Preventing Unhappy Post-Surgery Patients

For decades, optometrists have provided a continuum of care to patients when comanaging cataract and laser vision correction surgeries. Unfortunately, we sometimes have patients who return from surgery disappointed with the outcome. In these cases, have we as referring optometrists failed to do our jobs properly? Let’s look at some steps we can take to help prevent these unhappy or dissatisfied patients.

OPTOMETRY’S OVERALL ROLE

Optometrists play a front-line role in identifying the surgical needs of patients, and with a shift toward medically focused optometry and advances in diagnostics, we should hold ourselves and our profession accountable to ensure that we are maximizing our preoperative evaluation to improve efficiency and maximize patient outcomes.

To ensure a successful referral pattern, both a strong optometrist-patient relationship and an optometrist-ophthalmologist relationship must exist. Being at the forefront of eye care, it is only natural that we begin the patient education process, ultimately laying the foundation necessary for strong relationships and successful surgical outcomes. Patients are more engaged in their surgical journey when they are educated about any necessary additional testing, surgical options, and postoperative expectations.

Before referring a patient to a surgeon for cataract or laser vision correction surgery, the optometrist should complete an ocular assessment and have a discussion with the patient to understand their expectations and visual personality. Below are the various elements of the assessment to include.

THE OCULAR ASSESSMENT

Ocular Surface

Ophthalmologists recognize the value of optimizing the tear film preoperatively¹ and many are eager for the referring optometrist to own that management. Having an effective plan to manage it can reduce the potential for an unhappy patient returning to the office. Many optometry clinics offer point-of-service diagnostic tests for tear film and ocular surface evaluation. Matrix metalloproteinase-9 and tear osmolarity are critical tests for evaluating the stability of the ocular surface. Meibography and biomicroscopic gland expression can alert the clinician to the diagnosis of meibomian gland dysfunction.

Cornea

Diagnosing corneal pathology can help guide the surgical evaluation and plan. Topography and aberrometry are useful diagnostic tools for understanding astigmatism and corneal optics, along with diagnosing dystrophies and corneal degenerations. Each of these conditions can affect visual image quality or delay visual recovery. A medical history of autoimmune disease, diabetes, and herpes keratitis should be shared with the surgeon as part of this evaluation.

Crystalline Lens Evaluation

Ocular surface disease and tear film abnormalities can masquerade symptomatically as a cataract. Optometrists with access to objective technology to assess light scatter, glare, and lens dysfunction are able to help patients understand the degree of their cataract formation, and are better positioned to make an IOL recommendation or surgeon referral. Differentially diagnosing these conditions can help avoid misdiagnosing a patient’s chief complaint. Anyone considering refractive corneal or implantable collamer lens procedures, especially those approaching 40 years of age and older, must be educated about age-related presbyopic changes and cataract formation. It is also important to rule out a history of eye trauma or evaluate the eye for pseudoexfoliation so as to alert the surgeon to risk of zonular instability, if appropriate.

Vitreous Body Evaluation

It is not uncommon for patients to be more aware of their floaters after ocular surgery. Vitreous syneresis is normal in patients 40 years of age or older, and in some cases it can be visually significant. It is imperative that patients be educated about vitreous floaters before their surgical experience and about the affect the floaters may have on their vision after surgery. They should also understand the possible need for additional surgeries if the floaters become bothersome.

Fundus Evaluation

Assessment of the fundus and any suspicious findings warrant a retinal evaluation prior to sending the patient to the anterior segment surgeon. Conditions such as subclinical retinal holes and tears, lattice with retinal breaks, and advanced retinopathy are common considerations for a consult with a retina specialist.

Macular Evaluation

Subclinical epiretinal membranes, vitreous-macular adhesions, early macular degeneration and/or dystrophies or previous inflammation are very important pre-surgical findings. Macular pathology can affect visual acuities, visual perceptions, and the central visual field and can alert the surgeon as to what type of lens technology may be best suited to get that patient the best outcome they are seeking.

Binocular Vision Evaluation

Eye care providers appreciate that vision is more than just a refractive error. Decompensated phoria and fixation misalignment can trigger symptoms such as headaches, dizziness, neck stiffness, photophobia, and phantom dry eye symptoms.² Binocular vision can play a significant role in how patients respond symptomatically after refractive surgery. Alerting the surgery team to any binocular vision concerns can potentially keep patients from believing that eye surgery will significantly reduce their dependence on glasses and highlight that this treatment goal may not apply to them. Referring optometrists can educate patients that binocular vision dysfunction is a preexisting condition and not surgically induced.

Vision After Cataract or LASIK Surgery

Glare, halos, and dysphotopsia secondary to refractive surgical procedures should always be reviewed with patients, but not used to deter them from pursuing cataract and/or refractive surgery. Further discussing that a small percentage of the population may be prone to halos and glare³ can set a level of expectation that patients understand and appreciate. Most importantly, educating patients on all different vision correction options and the advantages and disadvantages of each empowers them to play a pivotal role in deciding what the best option is for their individual visual demands.

Visual Personality

Primary eye care providers often have an in-depth history with patients that helps to provide a unique level of understanding regarding the patient’s tolerance to blur and visual flexibility. Ensuring patients understand their own visual personality will help to guide the decision on what vision correction approach to take. Of course, it is also helpful for the surgical team to have insight into this decision.

DON’T SETTLE

The optometrist’s job should not stop with education. Optometry clinics that embrace technology such as specular microscopy, OCT, abberometry, topography, and tear film diagnostics engage even further in pre- and postoperative surgical management. Building a practice around clear communication and technological advancements alerts patients to the competency of both the referring optometrist and the recommended surgical practice.

WORK TOGETHER AND USE THE TOOLS AT YOUR disposal

Eye care has evolved tremendously in the past decade, and innovations in techniques and technology have forced the diagnostic landscape to progress, offering us deeper insights into patient eye health and visual functioning.

As the future demand for eye care and ocular surgery rises, it will be more important than ever for optometry to embrace new technology and collaborate with fellow optometry and ophthalmology colleagues to improve patient outcomes. We have the training, knowledge, and technology to make a difference, and patients appreciate and respect doctors who work together on their behalf.