Five Discussion Points When Diagnosing and Recommending Cataract Surgery

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By Nadia Virani, OD, of Kleiman Evangelista Eye Centers in Dallas, Texas; a division of EVP Eye Care in Denver, Colorado

The number of baby boomers rise and the average age of cataract surgery decreases, the demand of cataract surgeons is inevitably soaring. In contrast, the number of cataract surgeons is stable and not following the trend of the demand. A team care approach of optometry with ophthalmology to care for the rising number of cataract patients is going to be keystone to maintaining public health of our nation. The opportunity for optometrists in cataract surgery co-management to fill the gap between the supply and demand can be largely beneficial to our profession.

More than 40 percent of cataracts are referred to an ophthalmologist by an optometrist, and working within a surgical center in a large metro-plex, I can say the number is significantly greater than that statistic.

Many patients follow their primary care optometrist year after year. They refer in friends and family because of the report they have built, and trust they instill with their ocular physician. When first diagnosed with a cataract, patients maybe dismayed or anxious. They look to you for reassurance through what may be a uneasy situation for them. Although you may be diagnosing and recommending cataract surgery for several patients a day, it is important to stop and remember that to each of these patients, this is a life-changing diagnosis.

It is important that we thoroughly counsel our patients on what to expect with the next steps after the diagnosis is made. There are five things we should think about talking with our cataract patients about to help reduce concern and increase expectations regarding their ocular health.

1. What is a cataract?

First, although to us this diagnosis seems like common knowledge, the average patient may have heard of but does not fully understand what a cataract is.

One way to simplify the diagnosis to a patient is first letting your patient know that we have a natural lens that bend light coming into our eye to help us see. The cataract is a clouding of the lens which may make things seem blurry or hazy. Aging is the most common cause of cataract formation, and when proteins in the lens start breaking down clouding occurs. Cataracts form and progress at different rates, but when it starts affecting the vision, is when the discussion of removal begins.

2. What to expect at the surgery center

When going into a surgery center, patients may be a bit restless. Informing then on general procedures undoubtedly ease their experience. Most surgeons will be pleased to allow you to observe or shadow their offices prior to referring patients, so I always suggest inquiring into visiting your local ophthalmologist.

Most practices will do a comprehensive eye examination, including dilation to understand the full ocular health of the patient. The patient will also most likely get a topographic measurement such as a Pentacam (Oculus) or Orbscan (Bausch + Lomb), along with a measurement of axial length such as a IOLmaster (Carl-Zeiss) or Lenstar (Haad-Steit). The surgery will then most likely be scheduled for a subsequent visit.

3. Lens options

Every surgeon has their own preferences of lens choice, but it is important to know that your surgeon is comfortable with keeping up with current technology of lenses. There are many new technologies of lenses and more innovations will continue to emerge.

Providing your patient, a brief foundation by talking with them about genres of options will likely give them the information they need without convolution. Monofocal lenses can be utilized in several ways. A patient is able to have the vision targeted for either plano for decreased need of distance vision specs, or targeted for near vision to decrease need for readers. Monofocal lenses can also be utilized to gain monovision just as contact lenses would allow a patient. Contact lens trial to confirm ability to adapt to monovision prior to this option is highly recommended.

A well-utilized option in this day, is multifocal lenses. Most surgeons are using a concentric ring design including, but not limited to Restor (Alcon), Symfony (Technis) and the newest PanOptix (Alcon). With these multifocal lens options its impairative to tell your patients the availability of them, however ocular irregularities or abnormalities may limit the vision with these options. With both monofocal and multifocal options, toric impants are available to reduce astigmatism.

4. Surgical options

Generally, there are two ways a surgeon will choose to operate on a patient. Traditionally, or with the assistance of the femtosecond laser such as LenSx (Alcon). It is important to inform your patient that with either method, cataract surgery has shown to be wildly successful but with the innovation of the femtosecond laser, it has been shown to reduce the energy of the process dramatically leading to quicker recovery with less edema and inflammation during the post op period. Laser-assisted surgery has also shown to reduce human error during the surgical process mainly because the femtosecond is able to craft the capsulotomy and entry wounds for the surgeon. Better acuity outcomes have also been noted in comparison to traditional surgery because of the precision limbal relaxing incisions that can be made during the process to reduce mild amounts of astigmatism.

5. Recovery and expectations

After cataract surgery, your patient should know that generally restrictions only last for roughly one week after each eye has been completed. Of course, as is true with any medical procedure, unexpected complications may arise. In general, a patient should expect to have blurry vision for a few days after the surgery along with mild discomfort. Typically, heavy lifting and bending over may be limited during the healing period. A patient may be on medicated eye drops including an antibiotic and steroid, although some surgeons may inject the medication during the procedure itself, eliminating the need for a patient to instill the medication. The patient should understand that although these are general guidelines, every individual heals differently. Based on your agreement with your surgeon for post-operative care, the patient should be well informed for who they are seeing for their post-operative care and when they should expect to return to your care.

It is important that you as the trusted primary care optometrist well informs your patient about what to expect from the moment of diagnosis to recovery from cataract surgery. The ease of cataract surgery may be well known to us, but is nevertheless a anxiety prone moment for many patients. It is my hope that we take the time to well inform our patients of the processes they may encounter. The cataract population presents a large opportunity for optometrists to be involved in co-management of cataract surgery.

References
1. Nation Eye Institute. Cataracts. www.nei.nih.gov/eye/cataract. Sept 25, 2019.
2. Datti, NP Kanthamani K, Tanushree V. Subjectivestatisfaction and evaluation of glare and halos after multifoval IOL Implantation. JEDMS. 2014.
3. Popovic M., Muller XC, Efficacy and Safety of Femtosecond laser-assisted versus phacoemulsification cataract surgery. Ophthalmology. 2014; 178-182
4. Erie JC. Rising cataract surgery rates:Demand and Supply. Ophthalmology. 2014, 121 2-4
5. Murrill CA, Stanfield DS, VanBrocklin MD. Primary Care of the Cataract Patient. Connecticut: Appleton and Lange; 1994. 162-165.