It is not the number of good cases you do; it is the number of bad cases you do not do. I frequently think of this advice that Lee Nordan, MD, gave me when I began my practice. As the years go by, this pearl becomes more valuable. Although a happy patient may create referrals, it seems the unhappy ones are the biggest talkers.
Clearly, we surgeons have more reasons today to avoid bad outcomes and place more pressure on ourselves to do so. Everyone’s primary goal is to avoid the tragedy of significant vision loss in our patients. I am more affected by a bad outcome now than earlier in my career, if that is possible. As our practices mature, we deal with more friends and friends of friends. Perhaps the patients simply become closer and more personal to us. Maybe after years of seeing how fragile our sight is and how vital to us, we learn to more fully appreciate this gift. Plus, patients’ expectations are higher than ever. As the baby boomers become cataract patients, they seem to view eye surgery as they learned from PRK or LASIK: they expect rapid results, excellent uncorrected vision, and not even a slight loss of quality of vision, let alone a frank decrease. Finally, medical malpractice risks can have a devastating effect on everyone involved.
Luckily, technology continues to improve in ophthalmology. Just as femtosecond lasers augmented LASIK surgery, I believe they will add precision, efficacy, and safety to cataract surgery. Less manipulation, less fluid, and less phaco power in the eye should translate as lower endothelial cell loss and less vitreous loss. I am also extremely enthusiastic about the newest generation of microscopes. Not only do they let us see better to operate, but high-definition cameras and easily learned nonlinear laptop editing allow us to learn from our own cases as well as to share them with others. Instead of describing cases to colleagues in the hallways of convention centers, we can provide high-definition videos by e-mail or on Web sites like Eyetube.net. Amazing!
Another excellent aid in our quest for successful surgery is this year’s annual complications issue. I particularly like the multiple articles on preventing complications, always the best strategy for management. Jai Parekh, MD, MBA, provides excellent tips on making surgery go more smoothly. Daniel Chang, MD, offers a detailed perspective on Purkinje images to help better center IOLs to avoid dysphotopsias, especially useful information for multifocal IOLs. Christopher Starr, MD, describes in detail a new phaco technique designed to minimize risk that he has used when training residents. William Wiley, MD, discusses how to avoid errors in IOL power calculations. Richard Tipperman, MD, shares his thoughts on the proper use of a piggyback IOL to avoid complications and, in conjunction with Mark Packer, MD, provides important details on the technique. I found the article by Richard Packard, MD, especially useful as a review of the various possible complications with the IOL itself after a successful cataract removal.
I will conclude my comments with another pearl from Lee. He told me that the way to recognize a good surgeon is not necessarily by watching him or her perform routine cataract procedures but by watching him or her handle a complication. A surgeon’s skill level becomes evident when he or she must go outside his or her routine, shift gears, and improvise. I hope you enjoy this edition of Cataract & Refractive Surgery Today as much as I did.
