At the completion of this article, the reader should be able to improve their co-management of cataract patients, including:
- Understand the rationale for pre-operative patient education, and review an example
- Review the benefits and limitation of the different types of intraocular lenses
- Develop conditions for improved pre- and post-operative care of cataract patients
As demand for cataract surgery increases, optometrists are playing a greater role in the patient journey. In this collaborative article, optometrist KRISTIE BUTLER and ophthalmologist Dr LEWIS LEVITZ explain the definition of ‘skillful co-management’ and why it’s never been more important for optometrists to remain abreast of the newest cataract technologies, procedures and protocols.
Kristie Butler
BOptom, GCOT
Dr Lewis Levitz
MBBCh MMed, FCS(SA)Ophth, FRCSEd, FRANZCO
Vision Eye Institute
Practical cataract co-management
When it comes to cataract surgery and intraocular lens (IOL) selection, optometrists are in the privileged position of not just assessing eye health, but also of knowing their patients’ personalities, likes and dislikes as optometrists have often known them, and sometimes their families, for some time.
While most patients have heard the term ‘cataract’ and know someone who has had surgery, many are unaware of what is involved. Optometrists are tasked with the important job of patient education. That is: explaining what a cataract actually is, outlining the surgery and helping them understand the differences between the available IOLs. This is all done prior to referral for potential surgery.
Lifestyle, hobbies and profession as well as any unique visual requirements and personality traits must be acknowledged when selecting an IOL. This is in addition to ocular health, general health, previous ocular surgery and refractive error considerations. An increased significance is now placed on the visual outcomes of cataract surgery. Some patients, for example, will be hoping to achieve spectacle independence following cataract surgery. Getting a feel for your patient’s expectations is crucial for achieving successful results.
This case report describes how we explored a typical cataract patient’s option and came to a tentative decision regarding IOLs before referring her to the ophthalmologist.
Case report
At the optometry practice with Kristie Butler:
Mrs X, a 67-year-old female attended the practice with complaints of deteriorating vision. Her prescription, unchanged from her previous test over 12 months ago, was R +1.50 VA 6/7.5-2, L +1.75/-0.50×10 VA 6/9-2, Add +2.25. Her acuities had dropped a line in both eyes since her last test.
Slit lamp exam revealed anterior cortical and nuclear sclerotic cataracts and a healthy ocular surface (Figure 1). Fundus exam and OCT showed healthy optic nerves and maculae and her intraocular pressures were normal. It was evident her cataracts were the cause of her symptoms and acuity reduction. As she was unhappy with her current vision, we began the discussion about cataracts and their treatment.
I explained how her cataract would be replaced with an IOL. New technology means that there would be a variety of IOLs that could be offered depending on her particular needs.
Monofocal IOLs
Monofocal IOLs would be her first option, providing good vision at one distance only. Taking into account her prior refractive history of emmetropia until her late 40s, monofocal IOLs would be set for distance and she would require reading glasses for all of her close tasks, such as reading, using a tablet and her crosswords, all of which she enjoys.
Monovision IOLs
We then discussed monovision, having her non-dominant eye set for near, thus decreasing spectacle dependence. She was very interested in having some near vision without having to wear glasses but felt she would have trouble tolerating the distance blur in one eye. This is a better option for myopes, especially those used to monovision in contact lenses.
Multifocal IOLs
Her interest in potentially not having to wear reading glasses led us to talk about multifocal/trifocal IOLs and the extended depth of focus (EDOF) IOL. I explained how multifocal IOLs will give her good distance and near vision, however she may see haloes around lights at night. Even though she seems fairly easy going, does not have precise visual requirements and has no other pathology, this did not appeal to her as she often has to drive at night.
Extended depth of focus (EDOF) IOLs
EDOF IOLs are the latest innovation in addressing presbyopia at the time of cataract surgery. They give a good functional range of vision, with good distance and intermediate vision and reasonable near vision, with less side effects than the multifocal IOL. This will enable her to accomplish most daily tasks, such as driving, cooking, cleaning etc. without glasses, although she may have to wear reading glasses for books or fine print.
These days there are a variety of lenses which can offer a patient an extended depth of focus but which are not truly ‘multifocal’. These use different qualities of light to offer a range of vision while trying to decrease the unwanted visual phenomena which can accompany a diffractive multifocal lens.2 These include, among others, the Vivity (Alcon), Eyhance and Symfony (Johnson & Johnson), Lentis (Teleon Surgical), RayOne EMV (Raynere), IC8 (AcuFocus), and the At Lara (Carl Zeis Meditec).
The type of implant is less important that the communication between the optometrist and the ophthalmologist so that the optometrist is aware which type of lens was used.
We both believed the EDOF IOL would be a good fit for her lifestyle, so this was noted in my referral to the ophthalmologist. I explained that the ophthalmologist would take different measurements and assess her eyes further before helping her come to a final decision.
With the ophthalmologist, Dr Lewis Levtiz:
Ophthalmology today is as much about managing expectations as it is about providing eyecare.
When a patient is referred for a cataract assessment, they know that they will probably be offered an operation. They have certain questions on their mind: ‘Do I really have a cataract?’, ‘Do I trust the doctor?’, ‘How long will I be away from work, golf, swimming, driving?’, ‘Where will it be done?’ ‘How long will the recovery take?’. I assume that each patient has all of these questions when they walk in the door. The answers that the attending ophthalmologist gives must take into account the patient’s pathology, comorbidity, expectations, personality and possible changing visual needs.
The ‘discussion’ vs the ‘excuse’
The more time spent discussing the various options and the compromises inherent in each, the better it is for all. The patient regards an educational talk held before an operation as a ‘discussion’, while the same talk held afterwards is regarded as an ‘excuse’.
Once the diagnosis of cataract as the cause of the patient’s visual loss is confirmed, it’s vital to discuss the condition of the patient’s macular and cornea. If the patient has macular disease, then now is the time to mention it. If the cornea is dry or has irregular astigmatism, then mentioning it before discussing lens options enables the ophthalmologist to guide the patient away from choices they might want to make, but may not be in their interests.
As part of my standard approach, after these vital topics have been communicated, I then give a few minutes over to discussing options, briefly stating what the benefit of each lens may be for that particular patient. Because I know that the referring optometrist has already mentioned these concepts, and the person may have had time to mull them over, the discussion on options is made much easier.
Monofocal intraocular lenses
Monofocal lenses placed in both eyes with a similar refractive target is still a good choice for many. I explained to Mrs X that monovision probably will give the best and sharpest single image. She will still maintain good binocular vision. It is a good option for anyone happy to continue using their reading or multifocal glasses.
The downside is that if she chooses this option is that she may still need to wear glasses for reading. In order for her not to regard the cataract operation as a ‘failure,’ it’s important to clearly explain this possibility beforehand.
Monovision
Giving Mrs X the tried and tested option of correcting her dominant eye for plano and then leaving her non-dominant eye slightly myopic is also a choice. True monovision would mean she was left with a script of -1.00 whereas mini monovision is when the non-dominant eye is left with a script of between -0.5 to-0.75. This is both achievable and yet also not always achievable. There are so many individual variables, notwithstanding the fact that most lenses only come in 0.5 increments, that this option cannot be guaranteed.
The monovision lens option is great for people who have used contact lenses and are used to monovision.3 Mrs X has not used contact lenses previously. (Mrs X also has cataracts so a contact lens trial would not be a true reflection of what her outcome would be). The best thing about offering her monovision is that if she is unhappy, she can be referred for corneal refractive surgery after three months and be left emmetropic again. Mrs X turned down this offer.
Multifocal lenses
Mrs X was then offered multifocal lenses as she expressed a wish to be independent of glasses. As she was hyperopic before, I had no hesitation in offering her multifocal lenses.4,5,6,7 I explained that she will still need glasses for near work in poor light.
Mrs X was told that she will have halos around light at night and that it may take time to adjust to this ‘new way of seeing’.8 Pupil size, although important with the older diffractive multifocal lenses, is not as much of a contra-indication with the newer diffractive lenses.9 It is important to stress that corneal pathology or macular pathology will degrade the vision. The OCT scan which accompanied her from her optometrist visit gave me reassurance that she would do well. However, Mrs X was not keen on the idea of night time halos.
Extended depth of focus (EDOF) lenses
I explained to Mrs X that EDOF lenses are a compromise between monofocal lenses and multifocal lenses.10 There are various types on the market, which may give vision equal to that of a monofocal lens with the advantage of reading at arm’s length.11 There are also much fewer nocturnal dysphotopsia than with multifocal lenses.
A very recent study showed that an EDOF lens gave comparable distance vision as a monofocal lens but with the advantage of being able to read two extra lines at intermediate distance. There was no statistical difference in the patients reporting unwanted visual phenomenon, however these were reported less frequently in the monofocal group.12
I promised that I would let the referring optometrist know exactly what lens was used, as performing a post-operative refraction on someone with an EDOF lens is different to that performed with a monofocal lens. The patient with the EDOF lens should be left ‘more plus’ than with a monofocal lens.
As Mrs X had realistic expectations, and was willing to accept that she will still need to use reading glasses, I offered her an EDOF lens. She had uncomplicated surgery on each eye two weeks apart. She was given a combination of antibiotic drops for 10 days and steroid drops for one month. She was then referred back to her referring optometrist for review.
First post-operative visit
Mrs X could be seen either by her optometrist of her ophthalmologist for a day one post-operative visit.
Her vison would be assessed, but this is often variable and will depend on the amount of ultrasound power needed to remove the cataract and the health of the endothelium. Although the post-operative vision is usually much better than the pre-operative vision, a pinhole vision may need to be used in the occasional case.
The cornea would be assessed next. There may be a small collection of viscoelastic on the endothelium. This usually disappears in a day. The site of the corneal incision is checked to see that there is no iris prolapse.
The pupil may be normal or still slightly dilated on day one. Sometimes, the pupil looks irregular from the dilation. This should not be confused with a peaked pupil due to vitreous in the anterior chamber which can be more serious.
The lens should be seen sitting behind the anterior capsule in uncomplicated cases. Certain surgeons prefer that intraocular pressure not be taken on day one to avoid pressure on the wound, but an I-Care tonometry reading is reasonable. A slightly elevated pressure need not be treated as it may be due to retained viscoelastic.
Return visit at the optometrist’s rooms
Our patient attended my optometric practice for her final check a week after her four-week post-op visit. I was aware she had received the EDOF IOL and knew what to expect at the follow-up as I had received several correspondence letters from the ophthalmologist.
Her unaided acuities were R 6/6, L 6/6-2, near N6 at 40 cm. She was very happy with her vision. She could use her phone and tablet unaided and felt she only needed reading glasses for her crosswords and books. Final refraction was R plano VA 6/6, L -0.25/-0.25×180 VA 6/6, Add +2.25.
Conclusion
A thorough eye test and informed discussion regarding choice of IOL with an optometrist made our patient’s experience with the ophthalmologist and subsequent cataract surgery that much smoother.
Patient confidence in their IOL selection grows when they have consulted with two separate eye professionals prior to surgery. Ultimately, this leads to better visual outcomes and greater patient satisfaction.
More reading
Cataract surgery: Why patient reported outcome measures matter
New Zealand addresses cataract surgery ‘postcode lottery’
References
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10. Palomino-Bautista C, Sánchez-Jean R, Carmona-Gonzalez D, Piñero DP, Molina-Martín A. Depth of field measures in pseudophakic eyes implanted with different type of presbyopia-correcting IOLS. Sci Rep. 2021;
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12. Pantanelli SM, O’Rourke T, Bolognia O, Scruggs K, Longenecker A, Lehman E. Vision and patient-reported outcomes with nondiffractive EDOF or neutral aspheric monofocal intraocular lenses. J Cataract Refract Surg. 2023; 49 (4): 360-366.
