Letters to the Editor

Noncompliance Breeds Frustration and Risk

■ Thank you, Dr. Patterson, for sharing your medicolegal concerns over cataract patients' noncompliance with preoperative drop regimens (“The Best Laid Plans,” Viewpoint, June 2011). I have had the same concerns for many years.

Over the last decade, we have seen a variety of preoperative medication regimens recommended in many of the commercial journals and society meetings. Although these efforts to minimize CME and infections do have a scientific basis, they can be very expensive, and monitoring patient compliance is difficult. I too had always been concerned that there is medicolegal risk if a patient should arrive for surgery and be found not to have complied with the preoperative regimen. I have been concerned that not doing so is contrary to the current standard of care.

I practice in a rural setting. The population has to travel hours for surgery and is often in a lower socioeconomic group. I am sensitive to the costs of medications to patients and the inconvenince of sending them home due to noncompliance. Many do not have adequate support systems to ensure compliance.

With only rare exception, I have not given any cataract patients preoperative antibiotics or NSAID drops. I do give several doses of preoperative antibiotics with their dilating agent on the day of surgery, perform the usual betadine eye prep and careful draping, and give intracameral vancomycin at the end of surgery, as advocated by Dr. Mackool. Postoperatively, my patients get an antibiotic steroid drop and a topical NSAID if necessary.

I have not had any concerns or significant problems when using this regimen. I had been concerned that it was not standard of care based on all of the commercially sponsored articles that ophthalmic surgeons see regularly. My concerns were greatly reduced after attending the Kiawah Eye Meeting in 2010. I was able to ask the panel of well known surgeons from around the country whether or not the multiple regimens that are recommended represent the standard of care—all agreed that such recommendations were not. I also asked whether or not a regimen that did not include routine preop medications taken several days prior to surgery was contrary to the standard of care. All the surgeon panelists did not feel that such a regimen represented a deviation from the standard of care.

I believe ophthalmic surgeons can take comfort in knowing that such regimens, while recommended, are not the standard of care. I believe that not having the often recommended three-day preoperative regimen can control medicolegal risks, reduce costs to patients and still provide excellent care and outcomes. Thank you for giving this issue some much needed attention.

—Robert Mahanti, MD
Flagstaff, Ariz.

■ I just finished your Viewpoint article on preoperative medications. Like you, I spend a great deal of time during the preop exam explaining the peri- and postoperative care regimen to the patient (and his/her family). I designed my own instruction sheet that outlines the drop regimen in painstaking detail—and every patient gets this. Unfortunately, just as you have noted, I too still end up with poor/incomplete compliance from 10-15% of patients.

I don't think that there is a good solution to this problem. Patients seem to hear only what they “want to hear.” I have had several postop patients return to me on postop day #1 with multiple questions, all of which are outlined in the aforementioned instruction sheet.

In summary, you are not alone!

—Nicholas D. Mayfield, MD
West Georgia Eye Care Center

■ Interesting Viewpoint on patients who fail to comply with their preop instructions. One of my favorite stories (and which happens about four or five times per month per surgeon) is a patient or a pharmacist calling on the Saturday before a Monday morning surgery telling me that “the [name whichever drop you want] you prescribed is not on my formulary” or “is too expensive. Can you substitute another drop?”

With a five-man surgical practice, this is beyond frustrating, and you have to wonder what patients are thinking. Do they feel we should be available all weekend to field their calls about these issues and have 24 hour per day access to their preop records when they don't even know the name of the drop they want us to substitute for? Out here in Ohio, we feel your pain.

—Rich Orlando, MD
Columbus, Ohio

The Kids' Surgeons Are Alright

■ Paul Koch's As I See It column, “Who Should Remove Pediatric Cataracts?” (August 2011) opines that experienced anterior segment surgeons provide superior technical procedures. He cites pediatric ophthalmologist and skilled anterior segment surgeon Bob Sinskey's advocacy of a similar opinion. As a pediatric ophthalmologist, I believe Paul is mostly correct; however, there's more to know than surgical technique.

My wife Lisa and I have provided pediatric cataract care as a team for over two decades—years before Dr. Sinskey's position was known to us. I trained as a pediatric ophthalmologist, which entailed frequent strabismus and only rare cataract procedures at the busy University of Iowa hospitals and clinics. Ironically, I presented a paper on pediatric cataracts at Howard Gimbel's July 1990 Calgary cataract meeting. This same gathering ignited my wife Lisa's passion to be an anterior segment specialist. In a matter of months, her skills surpassed mine. As I enjoyed a busy and satisfying strabismus practice, I eliminated cataract procedures from my surgical repertoire. She performed all cataract procedures—including pediatric cases. I provided postoperative medical and visual (eg, amblyopia) management for all surgical kids' cataracts.

Many of my pediatric colleagues verbally admonished me for enabling an adult surgeon to perform pediatric cases. Hopefully, they objected because of patient outcomes instead of motivations of turf or lucre. Unfortunately, most of us regularly cared for patients operated on by high volume surgeons with disappointing results—especially poor vision.

Dr. Koch is correct about the technical procedure itself. For his 12-year-old patient, his adult-oriented team can obviously manage the entire service. On the other hand, the youngest patients are a different kettle of fish. Their scleral rigidity typically requires (perish the thought) sutures. Their postop inflammation demands closer clinical supervision and prolonged management unfamiliar to high-volume cataract practices. Those in the amblyogenic age range need careful and repeated refractions combined with aggressive amblyopia treatment and follow-up. This is most critical for monocular pediatric cataracts. Our team enjoys outstanding results. Our patients experienced fewer postop glaucoma and retinal complications over the years, and their visual outcomes likewise exceeded published reports.

An ongoing benefit to our pediatric cataract patients is the surgeon's constant attention to enhanced service. Posterior capsulorhexis with optic capture will likely avert vitreous procedures and repeated capsule procedures so common years ago.

—Amir Arbisser, MD
Pediatric ophthalmologist Bettendorf, Iowa