lens can still be a 20/20 eye). You remarked on the "reported" complication rate. There really is no one to report to (yet). Our ASC collects our data for internal audit purposes, but this is not public record. Reported usually means retrospecitive analysis of some centers' data that is in a publication and that is extrapolated to the general population. However, there is a push underway by the gov't to report YOUR complication rate when providing a patient with informed consent. That should be interesting.

 

[speyeder]

No need to do that. It was already stated that there have been NO complaints or lawsuits for 15 years in Oklahoma. Proof is in the pudding....

This statement is so absurd. Real surgeons know that if you operate, there will be complications. Only wanna-be surgeons who were trained by taking weekend courses would claim zero complications.

 

[WhatNEyeTem]

I'm not trying say cataract surgery is "easy." I'm talking about the public's expectations. People have high expectations of cataract surgery and some on this forum are bemoaning that fact.

My question is....should the public NOT have high expectations?

If not, why not? You're saying there is a 2-3% REPORTED complication rate but most docs are smart enough to not discuss their complications publicly. Does that mean that they're smart enough to not report them?

If that's the case, then what's the TRUE rate of complication? 3X higher? 5X higher? Does cataract surgery have a 20% complication rate?

What SHOULD the public's expectations be of modern cataract surgery?

Yes, patient expectations are high. But you have to remember that the complication rates between someone who has done 5000 cataracts will likely be lower than someone who has done 50 cataracts (e.g. 2nd or 3rd year resident). It is just reality that a lot of surgical training is performed on VA and low-income patients.

 

[MstaKing10]

I'm not trying say cataract surgery is "easy." I'm talking about the public's expectations. People have high expectations of cataract surgery and some on this forum are bemoaning that fact.

My question is....should the public NOT have high expectations?

If not, why not? You're saying there is a 2-3% REPORTED complication rate but most docs are smart enough to not discuss their complications publicly. Does that mean that they're smart enough to not report them?

If that's the case, then what's the TRUE rate of complication? 3X higher? 5X higher? Does cataract surgery have a 20% complication rate?

What SHOULD the public's expectations be of modern cataract surgery?

The candid discussion that must be had with any patient, regardless of surgical procedure to be performed, should include a discussion of the risks of surgery. This is legally known as informed consent, but from a surgeons perspective, it is also a chance to introduce to the patient the chance of complications and the likelihood that things don't turn out well. It is also an opportunity to gauge the patients expectations after surgery. This is a crucial part of the discussion and is not something to be avoided as you have alluded to. Denying a complication happened or avoiding the issue altogether is the wrong way to deal with this and most surgeons understand this. As has been stated before, anyone doing surgery will eventually run into a complication, it is GUARANTEED. The issue is how you deal with it and learn from the experience that will make you a better surgeon.

Most great surgeons are not necessarily proud of their mistakes but learn from them and are not afraid to discuss them, even publicly. At most meetings, there is usually a presentation, often given by well respected, fantastic surgeons, regarding surgical mishaps and how they were dealt with.

The question isn't should the public have high expectations, it is more about having realistic expectations. This can only be ascertained after a long and thorough evaluation and discussion with your patient. One size does not fit all.

The complication rate of cataract surgery is nowhere near 20%, but not all cataracts or patients are built the same, some are more risky than others. This too, needs to be discussed with the patient.

 

[Meibomian SxN]

Hate to burst your bubble, but I did my fellowship at Dean McGee in Oklahoma City and know of at least two instances of optometrists running into some problems.
One of the cornea faculty from Dean McGee was an expert witness for the prosecution in a lawsuit against a Dr. Melton for peforming PRK on a patient with know dry eye disease. Shockingly the dry eye symptoms worsened after the procedure.

(Crickets).....Really? Expert witness? Sorry to burst your globe, but any schmo can be a tool for a lawyer. Sounds like you met and learned from one...

Also there was a grand rounds presentation from the glaucoma fellow regarding a 5 year kid with a traumatic hyphema that was referred for high IOP. Not an unusual problem right? But what complicated things is the fact the optometrist had decided to do a A/C paracentesis. At the slit lamp. On a 5 year old kid. And inadvertently hit the lens with the needle. Resulting in a cataract. That required removal a few days later. I would consider that a complication.
So I guess there hasn't been zero complications or lawsuits as you have stated.

You're right, that makes 0.1%. But lets see, pseudophakia vs exploding globe? Hmm, who'd you rather....?

This statement is so absurd. Real surgeons know that if you operate, there will be complications. Only wanna-be surgeons who were trained by taking weekend courses would claim zero complications.

Let me guess, oMDs never take weekend training courses? Smh....

 

[WhatNEyeTem]

(Crickets).....Really? Expert witness? Sorry to burst your globe, but any schmo can be a tool for a lawyer. Sounds like you met and learned from one...



You're right, that makes 0.1%. But lets see, pseudophakia vs exploding globe? Hmm, who'd you rather....?




Let me guess, oMDs never take weekend training courses? Smh....

I'd rather have an Ophthalmologist operate on me any day of the week.

<sigh> Meibomian, you should have just went to med school. Instead, you will spend the rest of your life trolling these forums to satisfy your inferiority complex.

 

[bungo]

(Crickets).....Really? Expert witness? Sorry to burst your globe, but any schmo can be a tool for a lawyer. Sounds like you met and learned from one...

You're right, that makes 0.1%. But lets see, pseudophakia vs exploding globe? Hmm, who'd you rather....?

Let me guess, oMDs never take weekend training courses? Smh....

I don't know what you seek here, or even on the optometry forum for that matter. You basically attack any MD for posting anything over and over again while at the same time exposing your lack of knowledge about eye care. Something needs to change in your life outside of this website.

 

[200UL]

If Meibomian SxN is even a bit serious in his/her post, they will do very serious harm to patients during their career. Yes a ruptured eye is a catastrophic outcome, but you are missing the point. Ophthalmologists admit complications occur. We attempt to explain these possibilities to patients. The unethical optoms in OK and KY are successful in convincing lawmakers that complications do not occur in the hands of a bunch of snake oil salesmen ("optometric surgeon"). Yes snake oil salesmen is the correct term for people like been gaddie.

The great optometrist in OK who induced a cataract in a 5 year old lacked judgment and is more negligent than the doctor in training who had a ruptured globe. In your world this "pseudo-surgeon" did nothing wrong because the wise lawmakers never learned of a lawsuit - a lawsuit probably never occurred.

And please do not minimize pseudophakia in a 5 year old that was not induced by a complication from an indicated procedure. It is a complication from a unindicated procedure from a "surgeon" who has no judgement and poor clinical skills. This child will almost certainly have amblyopia, glaucoma. Those of us who have trained with actual complex surgical cases also understand that this is often the tip of the ice berg after pediatric cataract surgery (cornea complications, retinal complications often follow).

In other words, lack of lawsuits and complaints means nothing when measuring quality of care. I would have more respect for your the "cult" portion of your profession (who believes convincing lawmakers that you can do surgery = surgical training) if they actually spent time with surgical patients. Its obvious that you have drank the cool-aid and your patients will suffer because of this.

 

[speyeder]

Let me guess, oMDs never take weekend training courses? Smh....

Umm...ophthalmologists don't get their surgical training by taking weekend courses.

 

[Meibomian SxN]

I'd rather have an Ophthalmologist operate on me any day of the week.

<sigh> Meibomian, you should have just went to med school. Instead, you will spend the rest of your life trolling these forums to satisfy your inferiority complex.

Right, and you would have a preference to learning from organized ophthalmology tools also. Go figure.

Why try to call me a troll because I'm not your subjugated scribe? I'm oMD respecting & friendly, just not to those who slander my profession. I'm happy being an OD, just not happy with the direction of organized Optometry or Ophthalmology.

Something needs to change in your life outside of this website.

You're still an eye doctor student (resident) so you don't get a reply. Just make sure you don't go poking globes.

Its obvious that you have drank the cool-aid and your patients will suffer because of this.

...meanwhile ODs are STILL performing this procedure while you rant. Smh....

 

[Meibomian SxN]

Umm...ophthalmologists don't get their surgical training by taking weekend courses.

That's funny, because I see them advertised at your meetings ALL the time....

Do they teach you residents to be ethical at all? Or is that an elective in medical school?

 

[WhatNEyeTem]

Right, and you would have a preference to learning from organized ophthalmology tools also. Go figure.

Why try to call me a troll because I'm not your subjugated scribe? I'm oMD respectable & friendly, just not to those who slander my profession. I'm happy being an OD, just not happy with the direction of organized Optometry or Ophthalmology.



You're still an eye doctor student (resident) so you don't get a reply. Just make sure you don't go poking globes.




...meanwhile ODs are STILL performing this procedure while you rant. Smh....

Here... let me help you (reaching over to Meibomian)... get that chip off your shoulder. Oh yes, also... here's something to treat your yeast infection. You can thank me later!