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BLOG: Toward fewer bad surprises
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A refractive surprise after cataract surgery is a dreaded outcome for the surgeon and, more importantly, a satisfaction killer for patients. No matter what type of implant or procedure is used, patients’ satisfaction depends on the accuracy of refractive outcomes.
Paying close attention to the details of the steps necessary during patients’ preoperative evaluation will minimize the risk of an unwanted postoperative surprise.
Track data, perfect a process
It is important that we optometrists partner with ophthalmologists who recognize the importance of tracking cataract outcomes to truly optimize their outcomes. By analyzing their own data, surgeons who offer premium IOLs can develop a “surgeon factor” for their own cases, thereby increasing their success.
Our role in comanaging cataract patients is to provide the surgeon with important information about patients’ ocular health and visual needs. One factor to consider is the accuracy of corneal measurements on eyes that have been altered by previous refractive surgery or contact lens wear, both gas permeable or soft modalities. Additional calculations and formulas may be used to account for the differences.
Measure, measure, repeat
To start, precise biometry is integral to outcomes, as everything that follows in the process depends on this step. Axial length measured by ultrasound has been the gold standard, and the addition of optical biometry further enhances accuracy and adds more data. Accurate corneal measurements can be obtained with keratometry, Placido disc topography, scanning-slit topography, Scheimpflug-based systems and color-LED topography that uses ray-tracing technology. It has been suggested that for up-to-date IOL calculations, surgeons use three-variable formulas or more accurate theoretical calculations like the Holladay 2 or the Olson.
It is important that scans are repeated if axial length or keratometry measurements are inconsistent between the two eyes or do not correlate with the clinical picture. Surgeons should always delay surgery until they can obtain consistent, reproducible and high-quality measurements.
Additional diagnostic tests may include endothelial cells counts, pachymetry and B-scan ultrasound to identify risk factors.
Rise to the challenge
Once again, the importance of avoiding refractive surprises lies in patients’ high expectations for their outcomes after cataract surgery. If the patient is paying out of pocket for a premium procedure or implant, the pressure is even higher to nail the refractive outcome.