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Why Optometry Must Become Even More Involved in Cataract Comanagement

Setting your patients and surgeon up for success.

At A Glance

  • The time has come for optometrists to change their mindset and to integrate into the surgical process for better patient outcomes.
  • Optometrists need to become more efficient in serving patients, which means more than just surgery. It means evaluation, education, counseling, and providing decision-making assistance preoperatively, as well as providing what will be a tremendous number of postoperative care visits.
  • Our goal is to match patients’ long-term needs to today’s technologies.

There is increasing interest in the role of optometry in surgical care. Articles, meetings, symposia, and general discussion on the topic proliferate. Even the section of this magazine in which this article appears, CollaborativeEYE, emphasizes how much the role of the optometrist is evolving from primary eye care to surgical care. That said, much of the recent discussion in this area is about technological innovation or postoperative care. The time has come to change our optometric mindset and to integrate our- selves into the surgical process for better patient outcomes.

Fulfilling A Need

In 1989, a report from the Office of Inspector General of the US Department of Health and Human Services stated that 7% of cataract surgeries were the result of referrals to surgeons by optometrists.1 By 2013, industry data placed that figure at approximately 40%.2

It is estimated that the number of cataract surgeries performed world- wide will increase from more than 20 million in 2017 to more than 35 million by 2025.3 During that same time period, the supply of ophthalmologists is actually projected to decrease. The Association of American Medical Colleges projects that more than 6,000 additional ophthalmologists will be needed in the United States by 2020. In a 2017 report, the association projected a shortfall, citing increased demand for services exacerbated by difficulty increasing the number of high-quality surgical residencies.4

Couple increased demand and decreased supply of surgeons with decreased reimbursements, and the only option is to keep our surgeons in the OR where they can serve the most patients and be the most productive.

This future leaves eye care as a whole little choice. We have to change old models to become more efficient in serving patients. Serving patients means more than just surgery. It means evaluation, education, counseling, and providing decision-making assistance preoperatively, as well as providing what will be a tremendous number of postoperative care visits. Fortunately, optometry is perfectly positioned to step in to take on its role as part of the surgical team and fulfill this need.

Defending Relationships

The need for optometry to adapt to changes in patient volume and practice patterns provides a unique opportunity for the profession. We are facing a time when optometry practices struggle to differentiate themselves and retain patients. Integrating ourselves to become part of good surgical care will bring multiple benefits. Not only will it help to improve patient outcomes and facilitate patient throughput for surgical practices, it will also help optometry resist shifts in the health care market and the commoditization of eye care by potentially disruptive innovations such as online eye exams. 

The FDA is considering a project in 2019 to allow sales of traditionally prescription drugs for chronic conditions such as high cholesterol, high blood pressure, asthma, and migraine to be guided by an app rather than a doctor’s visit.5 Although the future of telemedicine and app-driven health care may be bright, the fundamental patient relationships that make primary care positive for both doctor and patient must be defended.

Stepping Up

What steps can you take today to become more involved with your patient’s surgical care? It is actually much easier than you may think, as this is care we are already providing in some form.

First, when you refer a patient for surgery, make sure his or her ocular surface is ready for that surgery. The best surgery, laser assistance, and IOL upgrade can fall short of patient satis- faction due to a fog of ocular surface instability. Treat lid disorders, dry eye disease, and any corneal conditions preoperatively to optimize the ocular surface and maximize patients’ potential visual acuity and set them up for success. 

Second, take a look at the patient’s keratometry (K) readings. We tend to over-focus on patients’ preoperative refractive (glasses) cylinder, which has little impact on postoperative induced astigmatism. If a patient is plano in each eye going into surgery, with glare complaints due to cataract and Ks of 42.00/44.00, he or she will not be happy with 2.00 D of postoperative cylinder and complaints of uncorrected glare.

This is a perfect example of why we as a profession need to become more involved in the surgical process. A simple assessment can tell us whether a patient is likely to develop astigmatism postoperatively. In addition to standard preoperative counseling, patients should be educated about what astigmatism is and why it is a factor for them before their procedure so that they can decide if it is something they would like to address. 

Education before surgery is key; otherwise, the same conversation after surgery may be viewed by the patient as excuses after the fact. See Why Your Patients Deserve Their Optometrist’s Recommendations for Upgraded Cataract Surgery for additional insights.

The Big Picture

Our goal is to match patients’ long- term needs—not just what they think they want today, but what they will need for rest of their lives—to today’s technologies. Only you know your patients, their eyes, their needs, and what current treatment options could work for them. Make sure you are comfortable with the surgical options and IOL choices your surgeon utilizes. Do not get hung up worrying about pricing structures. You are not having a tech talk or a price discussion, you are educating patients so that they can make a value decision that capitalizes on the once-in-a-lifetime opportunity of cataract surgery.

Stabilize the ocular surface, match new technologies to the patient, and take ownership of the optometric role as a part of the surgical team to become more involved in cataract surgery. Taking these steps will help you to improve patient outcomes, set your surgeon and your patient up for success, safeguard your practice and our profession for the future, and adapt to potential market disruptions in the rapidly evolving health care environment.

Why Your Patients Deserve Their Optometrist's Recommendations For Upgraded Cataract Surgery

How to preempt the ZMOT.

When it comes to “upgraded” surgery, discussions can get a little awkward. Are we selling an upgrade? What if the outcome isn’t ideal? What is the best lens for this patient? What if the surgeon doesn’t agree? Will I look bad? Will I make the surgeon look bad?

These questions are among the reasons why so many ODs shy away from making good recommendations to their patients. Unfortunately, not making a recommendation leaves our patients on their own, wondering what to do. So what is to be done?

First, I no longer consider toric IOLs to be upgrades. Yes, there is additional cost, but these lenses have become an obvious solution to me. The risk-benefit ratio is easy to appreciate and fairly easy to acceptably demonstrate by showing patients their corrected vision with and without cylinder correction. Additionally, many of these patients already wear toric contact lenses, so they even know the terminology.

Multifocal IOLs are a different story and are much more complex. It can be difficult to demonstrate postoperative vision at distance, let alone at near. Multifocal contact lenses do not compare readily to postoperative vision with multifocal IOLs. This process gets tough to make sense of, so many ODs simply stop short of recommending anything.

The problem is that the way we make decisions has changed. In 2011, the Google marketing resource Think with Google introduced a new way of thinking about purchase decisions: the Zero Moment of Truth, or ZMOT. ZMOT applies to literally every purchase decision we make, from toilet paper to cars to IOLs.

Think about how you would have replaced a broken television 15 years ago—way back before Circuit City went out of business. You might read Consumer Reports or talk to some friends, but eventually you would go to the store and talk to the salesperson. After discussing what you want, how you will use it, where it has to fit, and what is on sale, the conversation eventually comes to the moment of truth. This salesperson has become your trusted advisor, and you ask, “What would you do?”

That salesperson is now gone, and so is that moment of truth. Now, you read reviews on Amazon from complete strangers who may or may not know anything about the product or your needs. Q: Is this a good TV? A: I don’t know, haven’t received it yet. Really? How helpful is that?

If we do not take an active role in educating our preoperative cataract patients, they will seek knowledge in any way they can. When this happens, the quality of the advice and how much it actually pertains to their needs is completely left to chance. They are left facing a decision with ZMOT.

Who is the best trusted advisor for your patients? Who knows their eyes and their long-term needs? Who will continue their care over the long term? Who can best prepare them to make an educated decision that matches all of their needs to the best technology? The primary care optometrist they have trusted for years, that’s who. YOU!

  1.  Office of Inspector General, US Department of Health and Human Services. Ophthalmology/Optometry Relationships Involved in Cataract Surgery. April 1989. oig.hhs.gov/oei/reports/oai-07-88-00460.pdf. Accessed January 8, 2019.
  2.  Alcon. Data on file. December 10, 2013.
  3. Technavio. Global Phacoemulsification Devices Market 2019-2023. busi- nesswire.com/news/home/20181228005073/en/Global-Phacoemulsification- Devices-Market-2019-2023-Glaucoma-Surgery. Accessed January 8, 2019.
  4. Association of American Medical Colleges. 2017 Update. The Com-plexities of Physician Supply and Demand: Projections from 2015 to 2030. bit.ly/2017AAMC. Accessed January 8, 2019.
  5.  U.S. Food & Drug Administration. Statement from FDA commissioner Scott Gottlieb, M.D. on new efforts to empower consumers by advancing access to nonprescription drugs. www.fda.gov/NewsEvents/Newsroom/PressAnnounce- ments/ucm613692.htm. Accessed January 16, 2019.
Kristopher A. May, OD, FAAO
  • Optometrist, Coldwater Vision Center, Coldwater, Mississippi
  • kmay@sco.edu
  • Financial disclosure: Consultant (Alcon Surgical)
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