Understanding patient’s goals for better surgical outcomes

Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Mark Packer, MD, FACS, CPI. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Advanstar.

A while back, the “Happy Patient Project” endeavored to correlate data from psychometric questionnaires with satisfaction following refractive cataract surgery with multifocal intraocular lenses.[1]

At that time, the authors concluded that, “analysis of correlations between the psychometric profile and postoperative patient expectations is quite complex. Efforts of the Happy Patient Project will be continued.

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“What we have learned thus far is that patients are less happy with multifocal lenses when their personality profile showed high levels of control, tidiness, conscientiousness, and ambition,” the report continued. “These patients also had a harder time tolerating blurred vision and halos. Additionally, we have uncovered a correlation between patient expectations, clinical findings, and postoperative patient satisfaction.

“It is too early to propose a one-for-all patient selection questionnaire to improve postoperative satisfaction, but the project has provided useful indications on how to better select patients for refractive lenses,” the authors added. 

Personality trait factor

The choice of the psychometric tests used in the “Happy Patient Project,” e.g., the compulsiveness inventory, suggested an a priori belief that certain personality traits (like compulsive checking) exacerbate the dysphotopsia associated with multifocal IOLs. 

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I tend to agree, and I suspect that the use of a validated preoperative questionnaire may provide a springboard for the informed consent discussion with patients considering presbyopia-correcting IOLs. 

However, I hope that such a questionnaire would not be expected to replace the discussion.

Next: Tips to optimizing patient satisfaction

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Tabulated responses cannot supplant the physician-patient relationship.  When the patient returns with postoperative concerns and questions, the foundation of that relationship-built during the preoperative process-becomes the basis for understanding and reassurance. 

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Personally, I find the discussion of IOL options, and the matching of patients’ goals to the available technology, to be one of the most interesting and rewarding aspects of refractive lens surgery.  Listening closely while providing an honest assessment of the capabilities and limitations of each approach most often results in a successful decision.      

Optimizing patient satisfaction

Cataract surgery can completely remodel vision, improving color, clarity and brightness, and provide freedom from glasses or contact lenses.  However, cataract surgery has its limitations.  In order to optimize patient satisfaction, it’s important to help patients make intelligent choices based on their own personal visual goals.  

Understanding the patient’s goal is the key to achieving success, because without knowing where you’re headed, you will never know if you’ve gotten there. For example, I was seeing a 45-year-old woman in my office that had elected to have Crystalens implants a few months earlier.  She had been extremely nearsighted, and I encouraged her because Crystalens tends to perform well in nearsighted eyes.

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 When I measured her vision, however, it appeared that she would still need some over the counter reading glasses for small print.  While that’s not uncommon with Crystalens, it’s not ideal either. 

“Well, your distance and intermediate range vision are great,” I told her, “but it does look like you’ll be needing some readers for up close.” My tone must have suggested  compromise and defeat, because she said, “Oh, wait, Dr. Packer, don’t feel bad.”

“I’m incredibly happy.  You don’t remember, but I was here over a year ago asking you about options for me to get out of my contact lenses.  What you don’t know is that I had just gone through a divorce, and promised myself that I would achieve a goal I had all my life-to go sea kayaking with Orca whales on Puget Sound.  First I had to lose a hundred pounds to qualify for the kayak-training course.  Then I had to do something about my eyes, because I was afraid of losing my contact lenses at sea.  You’ve helped me achieve my dream and now I’m ready to go!”

As it turned out, near vision without glasses was not a deal to her.  I was relieved, and stunned.  I realized I had forgotten to ask her about her goals.  I knew I’d never forget again.

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Creating reasonable expectations for patients is based on familiarity with the attributes of available technology. Reasonable expectations for outcomes can be gleaned from the FDA Summary of Safety and Effectiveness Data for each particular IOL. 

Care must be taken in applying these data outside of the confines of a controlled clinical investigation, however, since any given patient considering surgery may or may not fit the inclusion and exclusion criteria employed in the trial.

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For example, in the Tecnis Multifocal (Abbott Medical Optics, Santa Ana, CA) clinical trial, 257 of 292 (88.0%) subjects at 4 to 6 months postoperatively stated that they were completely spectacle independent, that they “never wore glasses.” 

At that same time point, 255 (87.3%) stated they would choose the same IOL if they had it to do over again.^[2]  However, potential subjects with greater than 1 D of preoperative keratometric astigmatism were excluded from the trial, and keratorefractive correction of astigmatism was not permitted during the trial.

Therefore, one can surmise that, in order to achieve similar rates of spectacle independence and satisfaction to those demonstrated by the FDA reported data, one must either restrict patients to a maximum of 1 D of corneal cylinder or perform ancillary procedures in order to reduce pre-existing corneal cylinder to that level.

Completing the picture

Reporting personal experiences provides a more complete picture for patients considering surgery.  In order to optimize results, surgeons should keep records of their outcomes, including enhancement rates.  Patients should be informed pre-operatively of the chance they would need a second procedure in order to achieve spectacle independence.

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Cataract and IOL surgery is a complex field, and patients can easily get lost.  For that reason, it is critical that the surgeon provide a recommendation based on best clinical judgment and the patient’s visual goals. 

Several years ago, I was working as principal investigator for a particular multifocal lens trial.  One day. I had a visit from a woman from another state that expressed interest in participating in the study.  She had far advanced cataracts.  In fact, she met the criteria for legal blindness. 

I was surprised, because usually people who are interested in multifocal lenses and travel a far distance to see a particular surgeon are highly attuned to their vision and have surgery before their cataracts progress so far.  I asked her to tell me about how long she’d been bothered by cataracts.

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“Years,” she said.  “At first I thought I’d get Array lenses, but I didn’t like the idea of such severe halos.”  The Array was an earlier generation of multifocal that had fallen by the wayside.   “Then I considered Crystalens,” she went on, “but one of my friends had those and still had to wear reading glasses.  ReSTOR sounds okay, but I’m worried about the waxy vision.  So now I’m deciding about mix and match with ReZoom and ReSTOR, or Tecnis Multifocal.  What do you think I should do?”

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As we talked I learned that she had already visited two other surgeons who were principal investigators for this study.  I was her third opinion.  She had also visited a number of surgeons earlier on as she moved through the various IOL options.  Meanwhile, her cataracts had deteriorated to the point where her husband had to lead her through the airport because she could not read the signs.  Her goal was to maximize freedom from glasses and avoid side effects-both laudable and reasonable.  However, she was literally going blind while trying to reach it. 

By providing her with a strong recommendation, I gained the opportunity to perform her surgery and reach a happy outcome. 

No IOL, and no procedure, is perfect.  Every available option has inherent trade-offs.  The best strategy is to know you patient, know the options, communicate reasonable expectations, and move forward. 

Cosmetic or elective surgery-including refractive cataract surgery-is often part of a larger life-changing experience.  Early on in my career, I performed a fair amount of cosmetic laser eyelid procedures, and one of my very first patients was a young woman with especially puffy upper eyelids. 

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I was really happy with the results, and was looking forward to taking some photographs of her for my “brag book.”   But when she came back a month later, I didn’t even recognize her.  Not only did her eyelids look great, she had become a blonde and lost about twenty pounds!  I took the photos, but I thought no one would ever believe the before and after were of the same woman! 

Keeping an eye on the big picture of each patient’s journey, and understanding how we as ophthalmic professionals can help along the way, leads to the highest levels of satisfaction and success.

[1] Goes FJ.  Happy Multifocal IOL Patients:  Can we achieve this with better patient selection?  Cataract & Refractive Surgery Today Europe March 2011; http://crstodayeurope.com/2011/03/happy-multifocal-iol-patients/  (Accessed July 27, 2015).   

[2] Summary of Safety and Effectiveness Data.  http://www.accessdata.fda.gov/cdrh_docs/pdf/P980040S039b.pdf.  (Accessed 13 October 2013).