How Could This Happen to Me?

Everyone who deals with cataract patients knows that obtaining an informed consent is an important prerequisite to setting patients' expectations before cataract surgery, but they may not realize how high these expectations are among individuals receiving presbyopia-correcting IOLs. Even if these patients sign an informed consent and assure everyone that they understand the risks and benefits associated with these specialty IOLs, they never really believe that these caveats apply to them. Therefore, patients who develop complications express surprise, often declaring that they never imagined that their vision would be less than perfect with presbyopia-correcting IOLs. I work with many doctors within TLC Laser Eye Centers' Patient Advocacy Program to resolve the various problems posed by these patients.

Achieving success with refractive IOLs requires surgical skill as well as the ability to understand and deal with patients who are dissatisfied with their postoperative vision. We can learn to manage these unhappy people by becoming familiar with the technical and emotional issues that contribute to unexpected refractive results with presbyopia-correcting IOLs.

TECHNICAL CONSIDERATIONS
Presbyopia-correcting IOLs are different from other vision-correcting modalities such as eyeglasses, contact lenses, PRK, and LASIK because they present a new scope of potential problems. Refractive IOLs affect all aspects of a patient's sight, including accommodation and night vision. Resolving problems associated with these lenses can also be challenging, because patients may require additional intraocular surgery; however, this option is desirable only when other strategies have failed. Dealing with frustrated patients can be especially difficult if you are certain that their complaints will resolve without intervention during the postoperative period. What, then, can be done to make the patient more comfortable until this happens?

THE GRIEVING PROCESS
I find it is easier to help unhappy patients if put myself in their place and consider the emotions they are experiencing. Some of their problems may resolve with neural adaptation, but in my experience, patients are usually not comforted by the idea that their vision will improve in 1 to 2 years. From their perspective, they feel like they have experienced a significant loss of vision.

You may think that refractive IOL patients are exaggerating their problems by complaining of vision loss, especially if you compare their difficulties with those caused by other debilitating ocular diseases. Their emotions are very real, however, and can be described as grief.

The stages of grief are best exemplified by Elisabeth Kübler-Ross' On Death and Dying,¹ but I have observed several additional stages that apply to refractive surgery patients. These individuals may successively:

1. enter a state of shock;
2. express anger and frustration;
3. lose contact with their doctor as they begin to feel depressed and isolated;
4. develop physical symptoms such as headache, backache, and other disabilities unrelated to their eyes;
5. become anxious;
6. feel guilty about their decision to undergo cataract surgery;
7. resist returning to their normal daily routine;
8. experience renewed hope; and
9. affirm the reality of their loss.

It may take some time to identify patients who are dissatisfied with their presbyopia-correcting IOLs, but the earliest hints may come as they emerge from shock and begin to express the emotions they are experiencing. What follows is a scenario that may be familiar to some of you.

A patient who appeared to be well counseled and who had an uncomplicated surgery may begin to express uncertainty and dissatisfaction with his vision on the first postoperative day. Although he seems to respond to initial reassurances that it is too early to tell if the surgery is unsuccessful, he is probably in too much shock over his loss of vision to really hear what he is being told. Nevertheless, he nods his head, which most of us would conclude means all is well.

By the time the patient returns 1 to 2 weeks later, he has fully overcome his shock and is feeling angry and frustrated about his vision. Because the patient's rapid change from passive acceptance to expressing intense emotions may be offputting, many doctors in this situation miss an opportunity to provide help and prevent further misunderstandings. If the doctor appears indecisive, offers explanations that the patient feels minimizes the problem, offers "neural adaptation" as a solution, or cannot provide the reassurance the patient expects, chances are that he will only become more frustrated.

Many surgeons I have worked with over the years have reacted to this situation by asking themselves where the procedure went wrong, when in fact they need to ask why the patient is really unhappy. As a consequence, they may interpret the patient's complaints as a demand to remove the presbyopia-correcting IOLs. Although this strategy may solve the short-term vision problems, it puts the surgeon's long-term relationship with the patient in jeopardy. He really wants the doctor to express his regrets that the procedure did not meet the patient's expectations.

DEFUSING DIFFICULT SITUATIONS
I have developed a five-step strategy for dealing with dissatisfied refractive IOL patients that I call the 5 Rs: recognition; regret; responsibility; remedy; and realignment.

First, it is essential to recognize when you should express regret because you may only get one opportunity.

Second, it is usually best to convey your regret as clearly and simply as possible. I usually say, "I regret that you have had unexpected vision difficulties following your surgery" or "I am very sorry that you have had vision problems following your surgery." These statements show the patient that I believe his problem is real and that I am giving the matter the attention it deserves.

Third, it is critical to take responsibility not for the patient's problem but for providing a solution ("I take the responsibility to help you"). Your action alleviates some of the frustration and anger the patient is experiencing.

Fourth, you should explain all of the potential corrective options available to the patient, taking care to include as many details as possible. It is important to outline the options in order of importance and to always use an even, patient tone of voice. If you need to repeat the options, you can prevent confusion by presenting them in the same order every time.

In a worst-case scenario, it may not be possible to offer an immediate solution. When this happens, I say, "I am not sure what the next step is, but I will consult my colleagues to see if they have encountered a problem like yours. I will call you next Monday, and we can go over what I have learned then. Is that acceptable to you?"

The fifth and most essential step to is to realign the patient and enlist his help in finding a solution. I often explain that implanting presbyopia-correcting IOLs is a relatively new type of refractive surgery and, although problems are not common, I recognize that they occur. I emphasize to the patient that he can help other surgeons prevent similar problems in other patients by describing his symptoms and experience.

Realignment may not always work, but, when it does, it can be valuable tool for turning an angry patient into a willing ally. All of these steps help your patient move through the grieving process in a meaningful and appropriate way and affirm the reality of his loss. Once he understands what you can realistically do to help, he can develop a more balanced perspective on his vision and his life. Instead of expressing anger and frustration, he can return to his normal routine and begin to speak positively about his future.

PRESERVE THE LINES OF COMMUNICATION
I recommend practicing the 5 Rs for dealing with unhappy refractive cataract patients until you are comfortable with the process. The goal is to interact with these individuals calmly, always using the same tone of voice to express your regret until you find a solution that satisfies everyone.

The strategies presented in this article only superficially address the problems of dealing with individuals who are dissatisfied with their presbyopia-correcting IOLs. They can, however, help you avoid some early mistakes. Treating these patients with compassion shows that you understand they are grieving about their vision loss and that you are willing to work with them during this difficult time.

John Potter, OD, is Vice President for Clinical Services for TLC Vision Corporation. He currently devotes his full time and attention to patient advocacy, dispute resolution and conflict management in refractive surgery. Dr. Potter may be reached at (636) 534-2300.

1. Kübler-Ross E. On Death and Dying. New York, NY: Touchstone; 1997.