On the same page

In the second of two articles, Leigh Spielberg MD discusses the importance of efficient collaboration with trusted colleagues

Leigh Spielberg

Posted: Friday, June 1, 2018

Every step was like walking on egg shells, so I took it slow. Careful capsulorhexis with frequent OVD-refills of the anterior chamber; delicate hydrodissection; and meticulous divide-and-conquer phaco. I had to enlarge the main port to insert the wider cartridge needed for the high-dioptre IOL. I didn’t want to risk allowing the lens to get stuck in the incision, unroll in the anterior chamber or sneak a haptic into the sulcus. I slid the lens into the bag, sutured the main port, to reduce the likelihood of IOP-drop and choroidal effusion, and proceeded to vitrectomy.

Just as a hypermetropic eye can make for a difficult phaco, performing a vitrectomy is also a legitimate challenge. There is rarely a posterior vitreous detachment and there isn’t much room to manoeuvre to induce one. In this case, I had to use ILM-forceps to detach the posterior hyaloid from the optic disc. I always imagine the horror of a glaucoma specialist if one were to see this manoeuvre; one millimetre in the wrong direction and a few hundred-thousand nerve fibres could be destroyed instantly, ruining a lifetime’s worth of effort to save them.

Once the PVD had been induced, I breathed a sigh of relief; the rest of the vitrectomy proceeded pleasantly and uneventfully. What a relief!

Upon completion of surgery, I sent the following to our clinic WhatsApp group: “Update from the OR. Surgery OD completed. Core VTX > phaco + IOL > completion of VTX, including induction of PVD (a real joy in a +11D eye, let me tell you) + 360° laser + some gas to keep the eye pressure stable and prevent effusion due to IOP-drop. Koen: thanks for the advice.”

The next day, the IOP was 12mmHg and there were no complications. “Cornea still oedematous in every layer, but otherwise looks good so far!” I wrote to the group.

The next day, I performed the same surgery in the left eye as in the right. Fundus exam on post-op day one revealed choroidal effusion inferior, which increased in size by day one. I was worried it might continue to enlarge and encompass the posterior pole, despite a normal, stable IOP of 12. Koen Vermorgen, my glaucoma-specialist colleague, advised me to continue giving Diamox, as this would help keep the effusion under control. Meanwhile, I wanted to increase the IOP, so I brought the patient back to the OR and filled the anterior chamber with Endocoat.

This combination seemed to do the trick; the IOP increased slightly and the effusion stopped growing. I examined the patient daily until I was certain that the effusion was decreasing.

A week later, the effusion had disappeared! The IOP OS was still a bit high, so I referred the patient to Koen for further follow-up. He fine-tuned the glaucoma meds and referred the patient back to his local ophthalmologist.

I had learned a lot from this case, not only in terms of management strategies and surgical techniques, but also regarding efficient collaboration with trusted colleagues. With the trend towards niche subspecialisation, we have all developed our own, decreasingly overlapped knowledge sets. This can be a disadvantage when treating patients with acute pathology whose management requires a multidisciplinary approach. However, this increased subspecialisation means that there is a larger pool of knowledge from which to draw. Collaborative technology, like group texting, allows us to harness this pool almost instantly.

One of the paediatric ophthalmologists who works where I trained, and who regularly receives referrals from across the country for impossibly rare problems, harnessed the experience of his colleagues worldwide via an online forum. I remember a particular case in which a young patient of his had no discernible retina and only the most rudimentary vestige of an optic disc. He posted the details of this case online and received advice from the other side of the world.

The ideal situation would be for everyone to know everything. Yet clearly, this isn’t possible. Further, I noticed the beneficial effect of having all parties concerned being on the same page while treating a particularly difficult case. It helps us avoid the situation in which a patient appears in our subspecialty clinic, referred from a colleague, and we are then tasked with trying to decipher the thoughts and intentions of our colleagues’ treatment plans. It also gives us a certain feeling of “ownership” over the case, increasing our feeling of involvement.

Other uses of technology include protocols, accessible via intranet, that outline the steps that should be taken when patients with acute pathology of complex nature presents to our department. These include things like perforating trauma, endophthalmitis and corneal ulcer. Protocols not only allow everyone to be on the same page, but also allow ophthalmologists in training to initiate the first several steps of management, confident that they are doing the right thing and not forgetting any crucial steps.

The last I heard of our hypermetropic patient, he was doing well.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University, Belgium. The first part of this article appeared in EuroTimes Vol 23 Issue 2 page 34. Read here.

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