What is the role of the optometrist in managing cataract surgery patients before surgery?
In the preoperative examination, it is the optometrist’s role to make sure the patient’s ocular health is acceptable to undergo cataract surgery. A careful examination of the anterior and posterior segments must be performed, looking for dry eye syndrome, meibomian gland dysfunction, keratoconus or irregular astigmatism, Fuchs dystrophy and other corneal conditions, glaucoma, retinal holes, epiretinal membranes … the list goes on.
That really is just the beginning of the process of preparing the patient for cataract surgery. Patient education is also crucial. It takes time, but it saves time in the postoperative period. These are some of the lessons we attempt to convey to cataract surgery patients preoperatively.
Review visual goals and IOL technologies.
It is imperative to educate the patient on all the IOL technologies that are available to achieve their visual goals. This may mean a monofocal, multifocal, extended depth of focus, or toric implant—whichever is best suited to achieve the visual goals of the patient.
It may take time.
We explain that the patient is getting a brand new visual system. It is not going to be perfect on day 1, and it will take time for him or her to adjust and adapt to the new visual system.
It requires motivation.
Patients must recognize they have a visual issue (visual disability due to cataract) and be motivated to move forward with cataract surgery. The same is true about advanced IOL technologies. Patients will adapt better to an advanced technology if they are motivated to have it.
It requires belief.
Patients need to believe in the team that will be doing their cataract surgery and believe in the technology they have chosen to enhance their postoperative vision.
It requires support.
Patients need support from the optometrist in the postoperative period. Letting patients know in the preoperative period that you will be available to them after surgery can be comforting.
How does your approach vary in the presence of comorbidities such as dry eye disease or glaucoma?
Dry eye syndrome can and will affect the visual outcomes of patients after cataract surgery. I make sure to do a careful examination of the ocular surface in each patient, looking for signs of ocular surface disease. I use sodium fluorescein to look for corneal staining, evaluate tear breakup time, and order meibomian gland imaging if I suspect meibomian gland dysfunction on examination. If ocular surface disease exists, I initiate treatment before the patient undergoes cataract surgery. If the ocular surface disease is causing changes significant enough to alter biometry measurements and topography measurements, I postpone cataract surgery until those measurements normalize.
Patients with comorbid cataracts and glaucoma are not uncommon, as the prevalence of both diseases increases with age. The emergence of microinvasive glaucoma surgery (MIGS) procedures has changed the way patients with cataracts and glaucoma are managed. Many times, a patient will have mild to moderate glaucoma and a visually significant cataract. This is an opportunity not only to improve the patient’s visual quality but also to treat the glaucoma with a MIGS procedure done in combination with the cataract surgery.
What tactics does your practice use to educate patients on their condition and upcoming surgery?
I outlined some of our patient education goals above. Our team of technicians spends a lot of time doing all the diagnostic testing needed to prepare the patient for cataract surgery. They have a great understanding of the technologies we offer and the cataract procedure itself, so they are on the front lines of the initial education as it pertains to cataract surgery. While the patient waits for the doctor, a video plays in the room discussing the cataract procedure. Finally, the doctor has a thorough discussion on the cataract procedure. So patients are educated on the procedure three different times while they are in the clinic for the preoperative examination.
How do you measure success in cataract patients?
Our patients return to our clinic for an appointment about 3 months after their surgery so that we can discuss with them their satisfaction or dissatisfaction with their vision. This is a great time to take the next steps that are necessary to take patients who might be at the 5-yard line and not quite satisfied with their vision and get them into the end zone. Those steps may involve maximizing the ocular surface with dry eye treatment, considering an Nd:YAG laser capsulotomy, or considering fine tuning with refractive surgery.
We use the term “20/happy” in our clinic. A patient with 20/25 uncorrected vision, a healthy eye, and a small residual refractive error may be just thrilled with how he is seeing. Another patient with 20/20 uncorrected vision may be disappointed with how she is seeing because of subtle dry eye disease or the beginnings of posterior capsular opacification. It is important to listen to the patient and not make all treatment decisions after cataract surgery based only on visual acuity.
What is your schedule for follow-up visits?
Our patients return to us or the referring doctor on day 1, week 1, month 1, and month 3. Patients who have chosen an advanced IOL technology return to our clinic around 3 months postoperative for an advanced vision analysis. This visit allows us to assess the satisfaction they have with the advanced IOL technology that they have chosen.
What are the most common medication treatment regimens you employ?
Treatment regimens for postoperative care in cataract surgery continue to evolve. We offer patients two options, as long as there are no contraindications. One is the traditional approach of a topical antibiotic, topical steroid, and topical NSAID. The other is an intracameral injection of dexamethasone and moxifloxacin (Dex/Moxi 1 mL; Imprimis Pharmaceuticals) at the time of cataract surgery plus the use of an NSAID postoperatively. NSAIDs to be considered are bromfenac ophthalmic solution 0.075% (BromSite, Sun Pharma), bromfenac ophthalmic solution 0.07% (Prolensa, Bausch + Lomb), and nepafenac ophthalmic suspension 0.3% (Ilevro, Alcon).
In your integrated practice, who typically prescribes medication, and what is the preferred treatment pattern?
In our practice, the optometrists do the preoperative examinations to prepare a patient for cataract surgery, and they discuss the two options described above for postoperative medication for cataract surgery. Most patients choose the injection approach, as they enjoy the simplicity of it.
What is the most common barrier to creating a happy postoperative cataract patient?
It is important to set realistic visual expectations preoperatively in order for patients to achieve a happy outcome postoperatively. Early in my career, someone showed me this equation:
Patient Satisfaction = Results – Patient Expectations
The message here is that, if the correct visual expectations were not established with the patient, even if the cataract surgery is done perfectly, then patient satisfaction can and likely will suffer.