At the completion of this article, the reader should be able to improve their management of patients requiring cataract surgery including:
- Review the components of productive post-operative communication
- Understand and manage cataract patient expectations
- Review the elements of a good referral for refractive cataract surgery
- Understand the types of IOLs currently available
The best outcomes for patients with cataracts come from strong collaborative relationships between optometrists and ophthalmologists. Each play an important role in the evaluation and management of patients and their expectations. The authors of this article recently held a discussion on the topic, and the following conversation has been edited for clarity and educational content.
Dr John Hogden
MBBS BMedSc RANZCO
The Eye Health Centre, Brisbane
Jason Holland
B.App.Sci (Hons)(Optom) PGOT, CASA CO
The Eye Health Centre, Brisbane
National Director for Optometry, The Optical Superstore
Tessa Brushett
Surgical Account Manager
Alcon Australia
What do patients expect from cataract surgery?
Jason Holland, optometrist
When I went through university, we did very little on intraocular lenses (IOLs). When a patient developed cataracts, we were told, they had surgery and they got new glasses afterwards. That has changed a lot in recent years.
I think with the way IOL technology is heading, optometrists will have to upskill to develop their understanding of these lenses. Patients are keen to be less reliant on glasses and are starting to ask about their lens options before referral.1
Dr John Hogden, ophthalmologist
A decade ago, the average ophthalmic cataract surgical list consisted predominantly of monofocal IOLs with some surgeons aiming for a monovision refraction. Cataract surgery has improved; it’s relatively quick, highly effective and reliable. We’ve gone from using spherical monofocal lenses, to correcting astigmatism, then on to presbyopia-correction which is the latest advancement.2
Tessa Brushett, Alcon
Recently, Alcon commissioned some market research around patient expectations prior to cataract surgery and found that one in three patients referred for cataract surgery assume that the procedure will mean complete spectacle independence.3 The research challenges the idea that patients are happy with just great distance vision and that they don’t mind wearing glasses for everything else.
Patients were shown an example of vision with the Alcon PanOptix diffractive trifocal IOL, so 6/6 in the distance with some halos and glare and being spectacle independent for intermediate reading; an example of the Alcon Vivity extended range of vision IOL with excellent distance, great intermediate but needing glasses for reading with no glare or halos; and then a monofocal example, great distance but needing glasses for everything else. Ninety per cent said they would be interested in a presbyopia-correcting IOL (PC-IOL).3
Jason Holland
These outcomes really show that we (optometrists) need to initiate discussions about options more – both before referral and at the surgical consultation. Not all patients request trifocal or EDOF IOLs – but it’s obvious they would like to have that chat.
As the trends in patient care go from ‘cataract surgery’ to ‘refractive cataract surgery’, optometrists who want to make informed referrals want to know: how do we define that now, and what’s required?
Tessa Brushett
What we know is: providing information to the patients is almost as important as providing information to the referring ophthalmologist.
If one in three patients assume that they won’t need glasses after surgery, optometrists will need to manage their expectations. Established relationships between optometrists and surgeons allow an open forum for discussion about the IOLs that suit a patient and why they would like it.
Jason Holland
The referral is a big part of getting this process right. With PC-IOLs there is an adaptive process, so if the patient has had trouble adapting to multifocal glasses or contact lenses, if they have trouble adjusting to changes in refraction or are very particular personalities, it’s important to let the surgeon know.
Dr John Hogden
Modern cataract surgery is very much a refractive process4 and patients often want certain visual outcomes. The surgeon’s pre-operative process is about pairing the patient to the right lens and then communicating that back to the optometrist.
Jason Holland
In our practice, we use patient lifestyle questionnaires to start conversations about correction options. It prompts them to think about what they might want – often when you ask them, they aren’t sure (and many didn’t even know they have a choice).
The impact of dry eye
Dr John Hogden
Dry eye is so prevalent in the community, particularly with the aging population. Conditions such as inflammatory eyelid disease, EBMDs (corneal epithelial basement membrane disease) such as map-dot fingerprint dystrophy and visually-significant pterygium often need to be addressed before considering IOL surgery.
Optometrists are perfectly placed to identify and address these conditions with a slit lamp examination. These other pathologies might need to be addressed prior to cataract surgery and the optometrist can prepare the patient by informing them of the need to treat the other issue first to achieve a superior refractive and functional outcome.
Jason Holland
You can have the best IOL from the best surgeon, but if you don’t manage the ocular surface and tear film, the patient will still be unhappy. It is one of those issues that requires ongoing care and optometrists need to manage these people long term.
Aggressive management of dry eye by the optometrist will benefit the patient and the ophthalmologist and will facilitate a better patient outcome. A poor tear film delays surgery as we can’t do accurate measurements, topography and biometry. In our clinic, we routinely question the patients about dry eye symptoms, and encourage them to disclose even mild symptoms. We then do an indirect tear break up time and a digital expression of the meibomian glands to examine the quality of the secretions.
By being proactive about dry eye, the patient is more likely to have stable vision and less likely to become a dry eye patient post-operatively.
How do you go about patient selection?
Jason Holland
Alcon’s Light Intensity Distribution Diagram (figure 2) is a great little visualisation of the differences in the IOLs. Monofocal IOLs, at the top row, are great for distance, but vision drops off quickly when it gets to objects at an intermediate distance.
The second row is an earlier diffractive EDOF, which shows some little visual gaps which indicate there is not a continuous focus.
The third row is a diffractive trifocal, the PanOptix, where there is a distance focus then a long, clear focus stretch from intermediate to near.
At the bottom is Vivity where the continuous focus stretches from distance all the way through to intermediate.
Dr John Hogden
This graphic is really good as you can see there are pros and cons to every lens; what suits one person may not suit another so you can offer the patient a suite of lenses. In a consultation you try and tailor the offering, the patient may have AMD or severely dry eyes and this may modify what is recommended, but you can educate them and show them what the lenses can do and this works best when it starts with the optometrist.
Astigmatism
Jason Holland
Dr Hogden, with astigmatism and PC-IOLs, do you only correct over 2 diopters, or do you consider half a diopter or more is significant?
Dr John Hogden
At the Eye Health Centre we place incredible importance on the reliable and accurate measurement of astigmatism and to manage any dry eye and other ophthalmic pathology, listening to patients and seeing what their expectations are afterwards to get lens selection and outcomes just right. We can now offer a whole suite of lenses for patients, anything from a monofocal lens, to an EDOF lens or the trifocal, it is about matching the right patient to the right lens.
Astigmatism correction is very important and critical in getting good results for patients and PC-IOLs are less forgiving than a monofocal so we always want to address it. At the Eye Health Centre we use a lot of different measures, wavefront Placido, anterior segment OCT, checking the referral to see how much astigmatism is in the patient’s glasses and if it has fluctuated over the years to really nail the refractive outcome. Correcting down to 0.75 diopters of astigmatism is now the standard of care for us.
Post-operative care
Jason Holland
Research suggests several key things optometrists would like to hear back from the surgeon once the patient is discharged and returns to see them. They want to know if there is a complication as invariably they will be managing that with the ophthalmologist and interestingly they also want to know if the patient is satisfied with the surgery; are they going to walk in saying everything’s great or were there some issues and they’re not satisfied?3
Dr John Hogden
The communication needs to go two ways, there’s a lot of onus on the ophthalmologist to feed that information back and close the loop. Optometrists want to know if the surgery was routine? What IOL has the patient been given? What are their refractive needs or other optometric needs after surgery? They may need to see their optometrist six monthly to monitor for glaucoma. I try to put in as much information as I can about whether they need a weak pair of reading glasses or some sunglasses, whatever their needs might be moving forward. I also like to keep the door open so that if six or 12 months down the track there is an issue, then I can look after the patient and address any issues or any pathology that may have arisen.
We need to give all that information in the letter back to the optometrist and try to be really vigilant about it. It’s hard as a clinician when you don’t have all the information, so the more information we can provide the easier the job is afterwards for the patient’s optometrist.
There is a need to hand back to the optometrist at the end of the treatment process. Complex IOLs will require greater collaboration than we have had in the past.
Jason Holland
If you aren’t aware of the type of IOL your refraction can be off so PC-IOLs can catch you off guard. If you haven’t got the letter from the surgeon, it’s important to do unaided vision at distance and at near and you’ll quickly know if the IOL’s a monofocal or not, because they will have great distance vision and poor vision up close.
If you have a Vivity lens they will hold the reading card away from them to read it, and with PanOptix or other trifocal IOLs they will be able to read at approximately 60 and 40cm. Routinely we often just do unaided vision at a distance but moving forward, if someone has had cataract surgery, my first step would be to do unaided distance and near vision.
The next step would be retinoscopy to help see what the lens is, you are going to get a droplet like reflection for Vivity, almost like a keratoconic, while for diffractive IOLs you can see the rings clearly. You can also use the slit lamp.
Auto-refraction and duochrome generally don’t work well with PC-IOLs. When I’m refracting an IOL with any sort of multifocality, I’ll use 0.50D steps when refracting or a 0.50D cross-cyl rather than 0.25D.
These IOLs have complicated optics and you’ll find you’ll be less caught out by aberrations or minor idiosyncrasies of the optics if you use a larger step. I also find that you need to be mindful of pushing the plus in the refraction, as you can find that the patient keeps accepting minus and you end up refracting the intermediate part of the IOL.
Communications is key
Dr John Hogden
The key message is that communication between ophthalmologists and optometrists is really important. Optometrists know what the best options for patients’ vision corrections are and what works for their patients. They also know what patients expect of surgery and communicating this in your referral helps in the decision process as to what IOL will work best for your patient. Receiving correspondence back from the surgeon helps with understanding what the patient’s needs are moving forward and this should be an open dialogue. There are lots of IOLs out there, we just need to keep talking about it and seeing how we can better serve our patients.
Jason Holland
As Dr Hogden said, the overarching theme is communication. Let’s communicate with our patients better, let’s get more comfortable understanding IOLs and let’s collaborate with surgeons to get better patient outcomes.
More reading
IPL: A paradigm shift in the treatment of dry eye disease
Outdoor light exposure – the first step in myopia management
Don’t forget about myopia progression in adults
References
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18.Results from a prospective, randomized, parallel group, subject and assessor masked, multisite trial of 107 subjects bilaterally implanted with AcrySof IQ Vivity® Extended Vision IOL and 113 with AcrySof® IQ IOL with 6 months follow-up. †Snellen VA was converted from logMAR VA. A Snellen notation of 20/20-2 or better indicates a logMAR VA of 0.04 or better, which
means 3 or more of the 5 ETDRS chart letters in the line were identified correctly.
