When a patient is referred for cataract surgery, the surgeon often only has time to see the patient for 10 to 15 minutes. No matter how astute they may be, it is unlikely they will learn as much about that patient’s particular needs, idiosyncrasies and treatment successes and failures as the eye doctor who has cared for the patient for years or even decades. The relationship the long-term OD has with the patient is often the key to surgical success, especially considering the many premium intraocular lens (IOL) options available today. The choices are complex and the results are life-changing. Patients deserve the time, attention and insight that only an OD can offer.
Picking up the Mantle
America has a shortage of cataract surgeons, and that won’t change any time soon. It’s incumbent on us to assume the role of cataract quarterback. The trust is already there with your patients, and more will be seeking surgery as they age. The life expectancy for a patient at age 65 (a common age for cataract surgery) is in the upper 80s. That means at least 20 years of quality vision is riding on a once-in-a-lifetime decision. Consider the correction of astigmatism: glasses work but have distortions in the periphery, and while contact lenses have improved dramatically, they can still rotate and many elderly patients lack the dexterity or patience to deal with insertion and removal. For many patients, an IOL (which doesn’t typically rotate) will provide the best vision when correcting astigmatism closest to the nodal point.
Although nearly 50% of the population may qualify for a toric IOL (defined as >1.00D of corneal astigmatism), only about 8% have pursued it.1,2 Such a statistic is disheartening, given the years these patients could appreciate this vision, especially those with against-the-rule astigmatism, oblique or ≥1.25D of with-the-rule cylinder. Likewise, new presbyopic IOLs, such as extended depth of focus (EDOF) lenses, offer greater ranges of vision with fewer side effects than older designs.
Preparation is Key
Research shows the top reasons a patient is unhappy after cataract surgery include not treating underlying disease such as dry eye prior to surgery, residual refractive error (which could also be due to dry eye during the biometry measurements), not being aware of all options, not setting proper expectations or inappropriate IOL selection.
Because we are often the first to diagnose dry eye and we know more about who is an appropriate patient based on history, we are primed to nip these problems in the bud. The only remaining issue is understanding and discussing various IOL options and expectations, particularly for toric and presbyopic lenses. This is where ODs can up their game and better prepare patients with proper patient education.
Finally, ensure you are properly compensated for the extra testing (e.g., OCT, osmolarity, staining, topography) that goes into a premium IOL assessment and the time you spend educating patients. Remuneration should not be so high it would be construed as an inducement, but also should be more than the 20% of the basic Medicare fee alone, since it should reflect the extra preoperative work, advanced diagnostics and time involved in preparing patients who go on to pursue premium IOLs.
The recent approval of an IOL capable of being fine-tuned after surgery highlights the essential role an OD can play in cataract surgery. The Light Adjustable Lens (RxSight) reacts to UV light to alter its refractive power; applying doses of UV within a few weeks post-op can get the patient closer to emmetropia. Optometry could play the key role in determining what post-op correction is necessary and be compensated for this increased responsibility.
This month’s annual surgical issue tackles the vital role we play in cataract comanagement, to help you take charge of the process from before it starts until after it’s complete. The result is a more knowledgeable and better prepared patient, an ideal lens choice and visual results they can enjoy for the rest of their life.
1. McKendrick AM, Brennan NA. Distribution of astigmatism in the adult population. J Opt Soc Am A Opt Image Sci Vis. 1996 Feb;13(2):206-14.