Cataract
April 2023
by Ellen Stodola
Editorial Co-Director
When preparing for second eye cataract surgery, there are a couple of primary factors to think about, according to Brenton Finklea, MD. First, you want to identify the visual goals of the second eye and how that may change based on the outcomes of the first eye. The surgeon should recognize that the experience of the patient undergoing surgery may be different either during or after the second case, and the surgeon must counsel the patient appropriately to avoid concern or distress. Dr. Finklea conducted research on how patient perceptions differ between the first and second procedures.1
“From the patient’s perspective, they had more vivid experiences during their second eye surgery. They also tended to remember more of their experience following the second eye surgery,” Dr. Finklea said “That could be either a positive or a negative for them, depending on how the experience is perceived by the individual.”
Dr. Finklea said he likes to have a discussion with patients before second eye surgery to make them aware that they will experience more and be more alert during the procedure. But he stresses that they will be receiving the same amount of anesthesia as the first surgery. “Inevitably, they’ll say, ‘I’m much more awake this time; I don’t think you’ve given me enough anesthesia.’ We reassure them we’ve given the same amount,” he said. “But if you prepare them and prime their minds for that experience, they will be more relaxed and often see the increased awareness as a positive.”
Dr. Finklea said that he finds this important to mention just before the surgery so that it’s fresh in the patient’s mind. “When marking the surgical site on the day of surgery, I will let them know that they will feel more alert and awake during the surgery, despite getting equal anesthesia.”
He added that patients have a range of experiences with the first eye, which could depend on the patient, their susceptibility to the medications, their mental and emotional state, and how heavy-handed the anesthetist is. “Every patient’s perception of their first eye surgery is different and can vary widely,” he said.
Dr. Finklea said the perception of visual outcomes is very patient-dependent. Often the patients who are most concerned about the second procedure are those who had the “slam dunk” first eye, with outstanding day 1 postop visual outcomes and no irritation or discomfort. Any variation from that state of perfection creates panic, he said. “We are for the most part fortunate with how good patient outcomes are after surgery, so we have to diligently counsel patients that each eye is different,” he said.
When choosing which eye to operate on first in cases where there’s significant asymmetry between preop vision in the two eyes, he tends to operate on the more impacted eye first. For more evenly affected eyes, the approach changes. “When people are more symmetric in their cataract severities, often we’ll start with their dominant eye, especially when considering monovision or mini-monovision, to be sure we’ve nailed the distance outcome in this first dominant eye. We can then be a little more cavalier with the near or intermediate aim eye and will counsel them to expect the second eye to be more blurry at distance,” he said. “As we all know, patient satisfaction comes down to expectations and good counseling prior to going to the OR.”
Rosa Braga-Mele, MD, FRCSC, has also studied this topic.2 “In the study that we published, we found that for the second eye, patients generally felt that even if the procedure took the same amount of time and was done with the same surgeon, they thought it took longer, that the procedure hurt more, that their vision postop wasn’t as good as the first eye, and generally they had a sense of dissatisfaction with the second eye,” she said.
Dr. Braga-Mele’s theory is that many patients have an amnesia effect with the first eye due to the anesthetic and simply don’t recall the first procedure. “I think the amnesia effect is more pronounced on the first eye because there’s a higher elevation of stress with the degree of anticipation,” she said.
Generally, Dr. Braga-Mele said, ophthalmologists choose to do surgery on the worse of the two eyes first. Within 24 hours, the patient is seeing better than in the second eye, and there’s a huge “wow” effect. So when the second surgery is done, and they have a 20/20 first eye, anything you give them for the first 24–48 hours isn’t going to be better than that, which leads them to think something went wrong with the second eye.
Dr. Braga-Mele said she usually books the eyes a week or two apart. She also lets patients know preoperatively that they’ll have a 24- to 48-hour recovery with their vision. She stresses that each eye will heal differently. Dr. Braga-Mele said she likes to use a quote she learned from Dee Stephenson, MD: “Your eyes are like sisters, but they’re not twins.” She said patients understand that right away. “Each eye will heal differently and react differently to the procedure. The minute you say it’s normal, that alleviates a lot of the tension for the patient,” she said.
She added, “Most patients forget what I told them, so you have to reiterate right after the second eye is done.” When Dr. Braga-Mele sees patients the morning after surgery, she’ll immediately address this. “I’ll say that it’s completely normal for the second eye to seem like it took longer.”
Dr. Braga-Mele also does bilateral same-day cataract surgery, though not on all of her patients, and she plans to start a study looking at whether the second eye has any issues with this. In her experience, when patients have bilateral same-day cataract surgery, they don’t compare eyes as much and treat it more like one procedure.
No matter the timing between the procedures, Dr. Braga-Mele stressed the importance of educating the patient preoperatively, as well as right after the second eye on day 1 postop. “Patients will sometimes think they need to see immediately after surgery,” Dr. Braga-Mele said. “I always say, ‘You don’t have a hip replacement and expect to run a marathon the next day, so you can’t have eye surgery and expect to see perfectly the next day.’” She sets the expectation of 1–3 months.
Most importantly, Dr. Braga-Mele said you need to under promise and over deliver, and “you definitely have to do that more for the second eye than the first eye.” Patients are generally more at ease going into the second procedure and expect vision to recover quickly while also comparing it to the first eye. The comparison is the problem, so that’s why patient education is so important.
About the physicians
Rosa Braga-Mele, MD, FRCSC
Professor of Ophthalmology
University of Toronto
Toronto, Canada
Brenton Finklea, MD
Wills Eye Hospital
Philadelphia, Pennsylvania
References
- Venkateswaran N, et al. Comparison of patient perceptions of first- and second-eye cataract surgeries. J Cataract Refract Surg. 2021;47:819–820.
- Adatia FA, et al. Documenting the subjective patient experience of first versus second cataract surgery. J Cataract Refract Surg. 2015;41:116–121.
Relevant disclosures
Braga-Mele: None
Finklea: None
Contact
Braga-Mele: rbragamele@rogers.com
Finklea: bfinklea@oppdoctors.com
