BLOG: Talking with patients is critical to IOL postop success

ByJosh Johnston, OD, FAAO

In my previous blog, I noted that successful cataract surgery not only achieves its refractive target but also makes the patient happy and satisfied with his or her visual outcomes. It is all predicated on properly laying the ground work.

One of the most critical aspects of this preparation is optimizing the ocular surface to allow for the best postoperative vision possible. A careful clinical exam and the identification of any existing ocular pathology are also imperative.

Here I will further discuss IOL selection, postoperative concerns and refractive enhancements.

IOL technology

Multifocal, accommodating and extended depth-of-focus (EDOF) technologies are available for correcting presbyopia and astigmatism at the time of cataract surgery. Multifocal lenses work by splitting light into distance and near focal points, lessening the need for spectacles in those situations. These lenses may be contraindicated in some patients, as mentioned earlier. The lenses are available in high, mid and low add powers; the lower add powers are associated with less glare.

Accommodating lenses work by moving and flexing in the capsular bag, thus allowing for good distance and intermediate vision. Patients will not have to worry about glare and halo, but they will sacrifice near vision. Thus, the technology is a fit for patients who do not read, and examples include the Crystalens AO and Trulign (both from Bausch + Lomb).

More recently, we have added EDOF lenses to the conversation with patients. This new class of IOLs (Symfony, Johnson & Johnson Vision) provides good near and great intermediate and distance vision. The Symfony’s wide defocus curve allows for a larger sweet spot when hitting the refractive target, and the lens tends to better tolerate decentration, higher-order aberrations and residual refractive errors and astigmatism compared with a multifocal IOL. EDOF technology tends to be more forgiving.

Remember that a little handholding and extra customer service can make all the difference between a satisfied patient and an unhappy one. Take the time to explain what costs are covered and what will be paid for out-of-pocket by the patient.

Enhancements may be needed

Of course, the No. 1 patient frustration is residual refractive error. Optometrists should explain that enhancements after cataract surgery can be necessary and what form they can take such as, LASIK, PRK or limbal-relaxing incisions. Nd:Yag capsulotomy is often perceived by patients as a complication to cataract surgery. This is a conversation that should take place before surgery.

Comanaging optometrists can work to rule out any factor that may be having an impact on vision or the accuracy of refraction. Causes of blurred visual acuity/postoperative complications may include:

corneal edema;
pharmacologic mydriasis;
retinal detachment;
prolapsed iris;
corneal abrasion;
endophthalmitis;
bullae from increased IOP/edema;
elevated IOP;
residual viscoelastic in anterior chamber;
residual cortex in anterior chamber, posterior chamber;
decentration of IOL, subluxed IOL;
IOL in sulcus secondary to torn bag;
vitreous in anterior chamber; or
secondary uveitis.

Ocular surface disease should be reevaluated, and posterior capsule opacification should be checked. To enjoy optimized refractive outcomes, cataract surgeons must have:

accurate preoperative refraction, keratometry and biometry;
ongoing evaluation of surgical outcomes; and
modification of protocols based on outcomes.

The most important thing to remember is that an unhappy patient wants to be heard. It is critical to talk through patients’ results and find out their level of satisfaction. Comanagement postoperative cataract examinations should entail:

Perform a follow-up examination at 1 week and 1 month.
Monitor visual acuity.
Follow the patient for cystoid macular edema.
Monitor IOP.
Manage patient expectations.

For toric IOL patients:

Check proper axis alignment.
Dilate the patient, look at axis indicators.
If off-axis, the surgeon may need to rotate/realign in the operating room.

For patients with multifocal IOLs:

Educate patients on glare, halos and neuroadaptation.
Look for proper centration of the IOL.

For patients with accommodating IOLs:

Cycloplege patients for 2 weeks after surgery to prevent ciliary body movement and IOL shifting anteriorly.
Use readers for 2 weeks for near work to prevent a myopic shift.
After 2 weeks discontinue readers and begin near exercises to strengthen the ciliary body.

Remember, surgeons treat patients, not the eye chart. If an additional procedure is required, reassure patients that their results can likely be improved. It is important to not be defensive, but rather work with the patient to establish a game plan. They look to their eye care provider to be an advocate.