Patient expectations high as level of surgery advances

Editor’s Note: In this ongoing series of one-on-one interviews with key ophthalmic leaders, J.C. Noreika, MD, MBA, talks with Samuel Masket, MD, clinical professor of ophthalmology, David Geffen School of Medicine, Jules Stein Eye Institute, University of California, Los Angeles (UCLA). In his practice that manages complex cases, Dr. Masket sees a high volume of patients referred for dysphotopsia and addresses issues related to the condition. Dr. Masket also highlights some of his many achievements and contributions to cataract and refractive surgery and tracks the field’s trends-from the infancy of phacoemulsification and lens implant cataract surgery to femtosecond lasers and extended depth-of-focus IOLs.

Sight Lines By J.C. Noreika, MD, MBA

Dr. Noreika: Please tell us a little about yourself and your career.

Dr. Masket: I finished my training in 1973 and then spent 2 years on active duty with the U.S. Navy, as there was still a physician draft and I had been deferred to complete my residency. I spent a very short time practicing in the East, and in 1977 came to Southern California and established an academic association with the Jules Stein Eye Institute at UCLA that I have maintained since that time and I have been a clinical professor for many years.

Moreover, I have served as editor for the consultation section of the Journal of Cataract and Refractive Surgery for nearly 25 years. I am also a member of the Editorial Advisory Board of Ophthalmology Times.

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I had the honor of presenting the Binkhorst Lecture at the American Academy of Ophthalmology (AAO) in 1998, and this past year I gave the Kelman Lecture. Most recently, during the 2014 meeting of the American Society of Cataract and Refractive Surgery (ASCRS) in Boston, I gave the Jan Worst Medal Lecture at the International Intraocular Implant Club annual meeting.

Over my career, I have had the remarkable opportunity to interact globally with many colleagues and have had the honor of being a guest and named lecturer in varied countries, and still hold ORBIS missions dear to my heart. I was very privileged to have been president of ASCRS and a member of the Board of Trustees of the AAO.

I was very fortunate to be around during the infancy of phacoemulsification. When I started performing phaco in 1980, fewer than 5% of surgeons were using the technology. I learned phaco by watching Dick Kratz, MD, who was very instrumental in the early part of my career. I hold him in extremely high regard for his honesty with his patients, his surgical skills, and his innovation.

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Over the years, my practice has progressively gravitated toward complex cataract management and referrals typically are related to malpositioned IOLs, dysphotopsias, and the like. Six years ago, I added Nicole R. Fram, MD, a corneal trained surgeon to the practice; subsequently, she become my partner. She, too, has an interest in complex case management and together, we have a very interesting clinical practice in Century City, adjacent to Beverly Hills, CA.

Dr. Noreika: Let’s talk about patient expectations for cataract surgery. We have raised the bar so high. You practice in one of the highest-median income areas in the United States. I suspect your patients tend toward the far right side of that bell-shaped curve of patient expectations. How do you and your staff manage those expectations?

Dr. Masket: I am not convinced that socioeconomic status plays a large role in patient expectations. While we do practice in a very high-income area and take care of a number of affluent patients, I find that people at all socioeconomic levels can have high expectations, sometimes unreasonable ones.

Listen to what Samuel Masket, MD, of the Jules Stein Eye Institute says about his approach to unhappy patients, improvements in cataract surgery, and his challenge to young ophthalmologists in this interview with J.C. Noreika, MD, MBA.

It is important that patients understand what technology we have to offer and what cataract surgery can do for them. I am very frank, particularly with respect to the optical outcome of surgery and what their goal might be-whether we are aiming for distance emmetropia, intermediate vision, or near vision with monofocal lenses or with multifocal lenses. I make certain that patients understand the limitations of our technology.

Dr. Noreika: How do you counsel patients when suggesting a premium type of IOL or other refractive intervention?

Dr. Masket: The first conversation I have with a patient in that regard relates to spectacle dependence and how important that aspect of life is to them. If the patient understands that there is a balance between quality of vision and dependence on spectacles, as one goes up and the other goes down.

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I try to ascertain where they sit on that balance beam. Are they more motivated by vision quality, or are they more concerned with the convenience of spectacle independence?

Unfortunately, we cannot always give high levels of quality as well as spectacle independence. I make certain the patient understands this concept. Some patients absolutely abhor the concept of wearing spectacles, and others are very particular about their ability to see fine detail. Most patients lie somewhere in between and our task is to figure out where they fit in the mix. As I explain, unlike purchasing shoes or clothing, one cannot “try on” an IOL.

Dr. Noreika: Is this something that you do or something you delegate?

Dr. Masket: Decision making regarding the IOL, in my view, is something that the surgeon should do.

Dr. Noreika: What technologies do you use to assess cataract surgery candidates preoperatively?

Dr. Masket: It’s important to consider the patient’s lifestyle and for what tasks they prefer or require spectacle independence, whether they drive or fly for a living, etc. In addition to a comprehensive eye exam we evaluate corneal topography, evaluating the corneal surface and corneal astigmatism; I also use the OPD to evaluate higher-order aberrations.

If there is any suspicion about the appearance of the optic nerve or macular region, we perform optical coherence tomography. I am very cautious regarding macular health before choosing an IOL.

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Once we determine the normalcy of the eye, I consider what lenses might best fit that patient’s lifestyle.

To determine IOL power, we employ both the Lenstar (Haag-Streit) and the IOLMaster (Carl Zeiss Meditec) and run five programs on each in order to match axial length, chamber depth, and other parameters to determine what would be the best or closest power to match our optical goal.

We explain to the patient that while we try to match the closest power for the optical goal of surgery, unfortunately, there are certain assumptions in the formulae that cannot be avoided. I include intraoperative aberrometry in virtually all patients, and I change a significant number of IOLs based upon intraoperative aberrometry, despite preoperative calculations.