Phaco or Lensectomy by retinal surgeon

[Retinamark]

Here's an interesting question for general ophthalmologists (& it would be interesting to hear retina opinions on this too)
Let's say you have someone with a retinal problem and a moderate cataract, say 2+ NS. They need a Vitrectomy, let's say for a macular hole. Now, we know that the cataract will likely progress after the surgery, in some cases very quickly.
How much of an issue is it, whether the cataract extraction is combined with the retinal procedure, done before the Vx or done later.
For the patient's benefit, the ideal procedure in many cases is a combined Phaco / Vitrectomy. Do general guys like to come along & do that & then hand over to the retina guy? I would imagine that it is a big hassle to come into the OR to just do one case & it would be better to spend that time in clinic seeing another 5-10 people.
I get the impression that in some cities, no-one cares & the retina guy would do the phaco/vit & in other cities, it is a big deal & the retina guy has to struggle through the Vitrectomy with a poor view, so he can send the cataract back to the referring doc
This is an interesting topic with lots of clinical, financial & ethical issues...

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[PDT4CNV]

Here's an interesting question for general ophthalmologists (& it would be interesting to hear retina opinions on this too)
Let's say you have someone with a retinal problem and a moderate cataract, say 2+ NS. They need a Vitrectomy, let's say for a macular hole. Now, we know that the cataract will likely progress after the surgery, in some cases very quickly.
How much of an issue is it, whether the cataract extraction is combined with the retinal procedure, done before the Vx or done later.
For the patient's benefit, the ideal procedure in many cases is a combined Phaco / Vitrectomy. Do general guys like to come along & do that & then hand over to the retina guy? I would imagine that it is a big hassle to come into the OR to just do one case & it would be better to spend that time in clinic seeing another 5-10 people.
I get the impression that in some cities, no-one cares & the retina guy would do the phaco/vit & in other cities, it is a big deal & the retina guy has to struggle through the Vitrectomy with a poor view, so he can send the cataract back to the referring doc
This is an interesting topic with lots of clinical, financial & ethical issues...

At my institution we have 8 retina specialists and 6 retina fellows, from what I have observed, almost all of them tend to just do everything. The exception is they will usually have a cornea guy do the TKP. My feeling is that if another doctor refers a patient to you, then it is your privledge to take care of that patient's problems. Ultimately though, it is up to the patient to decide.

 

[ckyuen]

At my institution we have 8 retina specialists and 6 retina fellows, from what I have observed, almost all of them tend to just do everything. The exception is they will usually have a cornea guy do the TKP. My feeling is that if another doctor refers a patient to you, then it is your privledge to take care of that patient's problems. Ultimately though, it is up to the patient to decide.

If another doc refers you that patient you should send the patient back to the other doc for the phaco if you want to continue receiving referrals. A few reasons also. Not a lot of retina docs have iol masters, if they do they don't get a lot of referals. Not doing a lot of phacos means that complications are more likely to occur. More endothelial cell loss, etc. Also is it really worth it for the 340.00 you will get?

 

[PDT4CNV]

If another doc refers you that patient you should send the patient back to the other doc for the phaco if you want to continue receiving referrals. A few reasons also. Not a lot of retina docs have iol masters, if they do they don't get a lot of referals. Not doing a lot of phacos means that complications are more likely to occur. More endothelial cell loss, etc. Also is it really worth it for the 340.00 you will get?

I disagree, if the patient needs the cataract out as well as a retinal procedure, it is better to do the combined procedure. This is better for the patient and better for the healthcare system. If the patient does not require a retinal procedure, then it is more appropriate to send the patient back to his/her general ophthalmologist for the cataract procedure.

Most retina surgeons have b-scan ultrasound machines, iol master not necessary. I also highly doubt that the complication rate for cataract surgery is higher among vitreoretinal surgeons, at least at my institution. In fact, often the more difficult cataracts such as those with poor zonular support, the morgagnian, or dense psc cataracts with adherent or ruptured post capsules are not uncommonly referred to vitreoretinal surgeons to be done.

Lastly, endothelial loss is not so much an issue when using the "frag" to remove the cataract via a pars plana or post approach that many retinal surgeons would use for a "lensectomy" in a combined procedure.

 

[NDirish]

I disagree with PDT4CNV. As a grad of the same program, I saw plenty of combined CE/IOL (ant segment guy) c ILM, etc (done by the retina guy). M&W don't phaco and only do frag and I would argue that leaving the posterior capsule intact is a far superior end result, especially in a retina patient. WFMT occasionally have the fellow Phaco, but I think a combined (especially when you are in the same EFH, ASC, etc.) is the way to go-financial reasons aside. And I know most retina guys can't phaco (after fellowship-quick to become rusty) or they wouldn't be getting referrals.

While it is nice to have a retina guy readily accesible for "cataracts such as those with poor zonular support, the morgagnian, or dense psc cataracts with adherent or ruptured post capsules"-anterior segment guys should be and are doing these.

 

[PDT4CNV]

I disagree with PDT4CNV. As a grad of the same program, I saw plenty of combined CE/IOL (ant segment guy) c ILM, etc (done by the retina guy). M&W don't phaco and only do frag and I would argue that leaving the posterior capsule intact is a far superior end result, especially in a retina patient. WFMT occasionally have the fellow Phaco, but I think a combined (especially when you are in the same EFH, ASC, etc.) is the way to go-financial reasons aside. And I know most retina guys can't phaco (after fellowship-quick to become rusty) or they wouldn't be getting referrals.

I partially agree, what you state very well may represent the practice patterns of specific people. But my point, in addressing the original question, is that if a patient requires a retinal procedure and has a visually significant cataract, then it is fine, in my opinion, for the retinal surgeon to remove the cataract. If the patient's general ophthalmologist operates at the same place, then if he/she wished to do a combined procedure with the retina surgeon and remove the cataract, then that would be fine too. However, I think it is inapproriate to have the patient undergo two separate surgeries for financial or political/referral based reasons.

 

[Retinamark]

I partially agree, what you state very well may represent the practice patterns of specific people. Whether using the frag leads to an inferior result is debatable. But my point, in addressing the original question, is that if a patient requires a retinal procedure and has a visually significant cataract, then it is fine, in my opinion, for the retinal surgeon to remove the cataract. If the patient's general ophthalmologist operates at the same place, then if he/she wished to do a combined procedure with the retina surgeon and remove the cataract, then that would be fine too. However, I think it is inapproriate to have the patient undergo two separate surgeries for financial or political reasons as these should not influence surgical management of the patient.

That is a great response, I totally agree.
There are many retinal surgeons who can phaco perfectly well, & in most circumstances this is the preferred option
An alternative which I have seen very good retinal surgeons do if the cataract progresses rapidly during the vitrectomy, is to remove it with the frag leaving the anterior capsule intact. This allows safe placement of a PCIOL in the sulcus, with an intact capsular barrier behind it.

 

[NDirish]

"I think it is inapproriate to have the patient undergo two separate surgeries for financial or political/referral based reasons"
Agreed!

 

[ckyuen]

If you are the retina doc, and you want to keep getting referrals you will follow the phaco with your vit. This is in the patient's best interest. Believe me while it seems like the retina guys academically are the epitomy of ophthalmology, at least that's what they think, in the real world you are on the bottom of the food chain. You rely on referrals to pay the bills, if you build a bad name for yourself as one who will steal phacos no one will refer to you. If you offer to follow the refering doc and operate after him/her you will get a flood of business. This is how the real world works. I stay late all the time if my referring sources have a patient to send me. Your name is everything, and bad news spreads 100x quicker than good news. If you were to have a pc rent and have to put a sulcus IOL, guess how bad that would look the the referring md and he would tell everyone that not only do you do the phaco on someone elses patient you can't even do it right and you break capsule. All this for 50% of the fee. What's best for the patient is to have the surgeries performed one after the other. It's likely the referring doc is a better phaco surgeon, since they are doing it all the time. You're crazy if you do a ppl, and use the frag that thing is not harmless, and what happens when pieces drop and hit the retina, is this better than doing a 10 min phaco?

 

[Retinamark]

Do referring surgeons really want to make a special trip into the hospital just to do one case? I would have thought that by the time they drove in there, got dressed, did the case, got dressed again & went back to their office, they would have been better off seeing another 5 or 10 patients in the office.
If the referring doc has a list on the same day, at the same OR, then that would be fine, but I would think that would be very difficult to coordinate.

Also, I'm not talking about "stealing phacos". I'm talking about what happens when the view starts to get worse during the surgery, impairing the ability to peel membranes for example. This is the only time I would consider using the frag - ie once the Vitrectomy has already started. I think you're getting a little over-emotional to say that using the frag is "crazy". Do you realize that the frag is just a phaco needle without the infusion sleeve, which is not required since you have a large bore pars plana infusion cannula sewn in.

Over the past 6 years, I have scrubbed in with at least 50 different phaco surgeons, and around 5 retinal surgeons who also do the occasional phaco. All 5 of those retinal surgeons would rank definitely somewhere in the upper third of all the phaco surgeons, so I disagree with your statement that a retinal surgeon is more likely to get a PC tear. Like any specialty there is a wide range of surgical skills, and you just cannot make broad generalizations.

You ask what happens when lens fragments hit the retina? That is a theoretical consideration no matter who is doing the surgery, but I've never seen retinal damage from falling lens fragments.

I agree with you that if the referring doc wants to come in and do the phaco and hand over, then that is fine, but it really disappoints me when people get so greedy that they expect these elderly patients to undergo 2 separate surgeries, just so the referring doc can do another cataract. Not only is it bad for the patient, but for their son & daughter who needs to take time off work to bring them in for the surgery, and 2 lots of separate post-op appointments.

 

[JR]

I just want to say how great it is to have both of you guys on this forum; your real world prospective is invaluable for us who are starting to see the light at the end of residency tunnel . Please keep posting!

Ckyuen, you probably don't remember me, but I met you during my residency interview at your program. You had some great advice back then! Did you end up doing a fellowship?

 

[ckyuen]

If the view gets bad during surgery you do what you have to do. Also the frag does not have that protective sleeve making it much more likely to cause a burn at the wound. It's much more traumatic than the phaco needle. If preoperatively it is determined that the cataract needs to come out, you should schedule to do it with the other referring doctor on their time and follow on their OR day. You can do what ever you like but you just have to burn a referring source once to not get any patients from them again. Besides a topical surgery with drops you use to do a routine eye exam isn't all that traumatic. If you are going to frag and keep your pc in tack then you are a truly amazing surgeon. kudos to you. If you are going to use the frag in the ant chamber you're an idiot or you have not ever seen a corneal burn from the phaco tip. If you are planning on making the eye a one chamber eye with the frag and a ppl, you better make sure they are not diabetic and you do not have a one chambered eye. Also. If you are doing a ERM and you lose the view for whatever reason, and you remove the lens make sure you one have intraop a scan capabilities or when you leave the paitent aphakic be prepared to put a lens in for free for another visit to the OR. And be able to explain why the patient sees so much worse post op. So how does the patient save a trip to the OR in this case. Retinamark you mentioned two different things. Preoperatively if the indication for phaco is there tell the referring doc to do the phaco. most guys do it under topical in ten minutes and have 20/30 or better vision post op day one. it's a day procedure recovery is minimal. You can follow your referring doc then do your erm and vit. If my retina guy would not do this then I would find another guy. Retina docs are oversupplied in my area as they are in most major cities. In fact most retina guys do general also just to survive. But it may be different where you are. Also I don't believe that a retina doc doing phaco once in a blue moon is going to be in the top 3rd of the docs you have watched. If so you are watching the wrong surgeons. I would be happy to have you observe a case. Or your retina guys have extremely gifted hands and your phaco guys are awful. I know for a fact that when I started into private practice my first cases took me 20 minutes and very few came back 20/40 or better pod#1. And while i did not do a phaco for 5 or 6 months I was doing eye surgery up to the month before. And I believe I am an excellent surgeon. During residency many of the 20 or so docs who observed my class told me I was the best resident surgeon they ever worked with, and some told me they wished they could operate like me several years after practice. Now that I do cataracts every week, my average phaco is about 10 minutes, under topical, with almost everyone 80-90% having 20/30 or better vision pod#1 uncorrected. In fact my optometrist look at my pod#1 cases and ask if they are pom#1 b/c the eye is so quiet and the cornea so clear. I don't think most of your retina guys fall into that category. So with my patients I want to do the phaco. Why b/c I believe it will be in the patients best interest, and they will get the best job done. It's like anything else do it every week and you will be more efficient at it. Now for your second point if intraoperatively the lens gets hit during vitrectomy, which is the only reason I could see why you would loose your view and have it come from the lens intraop. Then by all means do what's right and take the lens out before the patient gets lens induced glaucoma and looses the eye. Even if the anterior capsule is intact and a patient with DM gets a cataract secondary to vit, nvi and nvg can develop so quickly. So take the darn thing out and get the eye quiet. I could also see needing to do ce for a VH when you find the lens is not clear enough to complete your procedure. Please do it then. But if you are one who routinely does ce/iol on your vits you will not have a lot of business in the near future. Heaven forbid you get a complication while it may have been just as likely to have happened in the referring docs hands you will never see a patient from that doc again. Especially if the patient has a poor result. THey will remind the referring doc of their bad experience with you and that will be the end of the referrals from that doc. THe patient may even ask their referring doc why they did not do the cataract since that is what they specialize in and at that point the referring doc can't defend you. If it's a vit gone bad they will say it was a difficult surgery and there are inherent risk. If it was a complication of ce/iol or even if I see a sulcus IOL I would be very upset b/c I would have known that more likely than not the ce/iol would have been better accomplished by myself. So to make a short response even longer. Again intraop decision I agree do what you need to do. Preop. Go ahead do it, but you won't be seeing a lot of repeat business.
I can also say anecdotally that from my experience with my program our 24 residents and about 16 fellows when it came to cataracts none of the retina guys were in the upper half. The best cataract guys usually went straight out to practice why b/c they were ready.

 

[ckyuen]

In response to original post. I would not do a ce/iol b/c I would expect that the cataract would progress quickly post operatively. How do you know this for a fact. How can you defend this in court when they say, well you felt the cataract was not visually significant yet you removed the lens, the patient develop "fill in the complication". Doctor do you make it a habit to go against the standard of practice and take out cataracts before they are visually significant putting the patient at risk. Then the turn to Doug Koch and say Dr. Koch do you operate on cataract that are not visually significant? Get ready to write a check.

 

[smiegal]

Is it true that there is currently an oversaturation of retina specialists in most cities?

Anyone know about the retina situation in Chicago and/or Milwaukee?

 

[ckyuen]

In a lot of cities there is an oversaturation. Especially out west. A lot of retina guys don't have a lot of volume. Some of my friends that interviewed in california interviewed in places like monterrey, areas outside of the bay area, near napa. Seemed like they were going to be lucky to get 20 patients a day. and you have to see a lot of patients per each vit for retina. Dont know about chicago or wisconsin.

 

[Retinamark]

I enjoy your posts ckyuen & I agree with much of what you say. I don't have a problem with a referring doc wanting to do the phaco before referring for a Vx. That's fine. But it does mean the pt has to undergo 2 separate operations, with all the involved hassle for the pt & relatives.

I don't agree that the frag is so traumatic. It doesn't have a sleeve, but I've never seen a wound burn because sclera is much more resistant to wound burn than cornea. No one would (I hope) ever consider using the frag through a corneal wound. It's not designed for that. I never mentioned using the frag to start a case with a lensectomy. There are older retinal surgeons who never learnt to phaco who might do that, but no young retina guy would. The frag is now reserved for retained lens fragments, or lensectomy after the Vx has started. There is more than 1 reason for that - diabetic cataracts can progress rapidly due to fluctations in sugar levels, even if there is glucose in the infusion fluid. Other cases requiring lensectomy include anterior PVR, anterior loop traction, anterior hyaloidal fibrovascular proliferation, giant retinal tear in some cases.

And just to clarify, the best way to do a pars plana lensectomy is to leave the anterior capsule intact. You obviously can't leave the posterior capsule intact.

This is such a fascinating topic. Seems like there is a lot of politics involved, which varies a lot depending on location. I'm starting to get the impression though, that whenever there is a conflict between politics and the best interests of the patient, politics often wins.