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.
• Monocular

Table: Factors Affecting Difficulty

[CLICK ON TABLE TO EXPAND]

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