This article is more than 5 years old. Information may no longer be current.
Managing patients expectations for premium results
First in a series of the top 10 reasons for poor premium IOL outcomes and how to remedy them.
For surgeons already entrenched in the premium IOL battlefield, and for those who are considering taking the plunge and upgrading their patients’ outcomes, I plan to provide some alternatives to your current thought processes for dealing with a number of the premium IOL challenges faced daily. This article is the first in a 10-part series that will address areas such as preoperative evaluation, astigmatism, posterior capsular opacification, cystoid macular edema, IOL calculations and malpractice strategy.
Our first focus — managing patient expectations — requires the surgeon to have a fine balance between knowledge, trust, confidence and flexibility. Our end goal is to have both a happy patient and a happy surgeon with minimal chair time and maximum profitability. Below are just a few things I have found helpful in making this possible.
Be knowledgeable
The “premier surgeon” must be educated on all forms of U.S. Food and Drug Administration-approved and soon-to-be-approved premium, or presbyopia-correcting, IOLs. Even if your preference is to use the Tecnis multifocal (Abbott Medical Optics), for example, you must know about the AcrySof IQ ReSTOR multifocal (Alcon) and the accommodating Crystalens (Bausch + Lomb), as well, to make the best possible IOL matches for your patients’ visual needs in terms of their professions, hobbies and activities of daily living.
Also, keep in mind that many patients are extremely Internet-savvy. They have likely spoken to their friends and may have even gotten other surgeons’ opinions before landing in your office. Be prepared to answer questions on all premium IOL options.
Limit the options
Although you should be knowledgeable of all the available options, it is also very important to minimize choices for your patients; otherwise, conversion rates will be poor due to technology confusion. If too many options are given, patients simply will not make a decision to upgrade and may delay proceeding with cataract surgery even with a monofocal option. My preference is to provide a patient with two choices: monofocal or one type of premium lens. The surgeon’s knowledge is critical to selecting the best premium IOL for that patient.
You should also find out what the patient’s motivation for choosing a premium IOL is in the first place. Unbelievably, many patients think they are having LASIK surgery when they are undergoing cataract surgery. Find out the wants and needs of your patient, job-related tasks (such as a truck driver with many night vision demands), hobbies (is this someone who takes a golf trip annually, or does he or she golf weekly?), etc.
Try to avoid IOL selection based on an annual golf trip or a hobby such as a 3-day hunting trip — rather, select a premium IOL for the needs of the patient’s other 362 days of the year. The bottom line is this: Listen to your patient and you will gain his or her trust. If the patient is co-managed, trust the opinion of the referring optometrist, who is even more familiar with the patient’s needs.
Preoperative counseling
Patients must be counseled preoperatively about the need for possible YAG capsulotomy and/or postoperative correction of residual refractive error. Let your patient know before surgery your plan to achieve emmetropia in terms of performing limbal relaxing incisions intraoperatively or laser vision correction postoperatively. If the latter, your patient should know whether the plan will be PRK or LASIK, as PRK will require more time off from work once scheduled.
Preoperative topographic analysis, which we will discuss in the next issue, is critical, as well. A patient with keratoconus or forme fruste keratoconus may not be a candidate for refractive enhancement postoperatively. The last thing a surgeon wants to do is explant an IOL due to improper expectation counseling and/or preoperative evaluation.
The more information these patients are given preoperatively will reduce chair time and patient dissatisfaction postoperatively. It is acceptable for patients to be told they may experience glare or halos postoperatively. These side effects are considered acceptable, especially if the FDA still approved these technologies. I always tell my patients halos will occur (most patients have them preoperatively, anyway, from the cataracts) and will subside considerably over a 6-month adaptation period.
Record patients’ decisions
Lastly, and unfortunately, the most chair time-consuming problem is the patient who declines the premium upgrade option preoperatively, has uncomplicated surgery with a monofocal aspheric IOL, and then complains postoperatively about the remaining need for glasses.
Although not out of malpractice necessity, we have our patients sign a consent waiver actually stating their decision not to upgrade preoperatively. In these cases, I hope they enjoy the big-screen TV they chose to spend their money on instead.
In the end, managing patient expectations should not be a daunting task, but rather a simple, efficient and positive informed decision process. There have been many catch phrases in the refractive world, such as “Capture, Match, Treat.” For patient expectations, consider the phrase “Listen, Educate, Adapt.” Listen to your patient and referring colleagues. Educate yourself on the various IOL technologies and your patients on the plan to achieve emmetropia. Adapt and be flexible in the postoperative period, whether it be managing ocular surface disease, posterior capsular opacification, macular disease or refractive errors or just giving a little extra TLC to your premium patient.
Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; 847-356-0700; fax: 847-589-0609; e-mail: mjlaserdoc@msn.com.
Disclosure: Dr. Jackson is a speaker for AMO, Bausch + Lomb and Alcon.