Learning from disaster

Complications such as capsulorhexis tears can be often be avoided by calm but prompt action when the surgery first begins to go awry, according to Brian Little DO, FRCS, FRCOphth, London, UK. “Despite the best training and quality of teaching available to us, all of us will have complications of one sort or another during our surgical careers. The underlying message that I want to get across is that the final outcome of any complication is determined not by the event itself but how you manage it. It is dealing with the unexpected, and it’s all about how you react when things go wrong,” Dr Little told the 37th Congress of the ESCRS in Paris, France. He noted that even the most experienced surgeons can still come to grief if they are excessively stressed. But when decisions must be made under stressful conditions, it is not quick thinking but calm consideration of the situation that will win the day. To illustrate how stress can affect decision-making, Dr Little described two famous incidents involving airplanes. In the first, which occurred in 1994, Lt Col Bud Holland, the most experienced test pilot in the US Air Force at the time, was doing a low-level practice flight in a B-52 bomber before his final retirement flight at an air show the following day. After completing the flyover he was approaching the tower and was told he had to alter his flight path to avoid flying over an ammunitions dump. His panicked response took the plane beyond its operational limits and it crashed killing all on board. The second example was the famous “miracle on the Hudson” in 2009. After flying into a flock of geese three minutes into the flight and losing power in both engines at 3,000ft, pilot Captain Chesley Sullenberger still managed to land the plane safely in the middle of the Hudson river and all 155 passengers survived. “Captain Sullenberger stayed calm under stress and assessed his situation, worked out his options and decided what he needed to do to land the aircraft, and three minutes later he did so and everyone survived. The difference between those two results is really your reaction to stress, Dr Little said. Capsular tears One dreaded complication in cataract surgery is capsular tears. Dr Little presented a case of a capsular radial tear-out occurring during cataract surgery as an example of how not to react in such circumstances. The case involved an eye with a deep chamber and a well-dilated pupil and a good red reflex. It was, overall, a fairly low-risk scenario and a very experienced surgeon was performing the procedure, Dr Little said. However, as the surgeon was creating the capsulotomy, he failed to notice that the ophthalmic viscosurgical device (OVD) was leaking out of the incision, and the chamber started shallowing. He ended up going too far out with the initial capsular incision. As the OVD continued to spill through the corneal incision, the capsulotomy began to spiral outward, and just when might have retrieved it, the surgeon pulled it, ruining the capsulotomy. Had he refilled the chamber with OVD the radial tear would most likely not have happened, Dr Little said. “This is what happens when you just rush things a bit and don’t react to what is actually going on, to the key indicators of what is actually going wrong. That is very much about losing your capacity to perceive clearly what is happening when there is adrenaline flowing and you are under stress,” he added. Once the surgeon saw what had happened and was calmer and therefore more rational, he refilled the eye with OVD, made a second incision, unfolded the capsular flap to provide better linear access and pulled it backward and centrally and retrieved it internally. However, Dr Little pointed out that the complication would never have occurred had he remained calm and taken the appropriate action in the first place. Brian Little: eye.surgeon@me.com

Tags: cataract and refractive surgery, stress management