The art of war

In the first of a new series, Soosan Jacob MD looks at the typical complications that can occur in the operating room

Soosan Jacob

Posted: Saturday, September 1, 2018

Complications – the most dreaded event within a surgical suite. Something that we all wish doesn’t strike us or the patient we are handling. But this remains an unattainable dream, as every ophthalmic surgeon – be it the novice or the veteran – has complications in one form or the other; major or minor, intraoperative or postoperative, objective, “clinically apparent”, or subjective, “within-the-patient’s-mind”.

Every one of us faces complications and strives hard to manage as well as avoid future similar situations. Prevention of complications and better surgical outcomes is also something that every innovator aspires for with newer surgical techniques and devices. In fact, it may not be entirely incorrect to say that without complications, there would not be any surgical progress!

The most important thing to do for complications is to prevent them. So, how do we do this? One thing is to be aware that complications can occur anywhere, at any time. Statistics are bound to catch up with everyone, but with practice and conscious effort and by avoiding shortcuts, they can be prevented.

I remember the first time, about two decades ago, when I was assigned to perform unsupervised, what we euphemistically call a relatively difficult case – a small pupil with a hard cataract. I thought I was prepared enough as I had done similar cases under supervision. But my confidence was shattered and my ego took a dive when I had a posterior capsular rent and didn’t recognise it until my mentor, who was watching from another room over a closed-circuit system, came to the OR, told me to get up and took over.

Adding insult to injury, my name was missing from the surgical list for a month and a half. Although I was disappointed at the time, it gave me time to introspect, reflect and learn to respect the eye and its complexities. It also made me resolve to educate myself about every aspect of surgery, including recognising and managing complications.

The first step towards this common goal that every ophthalmic surgeon has, is to know the procedure, possible complications and management strategies as well as putting in sufficient practise. It is advisable to go step by step, without skipping any, and in the hands of an expert, each step soon becomes second nature. Similar to the ‘10,000-Hour rule’ propounded by Malcolm Gladwell for becoming an expert, the more one practises, the better one becomes.

Analyse possible complications when going through steps mentally. Knowing possible complications and step-by-step analysis of the means to tackle these will help you avoid becoming flustered or panicky during an actual incident. As an ophthalmic surgeon, it is also important to be familiar with equipment and settings. One should try and become familiar with any new equipment and should not shy away from asking “foolish questions”.

The second step is to know the patient – to spend some time not only seeing the patient’s eye but also the patient as a whole. Simple things like knowing patient expectations and setting attainable ones, explaining expected surgical outcomes and risk of complications, taking care of systemic conditions like diabetes, hypertension etc, checking for known allergies, avoiding situations leading to positive vitreous pressure etc, help avoid many complications as well as postoperatively unhappy patients. Equally important is to go through a mental checklist, take a time-out just prior to surgery and then to try and perform surgery meticulously and to the best of one’s abilities. Calling for help when required and knowing when a referral is needed are also important – such as calling in a vitreo-retinal surgeon in case of a nucleus drop.

It should be remembered that complications can be per-procedural or post-procedural. The surgeon’s job is not over with the surgery. When a complication does occur, communication with the patient becomes crucial and it is important to explain the steps taken and the possible outcomes. The patient should be made partner to the medical care as he/she is the most important stakeholder. Postoperative follow-up and care, appropriate medications and finally a good refraction and spectacle prescription if indicated is important. Remember, the patient ultimately wants to be able to see clearly and not just be a beautiful clinical photograph.

Watching someone else manage a complication is one way to learn prevention and management; however, at times the surgeon actively managing the situation may not be in a position to explain steps taken.

Figs A-D: A posterior capsular rent occurs in a posterior polar cataract

Informative didactic articles and instructive YouTube surgical videos are also other effective ways to learn about complications. Sun Tzu’s The Art of War, which was written more than 2,000 years ago, and Karen McCreadie’s brilliant adaptation of it to the business world, can also be relevant in an ophthalmic OR when managing complications. Important lessons are knowing the environment and being aware of threats and opportunities as they come.

Sun Tzu says: “The general who loses a battle makes but few calculations beforehand.” Availing of favourable circumstances and being willing to modify strategy when required are essentials. He also advises selecting and marshalling one’s team properly, training them well, giving responsibilities for each team member and respecting their work. Attention to details, however small, matters in a crunch situation.

Another important aspect of managing complications learning to act fast. However, undue haste as much as undue delay should be avoided. The big picture, as well as long-term effects rather than short-term ones, should be considered before any decision. The surgeon should be able to control his irritation and stress and remove emotion from strategy. Recklessness, holding back and doing nothing and a hasty temper can all be pitfalls. Integration of expertise is essential, such as calling in a retinal specialist when necessary.

In the ensuing issues of this column, I will try and familiarise the reader with different complications an ophthalmic surgeon might face in cataract or refractive surgery and how to approach these. There may be many techniques and this column will try to simplify them and make them more easily understandable.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at