Give Patients the IOL They Need

Ask the right questions and the patient will tell you.

LARRY E. PATTERSON, M.D., WITH VICKEY HAWKINS, C.O.A.

I heard an advertisement a few days ago for a regional medical center emphasizing how only a handful of professionals are skilled enough to perform this state-of-the-art technique they offer at their facility — listening. If you are an ophthalmic surgeon, listening is critical. Listening and learning more preoperatively about your patients undergoing refractive cataract surgery (RCS) or refractive lens exchange (RLE) allows you to make an informed IOL recommendation. In my opinion, this approach is far more productive than postoperatively listening to the dissatisfied patient who is now frustrated because he can’t see to read the stock market reports without his glasses.

The key to successful preoperative listening is to devise techniques that concisely extract specific information from your patient, utilizing an economy of streamlined steps. In this article, I will offer a number of ideas that will help you provide patients with the appropriate procedure and IOL that will best meet their needs and expectations.

Take the Lead

I recently noticed my RCS and RLE procedures have been consistently higher in May and December, which correlates directly with the time after the American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO) meetings.

Like many of you, I return from these meetings excited about new techniques and technology, and that excitement is conveyed to my patients. If 95% of communication is visual or body language, then it is absolutely necessary that you are motivated and buy into the refractive options you are suggesting. A strong, confident demeanor and tone projects reassurance to patients and staff. Your recommendation is the foundation of the patient’s decision for your staff to build on and complete. I have found that taking key staff members to meetings is quite rewarding because they also return to the practice with a renewed sense of excitement and motivation. If discussing these procedures was only half as contagious as gossip we wouldn’t have to pay for advertising, so try to make it interesting and get your staff involved. There is a lot to be said for internal marketing.

Ask the Right Questions

We fill out a “How Well Can You See?” (Figure 1) form with each cataract patient. It requires “yes” or “no” answers to simple questions about difficulty experienced with everyday activities. It is a concise and efficient method for obtaining specific information about the patient’s vision.

This form primarily documents medical necessity for cataract surgery but also enlightens me as to the regular activities of the patient. The final question is, “Are you interested in treatment to help reduce your need for glasses?” Many cataract patients are unaware that spectacle independence is an option at their age and this question prompts them to consider it. Others assume spectacle independence is included in standard cataract surgery, which opens a door for discussion prior to surgery.

I discuss this final question with each patient. Even if they are not interested in RCS, this ensures they understand their need for glasses postoperatively. I no longer have to deal with complaints about needing glasses postoperatively because the patient now understands it is their decision. If the patient is interested, I open the refractive discussion by asking, “Do you mind wearing glasses?” The patient’s interest in spectacle independence is significant. I have seen many family members far more motivated than the patient. You must differentiate between the two. If a cataract patient feels that wearing glasses doesn’t bother him, I still review the basic refractive options, but I don’t push it.

Let the Patient Tell You

I personally underwent RK in the early 90s, followed by a PRK touch up a few years ago, so I can’t imagine not opting for a procedure that could reduce my need for glasses. But that’s me. Recommending refractive options for surgery is like buying a gift — you try to give them what they want, not what you would like to have. Additional costs and benefits aside, some patients really don’t mind wearing glasses at all and a few actually prefer to wear glasses for appearance or to cover up wrinkles. Don’t knock yourself out trying to figure out what angle you need to take to convince this patient why they should want to pay extra for spectacle independence. If you want your patients to be 20/happy postoperatively, educate them well but listen to what the patient is trying to tell you. Once the decision has been made, the patient signs the form documenting the impact that decreased vision has on the activities of daily living and whether they have chosen or declined RCS.

The surgical counselor will then fill out a separate brief refractive questionnaire (Figure 2) with any potential candidates for RCS/RLE This form includes questions about night driving, halos, computer usage, near vision and whether they’ve worn contact lenses in the past. For example, ask, “Would it bother you if you noticed some glare or halos at night after surgery?” Some people are adamantly opposed to the idea, but surprisingly the vast majority of patients feel they could adapt to halos just fine. Having their clear acknowledgement prior to surgery is very helpful. Cataract patients often already notice glare and halos at night and have a good foundation to form a knowledge-based opinion.

In addition to selecting preferred vision “zones,” we have patients list the three activities that would be most important for them to perform without glasses. I have found this to be particularly useful because the patients have an opportunity to prioritize their needs in their own words. We also ask, “If you could see to do most things without glasses after surgery, would it bother you if you had to wear them occasionally for certain tasks?” This is more of an indication of the patient’s potential for happiness than personality type. We generally don’t discriminate against personality types anymore, performed on the day of the patient’s exam. We use a checklist with a spreadsheet at the bottom to record multiple keratometry readings to ensure that all of the appropriate data has been recorded. The surgical coordinator documents and averages keratometry readings from the Epic (Marco Ophthalmic, Jacksonville, Fla.), IOLMaster (Carl Zeiss Meditec, Dublin, Calif.), manual keratometer and corneal videokeratographer. Any inconsistencies are reviewed and resolved prior to selecting the final Ks.

Internal studies within our office show the difference between Epic Ks and manual Ks to be minimal. To reduce the number of variables, we primarily use Epic Ks in calculating the IOL with the Holladay 2 program. After doing that, we also run SRK-T and look for any disparity. If there is a significant difference, we will lean toward the Holladay if the axial length is less than 22 mm, and SRK-T if it is greater than 22 mm.

Knowing more about the patient’s desires and the physical findings, we are finally able to recommend and discuss the most suitable lens or lens combination. While we discuss the available lens options, we avoid “cluttering” the patient’s mind with excessive details, pros and cons of each lens implant and focus on why this particular implant will meet their needs and desires.

Multifocal IOL Selection

There is not one multifocal lens that is perfect for every patient. I began using the now-discontinued Array (AMO) in 1997 with great success, which I attribute to excellent measurements, patient screening and counseling. I never had to explant one. Today, if a patient does a lot of intermediate work, I recommend implanting the ReZoom and perhaps the crystalens. If they are pleased with their near vision postoperatively, I implant a ReZoom bilaterally. But if they notice any difficulty with their near vision, I implant a ReSTOR in the fellow eye.

I now only implant the ReSTOR bilaterally if the patient has emphasized a significant demand for near vision and no desire for intermediate vision. Despite what consultants may say, many of our patients with bilateral ReSTOR implants are unhappy with their computer vision. Overall, my happiest patients are those with a ReSTOR/ReZoom combination. Patients who have successfully used monovision contact lenses are excellent candidates for monofocal implants. Bilaterally implanting distance dominant monofocal IOLs with astigmatic correction is a great option for patients desiring extremely clear distance and night vision and who do very little near work. They are infrequent, but do exist.

The Surgeon/Patient “Contract”

Our selection process enables us to enter into an agreement with the patient to achieve a desired result with a tailored procedure. After detailed conversations, we are aware of the patient’s visual expectations, but we must also make the patient aware of what we expect from them.

In addition to our standard consent for our cataract or other lens-based procedures, patients who are undergoing RCS/RLE sign a “Refractive Consent” detailing our expectations, allowing time for adjustment, explaining functional vision and reviewing insurance coverage. At the bottom of the consent, the coordinator checks a box for the appropriate procedure. The RCS option indicates the removal of the cataract is medically necessary. This portion will be filed to their insurance, but the refractive options are considered an elective and a non-covered service. For patients undergoing RLE, it essentially states this is an elective non-covered procedure and will not be filed to their insurance.

We also explain to patients that three things must happen for them to be satisfied with their vision:

■ If the patient is receiving multifocal IOLs, they ideally need to have them implanted bilaterally. We do have some patients who opt to have a multifocal IOL or crystalens in one eye only by choice, or because their other cataract does not meet medical necessity for surgery at the time. While having a multifocal IOL unilaterally can be functional, the best vision is obtained with these implants in both eyes.

■ The eyes need time to heal. Any corneal edema, inflammation or dry eyes may inhibit the patient from obtaining their best possible vision, especially with a multifocal implant. I have seen many patients with significantly improved vision following aggressive treatment for dry eyes.

■ Neuroadaptation is the final step. The brain needs time to adjust to the images received through this new multi-focal medium. Most patients are highly satisfied with their vision even a couple weeks after surgery. But it is not uncommon for the patient’s vision to measure better than they feel like they see. The image may be in focus, but the brain must adapt and learn to interpret the new format of the data it is receiving. When checking the same patient 3- to 6-month postoperatively, the vision may technically be the same, but the patient’s satisfaction and perception of their vision is often much improved.

What if It’s Not Perfect?

For the most part, complications with these lenses are not much different from standard monofocal implants. There are some exceptions with the crystalens, but that is beyond the scope of this article. And we often have to YAG these capsules a little earlier than with standard IOLs.

Enhancements are a different story.

I’ve been to training sessions for these lenses when enhancements were not even mentioned, as if suddenly there were no refractive surprises with multifocals. Well, guess what? Even if you are very careful, as outlined earlier in this article, sometimes things just don’t turn as planned, and the patient is quite unhappy. Being off by 0.50 D to 0.75 D of sphere or cylinder can make an otherwise perfect operation a failure in the eyes of these highly expecting patients who have just shelled out a lot of extra cash to be glasses-independent.

Yes, I know you explained to them preoperatively that there are no guarantees, and that they may still have to wear glasses full or part-time, but that doesn’t take care of the problem at hand.

Ideally, if you implant these lenses you need to be comfortable with a full spectrum of refractive surgical options, including LASIK, PRK and Conductive Keratoplasty (CK). Sure, you can always take them back to the OR and do a potentially risky IOL exchange or piggyback lens, but wouldn’t it be nicer to treat the patient who is 0.75 D postop with a 1-minute non-invasive CK in your minor room?

If you don’t perform these enhancement procedures, then have a good relationship with someone in your practice or community who does. And figure out ahead of time who pays for what. No cataract patient who has just paid thousands extra for a ReSTOR lens will be happy with an extra bill for $2,000 to touch up his surgery. We know a certain, small percentage of our patients will need an enhancement, so just like with LASIK, touch-ups are built into the original price.

Efficiency with Proficiency

I often write articles and deliver presentations on office and OR efficiency. I try to emphasize to never do anything in the name of speed (or the bottom line) that in any way compromises patient care. To be efficient you must be proficient. Complications and mistakes are inefficient. By reducing the number of steps you make, you also reduce the number of opportunities you have for error. That applies equally here.

Efficiency is an economy of steps and motions. Make concise and deliberate steps in your examination, decision-making, approach and delivery.

Listen to your patients and genuinely assist them in making one of the most significant choices in their lifetime. Give patients understandable options, offer your professional guidance and recommendations, but let them make the decision. Whether or not they opt for RCS with a multifocal IOL or standard cataract surgery requiring spectacle correction postoperatively, you will be left with a 20/happy patient. Never forget that a happy patient is your most significant and least expensive marketing tool. OM

Larry E. Patterson, M.D., is the medical director and surgeon of Eye Centers of Tennessee (ECOTN) and the Cataract and Laser Center. He is on the board of directors of the Outpatient Ophthalmic Surgery Society, the Ophthalmology Management editorial board and Health Talents International. He has also been involved with and led several medical missions to Central America and the South Pacific. He built and operated a multispecialty ASC in 1998 and a single specialty ASC in 2001. Dr. Patterson can be reached via e-mail at larryp@ecotn.com. Vickey Hawkins, C.O.A., has been the surgical coordinator for ECOTN for 12 years and has co-authored multiple articles on office and ASC efficiency.