Communication key to management of unsatisfied patients after cataract surgery

Cataract surgery, one of the most commonly performed procedures in the world, has long provided patients an option for safely and effectively improving their vision.

With the advent of more advanced technologies, however, patients have even higher expectations of their cataract surgery outcomes, as well as increased disappointment when they do not initially achieve those anticipated outcomes.

“Visual complaints have become more common because the expectations of patients have become greater due to the marketing of premium IOLs. Therefore, no matter how much time you spend [with patients] preoperatively, the patients think they are going to be getting 18-year-old eyes,” Farrell “Toby” Tyson, MD, said. “When they do not get perfect vision [at all distances], they are a bit disappointed.”

John A. Hovanesian, MD, FACS, OSN Cornea/External Disease Editorial Board Member, echoed Dr. Tyson’s sentiments, stating that a strong correlation exists between the price patients pay out of pocket for their cataract procedure and their overall expectations.

“A patient who has a purely non-elective cataract surgery because of visual complaint and chooses no upgrade option may be completely happy with a +1 D outcome after surgery,” Dr. Hovanesian said. “But that same patient with a refractive lensectomy is going to require a great deal of hand-holding.”

Additionally, patients’ expectations may depend on the type of vision they have before surgery.

Surgeons need to be involved in the preoperative discussions with patients, according to Farrell “Toby” Tyson, MD. Image: Tyson F

In 2005, Hawker and colleagues reported results from a prospective questionnaire study involving patients scheduled to undergo elective cataract surgery in one eye. One hundred eighty-nine patients completed the questionnaire, which assessed their expectations for their postoperative refractive outcomes.

The researchers found that on a 10-point scale, with 10 being the highest, patients’ median scores for the expected likelihood of needing glasses after surgery was 8 for both near and distance vision. However, patients who already wore glasses were significantly more likely to expect having to wear glasses postoperatively than those who did not, with median likelihood scores of 9 and 1, respectively (P < .0001).

In general, all of the patients placed high importance on being free from glasses after their cataract surgery. But those who did not previously wear glasses for vision correction did not expect to need them after an elective surgery and were therefore at a higher risk for being disappointed with their visual outcomes, according to the researchers.

Common complaints

There are many potential causes for patients’ complaints regarding their overall vision after surgery; therefore, it is up to the surgeon to do whatever it takes to determine the source of the problem, according to William B. Trattler, MD, OSN SuperSite Editorial Board Member.

“It could be something as simple as posterior capsular opacity causing the vision to be cloudy, or it could be that they are off target refractively and there is too much astigmatism,” Dr. Trattler said. “It could also be epiretinal membrane or cystoid macular edema. There are so many different causes, and it is our job to be the detective and figure out what it is exactly that is affecting the patient’s overall vision and making them unhappy.”

Dr. Trattler recommended performing comprehensive testing, such as topography, optical coherence tomography of the macula, refraction, fluorescein staining of the cornea and careful evaluation of the posterior capsule, to help pinpoint the root of the patient’s complaint.

Patients also often end up unhappy with their results if they are not fully educated about the available technologies, according to Uday Devgan, MD, FACS, FRCS, OSN SuperSite Section Editor.

“A big [issue] is not understanding the limitations of the current technology. If they choose a monofocal lens, for example, they will say, ‘How come I cannot see up close anymore?’” Dr. Devgan said. “With a multifocal lens, patients will say, ‘Well, this is a surprise. How come I’m seeing these dysphotopsias now?’”

Dr. Devgan emphasized that patients are far less likely to have complaints regarding the utility of their lenses if they know what to expect before surgery.

Preoperative education

A significant aspect to managing the unhappy patient after cataract surgery is to avoid the situation in the first place. Communication before surgery is of the utmost importance.

In 2004, Pager published a prospective study that compared patient understanding, expectations, outcomes and expected-outcome discrepancy with overall satisfaction.

Among the 120 patients who were surveyed immediately before and 1 month after cataract surgery, 60% expected to achieve a perfect score on the Visual Function Index (VF-14). The average expected VF-14 score was 96.1, but the achieved average score was 89.8. According to the study, patients’ most unrealistic expectations centered around nighttime driving, reading small print and doing fine handiwork. The study’s most surprising findings were that actual visual improvement did not correlate with visual satisfaction; rather, factors such as patient understanding and expectations correlated with satisfaction.

Kerry D. Solomon

“It really comes down to setting the appropriate goals and expectations from patients preoperatively in order to make sure that what someone is seeing postoperatively is not a surprise,” Kerry D. Solomon, MD, OSN Refractive Surgery Editorial Board Member, said. “The second thing is, when someone has blurry vision after surgery, to be able to provide answers and solutions for how to improve the vision itself.”

Dr. Solomon informs patients before their surgeries that despite the predictability of cataract surgery and all that modern technology has to offer, there is still a 15% to 20% chance that the outcome will be slightly off-target and a touch-up will be required. Additionally, patients who have chosen to receive a premium IOL are made aware that their enhancement will be included in that cost.

“Anything that is a surprise to a patient is going to be perceived as something that is wrong,” Dr. Tyson said. “As long as the patient is well-educated and there are no surprises after the surgery, they are going to tolerate more issues with glare or blur because they are expecting that.”

In the practice of Mitchell A. Jackson, MD, patients are presented with limited surgical options to streamline the education process and avoid confusion. Furthermore, it is important that patients who have other underlying conditions are aware that cataract removal is simply the first step in improving vision.

“It becomes important, even in monofocal patients, that if somebody has amblyopia or macular disease, [the surgeon] needs to tell them the cataract surgery will not fix those problems,” Dr. Jackson said. “Cataract surgery will get part of the problem, but they will still have to go back to a retinal specialist after the cataract is removed.”

Postoperative communication

If a patient presents with postoperative visual complaints, the surgeon must become his or her advocate. To fulfill this role, the surgeon’s staff also must be involved, according to Dr. Hovanesian.

“The patient wants to look for someone who is on his or her side. If you as a surgeon can anticipate that [he or she] is unhappy before you even begin your conversation, it can be a big step ahead,” Dr. Hovanesian said. “A surgeon’s staff is key in identifying those patients who are unhappy before they see the surgeon. Doing tests beforehand helps determine what the next step is.

“If the surgeon walks in and takes a position of advocacy for the patient, the patient is immediately disarmed and feels good about the fact that you want to help solve the problem.”

Having exam results before speaking with the patient not only allows the surgeon to be better prepared for the ensuing conversation, but also to take charge of the situation, according to Dr. Solomon.

“It’s much better when all of my staff knows what is going on and all the testing [is performed], so instead of saying ‘How are you doing, Mrs. Jones?’ I walk in saying, ‘Mrs. Jones, I see we are not seeing quite as well as I would like. The good news is there is nothing else going on. There is a small outlier for the refraction, which we talked about before surgery. … Here is our plan,’” Dr. Solomon said. “I have taken charge of the situation and turned a potentially anxious, unhappy moment into a ‘Thank you. I am glad that is all that is going on, and I agree with the plan.’”

In addition to being armed with solutions to the patient’s problem, a surgeon’s body language can play a significant part in helping to put the patient at ease.

Some studies have examined the many factors that can affect the quality of a patient’s surgical experience. Intraoperatively, the language and behavior of the physician and his or her team have been shown to have an effect on the experience. In one study, hand-holding demonstrated a significant decrease in patients’ anxiety levels.

Similarly, a surgeon’s body language and willingness to interact both verbally and physically with a patient who presents with a complaint postoperatively can be helpful in soothing that patient’s anxiety.

“One of the things I do as the doctor is to scoot my stool so I am sitting next to the patient, shoulder to shoulder, and together we look at the chart and see what we can do, as opposed to being across from them, like two chess players or opponents. I want to be on the same team,” Dr. Devgan said. “You must also totally quiet down and let them speak. They obviously have a valid reason for having an issue.”

After a patient has explained their concerns with their postoperative results, the surgeon must then make clear to the patient that he or she is willing to do whatever it takes to solve the problem, Dr. Tyson said.

“The biggest thing [for a patient] psychologically is that you as the surgeon have to be involved in the discussion. This is not something you relegate to an optometrist or a technician,” Dr. Tyson said. “The patient wants you to be actively involved in their care, and that means not only just the good outcomes, but also for the patients who have problematic or suboptimal outcomes. You also need to let them know that you are going to continue to be with them until the problem is solved.”

Management pearls

Although each patient’s case is different, the tenets of managing their outcomes are similar throughout many practices.

Dr. Trattler emphasizes the importance of doing everything possible before surgery to ensure a patient meets established expectations. “Having a very comprehensive preoperative evaluation for more than just the cataract to make sure there are no pre-existing conditions so you do not get a surprise after surgery is key,” he said.

Additionally, surgeons must remember to communicate thoroughly and clearly with patients.

“Always speak to patients in terminology they can understand,” Dr. Jackson said. “Be upfront … and be involved with the patient from the beginning. Be very honest with them and address the problem immediately.”

Although management of an unhappy patient may not be ideal, the surgeon must, above all, bring the patient closer as opposed to pushing him or her away, according to Dr. Hovanesian.

“Even though our human nature tells us to run away from problems, we have to run toward the patient who is unsatisfied. We have to give them all sorts of extra attention and make sure they leave the experience feeling taken care of,” Dr. Hovanesian said. – by Cara Hvisdas

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References:

• Brinton JP, Oetting TA. Patient communication during cataract surgery: An EyeRounds tutorial. Eyerounds.org. http://www.eyerounds.org/tutorials/communication-cataract-surgery.htm. July 28, 2011.
• Hawker MA, Madge SN, Baddeley PA, Perry SR. Refractive expectations of patients having cataract surgery. J Cataract Refract Surg. 2005;31(10):1970-1975.
• Moon JS, Cho KS. The effects of handholding on anxiety in cataract surgery patients under local anaesthesia. J Adv Nurs. 2001;35(3):407-415.
• Pager CK. Expectations and outcomes in cataract surgery: a prospective test of 2 models of satisfaction. Arch Ophthalmol. 2004;122(12):1788-1792.

• Uday Devgan, MD, FACS, FRCS, can be reached at Devgan Eye Surgery, 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; email: devgan@gmail.com.
• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; email: drhovanesian@harvardeye.com.
• Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; 847-356-0700; email: mjlaserdoc@msn.com.
• Kerry D. Solomon, MD, can be reached at Carolina Eyecare Physicians, 1280 Johnnie Dodds Blvd., Suite 100, Mt Pleasant, SC 29464; 843-881-3937; email: kerry.solomon@carolinaeyecare.com.
• William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; email: wtrattler@gmail.com.
• Farrell “Toby” Tyson, MD, can be reached at Cape Coral Eye Center, 3701 Del Prado Blvd. South, Cape Coral, FL 33904; 239-542-0175; email: tysonfc@hotmail.com.
• Disclosure: No products or companies are mentioned that would require financial disclosure.