Article Date: 2/1/2009

Keep Your Cataract Patients
co-management

Keep Your Cataract Patients

Follow these two tips to ensure your cataract patients remain in your care.

JUSTIN C. HOLT, O.D., Ogden, Utah

In the summer of 2007, About.com ran an article titled "Top 10 Reasons to Fire Your Doctor." Some of the reasons: "Lack of Confidence in Doctor's Ability;" "Questions Are Not Welcome;" "Doctor is Not Forthcoming;" and "Doctor is Cold and Unsympathetic." Because we, as optometrists, don't perform cataract surgery, we're at an even greater risk than other healthcare professionals of losing patients to other practitioners.

Given the About.com article and the power struggle that can erupt between O.D.s and M.D.s regarding the care of surgical patients, here are two tips that will give you an excellent chance of retaining your cataract patients.

1. Provide patient education

Although we encounter cataracts several times a day and realize that most are a normal symptom of advancing age that can be easily remedied via intraocular lens (IOL) implantation, we must remember that many of our patients who receive this diagnosis aren't aware of these facts. In fact, in the minds' of some newly diagnosed cataract patients, you might as well tell them they have cancer. As a result, it's essential you make the time to educate them regarding their diagnosis. Doing so not only instills their confidence in you as their eyecare practitioner but also meets their need for information and sympathy regarding their diagnosis.

Here are the five points you should cover:

Define cataract. Consider using a model eye as well as a patient-friendly (basic) ocular anatomy book to explain the cataract diagnosis and the specific clinical signs and symptoms associated with it. I've found that when the patient can actually see what I'm talking about, it facilitates his understanding of the diagnosis. Educate the patient that cataract development is a normal part of the aging process. This statement works to allay his fears regarding the diagnosis.

Inform the patient of the severity his cataract(s), again, by using visual aids, so he'll understand why you recommend a specific course of action. For example, if the cataract doesn't yet require surgery (as in cases of a slightly yellowed lens), explain why, and provide the patient with your best estimation of when you believe surgery will be necessary. Do the same if the cataract is at the point of requiring surgical intervention. For example, if the cataract is dense or brunescent, advise the patient that scheduling removal soon (i.e. no later than three months) is in his best interest to avoid surgical complication.

Regardless of the severity of the cataract, explain that it isn't going to go away and why, specifically, a new spectacle or contact lens prescription isn't going to offer much of an improvement in vision. Now, invite the patient to ask questions.

Clarify cataract surgery. The word "surgery" prompts anxiety in most people. You can put the cataract patient at ease the same way any practitioner would put a patient in need of surgery at ease — by educating him about what, specifically, is involved in the procedure. Do this by, again, referring to your model eye and patient-friendly anatomy book.

Inform the patient that an ophthalmic surgeon will make a small incision in his eye — usually about 3mm. Explain that he/she will insert a probe that removes the cataract and then implants an artificial lens, known as an intraocular lens (IOL), so the patient retains vision. Tell the patient you'll educate him on his IOL options once you've explained the operation.

If the patient is in good health and has bilateral cataracts, explain that the surgeon will perform the procedure on the eye that has the most visually significant cataract first for two reasons: (1) to ensure one eye maintains functional vision while the other heals. (2) So the surgeon can take measures to minimize the likelihood of complications in the second eye, should complications arise during the first procedure.

Educate the patient that the surgeon typically schedules surgery on the fellow eye one to two weeks later. If, however, the bilateral cataract patient is in poor health, tell him that the surgeon may decide to operate on both eyes at once.

Inform the patient that once the surgeon removes the cataract, it will never return, and that the surgery usually lasts less than 10 minutes. Further, educate him that due to the small incision, stitches typically aren't needed. Something else to consider: Because some of my past cataract patients have told me that having a cavity filled is more traumatic than cataract surgery, I tell my pre-cataract surgery patients this, as it sometimes helps to further relieve their anxiety regarding the operation.

(If you typically refer your cataract patients to one surgeon, ask whether you can observe him/her during surgery. Doing so gives you a great deal of information to draw on when patients need explanations of what to expect on the day of surgery.)

Now, ask the patient whether he has any questions.

Discuss IOL options. Explain that you're going to use your detailed knowledge of the patient's visual acuity and corneal health, matched with his lifestyle needs to ascertain which option is best and then which brand of IOL option is best. Educate the patient that knowing the status of his visual acuity and corneal health also enables you to decide whether refractive surgery (i.e. limbal relaxing incision [LRI] or LASIK) may be warranted to strengthen his vision post-implantation. (See "IOL Options," below.)

IOL Options
Aspheric IOLS:
  • AcrySof IQ (Alcon)
  • Affinity Collamer Aspheric (Staar Surgical Co.)
  • Akreos (Bausch & Lomb)
  • Elastimide Silicone Aspheric (Staar Surgical Co.)
  • SofPort AOV (Bausch & Lomb)
  • Tecnis (Advanced Medical Optics)
Presbyopia-Correcting IOLS:
  • AcrySof IQ ReSTOR +4.0D (Alcon)
  • AcrySof IQ ReSTOR +3.0D (Alcon)
  • Crystalens HD (Bausch & Lomb)
  • ReZoom (Advanced Medical Optics)
  • Tecnis Multifocal (Advanced Medical Optics)
Toric IOLS:
  • AcrySof Toric (Alcon)
  • Staar Toric (Staar Surgical Co.)

Once you and the patient decide which option will best meet his vision and lifestyle needs, inform him of both the pros and cons of the different brands within the selected option, so he doesn't experience any unexpected outcomes post-implantation. Remember: A prepared patient is a satisfied patient. An unprepared, or surprised, patient is dissatisfied, and this dissatisfaction may prompt him to seek care else-where or possibly legal counsel.

Now, invite the patient to ask questions.

Disclose surgery/IOL risks. Obviously, reviewing every one of the possible cataract surgery complications isn't possible. Therefore, explain the most common outcomes: unstable vision due to inflammation; feelings of pain or scratchiness resulting from superficial dryness or a small abrasion; the need for an additional small correction via spectacles, LASIK or LRI; initial halos and glare; and capsulotomy. (I tell patients that based on my experience and the experience of my partners, there's a 30% to 40% chance that the back of the implant may develop a "film" that takes roughly a minute to fix, doesn't require an operating room and doesn't return once it's "cleaned off.")

Explain your co-management role. Once the patient decides to proceed with the surgery, inform him you'll establish communication with the most appropriate surgeon regarding your indepth knowledge of the patient's ocular health and visual and comfort needs. Define "appropriate" as one who has a proven record in cataract removal and implanting the specific type of IOL.

Explain that you'll request the surgeon return the patient to you for postoperative care, as you, and not the surgeon, are fully versed in the patient's medical and ocular history — placing you in the best position to manage both the outcomes discussed and those outlined in the informed consent document you'll hand the patient. (See "Complications to Include on Your Informed Consent Document," below.)

Complications to Include on Your Informed Consent Document
  • Acute macular degeneration
  • Blurry vision
  • Capsulotomy
  • Choroidal hemorrhage
  • Complications associated with chosen IOL
  • Corneal abrasion
  • Corneal edema
  • Death
  • Dilated or irregular pupil
  • Diplopia
  • Endophthalmitis
  • Glaucoma
  • Haloes and glare
  • Implantation of an incorrect power IOL resulting in the need for glasses or an IOL exchange
  • Inability to implant IOL
  • Iritis
  • Loss of the eye
  • Macular edema
  • Photophobia
  • Ptosis
  • Retinal detachment
  • Retinal hemorrhage
  • Small correction via spectacles, LASIK or enhancing LRI

2. Establish communication with the surgeon

Now that you've established a rapport with the patient — and by so doing have revealed your value as his eyecare practitioner — send the surgeon a referral letter that indicates the reason for the referral, any notes regarding discussions you may have had with the patient about the chosen IOL and your intension to manage the patient postoperatively.

In addition, the letter should request communication from the surgeon about what specifically he/she does during the surgery and his/her preferred post-op drop regimen, so you can provide the patient with the most appropriate follow-up care.

Further, reinforce your comanaging role as the patient's primary-care optometrist in the letter by asking the surgeon to advise you of when, specifically, he/she will release the patient back into your care and how many days of the surgical global period for which the surgeon will be billing.

No practitioner wants a patient to "fire" him — and certainly not in this economy. Losing a patient to another practitioner not only hurts the patient, as he misses out on your expertise, but it also hurts the financial stability of your practice.

By providing your cataract patients with education regarding their diagnosis and establishing communication with the surgeon about your co-management role, you have an excellent chance of not only remaining in the employ of these patients but garnering patient referrals. OM

Dr. Holt is in group practice at the Mount Ogden Eye Center and Bountiful Hills Eye Center in Utah. E-mail him at jchod5150@yahoo.com.


Optometric Management, Issue: February 2009