By Mark Everett, OD   |  PCLI—Spokane, WA

Ami Halvorson, OD

 

PCLI—Portland, OR

From the EDITOR   Continual advances in the technology and outcomes of cataract surgery have naturally led to high expectations—sometimes beyond what is possible. In this issue, my colleague Mark Everett (recently awarded OD of the year in Washington) provides several tips that he has learned to help patients define success and have realistic expectations.

Much has changed in the 30+ years  I have worked in cataract comanagement. In the early 90s, there were only monofocal IOLs, the most predominant being non-foldable polymethyl methacrylate (PMMA).  Refractive targets were easy—plano OU, near OU, or monovision of some sort.

As time marches on, our shared clinical lives have become increasingly complex. With the advent of acrylic lenses, premium presbyopia-correcting IOLs, MIGS, and other ophthalmic technology, our communication with patients takes longer and is more complicated. The remarkable progression and successful outcomes have given patients and doctors high expectations. However, for some, they cannot be met.

ADJUSTING GOALS

As I navigate patients through choices, it often involves helping them adjust goals so that, in the end, high satisfaction is achieved. I’ve experienced this in my own life. Let me explain.

At age 40, I had a midlife crisis. In addition to being an eye doc, I wanted to be a cowboy. I listened to traditional cowboy music and wanted horses. The problem was my pasture wasn’t suitable for horses. A patient convinced me to rehabilitate it naturally with Scottish Highland cows. So I called a man for one steer but somehow got two young heifers instead. We ended up with a small cow/calf operation and sold beef. What was supposed to be horses turned into cows!

I didn’t know what I didn’t know. However, I had guides along the way who helped me navigate realistic expectations and definitions for success. For a decade, raising cows was a fantastic time for our family.

GUIDING PATIENTS

I’m sure you have had patients coming in wanting one thing and ending up with something else. But with your guidance, they left with great satisfaction—maybe even better than expected. In this era of ever-increasing expectations, some cataract patients may benefit from that expertise.

TRAIL TIPS

The keys to guiding cataract patients’ decisions are good communication and our ability to help them define success. Here are several trail tips I have learned along the way.

• 20/20 patients usually don’t qualify — It’s not unusual to see patients referred for cataract surgery with BCSVA of 20/20. Unless they have a significant refractive error, the wow factor of surgery would undoubtedly be reduced. But to qualify for surgery, their visual complaints must be consistent with cataracts, and we need to believe surgery will alleviate their complaints.

•  Dry eye can fool you — We are seeing an increasing number of patients referred for cataract surgery with good acuity and complaints consistent with dry eye. Now, there are 20/20 patients with such significant cataracts that you wonder how they see as well as they do. In these cases, surgery is usually effective and appropriate. But be watchful for dry eye as no one likes to hear a patient say they see worse after surgery than before.

• Cataract surgery can worsen dry eye — Unfortunately, many cataract patients have undiagnosed dry eye, and surgery often temporarily worsens their condition—sometimes up to a year. Although surgery may achieve 20/20 vision, new or worsening dry eye symptoms can dampen patient satisfaction.

• 20/20 can’t be promised — Some mild spectacle correction is often required after cataract surgery, so managing expectations is critical. This is especially important with patients who have had laser vision correction and expect to regain 20/20 vision with IOLs. I often explain that “Cataract surgery is performed to remove your cloudy lens, so normal modes of correction will work well again. It isn’t done so you can see 20/20 without glasses. Although 20/20 is often achieved, it can’t be promised.”

• If it ain’t broke, don’t fix it — Patients often say they’ve been told they have cataracts, so they want them removed. When asked if they are having difficulties, they sometimes say, “No, but I want them removed because they’ll just get worse.” Then, I explain that insurance does not pay for cataract surgery without patient complaints. “So if it ain’t broke, don’t fix it.”

• Near-vision loss can be shocking — Myopic patients often think that standard monofocal lens implants will improve their distance VA while maintaining near vision. I use a Jaeger card with their distance correction to show they will have no near-vision, and even the largest print will not be seen without reading glasses. This is a shocker for some. If patients want some near vision, I clarify their preferences for near or intermediate vision and their willingness to accept possible glare and halos with premium presbyopia-correcting IOLs.

• Put premium IOLs in perspective — When patients are willing to pay extra for premium lens implants, managing expectations and defining success is critical. I use the Jaeger card again to show that presbyopia-correcting IOLs will provide some functional near vision, but patients are unlikely to see J1, 2, or 3. In my experience, patients will often be disappointed with premium IOLs unless they understand in advance that they probably will not see the smallest three paragraphs. Some do, and it’s great when we exceed expectations.

CONCLUSION

If we fail to define success, our cataract surgery patients will do it for us, which may be unrealistic. But when patients, referring doctors, and comanagement center providers are all on the same page, success rates are high. Educated consumers are our best customers, and happy patients tell their friends.