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Optometrists’ roles vary in cataract surgery comanagement
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When patients develop cataracts, optometrists can help them navigate the surgical course, and an optometrist’s practice situation often dictates his or her specific role in patient care.
“I practice in an ambulatory surgical center specializing in consultative medical and surgical eye care,” said Maynard L. Pohl, OD, FAAO, clinical director, Pacific Cataract and Laser Institute, Bellevue, Wash. “When patients are referred by family eye doctors for consideration of cataract surgery, my role is to clinically evaluate each patient to confirm the diagnosis of a visually significant cataract, stabilize any co-existing eye disease prior to cataract surgery and determine the most appropriate surgical treatment plan.”
Primary care optometrists, on the other hand, typically follow patients for many years. “When patients develop a cataract, I see them every 6 months to monitor the situation,” said Kirk Smick, OD, FAAO, in private practice at Clayton Eye Center, Morrow, Ga. “When I can no longer improve their vision by changing their glasses prescription, I refer them to a cataract surgeon.”
He noted that it is the optometrist’s responsibility to identify the best cataract surgeon for each patient.
IOL recommendations
Based on patient criteria, the optometrist often makes IOL choice and power recommendations to the surgeon. Dr. Smick told Primary Care Optometry News that he helps determine IOL choice, but does not make power recommendations. Specifically, he determines whether patients are candidates for specialty IOLs.
“Some specialty IOLs are indicated for patients who want to be able to see both far away and up close without wearing any glasses. The criteria are pretty strict, and the vast majority of patients don’t qualify, but it’s our responsibility to determine this ahead of time,” he said.
If a patient does meet the criteria and has an interest in a specialty IOL, Dr. Smick will relay that information to the surgeon.
Dr. Pohl said that he chooses both IOL type and power based on the patient’s desired refractive endpoint in conjunction with the corneal curvature and A-scan measurements obtained by his technical assistant. Additionally, if patients want a reduction in corneal astigmatism, he presents options such as limbal relaxing incisions, toric IOLs or LASIK postoperatively. Dr. Pohl encourages referring optometrists to take an active role in addressing the optical considerations of their patients prior to surgery. “I then present the recommended plan to the surgeon. All pertinent information is specified on a cataract surgery order form, which is reviewed and co-signed by the surgeon,” he explained in an interview.
In some instances, the referring optometrist may prescribe preoperative medications. This is often dictated by geography. Dr. Smick said that, in urban areas, or if the surgeon is located near the optometrist, the patient will see the surgeon before the day of surgery. In these cases, the surgeon will prescribe preoperative medications. However, in rural areas, the optometrist often prescribes preoperative medications, and the ophthalmologist does not see the patient until the day of surgery. “This is a matter of convenience for the patient in many instances,” he said.
If patients have co-existing conditions, such as age-related macular degeneration, optometrists may perform glare testing, contrast sensitivity testing and pin holing, Dr. Smick said. “We want to make sure that the patient, after cataract surgery, is going to enjoy an increase in clarity of vision,” he said.
Postoperative care
Routinely, optometrists take over postoperative care of the patient the day after surgery. Drs. Smick and Pohl typically perform the 1-day follow-up examination.
“Although patients are presented with a choice of either returning to our center or their referring doctor for their postoperative care, the surgeon may mandate that the patient return to the surgery center for the 1-day exam if there are any concerns regarding stability of the eye following surgery,” Dr. Pohl said.
Once the optometrist has resumed care, he or she then monitors the patient and addresses any complications, consulting with the surgeon as needed. “I also monitor the patient’s medications and adjust them if necessary,” said Dr. Smick. “About 3 weeks after the surgery, most of the healing has occurred, and we can then check the patient’s vision to see if he or she needs a distance prescription. With modern surgical techniques, most patients need glasses only for near vision.”
Dr. Pohl recommends patients be evaluated at 1 day, 1 week and 1 month after uncomplicated cataract surgery. If patients experience complications or have co-existing eye disease, they may require more frequent visits during the immediate postoperative course or additional visits following the 1-month visit.
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Postop therapeutic regimen
Dr. Pohl’s standard postoperative topical medications currently are one drop of an antibiotic (tobramycin for mini scleral tunnel incisions and Quixin [levofloxacin ophthalmic solution 0.5%, Vistakon Pharmaceuticals] for clear-corneal incisions) four times daily and one drop of a steroidal anti-inflammatory (1% prednisolone acetate) also four times daily. The antibiotic is discontinued at 1 week, and the anti-inflammatory is used until the 5-mL bottle is empty.
Patients at greater risk for macular edema, such as patients with diabetes, are also prescribed a topical nonsteroidal anti-inflammatory drug (NSAID). Patients are prescribed one drop per day until the 5-ml bottle is empty.
All patients are given artificial tears to be used as needed for discomfort or dryness. “A protective eye shield for bedtime use is not a requirement, although it is provided to patients at risk,” Dr. Pohl said.
According to Dr. Smick and Dr. Pohl, the most important ingredient for successful cataract surgery comanagement is mutual trust between the referring optometrist and the ophthalmologist. “Trust is the bottom line,” they say. “The ophthalmologist has to feel that the patient is in good hands in the referring optometrist’s office after the surgery,” said Dr. Smick, “and the optometrist has to feel that the surgeon is the best surgeon available for whatever procedure needs to be done. Good communication is key.”
For Your Information:
- Maynard L. Pohl, OD, FAAO, is clinical director of Pacific Cataract and Laser Institute in Bellevue, Wash. He can be reached at PCLI, 10500 NE 8th St., Ste. 1650, Bellevue, WA 98004-4332; (800) 926-3007; e-mail: Maynard.pohl@pcli.com.
- Kirk Smick, OD, FAAO, is in private practice in Morrow, Ga. He can be reached at 1000 Corporate Center Dr., Ste. 100, Morrow, GA 30260; (770) 968-8888; fax: (770) 968-2465; e-mail: claytoneye@aol.com.