Risk Management

Phacoemulsification: Use Careful Patient Selection

 By Reginald J. Stambaugh, MD

Argus, August, 1993

Surgical removal of a cataract, when performed under the right conditions and using the proper technique, can be extremely rewarding for the patient. If complications occur and patient expectations are not achieved, however, the result can be disastrous for both patient and surgeon. Therefore, proper preoperative evaluation by the operating ophthalmologist is critical.

Improvements in technique, equipment, instruments and implants have driven the number of cataract extractions up to unprecedented levels in recent years, resulting in closer public scrutiny of the procedure and those who perform it. Further, misleading advertising promises for “painless, instantaneous vision” have contributed to unrealistic expectations in many patients. The result is that it is imperative for the ophthalmologist, who may be held legally liable for the outcome, to carefully evaluate patients before performing surgery.

Preoperative evaluation by the surgeon should assess not only the physical findings of the patient, but also the realistic needs of the patient. These needs are determined by such factors as the patient’s occupation, age, overall health, lifestyle, recreational activities and family obligations. The surgeon must consider whether surgery will improve the patient’s vision and whether improved vision will meet the patient’s needs and improve the patient’s quality of life. If the answer is yes and there are no physical contraindications, the ophthalmologist may feel comfortable recommending surgery.

Phacoemulsification has become the procedure of choice for many cataract surgeons. Ophthalmologists who have made the transition to phaco know it is not a simple procedure nor one without complications, and they have developed a healthy respect for the learning curve involved in perfecting this technique. Once the surgeon’s skill is established, patient selection becomes the most important risk management consideration for the surgeon.

Visual acuity should always be the primary criterion in preoperative evaluation. Determination of the glare factor may or may not be significant. While inflammation, infection, corneal scars, macular or retinal deterioration, optic nerve disease, etc., are generally accepted contraindications to ocular surgery, there are other less decisive factors to consider such as corneal endothelium, anterior chamber depth, size of the dilated pupil, grade of the nucleus and posterior capsule status.

Corneal decompensation with poor results can be prevented in selected cases, but even with improvements in technique, the stage of the nucleus and integrity of the capsule continue to be important criteria in the selection of phaco candidates. When emulsifying the nucleus, problems with the endothelium and posterior capsules, both critical structures, can produce complications, as experienced surgeons know.

Age of the patient is an important factor. The procedure is quite different in young patients who have minimal nuclear changes and a stronger posterior capsule that can tolerate more manipulation before rupturing.

Having done phacoemulsification and intraocular lens implants since 1975, including 10 years of specular microscopy and endothelium study, I have become more conservative in my selection of surgical candidates. Although the success rate of phaco is high, poor results in a patient with unreasonable expectations can result in the filing of a malpractice claim, even if the procedure is done properly. Given our litigious society and the competitive marketplace in which we practice, legal disasters may be avoided only if ophthalmologists remember that they are entrusted with their patients’ care, and evaluate each one’s needs, physical findings and expectations with integrity.