Play integral role in setting refractive target for cataract surgery patients

Issue: June 2000

Protocol is plano to -.50

Arthur A. Medina Jr., OD: In our patient management optometric network, which has existed since the mid-80s, we have developed a very efficient and effective cooperative relationship with certain surgeons. As an optometric network we selected particular surgeons for the various secondary and tertiary care needs. The entire system is protocol-driven. Each surgical procedure has its unique preoperative and postoperative patient information forms.

Our working relationship with our surgeons is based on clear and comprehensive communication. Our mutual objective is to rid each patient of ocular disease and obtain the best uncorrected vision.

The cataract patient protocol will typically leave the patient’s uncorrected vision as plano to -.50. Depending upon the special needs of a particular patient, we will then determine to alter this to a more appropriate postoperative refractive error. For example, if the patient is moderately farsighted and has a cataract in only one eye, we will elect to leave the patient’s postoperative refractive error slightly farsighted.

In my practice I typically communicate this to the cataract surgeon in the preoperative cataract information form and request the surgeon to target IOL outcome at a particular refractive error. With the explicit clinical data provided by the optometrist, our surgeons have learned to trust our long-term relationship with the patient and rely heavily on the optometrist’s recommendations for IOL outcomes. I have always been a strong advocate of active optometric cooperation in surgical planning and patients’ education regarding surgical outcomes and expectations. I am opposed to passive optometric comanagement.

Arthur A. Medina Jr., OD, has been in solo private optometric practice in San Antonio, Texas, since 1983. Dr. Medina is a member of the Editorial Board of Primary Care Optometry News. He can be reached at 1110 McCullough, San Antonio, TX 78212; (210) 225-4141; fax: (210) 229-9400; e-mail: artmedina@aol.com. Dr. Medina has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Target is decided upon with surgeon

Paul M. Karpecki, OD: There are two things necessary to provide the cataract surgeon with desired outcomes: being up on the latest technology in cataract surgery and having a good line of communication with the surgeon. The more educated you become and the more you are willing to learn from the surgeon, the more he or she will trust you and rely on your input. The result is better patient care than would be possible with the patient going directly to the ophthalmologist.

There are three areas in which I discuss options with the surgeon: monovision, specialty IOLs and refractive outcomes. If the patient has succeeded or failed in monovision with contact lenses, this information is extremely valuable to the surgeon. An IOL exchange is difficult to perform, and it might be avoided if this type of information is provided.

In addition to the question of monovision itself is the question of the amount of monovision. I prefer the target of –1 D for the nondominant eye, because it allows a very comfortable intermediate range while still providing a good balance with the distance eye. It allows patients to have “restaurant vision,” or the ability to see the menu, their food, the computer, telephone, make-up and speedometer, yet does not appear to affect stereo or distance vision to the extent of a –2 D or –2.50 D target. But for some patients who prefer a –2 D contact lens monovision fit and do extensive reading, this information is shared with the surgeon, who can now adjust the outcome.

Some patients have heard about multifocal IOLs or have friends who have had cataract surgery and no longer wear glasses, and those are the instances where I discuss multifocal IOLs. I mention that the multifocal Array (Allergan, Irvine, Calif.) has the greatest chance of minimizing dependency on glasses but also has some potential limitations.

For example, if I had a patient who wanted cataract surgery because he or she was bothered by glare at night, I wouldn’t recommend a multifocal IOL, as the incidence of glare with a multifocal IOL is greater. Also, the most effective multifocal IOL patients are those whose intended correction is near plano or slightly hyperopic. It is sometimes very difficult to predict the final refractive error in high myopes, hyperopes, astigmats or patients who have undergone a previous refractive surgery such as radial keratotomy (RK). I would avoid a multifocal in these patients.

I rarely suggest specific material types to the surgeon. However, I have learned from surgeons with whom I work, such as John Hunkeler, MD, that silicone IOLs may be a much better choice in postrefractive surgery patients because they can still be removed if the IOL calculation was significantly off target. This would primarily apply to patients who have had RK. A silicone IOL would allow the IOL to be removed without extending the original incision. Extending the incision could connect the two RK incisions and substantially change the corneal contour and may cause irregular astigmatism.

Today, cataract surgery is quickly becoming refractive surgery, and patients are starting to expect this. Some come in for refractive surgery and complain of glare or decreased vision only to discover that they have cataracts. Many times their goal was for a refractive procedure, and I am able to pleasantly inform them that two benefits to cataract surgery are removing the cloudy lens and possibly eliminating the need for glasses or contact lenses.

If the patient had a mild refractive error, usually the predictive outcome after cataract surgery is very satisfactory. In cases of high refractive errors, I discuss with the surgeon the patient’s desire to minimize the need for glasses after surgery. At our center, the surgeons will make a laser in situ keratomileusis (LASIK) flap immediately prior to the cataract surgery. This allows a LASIK enhancement for any residual refractive error once the cataract surgery has stabilized.

Finally, I also include preoperative information on patients who have had refractive surgeries such as LASIK or photorefractive keratectomy. This pre-refractive surgery data is extremely valuable to the surgeon and is clinical data that they would not otherwise have. The original keratometry readings and refractive error before any refractive surgery are particularly valuable in an optimal IOL calculation and, once again, better serve patients in the final outcome.

Paul M. Karpecki, OD, is clinical director of cornea and refractive surgery for Hunkeler Eye Centers. He is also a member of the Editorial Board of Primary Care Optometry News. Dr. Karpecki may be reached at the Eye Center of Kansas City, 5520 College Blvd., Overland Park, KS 66211; (913) 491-3737; fax: (913) 469-6686. Dr. Karpecki has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Discuss with patient first

Christopher Quinn, OD: In our referral center practice, we encourage our referring doctors to become actively involved in the process of selecting and recommending a certain refractive outcome for their patients. Cataract surgery today has become much more of a refractive procedure, and those doctors who get involved with the refractive outcome of their patients will be rewarded with high levels of patient satisfaction.

Each patient should receive a careful explanation of the expected refractive results and the options available for the correction of their refractive error postop. This discussion should take place before the patient consults with the surgeon. Some of the most dissatisfied patients are those who result with excellent best-corrected visual acuity but are unhappy or uncomfortable with their refractive result. Examples include those with anisometropia, those with residual astigmatism or those who just never understood that they may need reading glasses after surgery.

Our options for correcting refractive error after surgery are enhanced by careful preoperative testing (keratometry and A-scans) and by considering the wide variety of options for correcting postop refractive errors. Today, with toric IOLs, multifocal IOLs, astigmatic keratotomy and post-cataract LASIK, patients expect to know their options, and the family optometrist is the best one to explain it to the patient and then communicate the patient’s needs to the surgeon.

Christopher Quinn, OD, is in private practice at Omni Eye Services. He can be reached at 485 Rt. 1, Ste. A, Iselin, NJ 08830; (732) 750-0400; fax: (732) 750-1507; e-mail: cqod@home.com.