This column is one in an invited series by Dr. Osher. The series highlights techniques that may be helpful in particular to young practitioners.
Over a long career, I've incorporated certain “things” into my practice. In this column, I'll mention a few of these things which have proven to be very helpful.
One of the best investments which I have made since entering practice in 1981 has been the purchase of a high-resolution camera and monitor both in my examination room and in the operating room. By sharing the biomicroscopic appearance of the cataract with the family members accompanying the patient, they invariably develop a better understanding and a deeper empathy for the patient. Students, residents, fellows, and staff also enjoy observing the pathology while I am dictating my findings.
In the operating room, I have always allowed the family to observe the surgery which I have enjoyed narrating. If a rare complication occurred, I wanted the family to see how much time and effort were invested in trying to resolve the problem. Unfortunately, family observation has been suspended because of COVID at the time of this column. Real-time viewing not only has provided unique teaching opportunities but also has facilitated a higher level of staff involvement. Scrub technicians become more knowledgeable and by watching the monitor, can eventually anticipate my request before I say anything. Both in the clinic and in the operating room, the cameras and monitors have been invaluable.
In the clinic, I can record preoperative challenges and either routine or unusual postoperative findings for documentation and teaching. In the operating room, the camera and technology for recording every case is always on so if something unexpected happens, I can review the incident later in the calm and privacy of my office or home. This compulsive habit has been the best way to identify cause and effect, which ideally prevents recurrence. If I am truly bewildered, I will file the recorded case for the future review. Two of my favorite teachers at the Bascom Palmer Eye Institute, Donald Gass, MD, and J. Lawton Smith, MD, had a habit of filing their perplexing cases which helped each of these giants make major contributions to ophthalmology. Our video system has undergone expensive periodic updates, but cameras, monitors, and recorders remain indispensable to my practice for teaching and patient care.
Roll of Tape
When I consulted for the Zeiss team in developing Lumera, it was my goal to make the microscope a satellite office. Technologies from a number of companies have recently become available that will allow the surgeon to retrieve information from the clinic, while he or she is seated at the microscope. A simple alternative has been to summarize the pertinent clinical information on a sheet of paper which is taped to the microscope. In addition to the identifying patient information, it lists the refractive target, the IOL, the amount and axis of the astigmatism, the axial length, intraocular pressure risk factors, known allergies, and any other pertinent information, for example, a shallow chamber depth of 2.0 mm. I also like to record a few personal comments which are conducive to friendly communication between the patient and the surgeon. These comments may indicate that the patient likes golf, enjoys painting, or is related to someone on whom I've operated in the past. I can quickly see how well the patient did in the first eye which I'll incorporate into my conversation. Individualized chatter is very reassuring to the patient while I am getting ready to operate. The best anesthesia is not general or local… it's vocal.
Tube of Vaseline or Aquaphor
As a neophyte learning how to operate, I was frustrated by the frequent fogging of the microscope oculars. I tried coating the lenses which seemed to help, but eventually I began taping the top of my mask to the skin on my lower eyelids and over the bridge of my nose. This worked well throughout the day but left erythematous changes in my skin because the tape was painfully ripped off at the conclusion of the day. I happened to notice that many ophthalmic surgeons who embraced this practice developed significant laxity of their lower lids. Therefore, I began placing a thin film of Vaseline along my lower lids and over the bridge of my nose before putting the mask on, and the results were dramatic (Figure 1). There was absolutely no fogging of the oculars throughout the day, and the mask was removed atraumatically and painlessly when I finished operating. Some years later, I shared this procedure with Dr. Charles Kelman and he told me that he could have avoided several lower lid blepharoplasties had he been aware of this little trick. Newer mask designs reduce fogging, but I continue to seal my mask at the beginning of the day.
In my training, we routinely would cover the operated eye with a patch after retrobulbar or peribulbar anesthesia. The inability to blink after either of these blocks was often associated with a dry, irritated corneal surface when the patch, which invariably had loosened, was removed on the day after surgery. Moreover, stromal edema was often impressive because the patch prevented evaporation. Years ago, I came up with the idea of using 1 or 2 Steri-Strips for temporary lid closure. Each strip is cut to about 3/4 length, and a small tab is created to allow easy removal by the patient or family member approximately 2 hours after surgery after the short block has worn off (Video 1, available at https://links.lww.com/JRS/A773). This has resulted in a number of advantages which include optimal comfort, less stromal edema, minimal diplopia, and a healthy corneal surface the day after surgery. In contrast to a patch, the flesh colored Steri-Strips have been a cosmetic and functional hit with patients who require a block (Figure 2).
Piece of Paper
This habit may not be par for the course, but I have always given the patient a piece of paper with my home or cell phone number before he or she is discharged from the surgery center. Most patients who have just had their first eye operated upon may be anxious about what might happen that evening. It is tremendously reassuring for the patient to know that the surgeon can be reached the night of surgery. Patients always express their appreciation for this small gesture, and I almost never receive a call. This is exactly how I would like to be treated as a patient and I've never regretted this practice.