As the demand for cataract surgery increases in the United States, patient expectations regarding the perioperative surgical experience and ultimate refractive outcome continue to grow. Excellent outcomes can be consistently achieved by obtaining accurate preoperative data. To reflect this, our referral center practice recently revamped our cataract workup by adding additional diagnostic testing to our standard protocol. We’ve paired our new workup protocol with the integration of a femtosecond laser system (Lensar Laser System, Lensar) in the OR, and both steps have had immediate, positive effects for our patients.
CORNEAL TOPOGRAPHY AND OPTICAL BIOMETRY
Our standard preoperative cataract evaluation begins with a lifestyle questionnaire. When that is complete, corneal topography, optical biometry, and other data are obtained with multiple devices. We’ve recently added the OPD-Scan III (Nidek) as part of this process. This device generates a customized, comprehensive summary of patient data, including optical path difference, axial length, corneal topography, pupillometry, autorefraction, and wavefront aberrometry. This wide-ranging collection of data improves the likelihood of finding pathology that can influence surgical outcomes.
We pay close attention, for example, to findings such as high levels of higher-order aberrations (eg, corneal coma) or large angle alpha (the difference between the center of the limbus and the visual axis) that may limit patient success with multifocal or extended depth of focus IOLs.
In addition to being transferred into our electronic health record system, the OPD-III data are directly imported into the femtosecond laser system that assists the surgeon during astigmatism treatment. This eliminates the risk of a transcription error.
A second important change that we have made to our cataract workup is the addition of retinal screening. We used to reserve this only for patients with known pathology or for those considering advanced technology IOLs. We now obtain preoperative macular OCT and ganglion cell complex scans on every patient. (Note: When used as a tool for obtaining preoperative data, OCT should not be billed to Medicare or commercial insurance.)
By including retinal screening in our standard protocol, we can detect patients with subtle macular pathology (eg, vitreomacular traction, epiretinal membranes, lamellar holes) and more effectively identify patients with early glaucoma. An OCT scan may pick up a ganglion cell complex abnormality before definitive retinal nerve fiber layer defects become apparent. If we identify a potential problem, we can have the patient return to the clinic for further testing and possible treatment.
Microinvasive glaucoma surgery can reduce the treatment burden for a significant percentage of glaucoma patients. Because this type of surgery is generally performed during cataract surgery, it is incumbent upon clinicians performing cataract workups to identify patients with glaucoma. OCT technology helps us to uncover patients who may have otherwise been missed.
OCULAR SURFACE TESTING
Productive cataract consults and optimal patient experiences begin with the referring optometrist. In our practice, referrals are responsible for approximately 75% of our cataract volume. Our practice provides monthly continuing education lectures to community optometrists on a variety of topics, and lately we have focused our attention on preparing patients for refractive cataract surgery. The first step in that preparation is optimization of the ocular surface.
Identifying ocular surface disease (OSD), whether symptomatic or asymptomatic, and treating it appropriately sets up the patient for success. We encourage our referring optometrists to use point-of-care diagnostic testing to screen for OSD. Helpful screens include tear osmolarity testing (TearLab) and evaluation of elevated MMP-9 levels (InflammaDry, Quidel). These tests can detect the presence of OSD before more obvious signs occur. We emphasize to our patients that preoperative measurements will not be reliable if the ocular surface has not been stabilized, and that we will delay surgery until OSD is controlled.
ADDING TO OUR WORKUP
Surgical outcomes are highly dependent on the quality of the preoperative diagnostic workup. By adding new elements to our standard protocol, we’ve been able to identify the best candidates for advanced technology IOL implantation and microinvasive glaucoma surgery, while minimizing the risk of postoperative surprises.