Last month, we looked at the importance of initial patient education on cataracts and IOL options, as well as the optics involved in ensuring premium IOLs yield the most satisfied patient possible. This month we’ll look at making a good IOL recommendation.
Making the Recommendation
After you perform an examination on the patient, which indicates that cataracts are present, you should explain to the patient that he or she has vision-impairing cataracts that are significant enough to require surgery. If the patient agrees at this point to proceed with surgery, you can then finish telling him or her about the remaining findings of the eye exam.
Next, explain the three key elements regarding cataracts and cataract surgery:
- What is a cataract?
- What is cataract surgery?
- What are your lens options?
What is a Cataract?
A great way to show patients exactly what a cataract looks like is to have an eye model in every room. Show them the eye and point out the healthy, clear lens. Explain that while we are all born with a clear lens, when most of us reach about age 60, we all develop cataracts, which are a clouding of the lens.
You can then remove the clear lens in the model and replace it with a cloudy one to demonstrate this to the patient. Afterwards, it is appropriate to ask if he or she has any additional questions about cataracts.
What is Cataract Surgery?
Once you’ve answered the patient’s cataract questions, explain the actual process of cataract surgery. Describe how you make a small incision and create an opening in the cataract to remove the cloudy material by using an ultrasound, called phacoemulsification, and replace the old lens with a new, clear lens. You should then discuss the risks, benefits and alternatives to the surgery.
Finally, you’ll want to discuss lens options with your patient. Assuming a low amount of astigmatism (i.e., cylinder < 0.75 D), normal corneal topography and no other comorbidities (such as Fuchs’ dystrophy or macular degeneration), explain that there are two lens options: a standard lens and a premium lens. If appropriate, you’ll want to let the patient know if he or she is a candidate for one or the other lens or both.
You should explain that the standard lens option is a great lens, but it can only focus at one distance, either far away or up close, but not both. Conversely, the premium lens has the ability to allow you to focus at both distance and near in 80 percent of cases. Be sure your patients realize that nothing is 100 percent, but if they want to be less dependent upon glasses, the premium lens option is their best bet.
Reading Patient Readiness
Pay attention to body language. If the patient rubs his or her neck or squirms in the chair, the person is probably not ready to make a decision. Explain that the decision does not have to made that day. You may want to have your patient watch a video on cataract surgery and lens options at this point. If he or she is still undecided and wishes to discuss the lenses further, be sure to provide all the details wanted.
If the patient is still undecided, there is one great question that will tell you whether he or she is a good candidate for the premium lens or the standard lens. Simply ask, “Do you mind wearing glasses?” If the patient says emphatically, “No, I don’t mind wearing glasses,” then you may suggest proceeding with the standard lens.
Once a patient has decided to have cataract surgery and you’ve explained the different lens options, it is your job to provide recommendations that are best for his or her needs. Despite your best efforts, it is impossible for patients to understand the lens options as well as you do, thus they are depending upon you to make a recommendation that will best meet their needs.
If you have explained the condition, surgery and lens options well, and made a firm recommendation, we’ve found that most patients convert to a premium IOL right in the exam room, while the remaining convert while visiting with the surgery coordinator. Most surgery coordinators are also knowledgeable about financing options and can discuss those with the patient as well.
We’ve found that this process works best if you assess the patient’s visual needs and expectations and match these with the appropriate lens option. You can then tell the patient which lens option you recommend and leave the decision to him or her.
Additionally, think about the terminology you use. Do you use the term standard or premium, or multifocal or presby-IOL? Be sure the patient realizes that “premium” does not necessarily equate to premium vision, as some patients will see just as well, if not better, with a monofocal lens. Understanding your target audience is key.
If the individual uses monofocal and multifocal in their terminology while asking questions, you may want to continue with these terms. If not, start off using “standard” versus “premium” and then define them as monofocal or multifocal and discuss accommodating IOLs. The art of medicine is the ability to connect with patients and educate them, to provide the best recommendation matching the patients’ needs.
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About the authors: Lance Kugler, MD, graduated from Case Western Reserve University School of Medicine and completed his residency in ophthalmology at the University of Nebraska. Dr. Kugler did his fellowship training in cornea and refractive surgery at the Wang Vision Institute and the University of Tennessee in Nashville. He is also an adjunct clinical professor at the University of Nebraska Medical Center, serves on the YO Info subcommittee and is a graduate of the Academy’s Leadership Development Program (LDP).
Robert F. Melendez, MD, MBA, is a partner at Eye Associates of New Mexico, assistant clinical professor at the University of New Mexico in Albuquerque and section chief of ophthalmology for Lovelace Hospital in Albuquerque. Additionally, Dr. Melendez is author of Ophthalmology Buzzwords™, co-founder of the Juliette RP Vision Foundation, editor of YO Info and a graduate of the LDP. His contribution to the article is excerpted from a longer article that appeared in Ophthalmology Business.