BLOG: How to talk to patients through the cataract process

ByJosh Johnston, OD, FAAO

Successful cataract surgery – one that achieves its refractive as well as “happy” target – depends on properly laying the groundwork.

Certainly, we all know that cataract surgery today is truly refractive surgery, and patients’ expectations are higher than ever. Being aware of this up front, comanaging optometrists can then be finely tuned to the preoperative examination and discussion with patients.

Preoperative exam: Seek information, treat dry eye

For example, as part of the proper detailed case history, note pertinent personality traits and try to understand what is important to the patient. Identify his or her primary visual demands and their primary visual goals with surgery. In other words, ask the right questions. Many suboptimal outcomes are due to pre-existing ocular surface problems. The clinical workup to assess ocular health must include a comprehensive slit-lamp examination and evaluation of the ocular surface and tear film with diagnostics tests.

Diagnostic tests could include:

Dyes/stains such as sodium fluorescein, lissamine green
Tear break-up time
Tear meniscus height
Tear volume/production testing
Tear assay
Tear osmolarity equipment
InflammaDry (Quidel)

If the patient requires ocular surface treatment prior to surgery, in my practice we use a combination of agents including over-the-counter medications, prescription topical drops, nutritional supplements, and the proper management and treatment of systemic disease.

Optometrists also have available a variety of in-office treatments, ranging from LipiFlow (Johnson & Johnson) and intense pulsed light to other solutions like punctal occlusion, meibomian gland expression, amniotic membranes and even autologous serum.

To prevent postoperative surprises, it is crucial to identify any potential coexisting factors that may limit visual outcomes such as recurrent corneal erosions, corneal scar or pterygium. A number of other conditions can lead to limited outcomes after surgery, including corneal edema and guttata, amblyopia, previous trauma, weak zonules, retinal pathology, advanced glaucoma and binocular vision problems.

Expectations, IOLs

The preoperative conversation with patients is the foundation on which the optometrist places the patient’s expectations. Explain to them what glare and halo are and what causes them. Remind patients that there is some amount of neuroadaptation required for multifocal IOLs and extended-depth-of-focus IOLs. What level of independence from glasses is reasonable after surgery? Ensure there is alignment with what the patient expects.

Matching patients to the right technology is an important aspect of achieving refractive targets. Toric IOLs for example (AcrySof IQ Toric, Alcon; Tecnis Toric and Tecnis Symfony Toric, Johnson & Johnson Vision) provide excellent outcomes and decreased dependence on glasses and contact lenses for distance vision.

Next time, I’ll review the implant options and how to discuss postoperative enhancements. Laying the groundwork and being thorough are the best ways to ensure your cataract patients are ready for the surgical procedure as well as prepared for the overall experience. Clear communication enables effective education, leading to consistent outcomes. Remember, it takes a village to care for our patients.