CLINICAL

  ANTERIOR

‘EVERYTHING’S SO BLURRY’

A PRIMER ON CATARACT AND YOUR COMANAGEMENT ROLE

JOSH JOHNSTON, O.D., F.A.A.O.

RECENTLY, A 72- year-old Caucasian new patient presented complaining of mild blurry vision at distance. She revealed she underwent uncomplicated bilateral cataract surgery six months prior. Medical records from her previous O.D. showed the patient’s vision before surgery was 20/40 OD and 20/50 OS. Now, it was 20/20 OU, but she “wanted to see well at distance without glasses.” Her prior O.D. wrote in the patient’s record that he “discussed” toric IOLs with her, but she declined. Who was at fault for this patient’s outcome? The patient? The surgeon? Her previous O.D.?

Decades ago, the blame would lie 100% with the surgeon for not properly discussing the patient’s visual issues prior to the surgery. Today, however, the optometrist, as the primary eye care provider, could share the fault for not accurately educating the patient about her visual outcome sans toric IOLs.

Here, I discuss the etiology, symptoms, clinical signs, diagnosis and management options of cataract, so you can increase the likelihood of successful postoperative outcomes.

ETIOLOGY

Cataract is considered the most common cause of vision loss in patients older than age 40 and occurs when the crystalline lens opacifies. Nuclear (the most prevalent), cortical (lens “shell”) and subcapsular, also named posterior capsular (back of the lens), comprise the three main types of cataract. The nuclear type is slow growing, the cortical type grows from the lens’ outside edges toward its center, and the subcapsular type typically grows quickly.

Advancing age, high alcohol use, high myopia, diabetes, hypertension, obesity, smoking, prior eye trauma or eye surgery, exposure to ultraviolet radiation from sunlight, family history, hormone replacement therapy and the use of certain medications, such as topical and oral steroids, are risk factors for cataracts.

SYMPTOMS

Symptoms are contingent on the cataract type:

• Nuclear cataract. Patients may report temporary improvement of near vision, referred to as “second sight.” (It results from myopic shift.)

• Cortical cataract. Patients complain of decreased contrast sensitivity, blurred vision, glare and halos at night and a reduction in depth of focus.

• Subcapsular cataract. Patients report glare and halos. Of interest: Symptoms and clinical signs tend not to coincide because even a small opacity can have a profound effect on vision. The reason: A subcapsular cataract forms on the lens’ central posterior portion right in the visual axis’ center.

CLINICAL SIGNS

Clinical signs are also contingent on the cataract type:

• Nuclear cataract. Yellow and occasionally brown

• Cortical cataract. Spoke-like or wedge appearance

• Subcapsular cataract. Appears as a back-of-the-lens opacity

DIAGNOSIS/MANAGEMENT

Via slit lamp or ophthalmoscope, you can identify the presence of one of the three types of cataract. After making the diagnosis, ask the patient whether he or she experiences decreased functional vision during daily activities. If the patient answers “yes” or complains of glare and halos, prepare him or her for immediate cataract surgery by doing the following:

• Explain the diagnosis. Educate the patient about the clinical signs and symptoms of a cataract, so he or she understands why it’s affecting vision and requires surgery.

• Perform a comprehensive exam. It should include refraction, glare testing and a dilated exam to rule out limitations of vision from other problems, such as those stemming from the cornea and retina.

• Discuss surgical options. Educate the patient on the two types of cataract surgery to alleviate any fears he or she may have: “In standard cataract surgery, the surgeon uses hand-held blades to make incisions. In femtosecond surgery, the surgeon uses a laser to make incisions.” Also, provide education regarding the risks, benefits, complications and contraindications of the surgical options.

Note the fibrillar deposits at the pupillary margin. Surgeon communication is particularly important here for surgical preparation.

• Discuss IOL choices. This is contingent on the patient’s refraction, so you should be prepared to discuss the characteristics of all the lens categories as well as the nuances of the branded IOLs that fall under each category — doing so is essential for managing patient expectations. Accommodating, monofocal, multifocal, phakic and toric IOLs are available, with Alcon, Allergan AMO, Bausch + Lomb, Lenstec and Staar Surgical providing products.

• Explain postoperative care. Explain to the patient that he or she will require care after cataract surgery. This postoperative care includes checking the wound for leakage, IOL position assessment, IOP check, cover drop installation instructions, refraction, assessing the cornea for abrasions (rare) or edema, anterior chamber assessment for cell and flare and a discussion regarding no water in the eye/no eye rubbing/no heavy lifting or bending over.

• Refer for surgery. Maximize your patient outcomes by referring patients to the most competent surgeon with whom you have a good working relationship. (You can make this determination by interviewing and shadowing him or her for a few cases.) If your patient has specific desires regarding surgery type and IOL, tell the surgeon. Remember, this is your patient, so you know him or her best.

Finally, before the patient leaves with your referral, let him or her know the surgeon will perform additional testing, confirm the final surgical plan and then set a date for surgery. (See “Future Treatments,” left.)

THAT PATIENT

At the exam’s end, I educated the aforementioned patient about why her uncorrected distance vision was blurry, and I gave her the option of glasses, contact lenses and PRK. She chose glasses.

If a patient walks away from your office with a clear understanding of cataract, how he or she can be treated and the IOL options, that patient is on a trajectory toward a good outcome, and there is no blame game. OM

DR. JOHNSTON practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in co-managing cataract and refractive surgery patients. Email him at drj@gaeyepartners.com, or visit tinyurl.com/OMcomment to comment.