that works nicely, but not 100% of the time for 100% of the cortex. Rarely I will leave a little cortex in the fornix rather than risk additional problems.

WHAT’S IMPORTANT NOW

Lou Holtz has experienced great joy as a college football head coach. At the very heart of his coaching philosophy is what he calls the WIN approach to playing a football game. WIN is an acronym for What’s Important Now. It is probably the single best “technique” we can adopt to prevent complications and problems in cataract surgery. Let me challenge you, just as I try to constantly challenge myself, to continually ask yourself, “What’s important now?” And, not only for each cataract surgery case, but for each and every step of each and every cataract surgery case. By so doing, I find myself making small adjustments that will help avert problems. Again, I major in the minors.

Does the WIN philosophy work 100% of the time? Of course not. Not for football and not for cataract surgery. In fact, Holtz himself once opened his tele-

FIGURE 28–4 With the intraocular lens (IOL) in place, the posterior capsule is held back and, if necessary, it is now easy to further irrigate the remaining cortex. Here I show a U-shaped cannula being used through the phaco incision. However, a straight cannula through the side incision often works well also.

vision program following a devastating loss by saying: “Welcome to The Lou Holtz Show . . . unfortunately, I’m Lou Holtz.”

What do we do when, regardless of our best preventive measures, we encounter a glitch? How can we minimize damage when we hit that snag? The answer is simple, and yet difficult to carry out. We admit it. The thing to do is to acknowledge that we’ve fallen off the perfect surgery band wagon and deal with it. Deal with it now. As Vice President Alben Barkley said: “If you have to eat crow, eat it while it’s hot.” Denial might very well be the single greatest cause for complications in cataract surgery; and, yet, the most preventable.

The late John Wayne, known for his toughness and manliness, once made a very touching observation: “Tomorrow is the most important thing in life. It comes into us at midnight very clean. It’s perfect when it arrives, and puts itself in our hands.” May all your tomorrows in cataract surgery bring your patients new vision, and bring you that blissful feeling of a job very well done.

This chapter discusses my key steps for complication avoidance. But complications do occur, and so I describe the less common but most helpful maneuvers I favor to minimize damage and regain control of the situation. The discussion is not comprehensive. Rather, I present my personal favorites. These pearls work for me today, with my current technique. I am always looking for new and better pearls. As in any human endeavor, a surgeon will benefit from skills that add to strengths and compensate for weaknesses. Read this chapter with an open mind, and try to identify elements that resonate with your own current technique and skill set.

PREOPERATIVE

Some special steps in the preoperative evaluation will help ensure a good outcome on the day of surgery. In addition to a comprehensive preoperative examination including dilated lens and fundus exam, the surgeon must evaluate the patient from the perspective of the operative day. Is the patient oriented and able to cooperate? Do medical conditions, such as respiratory distress or spinal deformity, make a supine positioning impossible? Particularly if topical anesthesia is being considered, does the patient exhibit a high level of anxiety, or squeeze uncontrollably during applanation pressure measurement? Before narrowing in on the slit-lamp exam, take a moment to look at the orbital configuration. Deep-set eyes, high orbital rims, or a narrow palpebral fissure all argue for a temporal incision.

In the eagerness to examine the lens, don’t forget to note and institute preoperative treatment for ble-

The key insight of the grading scheme is the separation of nuclear brunescence from nuclear opacification. Each of these aspects is graded on a scale of 1 to 6. Most clinicians pick up the habit in residency of simply glancing at a cataract and jotting down “3+ NS” for a moderately advanced senile cataract that is well along in nuclear sclerosis (hardening). Yet we cannot directly judge nuclear hardness at the slit lamp. A patient may complain of multiplopia and have progressive myopic shifting of the spectacle correction, with a modest amount of green-brown coloration but a high degree of haze in the central nucleus and less haze in the periphery. The rating would then be NC 2 (minimal color) and NO 5 (very significant opalescence). An elderly patient with 20/40 distance, J 1 near vision might have a dark brown but relatively clear lens, similar to the color of Coca-Cola. The rating might be NC 6 or NO 3. In both cases, the rating is much more meaningful than 2+ NS or 4+ NS, respectively. The first patient needs surgery; the second may not.

The remainder of the LOCS classification deals with anterior (A) and posterior (P) opacities on a 1 to 4 scale. I have modified this to AC (anterior cortical),

PC (posterior cortical), and PSC (posterior subcapsular) to differentiate these types of changes because PSC cataracts typically cause more glare symptoms.

This rating system is not an empty exercise. In addition to sharpening the observations of the clinician, the ratings prepare the surgeon for the likely behavior of the nucleus during phacoemulsification. I use nuclear color and the patient age together to select which combinations of fluidics to employ. My phacoemulsification unit is programmed with five memory settings, and my admission note tells the operating room staff which memory setting to set up before I enter the room. This is both more efficient and safer than having the nurse ask, in midcapsulorrhexis, “Is 200 OK?”

Each surgeon needs to develop phaco memory settings appropriate for the technique and for the machine. For my high-vacuum phaco chop technique with the Allergan Surgical Sovereign unit, each memory setting represents a 100 mm Hg increment in the high vacuum setting, with corresponding increases in maximum phaco power and IV pole height. In all cases, flow is set at 28 cc/min. For example, Memory 3 is 300 mm Hg vacuum, 80% maximum phaco power

with surgeon foot pedal control. If I find that my preoperative prediction is inaccurate, then the memory setting is readily adjusted, but the preoperative evaluation system is highly accurate.

keratotomy if indicated; the IOL model and power; and the phaco memory setting. Any unusual elements (e.g., pseudoexfoliation or corneal guttae) are then reemphasized.

ADMISSION NOTE

The admission note and the operative note are key elements that can defend you or hurt you in the event of legal action. Accordingly, they should be fastidiously prepared to explain your plan and accurately convey the events of the surgery. Most importantly, the surgeon must use the admission note as a tool to maximize the potential for a complication-free surgery. The admission note is the surgeon’s opportunity to alert anesthesia and nursing personnel to key issues. These include the usual items such as medical allergies, systemic diseases, and medications, but also relevant issues such as anxiety, claustrophobia, back pain, tremors, language barriers, and many other factors that will have impact on the patient while undergoing surgery. As noted in the previous section on preoperative evaluation, the surgeon has many potential issues for which the admission note can be used as memory freshener. All of these elements should be typed in bold and, if particularly unusual or critical, bold italic. At the end of all my admission notes, after a statement of the risks that were reviewed with the patient, I list the preoperative keratometry and desired location of the wound, with the plan for astigmatic

STANDARD OPERATIVE PROCEDURE

The details of the standard operative procedure have been well covered in the preceding chapters. Individual surgeons will adopt aspects that suit their technique. The most important principle is that a surgeon may be pleased with today’s techniques and results, but should never be satisfied. The history of cataract surgery has proven that a highly successful procedure may always be improved.

Often neglected are the aspects of surgery prior to the first incision that may well determine the success or failure of the procedure itself. This begins with the preoperative evaluation discussed previously, and continues with the preoperative care of the overall patient, which must result in a maximally relaxed, comfortable, and confident patient who is medically stable.

At surgery, the patient must be positioned to be comfortable and simultaneously accessible to the surgeon. In the supine position, one or two pillows under the knees can avoid lower back pain, for example. The surgeon must take the time to examine overall patient positioning at the outset of the procedure. For example, to expose the superior cornea