ONLINE EXCLUSIVE
November 2023
by Ellen Stodola
Editorial Co-Director
D. Brian Kim, MD, shared a personal case about a valuable lesson he learned on the importance of the preoperative discussion and ensuring that the patient and their family fully understand the procedure they are undergoing.
In his case, Dr. Kim was treating a patient in his 70s who presented seemingly normal. He had a dense PCO in one eye and was NLP in the other. “I did a YAG capsulotomy, and he was 20/20 BCVA,” Dr. Kim said. “I expected to be greeted with a thank you, but instead I was hit with an irate and accusatory, “You blinded me!’” He complained of debilitating floaters. Dr. Kim explained that he may have had them before, and the PCO may have been obscuring them. However, he found that there was no reasoning with the patient, and he threatened to sue Dr. Kim. Dr. Kim later learned that the patient had undiagnosed dementia.
The important takeaway from this case is: If you suspect a patient does not fully understand what you are saying during the preoperative discussion, first require that a family member accompany the patient for future visits. Counsel them together about the procedure to help corroborate what was discussed. Query the family member about dementia symptoms. Second, inform the primary care provider and suggest an evaluation with a neurologist.
In Dr. Kim’s case, the patient seemed to understand the procedure and risks upon initial evaluation. However, the patient was new, and Dr. Kim didn’t know him well yet. “Developing a relationship with patients takes time,” Dr. Kim said. “If he was a long-time patient, I think I would have noticed subtle changes in his behavior over time.”
Looking back on the case, Dr. Kim noted that the patient came alone to his appointments, and this could have been a red flag. When a patient becomes combative, that’s a good time to get the family involved. “In this case, I was fortunate that he had a reasonable daughter. She took time off from work for his next visit. But keep in mind, family members can be a double-edged sword. Sometimes patients tell family members a one-sided, skewed story, but I was fortunate in this case,” he said.
Dr. Kim noted that this experience impacted how he proceeded with future cases. “Although in medical school and residency we learned about surgical complications and informed consent, I never formally learned how neuro-psychiatric issues can play an important role in this context. Now I strongly suggest surgical patients come with a family member for their preoperative consultation visit,” he said. “This helps to mitigate the potential for miscommunication and temper unrealistic expectations. This has many important implications, in particular with refractive cataract surgery counseling, regarding IOL power target, pros and cons of multifocal or EDOF lenses, dysphotopsias, etc., or patients with comorbidities such as macular degeneration, glaucoma, or any condition that may prevent best vision and cause the patient to be disappointed.”
Dr. Kim noted that when doing a preoperative evaluation for a YAG capsulotomy, he warns patients that they will likely notice more floaters after the laser. He tells patients that these will usually subside after a few weeks. “Equally important is to document any pre-existing Weiss ring or dense vitreous floaters and counsel the patient that these floaters will most likely persist and not improve after the laser,” he said.
Dr. Kim said to look out for patients who may have dementia or other cognitive impairment. “Although many are diagnosed, others are either unaware or in denial of their condition,” he said. “Although we as ophthalmologists are not typically the first ones to identify it, we can play an important role. By paying close attention and quickly involving family members and other specialists, we can make a positive impact on a patient’s neurologic health.”
About the physician
D. Brian Kim, MD
Professional Eye Associates
Dalton, Georgia
Relevant disclosures
Kim: None
