This article is more than 5 years old. Information may no longer be current.
Updated Dell questionnaire takes a closer look at patients' visual needs
Revisions include new descriptions of methods for accessing reading material, a self-assessment for measuring habitual reading distance and modified language regarding dysphotopsias.
Click Here to Manage Email Alerts
Not too many years ago, there was a clear separation between refractive surgery and cataract surgery. Refractive surgery was limited to modification of the cornea, while successful cataract surgery was typically followed by a new bifocal glasses prescription. Early pioneers such as Robert Osher began advocating combining astigmatic keratotomy with cataract surgery to reduce spectacle independence in the mid-1980s, but this was not widely adopted at that time. It took many years for the combination of improved biometry, modern IOL formulae, small-incision surgery, astigmatic keratotomy and toric IOLs to allow surgeons to routinely achieve good uncorrected distance vision after IOL surgery. The advent of multifocal, accommodating and extended depth of focus IOLs has essentially transformed cataract surgery into a form of refractive surgery. These new options have created a complex array of choices for the surgeon and the patient. And with multifocal IOLs now available in several add powers, the choices have become even more complicated. This trend will continue as new technologies emerge.
As a participant in early clinical trials for presbyopia-correcting IOLs, I was excited when we received approval for these lenses in 2004. But I soon found that a problem was brewing in my clinic. Suddenly, I was spending a huge amount of time explaining all the various IOL options to cataract patients. Sometimes after a long discussion, the patient would state that he had no interest in spectacle independence. Educational videos and surgical counselors helped, but I needed a way to quickly assess what my patients wanted their vision to be like after surgery, what compromises they would be willing to make to achieve those goals, and whether they would be willing to pay for this result. The result was a Cataract and Refractive Lens Exchange Questionnaire, which I first published in 2004. The questionnaire was helpful in streamlining my clinic, and other surgeons found it useful as well.
In 2016 I developed a new version of the questionnaire, which we spent several months validating in my clinic. Like the original version, the questionnaire asks patients to choose where they would like to see without glasses and forces them to prioritize distance, intermediate and near vision. It surveys the patient’s willingness to accept visual compromises such as dysphotopsias and loss of stereopsis in exchange for spectacle independence. The new questionnaire includes updated descriptions of current methods for accessing reading material, such as e-readers, tablets and laptops. It also contains a self-assessment test for measuring the patient’s habitual reading distance by using the vertical length of the paper of the questionnaire as a rough ruler. For physicians who wish to use the questionnaire on a tablet or laptop, a calibrated string can be used to determine habitual reading distance. Language regarding dysphotopsias has been modified to reflect the improved optical performance of newer multifocals as well as EDOF IOLs. Finally, the questionnaire contains a self-assessment of the patient’s personality ranging from “easygoing” to “perfectionist.”
Over the years, I have learned many lessons from the questionnaire. The occasional patient will simply refuse to fill out the questionnaire. This can be a warning sign. Other patients mark the questionnaire up with their own extensive editorial commentary, replacing my words with their better words. Some cross off their answers in a fit of indecision. Interestingly, most patients are surprisingly frank in their self-assessment of their personalities. One finding from our original validation of the questionnaire was that patients who marked their personality as exactly midway between “easygoing” and “perfectionist” tended to be less happy postop despite an excellent refractive outcome. The true secret of the questionnaire is that it subtly alters the expectations of patients by confronting them with difficult choices regarding their visual outcomes. They begin to realize that perfect vision at all distances without some degree of optical compromise is not always possible.
We ask our IOL patients to make important decisions regarding how they want to see after bombarding them with a lot of new information in a short period of time. Often, we are meeting these patients for the first time, and we know precious little about their daily lives and visual needs. The questionnaire attempts to gain additional insight into the needs, desires and personalities of our patients while educating them about the various options available. The questionnaire is available for download here. Physicians are free to modify and use it as they see fit.- by Steven J. Dell, MD
Reference:
Osher RH. Combining phacoemulsification with corneal relaxing incisions for reduction of preexisting astigmatism. Paper presented at: Annual meeting of the American Intraocular Implant Society; 1984; Los Angeles.
Disclosure: Dell reports no relevant financial disclosures.