Surgery

Lifestyle considerations for cataract surgery

Failing to account for the patient’s goals leads to dissatisfaction.

BY MARK PACKER, MD, FACS, CPI

To optimize satisfaction for refractive cataract surgery patients, the surgeon must help patients to make intelligent choices based on their own personal visual goals. By keeping abreast of developments in the field and being “on the same page” as their surgeons, technicians, office managers, nurses and other staff can help provide a consistent message to patients and enhance both the professionalism and reputation of their practice.

Without a comprehensive approach to refractive IOL counseling, patients may not adopt this technology or may be unhappy with it. (See Pre-surgery overview, page 37.)

Know the goal

Understanding the patient’s goal is the key to achieving success. For example, I encouraged a 45-year-old, extremely nearsighted woman to have Crystalens implants, which tend to perform well for nearsighted patients. When I measured her vision, however, it appeared that she would still require over-the-counter reading glasses for some small print. While not uncommon with Crystalens, it is not ideal either.

I told her, “your distance- and intermediate-range vision are great, but it looks like you’ll need some readers for up close.” My tone must have suggested compromise and defeat, because she said, “Dr. Packer, don’t feel bad. I’m incredibly happy.”

I did not know that she chose to address her eyes due to a planned trip to sea kayak with Orca whales on Puget Sound — she was afraid of losing her contact lenses at sea. Near vision without glasses was not a concern. I was relieved, but I forgot to ask her about her goals, a mistake I’d never make again.

In general, lifestyle questions revolve around two of the major categories of human life: work and recreation. Questionnaires distributed to patients by front desk personnel can help start the patient’s thought process about visual goals. However, a few direct questions and answers can rapidly get to the heart of the matter.

First, ask, “Would you like to reduce or eliminate your need for eyeglasses after surgery?” If the answer is yes, ask, “Would it bother you to see halos around lights at night?” Getting to an answer may require a bit more description and discussion of the optical side effects of multifocal IOLs, but if you allow the patient time and space to express concerns, it will become clear whether or not a multifocal IOL will be tolerable.

Next, address those activities for which freedom from glasses would be most desirable. First ask about the type of work (such as office or physical labor) and whether the patient focuses on paper or a computer screen.

Next, determine their favorite activities. Also, find out what range of distances would the patient most like to be able to see without glasses. The answers to these questions will help inform a decision about the add power of the multifocal IOL, the refractive target for an accommodative lens or the range of monovision.

Know your IOLs

Even when you know patients’ goals, you need to be familiar with the available technology to satisfy patient expectations. Glean reasonable expectations for outcomes from the U.S. FDA Summary of Safety and Effectiveness Data for each particular IOL. Also, take care in applying these data outside of the confines of a controlled clinical investigation, since patients considering surgery may or may not fit the inclusion and exclusion criteria employed in the trial.

For example, in the Tecnis Multifocal (Abbott Medical Optics) clinical trial, 257 of 292 (88.0%) subjects at four to six months postoperatively stated that they were completely spectacle independent, that they “never wore glasses.”¹ Potential subjects with greater than 1.00 D of preoperative keratometric astigmatism were excluded from the trial, and keratorefractive correction of astigmatism was not permitted during the trial. Therefore, one can surmise that, to achieve similar rates of spectacle independence to those demonstrated by the FDA reported data, one must either restrict patients to a maximum of 1.00 D of corneal cylinder or perform ancillary procedures to reduce preexisting corneal cylinder to that level.

Also, provide a complete picture for patients considering surgery. Keep records of your patients’ outcomes, including enhancement rates. Then, you can provide your personal experience to inform patients preoperatively of the chance they would need a second procedure to achieve spectacle independence.

Provide a strong recommendation

Refractive cataract surgery is a complex field for patients to understand. For that reason, it is critical to provide recommendations based on best clinical judgment and the patients’ visual goals.

Several years ago, I worked as both principal investigator and medical monitor for a particular multifocal lens trial. One day, a woman from another state visited me and expressed interest in participating in the study. She had far advanced cataracts, even meeting the criteria for legal blindness.

As we talked, I learned that she already visited a number of surgeons as she moved through the various IOL options. Unfortunately, these consultations only served to increase her confusion about the available lenses while her cataracts continued to deteriorate her vision. After reviewing the various lens options with her, and letting her know that I understood that the most important result to her was spectacle independence, I looked her in the eye and told her, “I honestly believe you will be best served by enrolling in this study.” When she agreed, I said, “You won’t be sorry,” and shook her hand.

By developing rapport, gaining her trust, then providing a strong recommendation, I gained the opportunity to perform her surgery and reach a happy outcome.

Remember the big picture

No IOL —and no procedure — is perfect. Every available option has inherent trade-offs. The best strategy is to know your patient, know the options, communicate reasonable expectations and move forward.

Also, remember that refractive cataract surgery can be part of a patient’s journey toward becoming a new person. Keep an eye on the big picture to help patients to achieve the highest levels of satisfaction and success. OP

REFERENCE:

Mark Packer, MD, FACS, CPI, is clinical associate professor of Ophthalmology at Oregon Health & Science University in Portland, OR. Disclosure: Dr. Packer is a consultant to Advanced Vision Science, Alcon, Bausch + Lomb, iOptics, Lensar, Rayner Intraocular Lenses, and STAAR Surgical.