Preoperative Test Workflow for Refractive Cataract Surgery

Have all relevant test data available when making refractive IOL recommendations.

By David F. Chang, MD

Undoubtedly the biggest change in our transition to refractive cataract surgery has been the more extensive preoperative evaluation and counseling of the cataract patient. Previously, when patients only expected us to wear the hat of a cataract surgeon, the preoperative discussion was reasonably simple. After explaining the diagnosis to a symptomatic patient, and discussing the surgical benefits and risks, we routinely exceeded most patients' expectations with our surgery. Now, many cataract patients also expect us to wear the hat of a refractive surgeon. The additional out-of-pocket costs are significant and patients understandably want to hear about all of their options. They ask many questions, and they take their time when pondering this important decision. Expectations are typically much more difficult to meet.

Managing Patient Expectations Preop

Properly and effectively educating the patient now takes much longer. I've found that it's extremely important, whenever possible, to begin this process of education and communication before the patient first comes to see me. Therefore, prior to each appointment, our office mails a welcome packet to every patient referred with a possible cataract. I've created a brochure covering cataract surgery that also describes the option of refractive IOLs for an additional out-of-pocket cost. I explain the concepts of presbyopia and astigmatism and briefly describe the differences between monofocal, multifocal, accommodating and toric IOLs. Most importantly, the welcome letter refers patients to my practice website, where they can learn much more about these options and about the process of scheduling and having surgery. Because so many patients seek medical information from the Internet, I use my own website to highlight specific messages that I want to emphasize—particularly in the area of postoperative refractive expectations.

Patients are also urged to complete the Dell questionnaire, which I have slightly modified for my cataract practice. These questions force the patient to contemplate and then prioritize their refractive goals. This very process helps to set the expectation that there is no perfect solution, and causes patients to analyze and observe when they do and don't need to wear eyeglasses. Finally, the Dell questionnaire is a very time-efficient method for the patient to document and provide me with invaluable information about his or her lifestyle and refractive needs. As a result of this previsit education and self-assessment, many patients arrive with a strong sense of whether or not they're interested in a premium refractive IOL, and they are anxious to learn about the costs and if they are a good candidate.

Although many patients are not interested in spectacle independence, and many others are not good candidates for premium IOLs, I believe it's important for me to at least inform every cataract patient about these options. I explain that many patients aren't good candidates because of their specific ocular findings. I also emphasize that there are no medical or safety advantages to these more costly options, and that they are essentially for convenience. The basic educational message shouldn't make the patient feel shortchanged if they ultimately receive a monofocal IOL.

Using Forum, all test results are accessible from any exam room computer. The large screen exam room monitor here displays the right and left eye topography/wavefront analysis.

Pre-testing

In addition to corneal topography, we perform ocular wavefront testing on every prospective cataract surgical candidate. Of course, the total ocular wavefront is usually abnormal in cataractous eyes. However, the iTrace combo (Tracey Technologies Corp.) combines topography and wavefront measuring technology in a single compact desktop platform and is able to distinguish between higher order aberrations that are coming from the cornea versus those arising from the lens. Knowing when there are significant higher order corneal aberrations is valuable in counseling any preoperative patient, and generally dissuades me from recommending a multifocal IOL. Likewise, corneal topography is important for determining the optimal power and axis for a toric IOL.

For many cataract patients, deciding which IOL to implant comprises the majority of the preoperative discussion. Faced with multiple options, it's very helpful for patients desiring reduced spectacle dependence to receive a specific recommendation from their ophthalmologist. It can become frustrating and confusing if the surgeon has to backtrack later in the process and change the initial recommendation. One example might be recommending a toric IOL to a high myope, only to later calculate that they need a +3.0 D lens, for which there is no toric model available. Alternatively, imagine spending a lot of time deliberating the multi-focal IOL pros and cons and expectations, only to later discover an abnormal topography or corneal wavefront analysis that makes a multifocal inadvisable. When I counsel the patient regarding IOL choices, it's therefore important for me to have as much information on hand as possible.

In addition to an autorefraction and autokeratometry, we obtain IOLMaster (Carl Zeiss Meditec) keratometry and biometry, and iTrace corneal topography and wavefront analysis on every prospective cataract surgical candidate prior to initiating the vision testing, refraction and examination. Performing keratometry, topography and wavefront analysis as pre-tests prior to the corneal drying effects of topical anesthetic and dilating drops also improves the test quality.

Office Workflow

As each new cataract patient arrives, we don't know if he'll be interested in or be a good candidate for a premium refractive IOL. Therefore, we routinely perform the same standard pre-testing mentioned earlier with the assumption that every patient may potentially be a multifocal or other refractive IOL candidate. The IOLMaster data downloads directly into the Forum network and data management system. We also download the iTrace summary display, which includes topography and wavefront analysis, for each eye into Forum. The patient then undergoes a refraction, a slit lamp examination, and tonometry performed by my optometrist prior to being dilated. Based on the refraction and the Dell questionnaire responses, my optometrist will determine which patient education videos to show the patient as they dilate. The EyeMaginations Chang Refractive IOL system consists of modular educational videos that describe toric, multifocal and accommodating IOLs, as well as astigmatic keratotomy. These modular videos enable us to show any combination of topics to an individual patient, in a more customized fashion.

Each exam room is equipped with a large touch-screen computer monitor that can alternately display Forum or the EyeMaginations Luma system. I may also use my website as a reference when directing patients to review a specific section at home. The patient and their family watch the selected educational videos while they dilate. Using the same large screen monitor during my consultation, the patient and I can view the IOLMaster data (including the individual axial length and keratometry measurements), pupil diameter display, and calculation sheet using multiple formulae for my preferred monofocal IOL. I can then display and discuss the iTrace topography and wavefront data with the patient.

As one might expect, patients are impressed when they see the graphical display and numerical data from their own ocular exam. Because the measurements were obtained so rapidly, they're often surprised to see how much information was gathered, and that we've performed a much more sophisticated and extensive evaluation compared to their prior eye exams. The educational value to the patient is also substantial. Because the concept of astigmatism is confusing, the pictorial display of their corneal topography is very helpful in explaining how astigmatic keratotomy or a toric IOL work. I may also pull up my website to direct the patient to a specific section to review at home.

Office Efficiency

If the patient is scheduled for cataract surgery, we will print the IOLMaster IOL calculation sheet (for the selected IOL) for the paper chart. If they elect some form of astigmatism management, we also print the topography. Otherwise, the data is not printed, but remains on our office server as a permanent record of their examination. Routinely doing all of this pre-testing on every cataract patient results in some unnecessary testing for those patients who won't need surgery, or won't elect any refractive services. However, because the IOLMaster and iTrace testing is so fast, and because with Forum the results are not routinely printed, there is little wasted time, paper and printing cost to do this. The benefit of having all of this information available when discussing an IOL recommendation more than offsets these slight disadvantages.

The ability to use Forum to capture, store and the display the data in any exam room has been invaluable for managing the preoperative testing for refractive cataract patients. We have so far chosen not to implement an electronic medical record system for our three-person ophthalmology private practice. However, I believe that Forum gives us some of the best advantages of what an EMR would otherwise offer. Digitally storing all IOL Master, iTrace, Visual Field analyzer, and Cirrus HC-OCT data has allowed us to significantly reduce our printing costs and the number of loose printouts in our charts. Networking large screen monitors in each exam room has improved our office workflow efficiency and patient education and satisfaction.

Premium refractive IOLs and services have compelled us to further improve our preoperative ocular and optical assessment of cataract patients. This testing is critical to properly counsel patients and construct an individualized refractive game plan. Thanks to new methods of data management and networking, any negative impact of this expanded preoperative testing on office efficiency and workflow can be minimized.

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Dr. Chang is clinical professor at the University of California, San Francisco, and in private practice in Los Altos, Calif. He has no financial interest in Tracey Technologies. His Zeiss speaking fees and EyeMaginations royalties are donated to Project Vision and Himalayan Cataract Project.