Discussing lOLs with Patients
A step-by-step process for dealing with those who may require cataract surgery.
Justin Holt, O.D.
With the aging population and the innovations in both cataract surgery and the variety of intraocular lens (IOL) implants available, discussions with patients about cataracts have not only become more frequent, but also a bit more involved. Further, both the patient's confidence in you as their primary eye care provider as well as their perceived success of the surgery hinge on these discussions. Do a good job, and that patient is sure to return to you.
Here, I take you through how to discuss IOLs with patients, from the initial talk of surgery to the support you should give following the procedure.
Ease the patient's mind.
When patients are informed they have cataracts and are to the point of discussing surgical options, oftentimes all they need to hear are the words “cataract” or “surgery” and their mind starts reeling. I've found it's reassuring to the patient to take a proverbial “step back” and ask him/her whether they understand what cataracts are.
When I discuss that the patient does in fact have a cataract, even if it is not to the point of needing surgery, I explain that there are not only a variety of types of cataracts, but that they are a normal part of life and could be in the cards for every-one. I feel it is important to stress that cataracts are very common, that they can occur at any age, that some babies are even born with them and are not the result of anything they have ever done or not done (such as not wearing sunglasses more often). I've found that explaining the anatomy of a cataract will also explain many of their symptoms and will help them understand why they are noticing more glare at night or their need for more light to read than previously.
The very last thing you ever want to do is make a patient feel they are being pressured in to having a surgical procedure. To give the patient an idea of the time involved in performing the surgery, I tell them that most cataract surgeries are over in less than 10 minutes and that it will probably be completed before they even realize it has begun. I also explain that typically the eye with the denser cataract is done first, as surgeons will almost never do both eyes at the same time.
Then, I let the patient know that the second eye is typically done two weeks later. It's important that the patient knows this upfront so there are no surprises.
Explain that cataracts don't necessarily require surgery.
Once the discussion of what cataracts actually are has taken place, I move on to discuss what to do about them. If the cataract is very mild or not causing any visual symptoms, I tell the patient that this is nothing they need to lose sleep over. I explain that cataracts do get worse, and this can happen very slowly or rather quickly, so I will monitor that with them annually, or sooner if needed.
Should the cataracts impair vision to the point that surgery would improve their visual quality, I discuss surgical options and IOLs. Again, many patients are weary of anything that involves the word “surgery.” I clearly explain to patients that their vision can no longer be improved because of the cataract, but that they do not need to have the surgery done.
Explain the different types of IOLs.
In each exam room I have a variety of ways to illustrate to patients what cataracts are, how implants are placed into the eye, and the different types of IOLs. These are useful as aids when discussing all kinds of different ocular conditions and surgeries as well. I use everything from small children's board-books to digital videos. Having an iPad in each room has been particularly useful. I can hand it to the patient and have him/her move the image, enlarge the image, play digital animations of the surgery or play a video of an actual surgery. I find that educating patients in this way eases their minds about the surgery.
Once I describe what a cataract is and the surgery to correct it, I always tell the patient that there are a variety of IOL choices. One option is to have both eyes corrected for distance. If this is the route they choose, you need to be very clear to the patient that he/she will need over-the-counter reading glasses. This can sometimes be a difficult concept for patients who have been nearsighted their entire life and have always been able to read without having to rely on glasses. If the patient is unaware of the fact that he/she will need glasses to read after the surgery, this can make an otherwise perfect outcome a tragedy in the patient's mind — something that could result in you losing the patient.
Monovision is another option for patients not wanting to incur much additional out-of-pocket expense, yet be able see both near and far without having to rely on glasses.
I briefly explain to patients who have a great deal of astigmatism both what astigmatism is as well as the fact that there are IOLs specifically designed to correct for this. If through our discussions, the patient asks about premium lenses, or “those new bifocal implants that my neighbor just got,” I briefly and very generally explain the pros and cons of premium lenses as well as the fact that there is an additional out-of-pocket cost to the patient beyond what their insurance will pay. (See “financial Discussions,” below.)
Emphasize your confidence in the surgeon.
I tell patients that, should a family member or I need eye surgery, this surgeon is the one that I would ask to do it (which is in fact true). This instills confidence in you and the surgeon as the team of doctors best suited to correct his/her eyes.
|I make it a point not to discuss actual dollar amount or specific lens brands/designs. I do this for two reasons. First, I do not want to keep up with the host of charges that the co-managing surgeon is charging for all the different types of IOLs, nor if there are or are not additional fees for limbal relaxing incisions (LRIs), and if fees are paid to the surgeon alone, or if the patient needs to pay a portion to the surgical center and another portion to the surgeon. This can be quite a hassle.|
Another reason is that different surgeons have better outcomes with different IOLs. Just because of their particular style of surgery, the way they like to make the rhexis, or the way they like to place the primary incision, or even the way they perform LRIs. Two surgeons could perform the exact same surgery on the same eye with the same lens and have two very different outcomes. For that reason, I leave the decision of which premium IOL to choose for the patient up to the surgeon. I only mention that there are several on the market, and that the surgeon will explain why a particular one would be best suited to that patient's eye for the best outcome.
Define the patient's post-surgery expectations.
This is probably the most crucial of the entire exam, as this is how the patient will be able to judge whether the surgery has been a success. I often tell patients that it is very likely that they will come out of the surgery, once everything is healed and the swelling is gone, able to see very close to 20/20 and only needing over-the-counter reading glasses. I tell patients that cataract surgery is not as precise as LASIK for example, and that they may still need a small correction for their distance vision, though it likely will not be much. Of course, if there is the presence of other ocular disease, their visual outcome may still be compromised, and this needs to be discussed with the patient beforehand.
|Below is a complete list of the possible complications that can arise from cataract surgery:|
• Acute macular degeneration
• Blurry vision
• Choroidal hemorrhage
• Complications associated with chosen IOL
• Corneal abrasion
• Corneal edema
• Dilated or irregular pupil
• Haloes and glare
• Implantation of an incorrect power IOL resulting in the need for glasses or an IOL exchange
• Inability to implant IOL
• Loss of the eye
• Macular edema
• Retinal detachment
• Retinal hemorrhage
• Small correction via spectacles, LASIK or enhancing LRI
I also explain that, should he/she choose to, the patient may still get glasses to wear all the time, despite only needing them for reading. Some patients have relied on glasses their entire lives and would feel uncomfortable without them, while others like the cosmetics of wearing glasses. I've had some patients tell me they don't want to give up their wearing glasses because it hides the bags under their eyes. If the patient elects to have a premium IOL, I discuss that he/she will undergo a neuroadaptive period that typically lasts approximately three months, but that it can vary with the individual patient.
Also, I tell the patient that, despite the fact that cataracts never return, about 40% of patients who undergo cataract surgery need to have a subsequent laser procedure performed, a YAG capsulotomy. Since I have already explained how the initial surgery is done, and the IOL is placed within the capsule and then contracts around the IOL, it is typically very easy for patients to visualize and understand how and why that may be necessary. Also you need to define all the other inherent risks of the surgery as well (See “Possible Complications,” left).
Refer back to the pre-surgery discussion.
Once the operation has been completed, I review with the patient the incision that was made and how it is held closed by the swelling around the incision and not by stitches. I tell patients that, because of the swelling, they will notice glare coming from that side of their eye.
I also remind them of the discussion we had about the IOL being placed within the capsule. I specifically tell them that because the IOL is much thinner than their natural lens, they may see what appear to be shimmering lights until the capsule contracts down around the IOL, holding it tightly in place.
See it through your patient's eyes.
Keep in mind that discussing this surgery to patients is “just another day at the office” to us, but to our patients, this is the only time they'll be having this discussion and possibly this surgery, and for some, it can be very emotional.
The more information you give the patient, the better chance of a positive outcome for both the patient and you. Guiding your patients through a potentially confusing process will strengthen their trust in you. OM
|Dr. Holt is in private practice at West Point Eye Center, in West Point, Utah. He graduated from the IAUPR then completed a residency at the University of Utah and VA Medical Center. He then worked for more than seven years at Mount Ogden Eye Center. He can be reached at firstname.lastname@example.org.|