Biography: Farid is director of cornea, cataract and refractive surgery and vice chair of ophthalmic faculty at the Gavin Herbert Eye Institute at UC Irvine.
Disclosures: Al-Mohtaseb reports she has financial interests with Alcon, Bausch + Lomb, Carl Zeiss, CorneaGen, Novartis and Ocular Therapeutix. Farid reports she is a consultant for Allergan, Bausch + Lomb, Bio-Tissue, Carl Zeiss Meditec, CorneaGen, Dompé, Johnson & Johnson Vision, Kala, Novartis, Orasis, Sun and Tarsus.
July 19, 2021
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BLOG: Setting expectations becomes more important in complex corneas

Biography: Farid is director of cornea, cataract and refractive surgery and vice chair of ophthalmic faculty at the Gavin Herbert Eye Institute at UC Irvine.
Disclosures: Al-Mohtaseb reports she has financial interests with Alcon, Bausch + Lomb, Carl Zeiss, CorneaGen, Novartis and Ocular Therapeutix. Farid reports she is a consultant for Allergan, Bausch + Lomb, Bio-Tissue, Carl Zeiss Meditec, CorneaGen, Dompé, Johnson & Johnson Vision, Kala, Novartis, Orasis, Sun and Tarsus.
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When surgeons must optimize a patient’s irregular cornea before cataract surgery, it is critical that they have a thorough and detailed conversation about the procedure and the ultimate visual outcomes that can be expected.

It is imperative that the surgeon clearly explains the limitations of the patient’s complex cornea as it relates to cataract surgery to set appropriate and realistic expectations.

Previous refractive surgery equals high expectations

Marjan Farid
Zaina Al-Mohtaseb

In both of our experience, patients who have had previous refractive surgery have the highest expectations for cataract surgery — they want that same “wow” effect that they had with LASIK or PRK. It is very important that surgeons temper that due to limitations of IOL calculations in this patient population.

Take, for example, a patient with decreased, blurred vision who is sent for cataract evaluation and has the expectation that cataract surgery is going to fix this. When they come to our clinics, we do a slit lamp exam and topography, finding epithelial basement membrane dystrophy, ocular surface dryness or maybe a Salzmann’s nodule.

The first thing we like to do is show the patient the Placido rings on topography, explaining that the cornea should have crisp, circular mires. Instead, because of their corneal pathology, they have smudged, irregular or missing mire rings. Patients understand much better when they can see for themselves. It can be difficult to tell patients who expect perfect vision after cataract surgery that they may still need glasses, and due to the cornea, they may still have some visual irregularities. They come in wanting surgery to fix their vision, so we have to take a step back and see if regularizing the cornea is a possibility before cataract surgery.

Use topography to educate patients

When we show the topography, we like to say, “If we don’t take care of the cornea, which is the front surface of the eye, nothing we do afterward is going to make you happy.” Then we describe whatever the treatment is that we are doing to do — whether it is a superficial keratectomy or dry eye treatments that include frequent eye drops or a procedure to treat meibomian gland dysfunction. We explain that we need to work together to heal the surface of the cornea (when possible), which may take some time, until we feel that the eye is ready for the cataract surgery. We explain that they will come back multiple times, and we will repeat their topography until we are satisfied that the surface is ready and as optimized as it can be. Sometimes the corneal surface was the real culprit in the poor vision, and treatment improves the patient’s vision so considerably that cataract surgery is not needed. The pathology may be the cause of the decreased vision and not the cataract. We prepare them from the start so they know it might take several visits and that we are a team. It is very important to set expectations from that first visit.

Conclusion

Instead of being frustrated, patients greatly appreciate the time we take to explain the situation and treat them appropriately, doing our due diligence to ensure they have the best outcome. We have had patients wait 6 months for cataract surgery, taking time for the corneas to be smooth, regular and stable after superficial keratectomies on both eyes and a regimen for ocular surface disease. Conversely, patients are unhappy and frustrated when they are rushed into cataract surgery and end up with suboptimal vision. Untreated ocular surface disease is often the No. 1 cause of postoperative dissatisfaction in cataract patients.