Tip #1 – Pick The Right Surgeon
Your patients look to you for guidance on their cataract surgery. The diagnosis of a visually significant cataract is a serious event for most patients and your patients will rely on your “insider knowledge” to recommend a good surgeon.
So what makes a good surgeon?
In my view, two primary attributes make a good surgeon. One is good surgical outcome and the second is a professional and pleasant personality.
To have good surgical outcomes, we expect a surgeon to have very low complication rates during surgery and then a post-op refraction where the patient is 20/happy (not necessarily 20/20 and plano). Any good surgeon can, and will, have complications sometimes, and complications do not mean malpractice. However, complications during surgery should be rare. So if you are getting several complications per year that occurred during surgery, that is a red flag and you should consider changing surgeons.
Also, we want a surgeon who is concerned about the emotional well-being of our patient. The surgeon should try to make the patientʼs experience through cataract surgery as pleasant as possible. If you receive numerous comments from patients that the surgeon was not respectful to them, was short with them, yelled at them, or belittled them, then that is a sign to change surgeons. Ideally, after the surgery, a patient should feel impressed with the surgeon and his staff, which will then reflect well on you.
Tip #2 – Identify Trends in Post-operative Visits
As you examine your patients for their post-op appointments, what are some methods that you can use to help identify the onset of a complication?
One of the best methods is to watch “trends.”
For example, lets imagine a scenario where a patient returns to your office for their one week appointment following cataract surgery. The patient has an IOP of 26. Is this a problem? The truth is, we donʼt know if this is a problem until we see which way the IOP is trending when compared to the patientʼs prior visit. If our patient had a 1-day post-op of 36, then we can see the trend is that the patient is getting better, then we likely have nothing to worry about. However, if the patient had a 1-day post op of 13, then we would have reason to worry. Because the patient is trending worse, it is time to intervene in some way to fix the problem.
The same rule of “trends” holds true for almost any other aspect of the eye following surgery. We expect trends toward gradual improvement. For example, VAʼs should gradually trend better and better over time. So if a patient presents to your office with 20/40 vision at their one week visit, we need to compare that VA with the prior visitʼs VA to see if there is a problem. As you monitor cell/flare, corneal edema, capsular wrinkles, etc, we expect all of these things to gradually trend better over time.
Tip #3 – The Drug Selection for Post-op Care
As a general rule, optometrists should use whatever drugs the surgeon recommends. In fact, the only time you should change meds is if there is a complication that has arisen after the patient has been released by the surgeon to your care. That being said, during the post-op period there are￼times when you may need to make changes to the meds the patient is using.
Of course the meds you want to change to will depend on the complication, however, the most common meds changes we make during the post-op period are to double the steroid use to quell excessive inflammation, or switch from generic drops to name band drops. Always make sure to communicate with your surgeon when you are changing medicines.
Lets talk about doubling the steroid first.
- If the patient has more cell/flare then is normal (more than trace to 1+ cell/flare), that is a good time to double the steroid.
- You can also double the steroid if the patient has a lot of corneal swelling, stromal edema or is prone to inflammatory disorders.
- There is really very little risk in doubling the steroid so donʼt hesitate to use it if you think it will help the patient.
The other common meds change that we make is to switch the patient from generic drops to brand name drops that can be used much less frequently. Probably the most common complication that a patient experiences during cataract surgery post-op is eye drop sensitivity/toxicity. Because the patient is putting in so many drops, it can irritate the ocular surface. The patient will complain of stinging and general irritation. When you examine the eye, the patient will have extensive SPK along with a trace amount of injection. Switching the patient to heavier dosage steroid, or 2 different brand name steroids is very helpful for these patients. The negative consequence of switching to brand name drugs is the cost, so that is a conversation you will have to have with your patient.
I hope these general tips have been helpful to you. Cataract surgery co-management is an interesting and fun aspect of practicing optometry. Remember that serious complications should be rare, but always make sure to communicate with your surgeon regarding any problems you are experiencing. Surgeons want to know how the patient is doing and are usually happy to talk to a referring optometrist. It is important to not feel hesitant to call them when problems arise.
Any questions? Just ask in the comments!
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