Endophthalmitis has been and remains the most dreaded complication of cataract surgery. Regardless of whether the surgeon uses a phaco machine or a femtosecond laser or performs manual small-incision cataract surgery, the reaction of the patient and his or her relatives and friends is exactly the same upon hearing that the patient has developed this sight-threatening complication.
Naturally, there cannot be a perfect standard operating procedure to engage with grieving and often hostile patients and loved ones. This article presents five pearls that have proved helpful to me in my 30-year career as a cataract surgeon, during which the occasional case of endophthalmitis has occurred.
KEEP ALL PARTIES FULLY INFORMED
Set realistic expectations for the endophthalmitis patient and his or her relatives. Remember that pessimism is better than unrealistic optimism. The patient wants to know exactly what the problem is and how you propose to tackle it, so be clear about what you intend to do next. Show that you are in command of the situation.
AT A GLANCE
• Postoperative endophthalmitis is the most feared complication of cataract surgery, but it need not mean a disaster.
• If a colleague refers a case of endophthalmitis to you, do not blame him or her or suggest to the patient that the case was handled ineptly.
• If endophthalmitis occurs, the surgeon should not succumb to the patient’s or the relative’s unjust demands but instead show empathy, answer all questions honestly, and, if necessary, seek the opinions of colleagues who are better equipped to tackle the case.
If you are not a vitreoretinal surgeon but have access to one at your institution, tell the patient that there is likely an infection at the back of the eye, behind where you have placed the IOL. Explain that this is best tackled by an expert in that area, and that is why you are referring the patient to your retina colleague. If you are in solo private practice, refer the patient to a vitreoretinal surgeon you trust, and offer a similar explanation to the patient and his or her relatives.
CHARGE NO ADDITIONAL FEES
Do not charge the patient any further visiting fees or consultation charges, even if the patient visits twice a day while the complication is addressed. However, resist any demands from the patient or relatives to refund the amount already charged for the IOL surgery. Explain gently but firmly that those fees were for services you already rendered to the best of your ability and were not dependent on outcome. Refunding cataract surgical fees can be seen as an admission of guilt and may lead to further demands for compensation, so this is best avoided.
If further vitreoretinal procedures are required in the same hospital, speak to the hospital authorities and get as many fees waived as possible. If you have referred the patient for care outside your hospital, explain the situation to the vitreoretinal consultant and ask him or her to be as reasonable as possible with the charges.
What the patient requires most at this stage is empathy. You must genuinely feel empathy for the patient; this cannot be faked. Place yourself in the patient’s shoes, and understand his or her frustration and fear. Spend quality time with the patient, more than you spend with routine postoperative patients. Provide comfort, hope (but not false hope), understanding, and compassion.
Always talk to the patient in the company of his or her spouse, significant other, or other present family member so that you do not need to have the same conversation twice. Give them as much information as possible. Do not get irritated if the patient repeatedly asks the same question, such as, “Doctor, will I be able to see?”
STAY CALM WHEN DEALING WITH RELATIVES
Patients with postoperative endophthalmitis suddenly sprout a million relatives. Often, some of them are located in different time zones, scattered across the world, and some may be doctors. They may be dermatologists or chiropractors, but they will think nothing of calling your cell phone at 3 am with words of wisdom and advice. They will demand a status report on the patient and question you in detail about why you are or are not following a particular line of treatment.
Keep your head cool. If the relative is calling at an odd hour, ask him or her to call again at a better time or to send you an email, which you can answer at your convenience. Remember, some relatives only want to show off their knowledge and are not genuinely interested in your answers.
Not all nonmedical relatives have the same intellectual capacity, so keep your answers as simple yet consistent as possible. Consistency is important, as relatives who have not talked to each other for years will suddenly compare what you have told them and try to discover contradictions in your statements. If possible, keep a record of what you have said and do not hypothesize or respond to questions you cannot truly answer.
DEVELOP A STRATEGY FOR ANSWERING COMMON QUESTIONS
How? Explain in detail all of the preoperative preventive measures you took, how you investigated the patient’s fitness, and how you operated only when his or her blood sugar was under control, for instance. Use documentation to show and explain that all guidelines have been met. (For example, I use the All India Ophthalmological Society checklist, available at www.aios.org.) Explain in simple terms that you sterilize your equipment, use disposables, and keep the operating room sterile.
Why? The patient will then ask, “If so many precautions were taken, why did this happen to my eye?” Explain to the patient that you do not know, but you have sent samples of the materials used, such as the saline bottles, for laboratory investigations. Mention that infections can come from exogenous and endogenous sources; the source need not be from the operating room, it could be from the patient’s own body, with a septic focus somewhere, or from the environment, contaminated eye drops, or other sources.
What are my chances of visual recovery and pain relief? Tell the patient that you cannot promise a particular visual outcome but will do everything possible to relieve his or her pain. If you are planning any interventions such as intravitreal antibiotic injections or vitrectomy, make sure that the procedures are well explained in advance and that written informed consent is received.
Can you remove my eye? Do not rush to perform an evisceration, no matter how hopeless the case appears or how strongly the patient demands it. The patient expects you to do everything possible to salvage some vision. There are anecdotal reports of patients with doubtful perception of light regaining useful vision after endophthalmitis treatment.
In the case of an eye with no perception of light that is developing panophthalmitis, be sure to get a second and, if necessary, a third concurring opinion that a destructive procedure is mandatory. The patient’s informed consent, of course, is crucial. A patient who begs for an evisceration today may sue you for rushing to operate and causing disfigurement and/or permanent vision loss by a destructive procedure tomorrow.
Postoperative endophthalmitis is the most feared complication of cataract surgery; however, it need not mean the end of your career. If it occurs, keep calm, do not succumb to the patient’s or the relative’s unjust demands, show empathy, answer all questions honestly and patiently, and do not hesitate to get the opinions of colleagues who may be better equipped to tackle the case.
More important, if a colleague refers a case of endophthalmitis to you, do not blame him or her or suggest in the presence of the patient that the case was handled ineptly. Remember, it could easily be your turn next to face the music. Praise your colleague and explain to the patient that this could happen even in the hands of the best surgeon in the world; it has happened to your patients on occasion as well.
Although endophthalmitis is a serious and dreaded outcome, it is rare, with reported incidence ranging from 0.13% to 0.7%.1 With the proper strategy, and with sensitive management of patients and their loved ones, it is possible to emerge from these cases with your head held high and reputation untarnished.
1. Mamalis N, Kearsley L, Brinton E. Postoperative endophthalmitis. Curr Opin Ophthalmol. 2002;13(1):14-18.
Quresh B. Maskati, MS, DOMS, FCPS, FICS
• Ophthalmic Consultant, Maskati Eye Clinic, Mumbai, India
• Financial interest: None acknowledged