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Patient evaluation, education, lead to refractive cataract surgery success
Communicating what the surgeon needs to know ensures optimal outcomes.
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Optometrists have a critical role to play in guiding our patients through the experience of cataract surgery. Even though surgical technology and intraocular lenses have never been better, the basics – refraction, ocular surface care and history-taking –are still essential for success. As someone who sees hundreds of pre- and postoperative patients, I think there are three steps that would help every patient get more out of surgery.
The first is to optimize the patient’s tear film prior to cataract surgery referral so surgery does not have to be delayed. Without a good tear film, we cannot obtain accurate IOL Master (Carl Zeiss Meditec), topography and keratometry measurements, which makes it difficult to select the correct IOL power and hit the desired refractive outcome the first time. Ocular surface health also affects the postoperative quality of vision, which has a direct impact on satisfaction.
Second, it is helpful if the referring doctor makes the patient aware that there are options to correct their astigmatism and reading vision at the same time as cataract surgery. Not only does this save time at the surgery center, but it reinforces trust in the referring OD and his or her base of knowledge about the surgery.
Finally, referring doctors should convey any relevant information from the patient’s history and vision correction experience that can help with IOL selection. For example, if the patient tried 10 different multifocal contact lenses and was not happy with any of them, that suggests we should be conservative in recommending multifocal IOLs. Or, if the patient has had good success with monovision in the past, he or she might be an excellent candidate for surgical monovision. The doctor who has years of experience with that patient is well positioned to supplement what we can learn during our relatively brief encounters at the surgery center.
Achieving patient satisfaction
We find that it is helpful to reduce the time between the first-eye and second-eye surgery for patients undergoing refractive cataract surgery. This is especially true in patients with very high preoperative refractions. In fact, we have moved from treating both eyes a week or a day apart to same-day sequential surgery. This may not be possible in many settings, but reducing that interval is important.
For any patient who wants spectacle independence for near, I take the time to obtain a bit more information about what “near” means in their world. For example, I present a reading card upside down to patients (giving it to them upside down causes them to readjust the reading distance to something they are comfortable with as opposed to just holding it at whatever distance it is given to them). When they flip it around to read, I get a good indication of where their ideal reading distance is.
I also ask patients how they spend their days. A patient who works all day at the computer will do well with bilateral extended depth of focus (EDOF) lenses, but someone who spends a few hours a day at a computer but also likes to read or sew may be a better candidate for the mixed-IOL approach I describe below. I also talk to every patient about night vision symptoms and the possible need for some mild readers for smaller print postop. The latest EDOF and low-add multifocal IOLs have greatly reduced the incidence of night vision issues, but I want patients to be pleasantly surprised by that, not bothered by a symptom they did not expect.
Custom-matched IOLs
We have found that an ideal combination to meet most patients’ visual goals is a Tecnis Symfony EDOF IOL (Johnson & Johnson Vision) in the dominant eye, paired with a low add (+3.25 D) Tecnis Multifocal in the nondominant eye. With this combination, patients maintain excellent distance and intermediate vision but get a little extra boost for their near vision thanks to the multifocal.
We recently conducted a single-center, prospective study to evaluate the effect of combining these two IOLs in 50 patients undergoing bilateral cataract surgery, with the two eyes treated about 24 hours apart. At the time, the Symfony toric was not yet available in Canada, so some patients who required an enhancement to correct astigmatism were removed from the analysis. In all, 3-month results are available for 32 subjects.
Of these, 97% had binocular uncorrected distance visual acuity (VA) of 20/20 or better, 97% had uncorrected intermediate VA of 20/25 or better, and 94% had uncorrected near VA of 20/25 or better at 3 months. The mean patient-selected best near vision was 37.2 cm, with mean VA of 20/22 at that distance. The majority (97%) of subjects reported no ocular symptoms (glare, halo, starbursts or blur) at 3 months.
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The data confirmed my expectation that customization of IOLs can provide better visual outcomes that are more likely to lead to full spectacle independence.
Postop management pearls
I typically see patients at 1 day and 1 week, and then send them back to their regular optometrist for the 1-month visit and beyond. It is important to recognize that one has to push plus in refracting patients with an EDOF IOL. Start at +1.50 D and move toward plano until the patient is reading the 20/20 line. That will give the spherical refraction. When I receive a postop stating that the patient is refracting at -1.00 D but sees 20/20 uncorrected, the likelihood is that the refraction was not correct. That patient does not need an enhancement — and he or she certainly does not need progressive spectacles. If anything, +1 D readers may be helpful for prolonged near work; otherwise, the lenses are doing exactly what they are supposed to do.
I have seen posterior capsular opacification earlier in younger patients. We like to wait for 3 months before doing Nd:YAG surgery, but only if we know an IOL exchange is not necessary.
The postop protocol for EDOF lenses includes Vigamox (moxifloxacin, Alcon) four times daily for a week, a 4-week Maxidex (dexamethasone, Alcon) taper beginning with four times daily and Ilevro (nepafenac ophthalmic suspension 0.3%, Alcon) once daily for 6 weeks. We put all patients on lid scrubs and Thealoz (Thea) drops before and for 6 months after surgery. We may also prescribe Restasis (cyclosporine A 0.05% ophthalmic emulsion, Allergan), Xiidra (lifitegrast ophthalmic solution, Shire), omega-3s or other agents on a case-by-case basis.
Comanaging doctors also need to encourage patients to continue to use their artificial tears after surgery. I have seen patients referred back for an enhancement consultation who simply had dry eye-related blur.
Finally, it is important to be encouraging. Any number of situations — the need for Nd:YAG surgery or enhancement, for example — can delay the result the patient is hoping for. It is important that we reassure the patient that everything will be all right.
Refractive cataract surgery is truly a great opportunity for patients to achieve the vision they want, and we are fortunate to travel on that journey with them.
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- Sondra Black, OD, was vice president and clinical director at Crystal Clear Vision in Toronto, Canada, which is part of the NVision Eye Center Network, but is currently an independent consultant. She is also a member of the Primary Care Optometry News Editorial Board. She can be reached at: drsblack@yahoo.ca.
Disclosure: Black reports she is a consultant to AcuFocus, Johnson & Johnson Vision, Labtician Ophthalmics and VGC.