Guide to Managing Patients' Expectations

You can help ensure the best outcomes with premium IOLs before you even schedule surgery. Here's how.

By Richard Tipperman, M.D.

As most anterior segment surgeons know, many patients still believe we remove cataracts with a laser and that no surgery is involved. When you couple these beliefs with the notion that all patients see a "perfect 20/20" following surgery, and no one has any ocular discomfort or irritation, it's clear we have a high hurdle to clear in the area of patient education.

Presbyopia-correcting IOLs pose an added challenge. Not only do they create new issues in terms of expectations, but it's clear from recent studies by the American Society of Cataract and Refractive Surgery, the average patient has an even poorer understanding of presbyopia than they do of conventional cataract surgery.¹

Virtually every surgeon reading this article has had this experience: Prior to conventional cataract surgery, you explain to a patient that he will see well in the distance without eyeglasses but will still need them for reading, only to have the patient return after surgery distraught, frustrated or angry that he "can't see up close without glasses." As ophthalmologists, we live with the concepts of near vision, distance vision and presbyopia day-in and day-out. They're comfortable and familiar terms. However, for our patients, these terms often are not very meaningful.

The key to managing patients' expectations is appropriate patient education. Often, surgeons are concerned about incorporating presbyopia-correcting IOLs into their practices because educating patients seems difficult and time-consuming. In this article, I'll describe how to accomplish this in a clear, concise and time-efficient manner.

AVOID TMI SYNDROME

Too much information (TMI) can create confusion and lead to indecision or, at the very least, difficulty in making a decision. Human nature is such that when faced with too much information, people tend to draw back and make a choice of omission rather than commission.

It's much easier for patients to understand and make an appropriately informed decision about cataract surgery when you break down the process into simpler steps. In our practice, we first counsel patients about cataract surgery itself. We don't discuss IOL choices until the patient has agreed to the surgery.

Once a patient has confirmed that he will proceed with cataract surgery, I'll typically comment: "You've decided to go ahead with surgery, which is really your biggest decision. Now, I want to discuss the choices you have about how you'll see after your surgery."

The advantage of this approach is it allows patients to "fix and close mentally" their decision to proceed with cataract surgery. Once this is done, they can evaluate their IOL choices more clearly.

A discussion of IOL choices for cataract surgery is much easier if the patient has at least some awareness of presbyopia-correcting cataract surgery. For instance, patients who know a friend or family member who's had premium IOLs implanted are the easiest to counsel because they're already "pre-educated." However, most patients are not in this situation, so it's beneficial to both the patient and the practice if the patient receives some information before a discussion with the doctor.

Again, too much information can be confusing. In our practice, we use a simple one-page explanation that helps patients think about day-to-day near vision tasks. It also provides information about the potential advantages of presbyopia-correcting cataract surgery, introducing the concept of multifocal IOLs to the patient. The glossy manufacturers' brochures then complement this information after the patient has had a chance to speak with the doctor.

EMPHASIZE THESE KEY POINTS

As my discussion with the patient continues, I'll explain: "With standard cataract surgery, you'll see well in the distance with minimal correction, but you won't have good vision for near work without wearing spectacles. If you'd like to have more functional and more natural vision up close without spectacles, then there is surgery that's definitely better than standard cataract surgery. It's called ReSTOR^® cataract surgery." (With very few exceptions, I use AcrySof^® ReSTOR^® IOLs for correcting presbyopia in my cataract patients.)

At this point, patients may start to ask questions about the two types of surgery. During this discussion or while patients are asking questions, I want to establish certain key points.

Point #1: In my opinion, the most critical point for managing patients' expectations is that cataract surgery using presbyopia-correcting IOLs is better than conventional cataract surgery with regard to near vision function. I explain to patients that up to 95% of my patients are extremely happy with their near vision when they have this procedure, and the remainder, although they wish they had better uncorrected reading vision, can still tell that they're better off than they would be with a monofocal IOL.

Note that I specifically try not to quote statistics about the percentage of patients not wearing spectacle correction because patients can have excellent outcomes yet still wear spectacles on occasion. Also, if a patient perceives total absence of spectacles as the gold standard, then he may have a terrific result yet still be dissatisfied if he needs to wear eyeglasses from time to time.

Point #2: I also want patients to understand that, early on, their near point for reading will likely be closer than what they're accustomed to. Because terms like "near point" don't mean much to patients, I physically hold their hands and demonstrate where material will be clearest for reading while I remark: "Early on, the sweetspot for your reading may be closer than you're used to, but we know that over about a 6-month period after surgery, it does expand for most patients."

Point #3: After demonstrating the near vision, I usually discuss intermediate vision. In my own clinical practice, I haven't seen clinically significant problems with intermediate vision with ReSTOR implants, and I believe this is related to how I counsel patients during this process.

I explain that the ReSTOR lens has two strong sweet spots — one for distance vision and one for near reading and working vision. Although most patients report that the midrange or intermediate vision is very good, it's definitely not as strong as the other two ranges of vision. Most patients find it more than adequate, but if they do significant midrange work, they may find that wearing spectacles makes this task easier.

As an example, a patient who received the ReSTOR IOL was a day trader who worked in front of four computer screens all day. Although he could read his computer screens without eyeglasses, he found it was more comfortable for him to wear them for this task.

Point #4: I counsel patients that they may need spectacles for some tasks. I'll say: "You'll probably wear some type of eyeglasses for some types of activities some of the time." I don't want patients to think they'll never wear spectacles again. Instead, I want them to view ReSTOR surgery as a way of obtaining more convenient, easier and more natural visual function than they'd obtain with standard monofocal cataract surgery.

Point #5: I also want patients to understand that typically the happiest and best functioning ReSTOR patients are those who receive the IOL bilaterally. I explain that although they may be pleased with their vision after the first eye is done, they'll have the best functional vision after their second eye is implanted. I also explain that many patients achieve their best functional vision 3 to 6 months after implantation of their second eye.

Point #6: The final concept I want patients to understand is the potential for glare and halo with multifocal lenses. I explain that, in my experience with the ReSTOR lens, only a small number of patients notice the glare and halo at all, and an even smaller number find the visual phenomenon bothersome. In most cases where these symptoms do occur, they'll resolve spontaneously over time.

Note that they do not, however, improve with implantation of the fellow eye. In the rare instances where a patient has had significant unwanted optical images following his first implantation, I won't proceed to the second eye surgery unless both the patient and I are satisfied with the clinical performance of the first eye. It's possible to place a monofocal IOL in the fellow eye of a patient with a multifocal IOL to improve distance vision and help with nighttime visual disturbances.

DON'T STOP AT PRE-OP

It's just as important to continue to educate your patients and manage their expectations after surgery as it is before surgery. Without question, my best educational tool is the "–3 diopter lens test."

To perform this test, give the patient sample reading material and tell him, "By holding a lens in front of your ReSTOR lens, I'm going to make it work like a standard lens. This will let us see the benefit you're getting from the ReSTOR lens."

Patients frequently look up amazed and say, "You mean that's what it would be like with a regular lens?" or "I can't see anything that way," or "Wow! This ReSTOR lens is really working!" Especially for a patient who may feel his reading vision isn't as good as he'd like it to be, the –3 diopter lens test is a great way to demonstrate how much benefit he's getting from the ReSTOR lens.

One overlooked pearl is that it's just as important to perform the –3 diopter lens test on your happiest ReSTOR patients. Even these patients, although they're happy, have no way of knowing how much better they are than if they'd undergone standard monofocal cataract surgery. At some point, these happy ReSTOR patients may meet a neighbor who had cataract surgery with a monofocal IOL and seems just as happy as they are (either because the neighbor doesn't know what he's missing or possibly because the neighbor has different visual needs). In any event, happy ReSTOR patients sometimes can suffer "buyer's remorse." The –3 diopter lens test demonstrates how much better they are for their near vision than if they'd chosen a conventional IOL. It reinforces their high expectations and satisfaction with the ReSTOR lens.

PATIENTS' CONCERNS: OBSERVATIONS VS. COMPLAINTS

Patients have no frame of reference for a normal postoperative experience, so they may remark on a variety of sensations, both visual and physiologic. Although these observations may sound like complaints, often patients are just looking for reassurance that these things are normal and not cause for concern. A classic example is the cataract patient who tells you, "My eye feels scratchy." You may interpret this as a complaint, but in reality, the patient wants to know whether this is normal or not. Typically, the surgeon's reassurance that this is normal and will improve is all the patient needs.

We hear these type of comments even more commonly from multifocal patients because there are more visual observations for these patients to note. For instance, ReSTOR patients may remark, "I have a hard time reading if the light is poor." In this instance, realize that the patient is not complaining but making an observation about his visual function and looking for reassurance that everything is all right.

Accordingly, I respond with, "That's right! What you're noticing is normal, and there are a few reasons for it: First, everyone has a harder time reading with poor illumination because the contrast is poorer. As a result, most people try to increase the available light to make reading better. And second, the ReSTOR lens is specifically designed to shift to a distance-dominant lens with reduced illumination, which markedly improves nighttime driving vision."

This response validates the patient's concerns, confirms that his observations are normal, explains the mechanism that creates what he's observing and offers a potential work-around.

You may notice a similar phenomenon with the ReSTOR lens and intermediate vision. The absolute best ReSTOR patients with the sharpest distance and near vision are typically the ones who notice their midrange vision is not as strong. These patients may tell you, "I don't see as well out there (demonstrating midrange) as I do at distance or near." Again, this is not a complaint. The patient is noticing the drop off in midrange compared to the excellent distance and near vision and wants to know if this is normal. I respond, "That's right! What you're noticing is normal. As we discussed preoperatively, the lens is strongest at distance and near, with a slight drop off in midrange. We know the midrange function does get better over about 6 months, but you may still wear correction from time to time for midrange activities." Again, this explanation validates the observation, discusses the cause and a potential work-around.

Managing patients' observations and concerns in the postoperative period is always easier if the patient was appropriately educated and counseled preoperatively.

ACHIEVABLE GOALS

Being able to provide our patients with crisp vision at every age for everything they do has become a more achievable goal, thanks to new technology IOLs. Cataract patients are understandably excited about their vision correction options. With appropriate education, we can ensure that excitement and satisfaction extend well beyond surgery day.

Richard Tipperman, M.D., is on staff at Wills Eye Institute and maintains a private practice in Bala Cynwyd, Pa.

REFERENCE

1. Results from Independent Harris Interactive Poll presented by Samuel Masket, ASCRS 2007, San Diego.