AS THE use of medication and technology in pre- and postoperative ocular surgical care advances each year, one thing must remain the same: Our commitment to preparing patients and, thus, ourselves, from unexpected outcomes. The question then becomes: How do we do this?
Here, I answer this question.
KNOW THE PROCEDURES
As co-managing optometrists, it is ultimately our responsibility to stay informed on all surgical procedures and our roles in each of them. For example, knowing how an IOL procedure will vary based on the type of lens implanted (monofocal, accommodating, toric multifocal, etc.) and how the treatment affects different conditions, such as how LASIK/PRK affects dry eye, will dictate how we approach a patient’s postoperative care.
With frequent advancements in medications and surgical procedures, staying current educationally can be a daunting task, but we must be knowledgable and, therefore, comfortable making decisions regarding patient care, regardless of the kind of treatment. (See, “Recent Surgical Advancements,” p.17.) Thus, knowing the procedures allows us to best aid patients in their own decision-making and to provide the best pre- and postoperative care.
To ensure we are up to speed on all procedures, it is imperative we have an open line of communication with the patient’s surgeon. This allows us to be informed of any new techniques or procedures that may be utilized, while also maintaining a relationship with the person with whom we are trusting our own patients. It is equally important we take advantage of journals available and any CE courses provided throughout the year. Medical advancements are commonly introduced through these avenues. Without performing our due diligence, we could easily fall behind in how to best treat, care and educate our patients.
PROVIDE PROPER PRE-OP DIAGNOSES/EDUCATION
We need to perform diagnostic testing prior to any surgical referral to make both us and our patients aware of existing conditions, such as glaucoma, AMD, epiretinal membrane, keratoconus, etc. Any condition not brought to the patient’s attention before a surgical procedure could be erroneously viewed by him or her as caused by the surgery.
(As a brief, yet related, aside, all records from tests performed at our offices should be sent to the patient’s surgeon when the referral is made. This guarantees the surgeon has all the pertinent information, which allows him or her to decide whether any additional testing should be performed.)
Before completing any exam, we, as co-managing optometrists, should communicate to our patients any potential postoperative side effects, such as ocular dryness after refractive surgery or glare and halos after multifocal cataract surgery. Setting expectations preoperatively streamlines postoperative visits, as patients are already fully aware of what is a cause for concern and what is a common side effect (e.g. blurry vision, eye irritation or one eye healing at a different rate than the other).
Ultimately, this step safeguards the patient from unnecessary fear or disappointment, while also protecting all doctors involved.
Recent Surgical Advancements
Here’s a look at significant procedures and devices and the role we play in each:
- Dropless cataract surgery.
Many ophthalmologists have been turning to this intravitreal transzonular antibiotic/steroid combination, developed by Imprimis Pharmaceuticals, which does not require the patient use topical drops postoperatively.
Role: Through the post-op visits, we should closely watch anterior chamber inflammation. If inflammation appears to be worsening, a topical steroid could be added and slowly tapered to help control and decrease the risk of cystoid macular edema. IOP should also be closely monitored for risk of a steroid response. The addition of a topical IOP reduction agent may be necessary if IOP becomes elevated.
- Microincision cataract surgery (MICS).
This surgery involves an incision of less than 1.8mm and has been shown to decrease the invasiveness of standard cataract surgery, while preventing surgically induced corneal astigmatism and reducing post-op corneal aberrations.
Role: We must be aware of postoperative refractive status, especially in patients who have elected a premium lens, since these patients may expect to be without refractive error after surgery. Patients who exhibit refractive error may need additional procedures, such as YAG capsulotomies or PRK/LASIK, to achieve their desired outcome.
- Microinvasive glaucoma surgery (MIGS).
Developed to decrease some of the complications associated with traditional glaucoma surgeries, such as sudden permanent loss of central vision, MIGS improve the outflow of the eye’s aqueous, effectively lowering IOP. An increasing number of options are available, specifically the AqueSys XEN Glaucoma Treatment System (Allergan), CyPass (Alcon) and iStent (Glaukos), with many more on the horizon, including the InnFocus MicroShunt Glaucoma Drainage System (Santen), which is currently under evaluation. MIGS options provide surgeons and co-managing doctors the opportunity to recommend dual procedures, allowing patients to correct two ocular issues simultaneously.
Role: If a patient elects to proceed with a MIGS, postoperative IOP should be watched extremely closely and compared with pre-operative IOP. MIGS should allow for a long-term decrease in IOP and, in some patients, the opportunity to decrease or eliminate topical IOP-lowering agents.
- TECNIS Symfony and Symfony Toric IOL.
This IOL, approved by the FDA for extended depth of focus and as a toric option, provides a full range of vision, allowing patients to focus clearly at distance; it mitigates the effects of presbyopia.
Role: We, as co-managing doctors, should record both distance and near VA at each postoperative visit. Also, we should look to ensure centration of the lens, as a postoperative lens shift can lead to unwanted visual side effects. If a toric implant is used, the toric markings should be noted at postoperative appointments as well, meaning that we, as the co-managing O.D., should dilate all patients receiving toric IOLs at the one-week post-op visit. If the toric markings or centration appear misaligned, the surgeon should be notified immediately, so that it can be repositioned.
MAKING THE SURGICAL REFERRAL
Once we’ve gathered our diagnostic data and provided patient education on both our findings and what the patient can expect, it is important we find a surgeon whom we can trust to act as an extension of our practices.
The surgeon selected should be our equal partner in care, meaning that prior to the surgery, he or she reviews our findings and discusses with us the procedure/surgical decision, the goals and when, specifically, the patient will be released. This is especially important because we must serve as the patient’s advocate. A lack of communication, or a miscommunication, between parties can lead to mistakes or unwanted outcomes, which can have negative ramifications, most importantly, on the patient, but also on your reputation and your business.
Further, it is paramount if we have any questions about what is or isn’t normal following a procedure, that we be comfortable contacting the surgeon, as he or she may be able to assist in postoperative care and may even want to see the patient him- or herself.
KEEP PRISTINE RECORDS
Throughout the patient encounter and referral, everything — meaning all testing (topographies, OCTs, fundus photography images, etc.), ocular findings, diagnoses requiring surgical intervention, data required for insurance companies (unless a patient is paying out of pocket), discussions we have with the patient and the patient’s complaint or reason for the surgery — must be documented for all parties.
Additionally, we and the selected surgeon should have copies of any signed patient consent forms. By maintaining proper documentation, all parties are fully educated and protected; patient care can be continued according to an agreed upon plan. Also, we, as co-managing doctors, can be notified easily should any complications arise.
REVIEW POST-OP EDUCATION
When the patient presents for his or her first post-op visit, it is important we remind him or her of what is deemed normal and what can be considered an abnormal side effect. Before any patient leaves the first postoperative visit, I am sure to inform the patient of what he or she is likely to experience, and I suggest the patient speak with surgical center staff, and keep a checklist of what is and is not considered normal. I say:
“Things should only continue to improve. If you continue to experience increasing eye pain or your vision worsens instead of improving, you need to let myself and the surgeon know because these symptoms could be signs of a serious infection and, therefore, should not wait to be discussed at the next visit.”
GOING OUT OF OUR WAY
By going out of our way to protect our patients, we not only establish a level of trust that ensures patients will continue to return to our care long after postoperative care is complete, we are also protect ing ourselves and our practices simultaneously. Everyone wins. OM