With each advance in
cataract surgery technology, our ability to customize and improve visual performance for our patients improves dramatically. On the other hand, these enhancements have changed the way that lay people feel about cataract surgery. Advertisements from both companies and physicians, as well as word of mouth, has created a milieu where patients expect
20/20 day 1 no-glasses sutureless no-patch, see everything without glasses (and did I mention we are all using lasers to do this?).
In the geography of my practice, ophthalmologists have affectionately coined the “Palm Beach county salute”, whereby patients perform alternate cover tests on themselves with their hand to compare vision between eyes – something very commonly seen on post-op day 1 of the second eye. While those patients with high expectations can be difficult to handle, there are techniques beneficial to managing these patients. In this series I will select several cases of patients referred to me, or seeking second opinion, because of “bad cataract outcomes”. The names have been changed but the stories all real.
Mrs. Stein is a 76 year old grandmother who recently underwent bilateral cataract surgery with 20/20 uncorrected distance vision. While she is satisfied using over-the-counter glasses for reading, she is enraged that the surgery has left her with puffy lower eyelids. Another patient, Mrs. Bell, has come in after cataract surgery with good vision as well, however her chief complaint is that now her conjunctiva appears yellow, when prior to surgery it was perfectly white. Then of course is Mrs. Pott, whose upper lids have drooped since her cataract surgery.
While all of these conditions may have been caused by cataract surgery, the likelihood that they truly were nears 0%. The pathophysiology, of course, is that now that the patient has become spectacle independent, they are able to clearly see the details of their face without them being masked by glasses. Without their old tinted cataracts, they are able to see the true colors after quite some time has passed. The most effective way to avoid this I have found is to take digital photos of the patients without glasses prior to surgery. If a patient is upset for one of these reasons post-operatively, I take another photo and have the patient compare the two. Typically this is enough to assuage the majority of cases. That said, some patients become very cognizant of their wrinkles or droopy lids, and if they desire I do not hesitate to offer a referral to our oculoplastics specialist.
Another common complaint after cataract surgery is dry eye. Certainly after keratome incisions or limbal relaxing incisions the cornea can feel more dry, but in most cases there were risk factors prior to surgery. A particular case sticks out in my mind:
Mr. Roberts is a 72 year old gentleman who recently underwent cataract surgery with a presbyopic intraocular lens. While his uncorrected vision is 20/20 and J2, he is miserable because he states his eyes are constantly irritated. He reports that his eyes have never felt this way ever. Slit lamp examination reveals ocular rosacea with 4+ meibomian gland inspissations and lid telangiectasias. Upon further review of systems, the patient states he had been placed on oral doxycycline and warm compresses in the past.
Certainly this patient has had an exacerbation of a chronic condition, but what could have better prepared this patient would have been a careful discussion prior to his surgery about his eyes. When I’m evaluating patients for cataract surgery, I pay particular attention to the lids and tear film. If there is any abnormality I discuss it with the patient and make sure to begin treatment prior to cataract surgery.
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We know you've had challenging patients too, right? Share your anecdotes and strategies by using the "Comment" link above to leave your thoughts... Conversely, some patients feel so endebted they feel compelled to empart their critical life-lessons (e.g.; "tip the waiter before the meal"). What has been your favorite?
-Ed