New M.D.
Just Cataract Surgery?

As a young ophthalmologist, one of the most vexing phrases I hear is, "it's just cataract surgery." I have heard this from fellow physicians, family and worst of all, from patients.

I did my training in Boston at a medical center that served a diverse community including veterans, the uninsured, immigrants from Haiti, Cape Verde and Eritrea, and a large, urban working-class population. Far too often, what these patients considered "blurry vision" the state of Massachusetts considered legal blindness. Some, despite financial means, had declined to wear glasses for decades, preferring instead to wander in the circle of least confusion. As a result, when these patients presented with cataracts, they had dense nuclear sclerosis.

Higher Risks, Satisfied Patients?

I recall obtaining informed consent from these patients, which involved discussing the obligatory need for glasses, the possibility of worsened vision from the surgery, the risk of retinal detachment, and yes, even the chance of losing an eye. At times, I was amazed patients consented at all, given the possibilities.

These surgeries were certainly challenging, but because most of our patients presented in the 20/100 to 20/200 range, they were generally pleased with their postoperative vision. Even patients with anterior chamber lenses and BCVAs of 20/60 were seeing much better than previously and were often grateful for the opportunity to have surgery.

Preop Counseling Challenging with Savvy Patients

Now, in my first year of practice, I serve a largely suburban Rhode Island population. My cataract evaluations begin with notes on a patient's chart such as "patient has trouble playing golf" and "complains about difficulty at bingo." Or the chart might read "patient failed his driver's exam."

Often, these patients are dissatisfied with fairly good visual acuities, especially the golfers. I've had patients who, while denying any visual limitations, insisted on their need for surgery, having been told they had cataracts by their optometrist. When I first began practicing, it was tempting to summarily schedule these patients for surgery. However, I quickly learned all it takes is a little bit of iatrogenic iris atrophy or a myopic surprise to turn an otherwise perfect case into a dissatisfied patient. Subsequently, one finds it's very difficult to improve a 20/30 eye, despite a little bit of nighttime glare.

After almost 1 year in practice, I have slowly adapted my practice patterns. To begin, I find myself turning some patients away or referring them to my boss, a man who has performed over 25,000 cases. I'm counting, but I'm not there yet. Next, I am careful about painting realistic expectations when I obtain informed consent. My patients insist they know all about "the laser surgery." Their children have had LASIK and their bridge partners don't need glasses anymore. I highlight preoperative conditions that might limit their vision after cataract surgery. I mention the possibility of sutures and prolonged eyedrop regimens. And I am careful to mention that while most people heal in a matter of days, some take weeks or even months.

Most importantly, I repeatedly stress to my patients three phenomena that continue to impress me, the surgeon. First, it's surgery — not "just cataract surgery." Second, every eye is different — right eye from left eye, husband from wife, neighbor from neighbor. And third (but not least important), as the old saying goes, "if it ain't broke ..."

Roxanne Woel, M.D., practices at Koch Eye Associates in Warwick, R.I. Her e-mail is roxannewoel@hotmail.com.