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Subspecialties Cataract, Practice Management, Health Economics and Policy

If You Think of It, Use It!

“Do you think I should use it?” is often heard in operating rooms from trainees regarding the use of surgical adjuncts when embarking on more complex cataract surgery cases. In the past, surgical adjuncts were often perceived as an unnecessary expensive luxury, and unfortunately these attitudes still persist today.

Here, we discuss how to minimize surgical complications with the appropriate use of surgical adjuncts – from pre-operative planning, simulation training, and strategic case selection for trainees derived from risk stratification. First, let’s look at the evidence for challenging incorrect attitudes.

The Scenario Modeling Study

In a recent paper published in Eye, we modeled a common cataract surgery scenario (a white cataract with suboptimal pupil dilation) to evaluate the real-world equipment costs associated with using surgical adjuncts (1). We also modeled the costs of having to deal with the complication of posterior capsule rupture and vitreous loss in that scenario to illustrate the advantages of using preventative surgical adjuncts. The results showed the profound advantages of spending a little early on, to save a lot later.

So, how do we go about ensuring a safe precautionary approach to ocular surgery?

Unsurprisingly, significant costs were identified with the management of vitreous loss using the Anterior Vitrectomy Kit (anterior vitrector, triamcinolone, acetylcholine, corneal suture), which outweighed any initial cost saving from not using adjuncts. Moreover, the additional medical costs of further procedures (such as secondary IOL insertion) and extra outpatient follow-up visits (which are not often acknowledged in the surgical environment) were greatly significant. Our basic modeling suggests that an additional initial spend on surgical adjuncts of £137.47 ($178.96) could potentially prevent a further £1293.60 ($1,684, more than a 9-fold increase) in direct medical costs in the complication scenario.

The simple model used in the study demonstrated that the prevention of surgical complications through using appropriate surgical adjuncts, rather than the subsequent management of complications, should always be the preferred strategy. So, how do we go about ensuring a safe precautionary approach to ocular surgery? It must begin prior to the procedure.

Planning at the pre-assessment stage

For me, the surgical process begins in the pre-operative assessment clinic. I want to identify any risk factors that may make the operation more complex. For example, I am looking to positively identify or rule out corneal guttata or scarring, pseudoexfoliation, poor pupil dilation, poor capsule visibility or phacodonesis prior to encountering it intra-operatively. Has the patient had intravitreal injections before? Have they ever used systemic prostate medications? Is the cataract a posterior polar? This holistic approach enables appropriate well-informed patient consent, alerts the whole surgical team to be prepared for predictable complexities, and ensures precautionary adjuncts are readily available to minimize and/or manage potential complications, should they occur.

The potential for any “straightforward” case to develop intra-operative complications should be assumed, and the risk mitigated through appropriate pre-operative planning. Surgical adjuncts and the necessary equipment used to manage this risk need to be present and available in theater for safe and efficient use. Adopting this “think-ahead” strategy maintains high standards in theater for all staff and promotes confidence in the surgeon and the patient.

Challenging the existing mentality

Current theater management attitudes towards lean equipment levels could lead to lack of availability of surgical adjuncts, if one is facing an entire list of complex cases. Therein lies the temptation to just “chance it,” and hope things will work out fine. Such an attitude is clearly not in the patients’ best interests, and so should be resisted. It is safer to adopt a different mentality: “If you think you need a surgical adjunct, just use it”, but this strategy obviously requires the adjuncts to be available at that point in time. If the whole theater team is educated to understand the importance of this principle, equipment stock levels will be at an appropriately high level; the true cost of not investing in adjuncts is the subsequent and much greater cost – to both the department and the patient – of managing a complication.

A strategy for success

We should all strive to make ocular surgery as risk-free and safe as possible, and I believe being armed with the necessary adjuncts helps achieve this goal.

There are already good studies demonstrating that Simulation Training provides effective exposure for trainees to learn and hone cataract surgery techniques, with an associated reduction in the rate of complications such as capsule rupture (3). Cataract simulators also provide management of common surgical complication modules, offering familiarity with these techniques prior to such events happening in real life.

Trainees and consultants alike need planned approaches, with the freedom and confidence to use adjuncts whenever they require, in the quest for safe uneventful surgeries.

These simulations include the use of surgical adjuncts such as trypan blue, triamcinolone, and pupil expansion devices, such as the Malyugin Ring. Effective Case Selection via risk stratification scoring combined with effective supervision ensures the trainee will be performing surgery on appropriate patients within their levels of competency. This approach also allows trainees to progress in a planned structure to more complex surgeries appropriate for their abilities. And it means they will reach the completion of their training with the breadth and depth of experience required to be independent ophthalmic surgeons.

Developing a lifelong learning attitude to engaging with new surgical developments through didactic teaching, expert videos, dry lab simulation, and hands-on wet lab training will help trainees learn new skills, and use surgical adjuncts and techniques effectively in the safe management of complex surgical scenarios.

One such example is the use of the Malyugin Ring 2.0, which is a device used to expand a small pupil. Small pupils can complicate cataract surgeries and there is a growing body of evidence supporting the use of the Malyugin Ring 2.0in various complicated cataract surgery scenarios (2). If used properly, following appropriate training, this mechanical ring device helps to prevent small pupil complications, which can be costly both financially, and in terms of patient outcomes.

Trainees and consultants alike need planned approaches, with the freedom and confidence to use adjuncts whenever they require, in the quest for safe uneventful surgeries. Early use of surgical adjuncts, such as the Malyugin Ring, intracameral phenylephrine, and trypan blue capsular stain, might help prevent further long-term costs by preventing complications. Equally, appropriate use of other surgical adjuncts – triamcinolone (combined with an effective anterior vitrectomy and the familiarity and ability to place a three-piece IOL in the sulcus); capsule retractors for stability of the bag in patients with weak zonules; and bespoke micro-instrumentation to address issues such as errant capsulorhexis or intra-ocular suturing – can all minimize the risk of turning a complex situation into a much worse complication.

An example adjunct: my experience with the Malyugin Ring 2.0

The Malyugin Ring was designed by Boris Malyugin (Professor of Ophthalmology, and Deputy Director General at S. Fyodorov Eye Microsurgery Institution, Moscow, Russia) to reduce the risk of complications associated with small pupils. In my experience, the Malyugin Ring provides good reproducible pupil dilation and iris stability. In comparison with iris hooks, the ring’s eight points of contact provide an evenly distributed tension on the iris, reducing the potential of “cheese wiring” through an atrophic iris. The spread of force and the lack of external attachment means the iris stays in the natural plane, so it doesn’t tent up or get traumatized by instruments being introduced into the eye. The Malyugin ring is also effective in limiting Intraoperative Floppy Iris Syndrome (IFIS) behavior. It prevents iris prolapse because the pupil edge is mechanically restricted by the ring.

When faced with a poorly dilated pupil unresponsive to intracameral phenylephrine, I go straight to inserting a Malyugin ring. It is always safer to place this device early in the operation, before the iris starts to billow, and prior to the anterior capsule being opened.

Before the insertion of the Malyugin Ring, I inject the dispersive viscoelastic device (OVD) into the anterior chamber and beneath the iris. Then, entering through a 2.0-2.2 mm incision, I insert the Malyugin ring via the introducer, directly engaging the distal scroll first, followed by two lateral scrolls. With the use of a second instrument, I engage the last scroll behind the wound. Removal is very straightforward. I find releasing the distal scroll provides the space required to safely engage and retract the ring back into the introducer, and then withdraw the entire device from the eye.

Figure 1. Trypan blue to improve visualization in white cataracts.
Figure 2. Intraocular forceps.
Figure 3. Malyugin ring insertion.
Figure 4. Malyugin ring final position.
Figure 5. Release of distal scroll.
Figure 6. Using a second instrument to protect cornea on withdrawal.

Cataract surgery can be made safer by preventing surgical complications with the use of surgical adjunct devices. The specific value of individual surgical adjunct use is unknown, but equally, the true cost and impact of a surgical complication to the patient is ill-defined, and goes far beyond the operating room costs. One must acknowledge that the appropriate use of surgical adjuncts will not always prevent complications. Conversely, it is also possible to avoid the use of any additional aids in complex surgery and “get away with it.” However, prevention rather than subsequent management of a complication should always be the favored approach. Adjuncts help deliver this strategy.

As a result of the findings in the published peer review paper, there should be greater confidence among trainees (and seniors) to go ahead and employ the necessary precautionary surgical adjuncts whenever they are indicated. I believe that it is a failure of surgical planning if the surgeon says, “I wish I had used...” during the operation. I have never regretted using a surgical adjunct: if I think of it, I use it!

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  1. A Jamison et al., “Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery”, Eye, 32, 1530 (2018). PMID: 29875386.
  2. B Malyugin, “Cataract surgery in small pupils”, Indian J Ophthalmol, 65, 1323 (2017). PMID: 29208812.
  3. J Ferris et al., “The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees”, Br J Ophthalmol, [Epub ahead of print] (2019). Available at: bjophthalmol-2018-313817.

About the Author

David Lockington

Consultant Ophthalmologist at Tennent Institute of Ophthalmology, Glasgow, Scotland, with sub-specialist training in cornea, cataract and anterior segment.

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