Those of us who have dedicated our careers to ophthalmic comanagement believe our patients do better in this model because of the combined and coordinated skill and experience of each doctor in the surgical process – referring primary care optometrist, surgery center optometrist and surgeon. Mutual trust and respect that is genuine combined with meticulous attention to communication lead to the best outcomes.
We use the word “process” deliberately; surgery is not an event, but a series of decisions and actions over time. We know where the greatest sources of uncertainty are in the process, and the primary care doctor who has usually spent many years counseling and preparing patients is most often the best guide of what we should do.
Now that we have the student a bit unsettled and unsure, we ask, “What’s the second thing you want to know?” Understandably nervous, they often provide no answer at all, so we tell them: What is the corneal toricity? Why? Because this measurement goes to the heart of our work – managing expectations – and determines whether a long and often confusing counseling effort needs to be included or ignored regarding the benefits of an astigmatism-correcting IOL.
Of course, because we are teachers, we always have more questions: “What is the third thing you want to know?” By this point, the student is wishing he or she had taken another rotation at the VA. But we usually give them this answer as well: What is their habitual refractive error?
It’s nearly impossible to not make a 3-D hyperope happy after cataract surgery. On the other hand, emmetropes or low myopes, particularly those with early cataracts and decent visual acuity, deserve caution and care. It is possible that their uncorrected vision after cataract surgery will be worse in some way at some distance that they have been used to. Does the relief of cataract symptoms, such as glare while driving at night, outweigh the uncertainty and compromise that may occur? Is now even the right time to do surgery at all?
In summary, there are three questions that we need to answer before entering the exam room:
--What does the referring doctor want us to do?
--What is the patient’s corneal toricity?
--What is their habitual refractive error?
Of course, there are more, including the most important question of all: What does the patient want? Cataract surgery is nearly always elective, and those three questions must be considered in context with the clinical exam before discussing the likelihood of achieving a patient’s goals.