Article

Pre-Operative Cataract Care

A look at the optometrist’s role in increasing the likelihood of an excellent surgical outcome

Meibography image of a cataract patient who had significant shortening and dropout of the meibomian glands.

Some years back, when lens-based refractive surgeries were added to the clinic at which I worked, a cataract patient presented refracting at -26.00 D pre-operatively. Her cataracts were extremely mild, but the early lens changes had prompted her to schedule a visit to consider intraocular surgery as a means to reduce her refraction. Due to the patient’s long axial length, I recommended a monofocal IOL targeted at distance. I brushed briefly over the reading glasses discussion regarding the patient’s extreme myopia:

“A -26.00 D patient certainly would expect to wear readers, wouldn’t they? After all, they were already reliant on glasses for all distances,” I thought. Big mistake.

Although the patient’s post-op vision was 20/25 at distance, she presented soon after complaining she couldn’t see anything at her nose distance and that, as a result, her “whole world had been turned upside down.” And thus, I learned the hard way that meeting patients’ expectations is the most important factor to successful cataract surgery outcomes. As primary eye care providers, it behooves us to do all we can to manage our cataract patients’ expectations. Moreover, in most instances we have been seeing these patients for years. Therefore, who knows more about their proclivities, hobbies and, most importantly, their visual demands than us?

With that said, I believe that we should address the following items prior to referring cataract patients for surgery, so we can provide them with the best opportunity for maximum satisfaction. It has been our acumen that has brought them to our practices and, thus, should guide them in their cataract surgical journey.

CATARACT STATUS

The first task for any clinician is to recognize and communicate the status of the cataract with the patient.

Subjective glare of worse than 20/40 or a VA reduction are the common factors, but a cataract doesn’t grow out of thin air. Start this discussion at the earliest signs of the lens changes.

Refer the patient for surgery when they are not seeing optimally, secondary to these lenticular changes.

DESIRED VISION

As illustrated in my case, it is critical to find out the patient’s desired post-op vision to ensure the likelihood of a positive surgical outcome. So, does the patient want to reduce their dependence on glasses? Are they expecting to wear reading glasses? Do they spend all day at a computer, and is that an important working distance for them? Do they drive extensively at night? In fact, a lifestyle questionnaire is a great way to assess your patient’s visual habits. You can obtain such questionnaires from surgical representatives, or you can easily create one from common questions you or your staff ask your contact lens patients.

Once you have the answers, you can make the patient aware of the IOL options that best match their desired vision and the individual pros and cons of each product to, again, manage her expectations.

OCULAR HEALTH

You should assess various ocular health factors prior to the procedure. Is the patient’s retina healthy? What about the cornea? For example, if the patient has certain ocular conditions, such as corneal dystrophy, AMD or active retinopathy, the surgeon may only feel comfortable inserting a monofocal IOL as opposed to a multifocal IOL.

Next, check the ocular surface for dry eye disease (DED). DED has been documented to affect the preoperative measurements, or biometry, used to determine the proper IOL power. Specifically, research shows that biometry can be off by as much as 2.00 D in both sphere and cylinder, secondary to an unstable tear film; resulting in the insertion of the incorrect power. Secondly, an unstable tear film can be the cause for discomfort post-operatively, increased risk of infection and inflammation, as well as a root of fluctuating vision. Thus, a healthy ocular surface is an integral part of a successful surgery. (For information on diagnosing DED, see https://bit.ly/2MgiJYe .) If the patient has DED, it is your, the referring optometrist’s, responsibility to properly treat the patient and ensure all is stable before referring them to the surgery center. (For information on the latest DED treatments, see https://bit.ly/2JED7Nz .)

POSSIBLE COMPLICATIONS

Modern-day cataract surgery is, arguably, one of the safest procedures patients can experience. However, it is still surgery, so there are complications. These include corneal edema, dislocation of the IOL, uncorrected refractive error and macular edema, among others. Also, patients may develop an opacification of the capsule and need a YAG procedure. (See “Post-Operative Cataract Care,” p.20.)

Manage patient expectations here by providing a comprehensive list of possible complications and letting them know that, although rare, complications may result. This serves to let your patient know that you are there for them before and after surgery.

Preoperative topography image shows irregular mires due to poor tear film resulting from dry eye disease.
Images courtesy of Marjan Farid, MD

SURGICAL EXPECTATIONS

The final item is the management of surgical expectations:

  • During consult. The referring optometrist, ideally, should spend a day at the surgery center and observe the consult and surgical flow. It is important for the referring O.D. to have a good working relationship with the surgeon and to know their criteria for inserting a premium IOL, for example, so the referring O.D. can pass this, among other, information on to the patient to manage her expectations and relate the experience she will have.
  • Prior to surgery. After this visit, you can make the patient aware that there will be multiple tests, such as topography, performed, that they will be meeting with the surgeon and surgical counsellor and they may spend a couple hours at this visit, as a result. Further, explain to the patient that, in most instances, they will be asked to make an IOL choice at this time and, thus, should be aware of additional costs for premium IOLs, if that is what they have opted for.
    Finally, counsel the patient that they will be on anti-inflammatory and antibiotic drops, to hasten the healing and induce comfort or a few weeks after surgery, and that healing isn’t instantaneous. Keep in mind, however, that your patient may have an injection or use a combo drop as well. Through my experience, I have found that for some reason, patients expect everything to be perfect immediately. I always ask patients, “If you had knee surgery would you expect to run a marathon the next day?” Patients must understand this is surgery, and it needs to be thought of as such.
  • Long-term. Patients need to understand that for many, ideal results don’t occur until both eyes have undergone IOL insertion. Also, explain that there may be a bit of adaptation to the IOL. For instance, if the patient has elected to have a multifocal IOL, they must understand it may take months for their brain to fully adapt to it and for comfort with night vision.
    Armed with this information, the patient is now equipped for their appointment with the surgeon.

CREATING HAPPY PATIENTS

By being aware of the items we should address prior to referring cataract patients for surgery, patients have an excellent chance of stellar surgical outcomes.

This is a growing population. They are living longer and having the procedure done at an earlier age, so these patients will be in their optometrists’ offices for years postoperatively. Let’s be there for them at the very beginning to ensure a long-lasting, happy relationship. OM