We hear a lot about the importance of managing patient expectations when it comes to vision-correcting surgery. However, to do that, you must realize that managing your expectations as the surgeon is a critical element in the creation of a successful refractive cataract surgery practice. You may not be conscious of what exactly the surgeon’s expectations should be — until you are confronted with a dissatisfied patient.

So, in the interest of helping you avoid such a situation, I’m going to review the necessary expectations for your role.

BE CLEAR ABOUT WHAT THE TECHNOLOGY CANNOT DO

Given the knowledge asymmetry about refractive cataract surgery, the surgeon bears the burden of establishing and delivering the strategic communication plan to patients. The refractive technology at our disposal simply rocks — but it has limitations. Know what you want to promise the patient, but understand that it is equally crucial to outline where the technology falls short. Make these points absolutely clear, not sugar-coated, and avoid complicated details or confusing terminology.

For example, if a presbyopic lens can reduce glasses use by 90% each day in most patients, this also means the surgeon should state clearly that it does not mean the patient will be “spectacle free.” Being equally assertive in detailing the pluses and minuses of the surgical outcomes sets reasonable expectations. Patients will feel more comfortable making decisions about a refractive surgical plan when they have all the facts.

Our instinct may tell us to soften the potential downside of the patient’s likely outcome because it could scare them away. But the opposite is true: Patients can handle the facts and want to hear them from their surgeon. Keep in mind, they already have half the information from the internet!

EXERCISE YOUR POWERS OF DISCRIMINATION

Don’t forget that you possess the power to choose who is a candidate for refractive elements in cataract surgery. Once you operate, you are metaphorically handcuffed to the patient and obligated to deliver on the implicated and intended expectations you created at the time of the cataract consultation.

Choose wisely. Experience will help you to recognize red flags, beyond ocular pathology, to steer clear of when offering freedom from glasses. A patient who changes glasses every 0.25 diopter, who asks questions while you’re still answering the first question or who insists on no glasses at all is at high risk for dissatisfaction with the outcome of a perfect surgery.

DON’T DO ALL THE TALKING

Be sure to listen. We are often so busy explaining the tremendous amount of information necessary for the cataract patient that we forget to do so. The patient will tell you everything you need to know to meet their expectations. Actively listen to their vision issues, the impact on their activities and their expectations from surgery. Key questions asked about these issues and answers truly heard will allow you to customize the surgical consult to meet their needs and expectations. That guidance may seem simple, but it takes effort to practice.

DON’T EXPECT TO ALWAYS GET IT RIGHT THE FIRST TIME

Expect about 6% of patients to express disappointment with their vision the first 3 to 6 months after surgery. Knowing this will allow you to research and develop a strategy to implement when the phenomenon does occur. Often this strategy begins before surgery — in warning the patient about the need for neuroadaptation, the need to rebuild the tear film and the impact of posterior capsule opacification if it develops in the early postoperative period.

Examples of action steps after surgery include providing a dry-eye regimen, encouraging the use of +2.00 reading glasses if neuroadaptation is delayed, tips on the need for strong lighting at near and helping patients find the fixed focal point for near.

Another critical action step: Reminding patients they will use near glasses 10% of their day with 90% glasses-free, as mentioned before surgery. Reassurance is key while listening to patient concerns. Sometimes using bilateral -2.00 trial frames in the exam chair allows you to demonstrate what near vision would be with a monofocal IOL and confirm to the patient that the focusing implant is working.

MASTER YOUR CHOSEN TECHNOLOGY

Know your beast. Sticking to a specific technology allows you to gain familiarity with it that you can bring to the next patient who comes to you for a cataract consultation. The surgeon is better equipped to counsel a patient on what, for instance, the IOL can and cannot achieve. Although technology is evolving rapidly and while we surgeons need to keep up, consider the impact change will have on your ability to know and manage expectations communicated to your patients.

EXERCISE CONTROL

It is amazing to reflect on what we can offer patients undergoing refractive cataract surgery compared to even 20 years ago. Despite this remarkable progress, however, the technology still does not compare to the eye of an adolescent with their natural lens. The latest and greatest IOL, for example, arguably is not always better than the progressive glasses your patient has worn for the past dozen years. As the surgeon, your role is to redirect the patient to consider their vision if they had received only a monofocal lens and did not manage astigmatism rather than receive a presbyopic implant.

Choosing the right candidates, actively listening, planning on postoperative interventions and gaining experience with one technology are all tools to manage your expectations for success. OM

About the Author

Scott LaBorwit, MD, is a principal at Select Eye Care, with locations in Towson and Elkridge, Md., and is an assistant professor, part-time faculty, at Wilmer Eye Clinic of Johns Hopkins Hospital, Baltimore. Contact him at: Sel104@me.com.