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Cataract Surgery: Tips And Tricks For Or Safety And Efficiency | Mar 2011

Practical Methods for Surgical Excellence

In the OR, a little modification of procedure goes a long way.

Every time I visit another surgeon’s ambulatory surgery center (ASC), I learn new ways to run my OR more efficiently and more safely. To return the favor, here are a few things my guests have found helpful about the way I run my facility.


In Rhode Island, a series of wrong-side surgeries was recently performed in a major teaching hospital. As a result of the publicity, every patient and his or her family are aware that wrong-side surgery can happen occasionally, so I visibly demonstrate that I will do everything I can to ensure that it does not occur in my OR.

First, when the patient schedules his or her operation, he or she is given a small bottle of dilating drops and instructed to instill the drop in the eye that is going to be operated on an hour or 2 before surgery. It is the patient’s responsibility initially to declare the eye on which I am going to perform surgery, and this step brings the patient to me with his or her pupil already dilated, which means that I have also saved time.

Second, when the patient arrives at the OR with his or her pupil dilated, my staff and I ask him or her, in front of his or her family, to raise the wrist corresponding to the eye that is going to have the operation. On that wrist, we tie a green (for go) paper wristlet, the same kind a person gets from a night club to prove he or she is over 21.

Third, before the patient is taken into the OR, we mark with a dot the side of the patient’s head with the operative eye. I cannot see that dot after the patient is draped, but I can see the green wristband as a last-minute confirmation of the surgical site.


There are two completely different types of medical records. The first consists of records in the office that I use over and over again. The second type consists of the medical records I use in the ASC that are only used once or twice. Electronic medical records are therefore not attractive to me for the ASC. As an alternative, I contracted with a company that develops scanning systems for banks to develop a scanning system for my ASC records. As I finish the day’s surgery, the records are scanned into what can be described as an electronic filing cabinet. On every page that goes in the chart is a barcode, which holds the patient’s basic demographics, the date of the surgery, and a description of what the page is (eg, the fact sheet, preoperative report, etc). At the end of the day, when my staff stacks the charts and scans the documents into the appropriate patient’s file, the system alerts them if they are missing a particular page.

My staff can scan a day’s worth of records, which could be 300 to 400 pages, at a rate of 60 pages per minute, which is a total of 5 or 6 minutes.


Patients with mild dementia can be emotionally fragile, which makes them a little more difficult to handle. If they are agitated, we give them a tiny dose of ketamine, about one-tenth the normal dose, to make them more comfortable. This small dose does not trigger ketamine hallucinations in patients with dementia and is very effective at calming them down. It has saved me from operating on patients whose nervousness may cause them to disrupt the surgery.


Because acrylic IOLs are temperature dependent, they are slow to open up after implantation. Room temperature and refrigeration of the IOL and balanced salt solution are all contributing factors.

I use the following household products to warm IOLs. My staff places the IOL and the viscoelastic in a baby wipes warmer, which warms them up to between 85° and 89°. The bottle of balanced salt solution sits in a candle warmer for less than an hour. The heating element on the candle warmer fits one bottle of balanced salt solution perfectly. As soon as the IOL, viscoelastic, and balanced salt solution are removed from the heating elements, they begin to cool down to room temperature. This does not matter if the case takes only a few minutes, but if the case takes 15 to 20 minutes, the materials will cool back down to room temperature before the case is finished. To prevent this from happening, under the drapes, I cover the stand with a heating pad to keep the IOL and viscoelastic warm during the operation. It is important that surgeons test the temperature of each unit and time how long it takes to reach the desired temperature to make sure they do not go above normal body temperature.


I use the iSert Preloaded IOL Injection System (Hoya Surgical Optics, Inc., Chino Hills, CA) for several reasons. First, the idea of having an IOL that has never been touched by human hands is attractive. Second, it is a luxury for me and my nurses not to have them spend time loading the lens. A distracted nurse is a nurse who is not helping me. Using preloaded IOLs allows me to have peace in the OR, because the nurses are not rushing or bumping into each other trying to catch up with me. They are watching me and are prepared to help me at any time.


Each of these steps has helped my OR run a little more quietly and easily. Maybe one or more will be helpful in readers’ facilities, too.

Paul S. Koch, MD, is the founder and medical director of Koch Eye Associates in Warwick, Rhode Island. He is a consultant to Hoya Surgical Optics, Inc. Dr. Koch may be reached at (401) 738-4800; paulkoch@kocheye.com.

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