Avoiding disasters in oculofacial surgery

Jeremiah Tao, MD, FACS, is a clinical professor of ophthalmology and the chief of oculofacial plastic and orbital surgery at the University of California, Irvine Gavin Herbert Eye Institute.

In 2025, Tao presented a keynote lecture titled "Avoiding Disasters in Oculofacial Surgery" at the International Congress of the Egyptian Ophthalmological Society (EOS) in Egypt. During this presentation, he discussed 4 major safety topics: preventing surgical fires caused by oxygen supplementation during procedures, using fentanyl to suppress dangerous sneezing reflexes during surgery, avoiding vascular complications from facial filler injections that can cause vision loss, and managing hemorrhagic complications through better techniques and medications such as tranexamic acid. He emphasized the importance of maintaining focus on fundamental surgical principles and cost-effective treatments rather than relying solely on expensive new technologies, advocating for efficient, safe, and inexpensive approaches to patient care.

Note: The following conversation has been lightly edited for clarity.

Ophthalmology Times: You presented at the EOS meeting in Egypt earlier this year. Can you summarize what you discussed in your keynote lecture?

Jeremiah Tao, MD, FACS: I was honored to be invited to be one of their keynote speakers at their congress. First time there, and it was quite an impressive meeting. I think they're considered some of the...leaders in that region in terms of advancement in ophthalmology and the science. My keynote lecture was just on avoiding disasters and...horrific complications in surgery. [I] covered several different topics.

The first was having to do with surgical fires, [which are] really surprisingly common in oculoplastic surgery, mainly because we very commonly operate with patients awake but sedated, and they receive oxygen supplementation, and so the oxygen [is] blowing onto the surgical field just adjacent to the nostrils. It gets into the surgical field, it causes the skin and the drapes and everything you know in your surgical field to become flammable when [they] normally [don't] ignite, and we use electric-cautery lasers and other heat devices. So it's really a setup for this horrific complication, and I think it's really important, because it's not talked about enough. It's considered a "never event" in the legal world.

So I think these [things] happen, and then there's sort of a little bit of hush, you know; there's an embarrassment about it. But at a recent American conference, I was talking about this topic, and I just polled the audience, and about a third of the room raised their hand when I asked [if they] had experienced a surgical fire. So it's quite relevant to people working on the face. Importantly, not only [do] people have injuries due to the burns, like scars and things like that, there actually are deaths associated with this. So a couple of people die each year in the United States, and the reported cases are something like 600 or 700, but if a third of the room has experienced 1 [case], it's probably way more common, and there's probably a lot of near misses. So with that topic, we have some strategies to basically decouple the oxygen, turn it off, namely. We also use drapes and...there [are] other concepts of how to shunt the oxygen away from the surgical field. So that was the first topic.

Another is an oldie, but a goodie. I wrote a paper years ago on the discovery of an anesthesiologist I worked with [who] seemed to be able to suppress sneezing. Sneezing and surgery are 2 events that are intuitively not compatible, and when you have needles and sharp objects around the eye, you don't want the patients to sneeze. And that's another thing that's relatively common. About 1 in 5 patients sneeze when they're on propofol, which is the hypnotic sedative that we give...right at the beginning of surgery, right before we inject, and that sedative seems to unleash the sneeze reflex. I know there's an opioid crisis, and we...all associate fentanyl with...horrific addictions and deaths and things like that. But in this context, a little bit of fentanyl before the propofol suppresses the sneeze reflex, and it can make the safety of injecting or doing things around the eyes improve, because the patient's head is still. It's always just a simple one.

Another topic that we covered was fillers. There's an ever-increasing aesthetics industry, and each year,...for the past 10 to 15 years, more people are getting facial injectables...and especially around the eyes. I presented a couple of cases where the injection got into the vasculature and then stroked out the eye. Unfortunately, there's really not much that can be done after it happens. The game's probably over, but I went over the topics. People have been discussing rescue therapies, including flooding the orbit and eye area with an enzyme to dissolve the filter. There's no proof that that works. That was essentially the take-home message.

The other take-home message with that topic was...avoidance. I think there are certain anatomical areas on the face that are more susceptible to this type of injury than others, and then [there is] technique. Things to consider are...a low-pressure technique and a low-volume technique. These are sort of intuitive. These are horrific, horrific events: patients [who are] totally healthy, going in for aesthetic procedures, [and] coming out with vision loss.

Then the last main topic is...every surgeon's nightmare: hemorrhagic complications, bleeding or bruising, or a compartment syndrome, where the pressure builds up so tightly that you have neurologic injury around the eye. We certainly have a concern for an orbit compartment syndrome, and we covered [how] the general consensus is to have patients take a holiday off anticoagulant medications.

But there are other things we can do to mitigate these bleeding risks, including better surgical technique or meticulous cautery when we're doing surgery. There [are] also other technologies that can help us. There are hemostatic agents [and] methyl cellulose sponges. There [are] gelatin sponges and other pharmacotherapies that we can combine with these devices. One really interesting one is tranexamic acid. This is an old medication that has been given very commonly in other big surgeries to reduce blood loss. We're kind of late to the party in oculoplastic surgery; I think [it's] only in the last 3, 4, or 5 years [that] people have discovered that it really seems to have a positive effect on reducing bruising. There's a lot of emerging evidence and good-quality studies that show that bruising is improved when you use this medication, either given as an IV [intravenously] or sometimes we just give it into the local injection.

It's essentially a very old medication that's been proved to be very safe, and it's very inexpensive. So when you have this triple threat of effective, safe, and inexpensive, it's something everybody should consider, because we do have a lot of medications that don't hit on all 3 of those, and...probably very few medications actually hit on all that. It's interesting to me that 20 years into practice, I was also a newcomer, a newbie, to discovering the benefits of tranexamic acid, and I think it's catching on. I think people around the world are increasingly using it. When I surveyed the audience in Egypt, I think that was a new concept for them. Actually, almost nobody, maybe 1 person in the room of... 100, raised their hand when I asked if people were starting to use this. But actually here, it's probably approaching over 50% to 70% of oculoplastic surgeons [who] are incorporating tranexamic acid in one format or the other, whether it's given IV or you can even give it topically during surgery, or, as I mentioned, inject it in the local. So that was my main talk.

OT: You spoke about mitigation and some pharmacological options. Is there anything you hope research will focus on as we continue to look for ways to make these procedures safer for patients?

Tao: I mean, like I said, we want things that are effective, safe, and inexpensive. I think...there is a trend where we're going to greater complexity, greater cost. That ties into the other topic. I recently [had] a book published that's entitled Efficient Oculofacial Surgery, which really boils things down to treating problems in...an effective, safe, and direct manner. The whole theme of the book is [to] essentially fix any problem within the scope of the field with just minimal instrumentation, minimal pharmacotherapies, minimal cost, [and] minimal complexity. I think that's the general theme of this talk, and we certainly want to avoid all these horrific...never events. Those are, you lose sleep and lose hairs on your head when these things occur, but they're surprisingly more common than people realize. Another sort of take-home message is the Hippocratic oath: you never want to do any harm. Sometimes we are in harm's way when we're in surgery; we have sharp objects near the eye and energy devices. A lot of things can go sideways very quickly, so I think it's just back to the basics and...good fundamentals.

OT: What do you think the value of discussing some of these basics and fundamentals is, as you spoke in Egypt? As we look at meetings around the world, sharing these topics across borders and cultures, what's the value in that?

Tao: I think there's a definite trend. At these meetings, everybody is excited about technologies. AI [artificial intelligence] is in every meeting across all spectrums of society, really. These technologies are exciting, but when we are trying to train the next generation of surgeons, [we must] continue [to have] a high level of quality. The populations are increasing everywhere. In Egypt, just like here, they were telling me that there's a doctor shortage, and there's an ever-burgeoning, booming population growth. We need treatments that are efficient,...safe, and inexpensive. If you pour hundreds and thousands and tens of thousands of dollars into pharmacotherapies that are not that effective, we're really going to bankrupt our entire system. So...these are old concepts, but I think they're just getting a little bit lost in the meetings.

I think a young attendee or a new doctor to these meetings may think that they are behind the times or need to purchase equipment; stereotactic navigation equipment is...the best example in oculoplastic surgery. These are technologies that are interesting, and they may be useful in the training context, but I think we are rearing surgeons who are dependent on these technologies, as opposed to good surgical principles, which include good technique but also understanding direct intraoperative surgical landmarks. I think without these types of skills and knowledge, our health care system may be doomed, and sometimes new isn't necessarily better. These technologies don't add meaningful value in terms of outcomes, in terms of what the patient receives. So that's important to keep that context. Like I said, these meetings are dominated by new technologies and the latest and greatest, and they sometimes don't correspond to safe, effective, and inexpensive.

OT: As we look toward the future of ophthalmology and oculoplastics, where do you hope the field is headed?

Tao: I hope we maintain emphasis on...humanistic aspects. You meet another person on the other side of the examination; the slit lamp, I think, is something that might be lost. AI is certainly going to overtake a lot of the things we do, a lot of the diagnostic things. I can't imagine that anybody would believe that a human's database––the most experienced ophthalmologist, let's say, has 60 years of seeing eyes––[can compare with] a computer that has the whole world history of any imaging of an eye. So to rely on the human to make some of these decisions, it's impossible to believe that we're going to continue doing this because of the diagnostic error. With surgery, I think these technologies will add value in certain ways over time, but at the end of the day, a lot of these surgeries are still reliant upon good technique, processing, and ultimately, human interaction that AI [does] not [have]; it's further down the line. I think we need to ensure we apply these new technologies where [they add] value and then be careful not to over-embrace them, where they may compromise our ability to deliver a quality, effective medicine.