Oftentimes when we perform cataract surgery we even impress ourselves with results. Take for example the “black cataract” patient who, after an arduous removal process, returns the following day with
20/20 vision. Smaller incisions and more efficient phacoemulsification devices have allowed us to deliver post-op results with almost guaranteed excellence, but there is something we cannot miss: pre-operative eye pathology. If pathology, be it glaucoma or macular degeneration or anything else, is discovered after cataract surgery is performed, the patient satisfaction will be much lower. A few patients I recall very well:
Mrs. Kroll is a 70 year old female who underwent bilateral cataract surgery. While her first eye went great, she feels the second eye does not see as well. While slit lamp and dilated examination appeared completely normal, OCT imaging revealed vitreomacular traction with distortion of the foveal contour. Despite counseling and education, the patient was difficult to convince “it was a totally different surgery. The first eye I saw red lights. This time I saw blue lights, and afterwards my eye itched much more…I know he did something different”.
Mr. Johnson is an 82 year old male who underwent cataract surgery in his right eye. While his vision improved from 20/200 to 20/40, he still felt it things weren’t as clear as he’d expected. Dilated exam revealed drusen and OCT imaging documented intraretinal fluid. A fluoroscein angiogram performed by a retinal specialist found a choroidal neovascular membrane for which he underwent intravitreal Avastin. His other eye, while also with drusen, appeared to have no evidence of leakage. The patient stated “I should never have had cataract surgery. My friends warned me it could give me macular degeneration.”
We have all experienced the patient that does not want to hear the risks of cataract surgery, or if they do they then respond, “Oh I know there are risks but I know nothing will go wrong in your hands…” While we may be tempted to smile and promise them uncomplicated surgery, it is critical to treat all patients alike and point out any predisposing factors that, although may never cause a problem, are easier to discuss with the patient prior to surgery than afterwards. If the patient has pseudoexfoliation, they should understand the increased risks not only during cataract surgery, but lifelong in terms of lens stability. Dry eye patients should be reminded of their foreign body sensation and irritation. Fuchs dystrophy patients should also be informed as to their diagnosis and what it may mean regardless of “perfect” cataract surgery. Patients who have never heard of macular degeneration should be told if they have some degree present, and those with advanced disease should understand their post-op vision will be limited.
Personally, I perform corneal topography on all my cataract patients and OCTs on patients with any question of macular pathology. I’m surprised by how many patients I discover with forme fruste keratoconus, high astigmatism, or even wet macular degeneration. That said, I have found that going forward with this data allows me to much better manage patient expectations which will ultimately culminate in greater patient happiness.
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