Uncooperative patients

There are a range of physical, psychological, sensory and cognitive factors that can contribute to a patient’s inability to cooperate during a cataract procedure. A compassionate but objective approach is necessary to achieve the best results, advises Zaid Shalchi MD, Windsor, UK. “All patients want to cooperate; they want a good outcome and they want their surgery to be successful. They want to make their surgeon’s life easier. It’s all about trying to understand why they can’t cooperate and what you can do to help them,” he said during the 25th ESCRS Winter Meeting. He noted that blaming non-cooperative patients makes the surgeons themselves become the victim, which is quite disempowering. Instead, surgeons should approach such patients the same as they would a surgical difficulty. For example, in the case of an eye with a small pupil one would not blame the patient for the problem. Rather, more typically one would assess the problem and decide on a course of action on that basis. In the case of small pupil, that would most likely be the placement of pupillary ring to allow the performance of the surgery as a routine procedure. “This way you waste no vital energy and you remain calm and when the ring comes out, it is actually a beautiful operation. When you’re dealing with your patient who is not able to cooperate you want to do the same thing, which is to normalise the situation.” COMMON NON-COOPERATIVE SCENARIOS People with dementia are making up an increasing proportion of cataract lists, and many of these patients typically have communication difficulties and memory problems that can make it difficult for them to cooperate in a surgical setting. However, in patients where the condition is mild to moderate, sometimes all that is needed is reassurance and a good explanation of what’s happening before surgery. Sedation is rarely helpful in patients with dementia, and it usually makes dementia and compliance worse. General anaesthesia is sometimes necessary if the dementia is particularly severe. Patients with severe hearing loss also have communication difficulties. Again, a good explanation of the surgery beforehand, together with sub-Tenon’s block, which provides ocular akinesia as well as anaesthesia, can be very helpful. Head-taping is a technique that is useful in limiting the mobility of the patient’s head and is especially helpful in those with difficulty communicating during surgery. It involves putting a band of tape across the patients’ forehead, giving the surgeon much more control, particularly when operating temporally when patients have a tendency to turn away when the surgeon’s hand is on the side of their head. POSITIONING THE HEAD However, some patients, particularly the older ones, will have difficulty in positioning so that their face is parallel to that of the floor of the theatre, as is ideal for cataract surgery. Sometimes, all that is needed is to make them more comfortable by placing a piece of foam beneath their neck. However, patients with heart failure, obstructive pulmonary disease or obesity need to have the weight taken away from their chest to allow for easy breathing. That can be achieved by having the patient sit up slightly with their neck hyper-extended. Patients with kyphosis are often physically unable to extend their head on a plane with their body. In those cases, one option is to arrange the trolley so that the patient’s head is lying fairly flat on the bed, but the rest of their body is tilted upward, providing easy access to the surgeon from the side of the trolley. Claustrophobia is a very common condition encountered in surgery. Although classically defined as an irrational fear of confined spaces, it is really much more complicated, involving the fear of losing control and not being able to leave a certain place. Cutting the drape or using a clear drape can be very useful, although sometimes sedation will be necessary, Dr Shalchi said. He noted that anxiety during surgery is normal for most patients and very often hand-holding can be just as good as or better than oral or intravenous sedation. If the patient cannot or does not wish to hold hands, oral or intravenous sedation is very effective. “In many cases it’s not just the medication you’re giving, it’s also the thought that they have been given something that makes them relax,” he added. Zaid Shalchi: zshalchi@gmail.com