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Up Front | Sep 2008

Counseling Cataract Patients Who Have Undergone Refractive Surgery

For each installment of "Today's Topics," section editor John F. Doane, MD, identifies a hot-button topic in cataract and refractive surgery and asks several experts to share their thoughts.

How do you counsel patients with prior refractive surgery regarding the refractive accuracy of IOL implantation? What policies does your practice have to address significant refractive surprises after cataract/IOL surgery for these patients?

My colleagues and I advise patients with a history of refractive surgery that, despite extensive preoperative testing and the availability of multiple formulas for IOL power calculations, their visual outcomes may not exactly match the intended target. Refractive surgery alters the corneal curvature and therefore makes accurate preoperative measurements challenging, especially if we rely solely on the readings from our equipment. I offer patients the contact lens method or the historical keratometry method as a way of measuring and calculating corneal curvature more accurately.

We offer our patients several options to further improve their vision after cataract surgery, including laser vision correction, an IOL exchange, and a piggyback IOL. Patients who upgrade to a premium (presbyopia-correcting) lens must pay an additional fee, as must those who have treatment for residual astigmatism after receiving a standard IOL. The latter fee does not apply to patients who choose presbyopia-correcting IOLs, because limbal relaxing incisions are included in their premium IOL package.

My office has been providing laser-based refractive surgery for more than 12 years, and my colleagues and I performed RK before that. Currently, we regularly see cataract surgery patients who have had refractive surgery. Experience has taught me that it is beneficial to counsel each of these patients personally in great detail about the uncertainties of refractive outcomes. In addition, I shy away from multifocal lenses in this group and prefer to use monofocal or accommodating IOLs. When significant refractive surprises occur, I tend to favor early lens exchange over laser-based procedures. I bill the insurance company for additional interventions whenever possible.

If we previously operated on a patient, or if we can safely treat his residual refractive error after the implantation of a specialty lens, we charge him a small fee to cover our costs. If the patient chose a standard lens and had refractive surgery elsewhere, we charge our regular rate for refractive surgery. By properly managing the patient's expectations, providing quality care, and giving a lot of personalized attention, we create a very strong referral group for our practice.

Patients who underwent successful corneal refractive surgery in the past typically have unrealistic expectations about the outcomes of cataract surgery. Most still want the luxury of spectacle independence. They may also have a friend or family member who no longer needed glasses after cataract surgery. To defuse a potentially dramatic situation, I review with patients all of the different scenarios—from the need to suture dehisced RK incisions to the inherent unpredictability of IOL calculations—that could affect their outcome. I also identify the safe surgical and nonsurgical options that I can offer if cataract surgery does not meet their expectations. It is important to remember that, if the patient has forme fruste keratoconus, you do not have the option of performing a secondary bioptic corneal procedure.

I also have patients read and sign a special consent form that covers the issues we discuss as well as a waiver, which states that they are financially responsible for any additional surgical or nonsurgical intervention required to achieve their visual goals ("to clear the window to the eye") if the original cataract procedure does not satisfy their expectations.

Section editor John F. Doane, MD, is in private practice with Discover Vision Centers in Kansas City, Missouri, and he is Clinical Assistant Professor for the Department of Ophthalmology, Kansas University Medical Center. Dr. Doane may be reached at (816) 478-1230; jdoane@discovervision.com.

Harvey L. Carter, MD, is Director of the Carter Eye Center, in Dallas. Dr. Carter may be reached at (214) 77512775; hcarter@cartereyecenter.com.

Mark A. Kontos, MD, is a partner of Empire Eye Physicians, PS, of Washington and Idaho. Dr. Kontos may be reached at (509) 928-8040; mark.kontos@empireeye.com.

Stephen A. Updegraff, MD, is Medical Director of Updegraff LASIK Vision in St. Petersburg, Florida. Dr. Updegraff may be reached at (727) 822-4287; updegraffmd@lasik4me.com.

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