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Up Front | Mar 2007

Screening and Evaluating Presbyopic Patients

Streamlining and getting the most from preoperative consultations.

Consultations for cataract and refractive lens exchange surgery have become significantly more complicated. Ten years ago, I would diagnose a cataract and discuss the risks and benefits of as well as the alternatives for surgery with the patient. That was about it. The most complex question I would encounter was the occasional request for monovision. The type of IOL was rarely a topic for discussion. Overall, patients were happy to achieve good uncorrected distance vision, with readers needed for close vision. They were delighted to avoid the week of bed rest and aphakic spectacles they had seen their parents endure after cataract surgery in the 1960s and 1970s.

Today, consultations range from discussions similar to the aforementioned to explanations of the nuanced advantages of aspheric IOLs, descriptions of accommodating and multifocal IOLs, and the possibility of laser vision correction as an enhancement procedure. Recent decisions by the Centers for Medicare & Medicaid Services have introduced into the equation the possibility of large financial contributions by patients for New Technology IOLs. Moreover, people sometimes perform exhaustive research on the Internet before choosing a surgeon. In fact, I can assure you that some future potential patients will read this article. A strength and weakness of the Internet is that the information is completely unfiltered, and patients may present with demands for a technology that is completely inappropriate for them. Sometimes, I yearn for the serenity of a LASIK consultation with an obsessive-compulsive optical engineer.

Discussions with patients about cataract and refractive lens exchange surgery were taking a long time, and some people left confused, resulting in additional follow-up consultations. Still, I realized the importance of clearly conveying the complexities of the various IOL options to patients. As the volume of these consultations threatened to overwhelm my clinic, I instituted some changes.

During the workup process, individuals considering cataract or refractive IOL surgery watch a video introducing the concept of a presbyopia-correcting IOL. Next, they complete a questionnaire that clarifies their postoperative visual goals. Although the survey provides a wealth of information, I have learned that, perhaps most importantly, it alters patients' perceptions of the surgery. The very nature of the questions lets them know that compromises are inherent in any surgical option. The final question asks patients to rate their personalities from easygoing to perfectionist. The technician working the patient up also rates the patient on this scale, and I do the same after my consultation.

With the survey results in hand, my consultation becomes relatively straightforward. Typically, I will direct cataract surgery patients who are interested in good uncorrected distance vision and have corneal astigmatism toward a limbal relaxing incision or a toric IOL. Both options involve an out-of-pocket expense for patients. If they also want good uncorrected near vision, the discussion focuses on presbyopia-correcting IOLs or monovision. Because all of the presbyopia-correcting IOLs can produce successful results, a definitive recommendation from the surgeon is important. This advice should be based upon the technologies with which the surgeon is most comfortable. The patient deserves a statement such as "Based upon what I see today and what you have told me, I believe the best technology for you is X." Meandering, circular discussions of every possible combination of IOLs serve the interests of no one.

I typically tell patients interested in presbyopia-correcting IOLs that spectacles of some variety are in their future, but I explain that my goal is to reduce their need for glasses to a bare minimum. This is an important psychological milestone for patients. If they balk at this statement, I may reconsider their candidacy for these IOLs.

I also tell these patients that the treatment plan sometimes involves a second procedure to touch up the results of the first surgery. I stipulate that I will gladly perform the enhancement at a discount but that I am unable to do it for free. You may wish to actuarially bundle the costs of these enhancements into the price of your surgical procedure. Regardless, the patient will appreciate knowing this policy in advance.

If your patients undergo surgery with an expectation of perfection, you will be severely faulted if you do not deliver. Many fail to grasp the concept of variable human responses to surgery despite being told about it several times. Educating patients so they truly understand the possible outcomes of their surgery will make you both happier.

I often survey patients postoperatively to see how they rate their vision. Although, in general, those with the best objective vision are subjectively the happiest, it is amazing to observe the occasional total lack of correlation between these metrics. Some patients seem eternally happy no matter what I do, and some are clearly unhappy before, during, and after their surgical experience. It would be nice if these two types of patients would identify themselves upon their initial presentation to the clinic. Based upon the results of the postoperative surveys, I continue to make subtle refinements in my surgical strategies.

New IOL technologies have made the surgeon's job more interesting and complex. The stakes are higher now that patients are paying out of their own pockets for certain lenses and/or astigmatic correction. It is important to identify what they desire to achieve with surgery quickly and accurately, to set their expectations appropriately, and to recognize that their psychological makeup may affect their perception of the surgical outcome.

The Dell questionnaire is available at http://www.crstoday.com/Pages/DellIndex.doc.

Steven J. Dell, MD, is Director of Refractive and Corneal Surgery for Texan Eye Care in Austin. He is a consultant for Advanced Medical Optics, Inc., and Eyeonics, Inc. Dr. Dell may be reached at (512) 327-7000; sdell@austin.rr.com.

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