1st April 2011
Cataract Patients and New Expectations
Are cataract patients’ expectations increasing? At PCLI, we have certainly seen a shift in the last 5 years. And it makes sense. Today’s cataract population has seen dramatic increases in technology. They are familiar with laser vision correction and many have undergone this treatment. As demanding baby boomers begin to suffer lens opacification, expectations will likely continue to rise.
Heightened expectations create an opportunity for optometry. Primary care ODs can maintain a competitive edge by participating in the cataract surgery process. I see it happening among my private practice colleagues. Doctors who are thriving most are active in:
- Offering thorough education
- Assisting with IOL recommendations
- Referring to the most suitable surgery provider
- Providing post-op care
By perfecting this relationship, family eye doctors increase patient trust, build loyalty and instill confidence in the care they provide. Practices prosper when heightened expectations are met and exceeded.
Education is the key to success. Today’s patients need to know what cataracts are, when it is appropriate to proceed with surgery and what to expect before and after. Early counseling avoids surprises and establishes your role as the expert. And when their vision does begin to diminish, patients will not be fearful. Instead, they will seek your advice.
Many cataract surgery patients expect less spectacle dependence and you have the opportunity to recommend IOL options that can make a big impact on their decision. Unfortunately, most optometrists defer this to surgery providers.
However, we see less anxiety and higher levels of confidence in patients educated by their family optometric physicians. Thorough education regarding IOL options and their risks and benefits is an excellent step to fostering patient trust and long lasting relationships.
Prior to cataract surgery, your patients will also benefit from the following conditions being discussed and managed:
- Blepharitis/hordeola – Treat moderate to severe cases to reduce risk of endophthalmitis.
- Dry eye – Should be treated since surgery can make it worse. Aside from questioning patients about typical symptoms, you might specifically ask if decreased vision is constant, fluctuates throughout the day or from day to day, changes with every blink, or worsens with reading. If so, set right expectations by letting them know dry eye symptoms will persist after cataract surgery.
- Corneal stability – Corneal molding is common with rigid gas permeable lenses and possible with soft contact lenses (i.e. toric and high powered SCLs). All contact lenses (hard or soft) should be out at least 1 week or until keratometry readings are repeatable. Advise patients that everything has been done to obtain the most accurate measurements, but even then their corneas can continue to change.
- Pterygium, Salzmann’s Nodules – If these conditions induce significant astigmatism, they should be removed prior to cataract surgery. Otherwise, irregular astigmatism would increase the chance of refractive surprise, hinder subjective vision improvement, and likely result in a challenging spectacle Rx. Although surgical removal requires 4 to 6 weeks healing, patients will be much more pleased with their cataract surgery outcome.
- Corneal Guttata – Moderate cases increase risk of post-op corneal edema. Vision will likely be foggy the day after surgery but will typically improve within a week or two. Advance awareness of this delay will help establish right expectations. Patients with severe cases should know that corneal edema may not resolve and could require corneal transplantation.
- Flomax – Alpha-blockers prescribed to treat benign prostatic hyperplasia are associated with intraoperative floppy iris syndrome (IFIS). Frequency and severity is more with Flomax (tamsulosin) than other alpha-blockers. IFIS can manifest as poor pre-op pupil dilation, iris billowing or floppiness, iris prolapse to the incision, and progressive miosis that may require small-pupil management during cataract surgery. Patients should know about this risk, but the complication rate from cataract surgery is low. Reassure them that you will inform the surgeon, but there is no need to discontinue the medication since IFIS can occur with current or previous use.
- Pseudoexfoliation, Traumatic Cataract, Phacodonesis – Patients should understand the risks associated with zonular compromise. Our surgeons may use a capsular tension ring (CTR) during cataract surgery to distribute forces over the entire capsule. If the capsule is unstable, the IOL may be placed in the sulcus, anterior chamber, or be sutured to the posterior side of the iris. If there is poor pupil dilation, iris retractors or additional viscoelastic can be used.
- Retinal stability – Diabetic retinopathy, macular degeneration and glaucoma are the most common retinal conditions that need to be stable prior to cataract surgery. Before surgery, newly diagnosed wet AMD, non-proliferative diabetic retinopathy with CSME and proliferative diabetic retinopathy should be evaluated and deemed stable by a retina specialist. Once a green light for surgery has been given, pre and post-op use of a topical NSAID can help prevent post-op macular edema. We recommend that glaucoma suspects have a baseline VF and glaucoma work-up prior to surgery, even though significant cataracts can lead to unreliable results. These patients should also know that post-op IOPs can cause further glaucomatous damage.
- IOL options – Patients need input and advice with IOL options. Although it is good to quickly review all the choices, I suggest beginning with a question: How motivated are you to decrease your dependence on glasses?
A few points may be helpful:
- Torics – Good candidates have 1.00 – 2.25 D of corneal (not refractive) astigmatism. To find consistency, measure corneal astigmatism by several methods.
- Multifocals – Good candidates must be willing to accept a slight decrease in sharpness of vision and should be prepared for possible use of glasses for one specific activity such as reading for long periods or night driving. Slight halos around lights require adaptation over several weeks or months. Patients usually do best when multifocals are used in both eyes. If indicated, residual correction can be treated free of charge with laser vision correction.
We see a steady shift in cataract patients’ desire for information. Their expectations for knowledge about surgery, options, and implications are on the rise. By catering to these needs, family optometric physicians can strengthen relationships, trust and loyalty. If you choose to be involved, I believe your practice will grow.