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Preoperative Orders for Cataract and IOL Surgery
PREOPERATIVE ORDERS FOR CATARACT AND IOL SURGERY
To the Editor: A hospital where we do most of our surgery recently formed a committee of a podiatrist, an anesthesiologist and a general surgeon, and they are attempting to instigate rules and regulations that CBC, urinalysis, chest x-ray, and EKG be required prior to cataract surgery with intraocular lens (IOL) implantation when done under local standby anesthesia. Enclosed is a letter which we wrote in response to their committee. The issue is still in doubt. I would request your comments on the letter:
letters to the editor This section is an open forum and consists of the opinions and personal commentary of the writers. The views expressed are exclusively those of the writers and do not purport to reflect those of ASCRS or the Journal.
There has been much discussion recently at the hospital about what preoperative tests are appropriate for local anesthesia with monitoring by an anesthesiologist. For the past five or more years, we have performed approximately 2,000 to 3,000 cataract extractions and IOL implantations under local anesthesia monitored by an anesthesiologist with no preoperative orders prior to surgery. The procedure is for the surgeon to take a history and physical, do a brief physical examination, and report any relevant findings to the anesthesiologist. The anesthesiologist, in tum, does a history and physical prior to the local retrobulbar block. If the surgeon or anesthesiologist feels that laboratory tests, consultations, or other medical specialists are needed prior to the surgery, these are obtained; the surgery may be postponed until they are performed. No routine lab tests, such as CBC, urinalysis, EKG, or chest x-ray, are ordered. The patient is given oxygen by nasal cannula. Blood pressure, pulse, and respiration are monitored by the anesthesiologist and registered nurse in the preop area. The patient is constantly monitored by the anesthesiologist and nurses. The block is given after the anesthesiologist sedates the patient with intravenous diazepam ~alium®) or intravenous thiopental sodium (Pentothal ) using the minimum amount for sedation. The average dose of Pentothal is 40 mg to 60 mg and the average dose of Valium is 2 mg to 4 mg. Retrobulbar block is one-half of 0.5% bupivacaine hydrochloride (Marcaine®) and one-half of 1.0% lidocaine hydrochloride (Xylocaine®). Approximately 2 mL to 5 mL are used. Sometimes additional periorbital block (Van Lint) is given lateral to the orbit with Xylocaine alone. The danger of this block, reported in the literature, is minimal. However, there have been two case reports where Marcaine has infiltrated around the optic nerve back to the dura, which is followed by short periods of respiratory apnea. This clears spontaneously in one to two minutes. For this reason, monitoring by the anesthesiologist is desirable. In patients with stoic nervous systems, sometimes the block is given without any IV medication and only anesthesia monitoring.
J CATARACT REFRACT SURG-VOL 12,
MARCH 1986
171
After the block, vital signs monitoring is continued and a "Super Pinky" or Honan balloon to apply pressure is placed on the eye for 15 to 20 minutes to obtain a soft eye for surgery. During this period, the patient is constantly monitored by the registered nurse. Blood pressure, pulse, and respiratory checks are given constantly. The anesthesiologist is in the next room monitoring the patient being operated on and can leave at any time to assist the nurse. Modern cataract surgery with IOL implantation takes approximately 15 to 20 minutes of surgical time. Two to three cases are performed per hour. The turnaround time depends on the rooms available and the help available at the out-patient facility, the office, or the hospital. The retrobulbar block is done between cases. Peer review on a national basis has finally mandated that cataract surgery be performed on an out-patient basis. The patient arrives one hour before surgery, may leave after surgery, and is seen in the office the following morning. We are now questioning if cataract surgery is any longer a hospital procedure. In the past, cataract surgery patients were admitted to the hospital prior to surgery and discharged the day after surgery. The routine testing was a CBC, urinalysis, chest x-ray, and EKe. It became agonizingly apparent that these tests were useless for cataract surgery. At no time in the 15 years prior to the present routine was surgery canceled or changed as a result of these tests. Even with metastatic cancer of the lung, modern cataract surgery with IOL implantation can improve sight so rapidly that the patient has the benefit of good vision in his or her terminal days. In 1983, the Food and Drug Administration suggested that all routine chest x-rays be discontinued. We ask why the other tests are routinely ordered and what use they offer for short-term surgery. Medical-legal reasons are the only answers we can find for routine testing. Recently, however, legislation as reported in the Malpractice Act of 1985 states that ordering useless tests is a criminal offense. Howeffective these tests are in preventing a malpractice suit is questionable. All of us in medicine have the best interest of our patients as our number one concern. It is also obvious that there is a difference of opinion as to the best interest for cataract surgery with IOL implantation monitored by anesthesiologists. On one side is a group of physicians who state that (1) if anesthesia with standby or monitoring is done, there must be a routine EKe, routine chest x-ray, routine CBC, and routine urinalysis prior to doing the case; (2) if there is no anesthesiologist and it is a straight local, no tests are needed; (3) if anesthesia is standby, the anesthesiologist must be prepared to give a general anesthetic. However, the eye case takes 15 to 20 minutes. The eye 172
is in such a position that general anesthesia would not be possible if surgery had begun, as intubation would be dangerous around an opened eye. If general anesthesia were needed, the case would be canceled, rescheduled, and all the required tests ordered prior to the general anesthesia. On the other hand are ophthalmologists who do many cases and agree that it is not in the best interest of patients to do routine lab tests. The tests ordered on a routine basis are felt to be superfluous. Remember, the surgeon or the anesthesiologist may order tests prior to surgery if indicated in his or her medical judgment. Also, the tests cannot be done during the one hour prior to surgery, as the EKe committee does not have a member in the hospital at all times to read the EKe, nor is there a radiologist to interpret the chest x-ray in the hospital at all times. There have been suggestions that the patient go to the hospital for the routine tests during the week prior to surgery. This has been done in the past, but the patient's resistance to this routine made it most unsatisfactory, not only for the patient but also for the surgeon. It increases the patient's anxiety, while the anesthetic techniques used have many anxiety-quieting details. For example, false teeth are left in during surgery. If the patient has a contact lens in the other eye, it is left in during surgery. The patient is allowed light juices on the morning of the surgery. A nonhospital approach to admission and care is strictly maintained. After the operation, the patient can sit up, have juice and soup, and is near other patients to discuss with the patient being prepared for surgery how nonthreatening the procedure was. Walking out of the hospital, the postop patient can talk to families and other patients waiting in the lobby. All these techniques have a calming effect on all concerned. If the proposed rules are adopted and cataract surgery allowed with only local anesthesia unless routine tests are ordered, the anesthesiologist is eliminated from being allowed to participate in the surgical procedure. The patient, obviously, would not get the best care as (1) there would be no sedation during the "fear of the needle"; (2) there would be no monitoring of the elderly patient; (3) there would be no secondary history and physical, as only the surgeon would see the patient; (4) there would be no monitoring of the rare possibility of respiratory apnea; (5) the chance of malpractice would be increased. We invite you to examine critically the modern cataract surgery being performed at our hospital. We invite your comments. We invite your criticisms. We also invite each one of our staff and administration to observe surgery. Come into our open operating room. See how the patients are monitored. See the care given each patient. There is nothing that is ever done to jeopardize the patient's safety and care. We do require
J CATARACT REFRACT SURG-VOL 12,
MARCH 1986
the highest standards for our operating room personnel. We demand that we all must work at our best to the utmost of all our training and skill. We all care about the patient. Cataract surgery has made a cosmic leap in the past 20 years. Social understanding, hospital requirements, and government regulations lag and drag on the advances in modern technology and expertise. We respectfully request that the medical staff, administration, and board of trustees continue to lead, not only in ophthalmology but all the various medical disciplines, unencumbered into the future. Our future is indeed bright and, most of all, interesting. May we all meet its challenges.
The area of the intersection of a plane with a cylinder is determined by the formula: A=
where § is the complimentary angle of the cutting tip. Assuming a cutting tip radius of one unit, a comparative table may now be produced:
Alvan Balent, M.D. Linda L. Civerchia, M. D. Fort Lauderdale, Florida
USING THE ARGON LASER TO CUT SUTURES To the Editor: We read with interest the consultation section in the November issue regarding techniques for cutting sutures to minimize astigmatism. All those who described their technique performed the cutting with knives or needles. We were surprised that nobody uses the argon laser to cut sutures. Our technique is to have the patient sit at the laser slitlamp; no topical anesthesia is used. Using the bluegreen light with settings of approximately 50 microns, 1. 5 watts, and 0.02 seconds, we focus accurately on the suture and break it with one burst. If it does not break immediately, it is usually because the conjunctiva is slightly edematous above it or the suture is not tight enough to be on stretch. One or two more bursts will always do the trick. This method is advantageous because it is noninvasive, does not cause bleeding, and the knife or needle cannot slip into a place where it does not belong.
'1Tr2
sin §
Cutting Tip
Area Units
15° 30° 45° 60°
0.81 0.91
1.11 1.57
Therefore, a surgeon switching from a 30° tip to a 45° tip would experience a 22% loss of suction pressure. Similarly, changing from a 45° tip to a 60° tip would yield a 41 % loss in suction pressure. Irwin S. Weiss, M.D. Pieo Rivera, California
I. Allen Chirls, M.D. John W. Norris, M.D. South Orange, New Jersey
ASPIRATION PRESSURE OF PHACOEMULSIFICATION TIPS To the Editor: The phacoemulsification surgeon now has the choice offour cutting tips: 15°, 30°, 45°, and 60°. The sharper, more acutely angled tips are useful in mobilizing the nucleus but suffer from a lack of aspiration pressure. This is, of course, due to their larger port size. The manufacturer has not been able to supply information on the port area of each tip. Knowing this would help one anticipate the suction of one tip relative to another. J CATARACT REFRACT SURC-VOL 12,
MARCH 1986
173
To the Editor: A hospital where we do most of our surgery recently formed a committee of a podiatrist, an anesthesiologist and a general surgeon, and they are attempting to instigate rules and regulations that CBC, urinalysis, chest x-ray, and EKG be required prior to cataract surgery with intraocular lens (IOL) implantation when done under local standby anesthesia. Enclosed is a letter which we wrote in response to their committee. The issue is still in doubt. I would request your comments on the letter:
letters to the editor This section is an open forum and consists of the opinions and personal commentary of the writers. The views expressed are exclusively those of the writers and do not purport to reflect those of ASCRS or the Journal.
There has been much discussion recently at the hospital about what preoperative tests are appropriate for local anesthesia with monitoring by an anesthesiologist. For the past five or more years, we have performed approximately 2,000 to 3,000 cataract extractions and IOL implantations under local anesthesia monitored by an anesthesiologist with no preoperative orders prior to surgery. The procedure is for the surgeon to take a history and physical, do a brief physical examination, and report any relevant findings to the anesthesiologist. The anesthesiologist, in tum, does a history and physical prior to the local retrobulbar block. If the surgeon or anesthesiologist feels that laboratory tests, consultations, or other medical specialists are needed prior to the surgery, these are obtained; the surgery may be postponed until they are performed. No routine lab tests, such as CBC, urinalysis, EKG, or chest x-ray, are ordered. The patient is given oxygen by nasal cannula. Blood pressure, pulse, and respiration are monitored by the anesthesiologist and registered nurse in the preop area. The patient is constantly monitored by the anesthesiologist and nurses. The block is given after the anesthesiologist sedates the patient with intravenous diazepam ~alium®) or intravenous thiopental sodium (Pentothal ) using the minimum amount for sedation. The average dose of Pentothal is 40 mg to 60 mg and the average dose of Valium is 2 mg to 4 mg. Retrobulbar block is one-half of 0.5% bupivacaine hydrochloride (Marcaine®) and one-half of 1.0% lidocaine hydrochloride (Xylocaine®). Approximately 2 mL to 5 mL are used. Sometimes additional periorbital block (Van Lint) is given lateral to the orbit with Xylocaine alone. The danger of this block, reported in the literature, is minimal. However, there have been two case reports where Marcaine has infiltrated around the optic nerve back to the dura, which is followed by short periods of respiratory apnea. This clears spontaneously in one to two minutes. For this reason, monitoring by the anesthesiologist is desirable. In patients with stoic nervous systems, sometimes the block is given without any IV medication and only anesthesia monitoring.
J CATARACT REFRACT SURG-VOL 12,
MARCH 1986
171
After the block, vital signs monitoring is continued and a "Super Pinky" or Honan balloon to apply pressure is placed on the eye for 15 to 20 minutes to obtain a soft eye for surgery. During this period, the patient is constantly monitored by the registered nurse. Blood pressure, pulse, and respiratory checks are given constantly. The anesthesiologist is in the next room monitoring the patient being operated on and can leave at any time to assist the nurse. Modern cataract surgery with IOL implantation takes approximately 15 to 20 minutes of surgical time. Two to three cases are performed per hour. The turnaround time depends on the rooms available and the help available at the out-patient facility, the office, or the hospital. The retrobulbar block is done between cases. Peer review on a national basis has finally mandated that cataract surgery be performed on an out-patient basis. The patient arrives one hour before surgery, may leave after surgery, and is seen in the office the following morning. We are now questioning if cataract surgery is any longer a hospital procedure. In the past, cataract surgery patients were admitted to the hospital prior to surgery and discharged the day after surgery. The routine testing was a CBC, urinalysis, chest x-ray, and EKe. It became agonizingly apparent that these tests were useless for cataract surgery. At no time in the 15 years prior to the present routine was surgery canceled or changed as a result of these tests. Even with metastatic cancer of the lung, modern cataract surgery with IOL implantation can improve sight so rapidly that the patient has the benefit of good vision in his or her terminal days. In 1983, the Food and Drug Administration suggested that all routine chest x-rays be discontinued. We ask why the other tests are routinely ordered and what use they offer for short-term surgery. Medical-legal reasons are the only answers we can find for routine testing. Recently, however, legislation as reported in the Malpractice Act of 1985 states that ordering useless tests is a criminal offense. Howeffective these tests are in preventing a malpractice suit is questionable. All of us in medicine have the best interest of our patients as our number one concern. It is also obvious that there is a difference of opinion as to the best interest for cataract surgery with IOL implantation monitored by anesthesiologists. On one side is a group of physicians who state that (1) if anesthesia with standby or monitoring is done, there must be a routine EKe, routine chest x-ray, routine CBC, and routine urinalysis prior to doing the case; (2) if there is no anesthesiologist and it is a straight local, no tests are needed; (3) if anesthesia is standby, the anesthesiologist must be prepared to give a general anesthetic. However, the eye case takes 15 to 20 minutes. The eye 172
is in such a position that general anesthesia would not be possible if surgery had begun, as intubation would be dangerous around an opened eye. If general anesthesia were needed, the case would be canceled, rescheduled, and all the required tests ordered prior to the general anesthesia. On the other hand are ophthalmologists who do many cases and agree that it is not in the best interest of patients to do routine lab tests. The tests ordered on a routine basis are felt to be superfluous. Remember, the surgeon or the anesthesiologist may order tests prior to surgery if indicated in his or her medical judgment. Also, the tests cannot be done during the one hour prior to surgery, as the EKe committee does not have a member in the hospital at all times to read the EKe, nor is there a radiologist to interpret the chest x-ray in the hospital at all times. There have been suggestions that the patient go to the hospital for the routine tests during the week prior to surgery. This has been done in the past, but the patient's resistance to this routine made it most unsatisfactory, not only for the patient but also for the surgeon. It increases the patient's anxiety, while the anesthetic techniques used have many anxiety-quieting details. For example, false teeth are left in during surgery. If the patient has a contact lens in the other eye, it is left in during surgery. The patient is allowed light juices on the morning of the surgery. A nonhospital approach to admission and care is strictly maintained. After the operation, the patient can sit up, have juice and soup, and is near other patients to discuss with the patient being prepared for surgery how nonthreatening the procedure was. Walking out of the hospital, the postop patient can talk to families and other patients waiting in the lobby. All these techniques have a calming effect on all concerned. If the proposed rules are adopted and cataract surgery allowed with only local anesthesia unless routine tests are ordered, the anesthesiologist is eliminated from being allowed to participate in the surgical procedure. The patient, obviously, would not get the best care as (1) there would be no sedation during the "fear of the needle"; (2) there would be no monitoring of the elderly patient; (3) there would be no secondary history and physical, as only the surgeon would see the patient; (4) there would be no monitoring of the rare possibility of respiratory apnea; (5) the chance of malpractice would be increased. We invite you to examine critically the modern cataract surgery being performed at our hospital. We invite your comments. We invite your criticisms. We also invite each one of our staff and administration to observe surgery. Come into our open operating room. See how the patients are monitored. See the care given each patient. There is nothing that is ever done to jeopardize the patient's safety and care. We do require
J CATARACT REFRACT SURG-VOL 12,
MARCH 1986
the highest standards for our operating room personnel. We demand that we all must work at our best to the utmost of all our training and skill. We all care about the patient. Cataract surgery has made a cosmic leap in the past 20 years. Social understanding, hospital requirements, and government regulations lag and drag on the advances in modern technology and expertise. We respectfully request that the medical staff, administration, and board of trustees continue to lead, not only in ophthalmology but all the various medical disciplines, unencumbered into the future. Our future is indeed bright and, most of all, interesting. May we all meet its challenges.
The area of the intersection of a plane with a cylinder is determined by the formula: A=
where § is the complimentary angle of the cutting tip. Assuming a cutting tip radius of one unit, a comparative table may now be produced:
Alvan Balent, M.D. Linda L. Civerchia, M. D. Fort Lauderdale, Florida
USING THE ARGON LASER TO CUT SUTURES To the Editor: We read with interest the consultation section in the November issue regarding techniques for cutting sutures to minimize astigmatism. All those who described their technique performed the cutting with knives or needles. We were surprised that nobody uses the argon laser to cut sutures. Our technique is to have the patient sit at the laser slitlamp; no topical anesthesia is used. Using the bluegreen light with settings of approximately 50 microns, 1. 5 watts, and 0.02 seconds, we focus accurately on the suture and break it with one burst. If it does not break immediately, it is usually because the conjunctiva is slightly edematous above it or the suture is not tight enough to be on stretch. One or two more bursts will always do the trick. This method is advantageous because it is noninvasive, does not cause bleeding, and the knife or needle cannot slip into a place where it does not belong.
'1Tr2
sin §
Cutting Tip
Area Units
15° 30° 45° 60°
0.81 0.91
1.11 1.57
Therefore, a surgeon switching from a 30° tip to a 45° tip would experience a 22% loss of suction pressure. Similarly, changing from a 45° tip to a 60° tip would yield a 41 % loss in suction pressure. Irwin S. Weiss, M.D. Pieo Rivera, California
I. Allen Chirls, M.D. John W. Norris, M.D. South Orange, New Jersey
ASPIRATION PRESSURE OF PHACOEMULSIFICATION TIPS To the Editor: The phacoemulsification surgeon now has the choice offour cutting tips: 15°, 30°, 45°, and 60°. The sharper, more acutely angled tips are useful in mobilizing the nucleus but suffer from a lack of aspiration pressure. This is, of course, due to their larger port size. The manufacturer has not been able to supply information on the port area of each tip. Knowing this would help one anticipate the suction of one tip relative to another. J CATARACT REFRACT SURC-VOL 12,
MARCH 1986
173