The many advances in cataract surgery in recent years have led to better outcomes and highly satisfied patients. Nonetheless, we’ve all had patients walk into our office unhappy with their results after cataract surgery, and it probably happens more often than we’d like.
There are many ways to ensure that patients have a pleasurable experience with cataract surgery, and that experience starts with you, their primary eye care provider.
Patients typically take your recommendation regarding choice of a surgeon to perform their cataract surgery. Therefore, it’s important to familiarize yourself with the techniques, lens options (ie, extended depth of focus [EDOF] IOLs, multifocal IOLs, toric IOLs), and technologies used by your preferred surgeon. Take the time to shadow the surgeon in the clinic and in the OR. You’ll get a better understanding of what your patients’ experiences will be when they arrive for their evaluation and surgery.
Before referring a patient, perform a thorough examination of the anterior and posterior segments. Patients with signs of blepharitis, dry eye syndrome, or corneal conditions should be aggressively treated before referral. This may require starting patients on artificial tears, lid hygiene regimens, or antiinflammatory drugs such as cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), lifitegrast ophthalmic solution 5% (Xiidra, Novartis), or a steroid. For other patients, in-office procedures such as punctal plug insertion, meibomian gland procedures, or microblepharoexfoliation may be needed. Actively treating these conditions will help optimize the patient’s results and prevent infection.
Additionally, patients with preexisting conditions that might affect the visual outcome of surgery, such as epiretinal membrane, diabetic macular edema, or amblyopia, should be informed of this before referral.
Let patients know what to expect during the evaluation and surgery, and educate them regarding the types of IOLs available, including toric IOLs for patients with astigmatism and multifocal or EDOF lenses for those interested in presbyopia correction.
Be sure to tell patients that these premium lens options may give them freedom from glasses at some distances, but they may still need them for near vision or certain tasks. Make sure to set proper expectations by emphasizing that they will not be completely independent of glasses. Also, provide patients with educational materials about cataract surgery so they’re well prepared when they meet the surgeon. Many surgical practices will have this information available as well.
There will be many patients who don’t achieve 20/20 vision after surgery but are nonetheless happy with their results, and there will be others who achieve 20/20 but are still unhappy. Both types of patients must be examined to determine why they are not seeing 20/20 or are dissatisfied.
Before examining patients postoperatively, I believe it’s best first to listen to the patient’s complaints. This shows him or her that you are concerned and helps you form a better understanding of what may be the underlying issue. For example, if a patient complains of a sandy, gritty sensation, this is likely due to dryness, whereas a patient complaint of hazy, cloudy vision could be caused by corneal edema, inflammation, or macular edema.
Some patients may tell you about their friends who could see clearly the day after their surgery. I explain to these patients what is causing the decreased vision or other symptoms, and I reassure them that their vision should continue to improve. After listening to the patient’s complaints, I like to approach the examination on a step-by-step basis.
Step No. 1: Evaluate the Surface
The ocular surface is where many patients’ complaints originate. The patient’s VA and manifest refraction evaluation may give clues about dryness as well, especially if the patient has to blink multiple times or the refraction is inconsistent.
If the patient had a diagnosis of dry eye preoperatively (see the section on Preoperative Evaluation), he or she should be aware that dry eye may become worse during the postoperative period and may now have to be treated more aggressively. As many surgeons temporarily suspend patients’ use of lifitegrast or cyclosporine during the postoperative period, these patients may need to use artificial tears frequently. I often insert punctal plugs during the postoperative period because using multiple drops can be difficult for many patients.
Some generic drops can be toxic to the cornea because of their preservatives and can cause significant dryness. If possible, prescribe branded medications, as they do less damage to the cornea.1 Additional treatments may include application of a gel or an ointment at night and in-office procedures that are usually performed after discontinuation of the postoperative drops.
Step No. 2: Evaluate for Inflammation
Rebound inflammation can often frustrate patients, especially once they have finished their medications. In these patients, topical medications should be tapered slowly to prevent further flare-ups. This is important in individuals with a history of uveitis.
If the inflammation is difficult to control or is not improving after switching to a more potent topical steroid such as difluprednate ophthalmic emulsion 0.05% (Durezol, Novartis) or to oral steroids such as a methylprednisolone dose pack, the surgeon may need to intervene to consider other modes of treatment, including sub-Tenon injection.
Step No. 3: Evaluate the IOL
Check for centration in an undilated pupil, especially in patients with an EDOF or a multifocal IOL. If the refraction is not consistent with the goal from surgery, the patient should be dilated to check for cystoid macular edema (CME), toric IOL misalignment, and posterior capsular opacification.
If a toric IOL patient has residual astigmatism >0.50 D any time after the week 1 postoperative examination, the IOL has likely rotated, and this will probably require surgical intervention. Additionally, if there are signs of posterior capsular opacification that correlate with the patient’s complaints and vision, the patient should be referred back to the surgeon for Nd:YAG laser capsulotomy. Inform the patient that most surgeons typically wait about 90 days before performing the laser procedure.
Step No. 4: Evaluate the Retina
A decrease in vision, complaints of floaters, or hazy vision may signify CME, especially if anterior segment findings are within normal ranges. Patients should be dilated to check for further retinal pathology and evaluated for CME. Many times, CME is subtle and may require OCT to confirm the diagnosis. Treatment for CME can vary across surgeons, so it’s important to become familiar with your cataract surgeon’s protocols and to communicate with him or her about any of these issues.
Step No. 5: Evaluate the Patient
Why is the patient unhappy? IOL exchange, dysphotopsia, halos? Whatever cause you identify, reassure your patient that you will work with the surgeon to address the issues and form an appropriate management plan.
COMMUNICATION IS KEY
Building a strong relationship with the surgeon and communicating well with him or her are key factors in properly managing cataract patients. In many instances, you will be able to address and successfully treat patient complaints yourself. However, in some cases the surgeon will have to become involved. The referring provider should send chart notes that include previous treatments in order to ensure that the surgeon is fully informed and the patient receives the best care.
Listening to the patient is the first step in working toward achieving your patient’s happiness following cataract surgery. Examining and treating your patient to your full capabilities will help you build rapport with both the patient and the surgeon.
When you explain a problem to an unhappy patient, use terminology that the patient can understand. In situations in which further treatment and evaluation by the surgeon are needed, communicate and collaborate with the surgeon before the patient sees him or her.
By following these steps, you can provide your patients with cataracts with the care they need to ensure their successful and happy outcomes.
1. Caceres V. Brand vs. generic ophthalmic medications. EyeWorld. February 2016. www.eyeworld.org/article-brand-vs–generic-ophthalmic-medications. Accessed September 16, 2019.