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Open communication in cataract comanagement essential for patients’ health, comfort
The patient’s interests come first in any surgery; therefore, it is vital that surgeons and comanaging optometrists effectively work together to provide the best possible care to postcataract surgery patients.
“Cataract surgery is a profound experience in most patients’ lives, and together we need to make sure that it’s a smooth, comfortable and painless one — and one without fear or anxiety,”
Exchange mobile phone numbers
“The most important thing in a successful comanagement relationship is open lines of communication between the surgeon’s and the comanaging optometrist’s offices,” Hovanesian continued. “I give my cell phone number to all of the referring doctors that I work with so they can contact me directly at any time no matter where I am. And I encourage them to use the cell phone number because it bypasses any other challenges that might compromise their ability to communicate. Very often, a 3-minute phone call can answer questions that might put aside fears of a complication or allow the patient to be referred back more urgently if the case is serious enough.
“Good follow-up and good sharing of information is essential,” he said.
Iritis after a complicated cataract surgery.
Image: Karpecki PM
PCON Editorial Board member
“Having each other’s cell phone numbers is a must,” he said. “There must also be documentation, such as a referral letter and a postsurgery letter, outlining the procedure, the results and the follow-up schedule. I also believe that email addresses and office numbers are necessary to have.”
Karpecki added that the surgeon or the optometrist in the surgery office that serves as the clinic’s medical director should be the one who opens the lines of communication so the comanaging doctor never feels as though he or she is intruding, or that he or she cannot call because a question may be too basic.
“The most important thing the ophthalmology or surgical practice should know is they are in a privileged position to be receiving these patients,” Karpecki said. “The patient should be treated well, the comanaging doctor should be respected, and the patient should be returned for postoperative care and primary care needs in routine or uncomplicated cases.”
The optometrist should remember that when comanaging a complicated patient, they do not have to go it alone, he said. “If they have questions, they should pick up the phone and call the surgeon or center director optometrist.”
According to Hovanesian, this is a point that cannot be stressed enough — not only so comanaging optometrists know exactly when to refer a patient back to the surgeon, but also so they can educate the patient about the problem and what the surgeon will be doing to correct it.
For example, if an intraocular pressure of 30 mm Hg postoperatively is sustained beyond 48 hours, or if the pressure increases after this time, this would signal a departure from the normal postoperative course. The clinician would suspect lens particles or a steroid responder effect, Hovanesian said.
To rule out lens particles, the clinician would look for signs of anterior chamber inflammation with anterior chamber angle gonioscopy, he said. Also, a dilated fundus exam would allow the practitioner to look for retained lens particles in the vitreous, and sometimes B-scan ultrasound may be necessary.
If the optometrist feels comfortable releasing fluid from the anterior chamber, which can safely be done in the office, that would rapidly lower the IOP, he said.
“Alternatively, topical medications can be added,” Hovanesian said. “For this, I like brimonidine because it has a rapid onset of action and a rare side effect profile, at least during short-term use.”
Karpecki follows a similar approach and typically recommends a combination drop of brimonidine/beta-blocker provided the patient has no respiratory issues.
Know your level of experience
The optometrist’s level of involvement with treating postoperative complications depends on his or her experience and comfort level, Hovanesian said.
“There’s a big difference between somebody comanaging his first and somebody comanaging his 500th cataract patient,” he said. “In a lot of cases, there are very capable ODs who can handle pretty complicated patients and do so with the same skill that a surgeon would.
“You just have to be honest with yourself as to what your experience level is,” Hovanesian said. “We have to put our ego second and the best interest of the patient first. That’s a really important guiding principle for surgeons, too.”
The geographical distance between the surgeon and comanaging optometrist may also dictate who handles any postoperative complications.
Either way, the surgeon can still be involved in the treatment on an advisory basis, Hovanesian said.
“By definition, when there are complications, things are not going in the normal pathway, so there is no recipe that fits every situation,” he said. “The fact is that most surgeons have more experience dealing with more kinds of complications than most referring ODs by nature of our work. There’s a wide range of knowledge, so we really need to be involved in the process of screening some of these challenges.
“The bottom line is don’t hesitate to contact a surgeon about something that concerns you, even if you think it may not be too serious,” he continued. “We, as surgeons, want to know how our patients are doing and we want to have feedback on our surgical techniques and how they worked.”
Karpecki agreed. “All findings should improve with time, but if they get worse, that could be serious. If you feel like something’s not right, even if it’s a hunch, call the surgeon,” he said.
Karpecki added that it also a good idea for optometrists to continue to educate themselves in this area. “Know what findings are normal for any postcataract patient and what constitutes a complication. Also, visit the center you comanage with and observe the postops and the cataract surgery.” – by Daniel R. Morgan
For more information:
- 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; fax: (949) 380-7856; drhovanesian@harvardeye.com. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Phasellus id dolor est.
- Paul M. Karpecki, OD, FAAO, can be reached at Koffler Vision Group, Eagle Creek Medical Plaza, 120 N. Eagle Creek Dr., Suite 431, Lexington, KY 40509; (859) 263-4631; paul@karpecki.com.