Cataracts are an inevitability. If you live long enough, you will have cataracts. But cataract surgery is elective surgery. The determining factor in moving forward with surgery is the patient’s perception of his or her own visual limitations due to the developing lens opacity. In other words, it is time to do something about it when the patient is bothered by the cataracts.
As primary eye care providers, optometrists see patients throughout their lives, and therefore optometrists are the ones who field many of the questions patients will have as their vision begins to be affected by cataracts. We are the ones who can tell patients what to expect—what is involved with cataract surgery, what the risks are, what the outcomes are likely to be, and so on. And we are the ones, in most cases, who will see these patients again after surgery, not only for postoperative follow-up care but for continued care through the rest of their lives.
It is vital, therefore, that optometrists play the role of educators for their patients who are dealing with the onset of cataracts. There are fears associated with the safety and risks of the procedure. There are questions about the level of experience of the ophthalmologist they will be referred to. There are discussions to be had about which vision-correction options are best. There are myths to be addressed, and, importantly, there are appropriate levels of expectation to be set. Optometrists are in the best position to address all of these perioperative issues.
DIAGNOSIS AND REFERRAL
As mentioned above, it is the patient’s perception of his or her own debility that determines when it is time for cataract surgery. The optometrist can measure visual acuity, but it is up to the patient to determine when night driving problems, halos around lights, or other markers of poor vision become bothersome enough to warrant surgery.
Once the diagnosis is made, the optometrist must do a thorough preoperative workup to help determine the best options for the individual patient. One vital area to explore is the condition of the ocular surface. Is dry eye disease present? Does the patient have an epithelial basement membrane dystrophy or some type of other ocular surface condition? Any problem like this should be addressed prior to referral.
This is a valuable role that optometry can play prior to surgical referral. When ocular surface issues are addressed before referral, the surgeon will obtain more accurate biometry measurements, which leads to more accurate lens selection, a happier patient outcome, and fewer postoperative problems with dry eye disease. This is particularly true if the patient is interested in selecting a premium IOL that corrects astigmatism or provides multifocality.
Counseling on IOL selection is another area in which optometrists can make a big difference before referral. There are many IOL options today, and patients need to know the advantages and tradeoffs for all of the IOL choices on offer.
Monofocal lenses are the most common type of IOLs, providing correction at a single focal length. IOL power is selected based on biometry, keratometry, and other measurements, fed into one or more IOL power calculation formulas.
Many patients today are interested in avoiding or minimizing the need for spectacles or contact lenses after surgery, so correction of presbyopia is increasingly important. Monovision is one way to allow a patient to see both near and distance using monofocal lenses, with one eye corrected for near and the other for distance. Some patients can tolerate monovision and some cannot. The optometrist can offer a trial with monovision contact lenses for those who may be interested in this option. The principal tradeoff with monovision is some degree of loss of stereopsis because of the different foci in the patient’s two eyes.
Multifocal IOLs provide simultaneous vision at two or more distances—near and distance. The advantage is the reduction in need for external correction. Tradeoffs can include halos and glare, reduction in contrast sensitivity, and a period of neural adaptation as the brain learns to deal with the projection of multiple simultaneous images on the retina.
Many patients have some degree of astigmatism, and for these patients a toric IOL may be the best solution. Recently, US surgeons gained access to a multifocal toric IOL, so now it is possible to correct astigmatism and provide multifocality all in one lens. In my opinion, a patient with astigmatism has a great opportunity to see better at distance if the astigmatism is corrected with a toric IOL or multifocal toric IOL.
Another recent choice in IOL selection is an extended depth of focus IOL. This IOL gives a range of clear vision from intermediate to distance using “echelette” technology combined with spherical and chromatic aberration correction. It is also available with astigmatic correction.
One of the biggest challenges in the IOL discussion is communicating all of these options to patients in a way that makes sense and does not overwhelm them. Patients will have questions. It is a good idea to provide brochures when possible, or to have some of this information available on your practice’s website where patients can find it easily.
As with any surgery, it is important to set patients’ expectations appropriately. There can be visual symptoms after surgery, such as seeing glare or halos at night, especially with multifocal IOLs and, to a lesser degree, extended depth of focus IOLs. Additionally, it is important for patients to understand that the surgeon may not hit the refractive target on the nose, and an enhancement procedure may be necessary to achieve plano correction, or as close to it as possible. This might take the form of an excimer laser refractive correction if the cataract surgeon also performs refractive surgery.
Patients must also understand that, despite our best efforts and those of the surgeon, spectacle correction may be necessary after cataract surgery. It is best never to promise that the patient will be free of glasses postoperatively. Better to under-promise and over-deliver, which makes for happier patients.
Another delicate conversation concerns the limitations of insurance and the need for out-of-pocket payments. Insurance and Medicare cover only the cost of a standard monofocal IOL. The costs of premium IOLs, including toric and multifocal IOLs, are not completely covered, and patients must pay out of pocket for the balance of the cost of the IOLs. These prices can be significant.
Therefore, it is important for optometrists to establish not only what their patients want, but also what they can afford, and whether they are willing to pay for the convenience provided by the premium IOL. The discussion of costs should not be delayed until the patient is sitting in the surgeon’s examination lane.
TAKE THE TIME
During the cataract evaluation, there is a lot going on—tests, lights, measurements, etc. It is a challenge for patients going through this process, so it is important for the optometrist to take the time to walk them through the process. Provide written information and allow them time to ask follow-up questions and explore their options on the internet. Patients do not always have a chance to voice concerns with the surgeon.
Leading up to surgery, education is vital. Optometrists are positioned to offer advice and perspective on surgery and IOLs ahead of time and assess patients based on their habits and personalities. Not all patients are good candidates for every IOL option. When expectations regarding the procedure and results are properly managed, patients are better prepared for the experience and they understand the possible compromises involved in their IOL choices.
Whether the concern is safety, side effects, astigmatic correction, or a comparison of monofocal, extended depth of focus, or multifocal IOLs, patients require clear and effective communication before making decisions regarding their options. As primary eye care providers, optometrists are the best sources of this information. We must help guide these decisions accordingly, having typically established a relationship with patients and earned their trust over time.