Chapter 1 Assessment - Difficulty Factors
Why should you assess the difficulty during the preop?
- Which surgeon should do case (e.g., Attending vs. 1st year resident)
- Estimate length of case
- Determine need for additional supplies/equipment
- Determine the type of anesthesia
Difficulty Factors (in decreasing order of importance):
- Zonular laxity (e.g., due to pseudoexfoliation syndrome, history of trauma, Marfan's syndrome)
- Small pupil size (why is it small? pseudoexfoliation syndrome, diabetes after laser treatments, central posterior synechaie (CPS), floppy from Flomax)
- Cannot lay flat for very long, e.g. COPD, claustrophobia, tremor, severe obesity
- Big brow limiting superior access
- Narrow angle limiting anterior chamber space
- Predisposition to corneal decompensation, e.g., corneal guttata, posterior polymorphous dystrophy (PPMD), and hard nucleus
- Poor red reflex due to a white or black cataract making case difficult.
- Previous surgery, such as existing trabeculectomy surgery or pars plana vitrectomy (PPVx)
- Predisposition to exposure, eg: botox treatment with lid paralysis, previous lid trauma, and diabetes.
- Patient is taking anticoagulants, e.g., coumadin, aspirin, or Plavix.
Table: Factors Affecting Difficulty
[CLICK ON TABLE TO EXPAND]