Innovation in Ophthalmology: Interview with Dan Schwartz, MD
Neepa Shah, MD Vitreoretinal Surgery Fellow Weill Cornell Medical College The complications session at VBS was one of the highlights of the meeting. Moderated by Andrew Schimel from Miami, multiple surgical complication videos were presented and discussed. The panelists who guided the discussion were: Efrem Mandelcorn from University of Toronto, Dean Eliott from Mass Eye and Ear, and Flavio Rezende from University of Montreal. The first submitted video showed a complex rigid ACIOL removal, with trauma to the iris and posterior segment. Some suggestions that were given included: 1) making a large scleral incision from the beginning to allow for easier removal, 2) removing the lens slowly, 3) using a soft tip to aspirate the lens if it falls posteriorly, 4) putting viscoelastic in the anterior segment to facilitate removal of the IOL, 5) not using iris hooks unless absolutely necessary as they can cause the lens to move posteriorly. There was mixed consensus as to whether laser was necessary around iatrogenic breaks and hemorrhage created posteriorly. The second video presented showed a globe perforation during a buckle-vitrectomy. There was discussion on how to deal with this – if the perforation is small, such as from a needle perforation during a scleral pass, one can simply elevate the IOP and tamponade bleeding with the finger. If it is larger, one needs to treat this like a globe rupture ensuring closure of the scleral defect with suturing. Many physicians stressed not to chase after subretinal blood by creating a retinotomy, as this can do more harm than good. The third video showed a pneumatic displacement for VMT that failed and created a macular hole associated with a retinal detachment. In hindsight, the audience felt that the pneumatic not the best choice as the patient was monocular, but the complication was fixed with surgical repair and ultimately an autologous retinal transplant for the macular hole, with some visual improvement. The fourth video showed a case of submacular triamcinolone during a complex giant retinal tear repair. While attempts were made to remove as much of the material as possible, and the patient fortunately did great even with a small amount remaining in the subretinal space. The fifth video was of a complicated dexamethasone implant removal. The panelists and audience discussed other easier ways to remove the implant from the eye – using vitrectomy, a large gauge angiocatheter, fragmatome, phaco probe, or viscoelastic in anterior chamber to mobilize the implant in a controlled fashion. It is important to remember that dexamethasone implants cannot be used in a patient without an intact posterior capsule or zonular instability (black box warning). The sixth video, which generated the most discussion, and ended up winning the prize for the best video, showed a routine secondary IOL procedure complicated by a fire on the drape around the eye from the high-temp disposable cautery. All ocular procedures are in theory high risk for fire, especially with oxygen flowing under the drape, so some tips to remember are to turn the oxygen off when the cautery is on, perform a secondary time out, and always have sterile water available. Dr. Harry Flynn then presented a case series of post-operative CRAO. It may be possible that the retrobulbar blocks were associated with these findings, but it is hard to know for sure. The last video was of a loose buckle reoperation. The panelists encouraged all surgeons to know how to both suture buckles and create belt loops. This session concluded with pearls from all the panelists:
Dr. Eliott stated that a good surgeon is detail oriented and meticulous; he or she doesn’t cut corners.
Dr. Rezende encouraged young surgeons to be resilient and not give up, even if they experience challenges or complications.
Dr. Mandelcorn said to be nice to your family, patients, etc but not with your tamponade – if you’re thinking of a stronger tamponade, go for it!