PREPARING PATIENTS prior to their appointments for cataract surgery increases the likelihood they will make the best decision for their needs and be happy with their visual results; it also re-emphasizes to them your value as their primary eye care provider.

Here are four steps to prepare patients for cataract surgery:

1 INSPECT THE OCULAR SURFACE

Should the patient have untreated dry eye disease (DED) prior to cataract surgery, the surgeon will not be able to obtain accurate keratometric values, which can alter the IOL power selection, making a significant difference in the residual refractive error, reveals the Journal of Cataract Refractive Surgery.

This issue is present even if the selection is a monofocal IOL. If a premium IOL is selected, not only does the power of the IOL become a very important endpoint, but the quality of the light coming through the cornea and diffracting through the multifocal, or extended depth of focus (EDOF), IOL can have a profound negative effect on the results the patient anticipates. In short, identifying DED is a crucial step.

If DED is found, start the patient on a pharmaceutical treatment, along with an artificial tear and, perhaps, a supplement to help rehabilitate the surface prior to the referral for cataract surgery. Rehabilitation time varies, depending on the extent of the dryness, but typically takes four to six weeks minimum.

2 DISCUSS IOLs

Naturally, the focus of the cataract surgical discussion revolves around the IOL. Therefore, it is important that you find out “how” the patient uses his or her vision. Once you know the patient’s lifestyle and, therefore, visual needs, you can introduce the available IOLs that may meet those needs. To best accomplish this, obtain educational tools from the surgeons you work with, seek resources from the IOL manufacturers and find online education modules to help demonstrate concepts to patients. The IOL options:

• Monofocal. This IOL has one power, likely to correct the patient’s distance vision. This patient would utilize spectacles for corrected near vision or residual astigmatism. As a result, the monofocal IOL patient is one who does not mind wearing glasses and has not expressed an interest in reducing his or her dependence on spectacles.
• Toric. This IOL contains one power, but also corrects for astigmatism. This toric patient is similar to the monofocal patient, but who has astigmatism. Consider offering it to patients who have greater than 0.75D of astigmatism, because it offers a unique opportunity for the patient to have better distance vision.
• Multifocal. This IOL provides simultaneous vision by splitting light into multiple distinct foci, likely near and distance. It provides an opportunity to reduce dependence on spectacle correction.
• Multifocal torics. These work in the same fashion as a multifocal IOL, but, in addition, correct for residual astigmatism. This IOL also provides an opportunity to reduce dependence on spectacles.
• Accommodating. Accommodative IOLs create pseudo accommodation by shifting the IOL forward and changing the vertex distance with contractions in the ciliary muscle. The effective pseudo accommodation will vary according to the power of the IOL as well as how far the lens moves forward in individual patients. The higher the IOL power (as in a hyperopic patient), the less the IOL must move to create the accommodative change. The less the lens power (as in a myopic patient), the more the lens has to shift to create the accommodative change. Therefore, selection of your patient and patient education on the realistic expectations that the accommodative change is variable is important. (Often, modified monovision is utilized to ensure the patient will have at least intermediate vision with the outcome and possible near vision if the lens shifts appropriately.)
• EDOF lens. An EDOF IOL delivers a continuous, full range of high-quality vision from intermediate to distance. It corrects for chromatic aberration to provide sharp vision in all lighting conditions. (The FDA created a separate class of IOL implant as a result of the chromatic aberration technology.)

Recommending advanced IOL technologies to your patients is important to your practice’s health, as well as your patients’ quality of life. Your practice’s reputation depends on your ability to provide patients with the best quality of care. Many of the additional diagnostic tests, treatments for DED and consultations are both billable and advanced beneficiary notice cash procedures. (Be sure to be transparent about out-of-pocket expenses.) Along the way, you also will be increasing patient loyalty.

3 ADDRESS PATIENT EXPECTATIONS

It is important to advise patients that they will be presented with the various IOL options during the cataract evaluation with the surgeon. The education you provide will start the decision-making process and allow the patient to be prepared with any questions he or she might have regarding IOL selection.

Once the patient has decided on the IOL, it’s crucial you discuss what he or she can expect during and after surgery. Particularly, address what the patient can expect from the specific lens category and brand chosen. Be sure to not make any guarantees.

In addition, realize that patients can be fearful of cataract surgery and, thus, view the entire process as negative. You can counter that by explaining that new advances have made it an ideal time to have cataract surgery; the surgery can give them the opportunity to select the appropriate IOL to enable them to keep doing the hobbies and activities, which they may have been struggling with because of their cataracts.

4 TALK TO YOUR SURGEON

Forward the patient’s medical information and details about the IOL discussion to your surgeon of choice. Also, follow up with a phone call, so you can answer any questions, ask for suggestions on discussing the premium technology and ensure you are both on the same page with regard to the patient’s IOL choice. (See Web version for more on “Surgeon Referrals.”)

ACHIEVING SUCCESS

Our job is to care for patients’ visual needs through every stage of their lives. By following the four steps outlined, you’ll ensure a mutually beneficial outcome. OM

DR. DEVRIES has a degree in financial management, from the University of Nevada School of Business, and is co-founder of Eye Care Associates of Nevada, a medical/surgical co-management referral practice. He is a consultant to Johnson & Johnson. Email him at drdevries@nveyelaser.com.