Module 3: Patient Counseling

Ophthalmologists have the incredible ability to transform vision from poor to great. To be successful, surgeons must be confident in their ability to deliver outstanding patient outcomes. However, humility and honesty also go a long way in conveying the limitations and potential risks of refractive cataract surgery. Find out how Tal Raviv, MD, confidently manages expectations, even for the most demanding patients.

Q. How much time do you recommend surgeons spend counseling and educating patients about premium cataract surgery?

Tal Raviv, MD: A surgeon’s ultimate goal should be for patients to be fully informed by the time they enter the exam lane. However, the amount of time we spend with patients varies, as the level of education and counseling we provide depends on the knowledge a patient already has upon arrival to the appointment. Some patients will educate themselves by researching online and reading the materials our staff sends them, while others will wait for us to fully educate them during their visit. In my practice, my colleagues and I spend as much time as needed in a no-pressure environment until patients fully understand the preoperative, intraoperative and postoperative steps of the procedure and, thus, can make an informed decision with which they will be comfortable in the long term.

Q. What types of resources do you suggest practices provide to help educate patients about refractive cataract surgery and astigmatism correction?

Raviv: Just as there is no specific, prescribed amount of time we spend with patients, there is no one exclusive method to educate them about premium cataract surgery. However, I recommend that surgeons use a multipronged, multi-staff-member approach with various sources of information that will help to drive home patients’ choices for visual outcomes. No matter how surgeons choose to educate and counsel patients, the goal should never be to upsell them on more expensive premium procedures.

In my practice, once we schedule patients for consultations, we conduct the following steps to educate our patients:

1. Direct patients to our website. This helps them get familiarized with the perioperative process through videos and animations.
2. Send patients an information packet via regular mail. This information relates specifically to our practice and our physicians, rather than brochures from manufacturers, which tend to confuse them. Our information details the ways in which our practice approaches refractive cataract surgery and the refractive packages we offer. Although we also send information via email, I highly recommend sending everything by mail, as we have found that patients are more likely to open our package and read the information.
3. Provide additional information in the reception lounge. When patients arrive for consultation, we provide further educational materials to review on a tablet and on our waiting room display screen.
4. Involve staff members, per the surgeon’s discretion. For example, although our technicians are not involved in formal consultations, they do inform patients about the various measurements and diagnostic tests we perform on new patients with cataracts.

Finally, one of our in-house optometrists performs initial examinations and discusses with patients their lifestyle, how often they use glasses and their postoperative visual goals. Based on this information, the optometrist recommends ways to help achieve the best outcomes so by the time patients see me, they are well-prepared and well-educated, and I am then able to home in on a recommendation that will best suit each patient. I can use our time together more effectively and have a high-level discussion that will help patients make the ultimate decision to undergo either femtosecond laser-assisted, intraoperative wavefront-guided cataract surgery with premium IOLs, or traditional surgery with monofocal IOLs.

Q. How can surgeons help patients retain the information provided during consultations?

Raviv: I think most surgeons would prefer someone else be present during consultations with patients, whether it is a family member or friend. I always say four ears are better than two, so the more the merrier. Having more people present helps us avoid miscommunications about aspects such as whether a procedure is covered by insurance. We also make sure our patients leave the office with written documentation of our various refractive options.

Q. What specific information is best to obtain from patients during consultations?

Raviv: In my experience, it is best to determine how patients currently use — or do not use — their glasses. For example, a patient with hyperopia may wear low-powered progressive glasses fulltime, so I know that we can hit a home run by tweaking that patient’s distance vision enough to not require glasses, and correct his or her near vision enough to require only occasional spectacle use.

Surgeons should always ask probing questions to obtain a detailed history of spectacle and/or contact use. We want to uncover the rare patients who do not use glasses at all preoperatively and who expect to be spectacle-free postoperatively. In general, patients with low myopia are slightly more challenging, so the more questions asked, the better, such as:

• “Do you take your glasses off to read despite wearing progressives?”
• “Do you wear contact lenses?”
• “Do you wear reading glasses over your contact lenses?”
• “If we achieve excellent distance vision only, would you be open to wearing reading glasses to perform close-up tasks such as viewing your watch?”

It is extremely important to understand how patients currently use their glasses, as I do not want to take away a preferred visual distance. In addition, patients must realize that, to achieve great distance vision, they may have to sacrifice some level of near vision, depending on the IOL we choose.

It is also key to find out patients’ occupations and activities, and go beyond simply inquiring about hobbies. A patient may be a hobbyist of small crafts but may not want only crisp near vision, especially if he or she is also an avid walker or runner. In this case, good distance vision would also be beneficial to enjoy his or her surroundings. In addition, patients may simply change their mind about their visual priorities as they grow older, so I may want to provide good vision for more than just one activity. I give patients details about the three zones of vision and help them decide on monofocal IOLs, which will provide one clear zone, or a more advanced IOL that can correct two or three zones.

Q. As advanced as refractive cataract surgery is, it does not allow patients to achieve full spectacle independence in most cases. How do you suggest surgeons set realistic expectations for patients undergoing premium cataract surgery?

Raviv: Surgeons first must determine whether a patient is a candidate for premium IOLs such as multifocal or extended depth of focus IOLs. They must also determine whether a patient has astigmatism and how much. Currently, only two diffractive toric IOLs are FDA-approved for use in patients with astigmatism in the U.S. — the AcrySof IQ ReSTOR toric IOL (Alcon Laboratories, Inc.) and the Tecnis Symfony toric extended depth of focus IOL (Johnson & Johnson Vision [formerly Abbott Medical Optics]).^1,2 This considerably limits options for patients with high astigmatism.

Once I confirm the type of IOL for which a patient is a candidate, I communicate the following message:

“I have access to every FDA-approved IOL in the U.S., and these are some of the best IOLs we have in the world for giving you freedom from glasses. However, nothing is perfect, and there will always be compromises. Here is the best IOL we have for what I believe you are looking for, and here are the compromises with this approach.”

A refractive cataract surgeon must also address unanticipated complications or refractive results. For a complex cataract, I always highlight that the first goal is a perfect, complication-free extraction, and the planned refractive correction may need to be adjusted after an unexpected event.

In addition, just as a LASIK surgeon can manage under- and overcorrections, so should a refractive cataract surgeon. I let patients know that, should their visual results not meet their expectations, I can address most problems with an IOL exchange, IOL rotation, PRK or LASIK and include these services as part of the refractive package.

Surgeons should always strive to achieve patient satisfaction and in my experience, this approach to patient counseling helps to reign in their expectations so that they will be happy postoperatively, even if they need an enhancement procedure.

Q. How do you speak to your patients about astigmatism? How can surgeons describe it in a way that is easily understood?

Raviv: Other than spherical equivalent, astigmatism is the most common lower-order aberration that refractive cataract surgeons treat. I explain to patients that the shape of the cornea determines how light bends upon entering the eye. An oval-shaped cornea bends light in a way that creates multiple focal points on the retina, rather than one single point of focus. The result is blurred vision and residual astigmatism. For decades, IOLs have been round and, thus, unable to correct astigmatism; patients would need to wear glasses to adjust for it. However, one surface of a toric IOL is oval- or cap-shaped to accommodate an oval cornea and help to neutralize astigmatism so that patients may be less dependent on glasses postoperatively.

Q. Once patients leave your office, do you keep the lines of communication open to address their additional questions or concerns?

Raviv: No matter how thorough the consultation, surgeons and staff members should always be prepared to address calls from patients after they leave the office. Before they leave, I make sure to personally introduce patients to our surgical counselor who fields calls and answers most questions. However, if patients have questions that my staff cannot answer, then they are encouraged to call me and leave a message, and I will respond as soon as I am able.

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