ONLINE EXCLUSIVE

ASCRS News
May 2024

by Liz Hillman 
Editorial Co-Director

While there a lot of different technologies that can give patients excellent refractive results after cataract surgery, Richard Tipperman, MD, said that this area keeps expanding and improving all the time. As more options become available, it increases the complexity of talking to patients, helping them understand the options, determining what’s best for them, and managing their expectations. 

This is what the symposium Having “The Talk” focused on at the 2024 ASCRS Annual Meeting. 

‘The Talk: Explaining Toric and Presbyopia-Correcting IOLs’

During the symposium, two main speakers, David F. Chang, MD, and Cathleen McCabe, MD, shared their tips for explaining presbyopia-correcting lenses to patients. Dr. Chang explained that it is more important than ever to be both effective and efficient in explaining the refractive IOL options to patients. 

To simplify the decision, he tells patients that everyone gets one of three types of lens implants: 1) single focus, 2) extended focus, or 3) multiple focus. The “toric” feature can be added to any lens platform if needed. “A big problem is that many patients simplistically think in binary terms—glasses or no glasses, near vision or far vision, 20/20 or not,” he said. “We must convey that eyesight is a continuum of quality and focus.”

“I explain that our eye is a camera and that we all need to see at four different zones,” he said. Zone 1 is far distance vision, zone 2 is indoor distances, zone 3 is arm’s length, and zone 4 is reading distance. “I’ve basically explained the defocus curve with the four zones corresponding to plano, –1.00. –1.75, and –2.50.” This helps him to explain that “extended focus” lenses cover three zones, and “multiple focus” lenses cover four zones. To describe the continuum of quality, Dr Chang uses grades where A = perfect, B = good, C = passable, and D = poor.

When the patient asks if they will be 20/20 after surgery, he uses the analogy of putting to explain the probability of achieving emmetropia. “I explain that unlike with contact lenses where we can get multiple putts, cataract surgeons only get one putt,” he said. “It is possible that their uncorrected distance vision could be an ‘A,’ but because we cannot try different IOL powers, it might end up a ‘B+,’ which means very good.” Glasses could occasionally be worn if an “A” is required, such as for freeway driving at night. “This also helps me to explain that the multiple focus lens gives them a ‘B’ for zone 4, so that they can read without glasses if the lighting is adequate, such as for cell phone text messages,” he continued. “But if a ‘B’ isn’t adequate, such as for sewing or fine print, they can simply use readers to get to an ‘A.’” Dr. Chang emphasized the importance of explaining what the patient currently sees without eyeglasses, using this camera/four-zone analogy.

Cathleen McCabe, MD, talked about the patient conversation for toric IOLs. Her observations start from the moment she enters the room. She sees if the patient is reading and if so, using glasses? Who did they bring with them? Are they holding a stack of papers, gaggle of glasses? Are they smiling or have their arms crossed? Instead of saying “Nice to meet you,” she’ll say, “So nice to see you,” because it might not be the first time she’s meeting them.

She’ll then say, “I understand you’re not seeing as well as you’d like” and asks if they’re having trouble with their vision. The patient’s response helps confirm they’re hearing her and gives info on their chief complaints. Then she’ll go through what diagnostic testing has helped her learn, followed by an overview of her findings, and a summary of their ocular health.

If they have astigmatism, she’ll inform them that they have an optical condition that can affect their quality of vision and that it’s important to treat at the time of cataract surgery. She’ll discuss the limitations of glasses for astigmatism. She also shared her discussion nuances for the patient who has mixed astigmatism.

Dr. McCabe tells her patients, “You have to choose where you want to see and how independent you want to be from glasses after,” but she also tells them there are no bad choices. 

‘The How: Pearls for the Counseling Process’

Dr. McCabe said her “how” begins with education before the visit. Video links are sent via text message to the patient. She said this helps them feel like they’ve had a meaningful interaction with her before they’ve met. The videos include a welcome message, address areas of concern (namely cataracts), and begin to lay the foundation for their lens options. Dr. McCabe said they introduce the idea of out-of-pocket pay as well.

In addition to this preop education, Dr. McCabe said to make sure your website is accessible and has links to educational content. She has conducted cataract seminars and provides printed materials. “Make sure all the messages in all the different forms are consistent.” She also emphasized consistent messaging among staff at all touchpoints with the patient.

In the exam room, Dr. McCabe advised encouraging patients to bring a family member with them (or call a family member and put them on speaker), record the conversation, be an active listener, and ask the patients to repeat back what they understand. “Be sure to ask open ended questions at the end of the exam,” she said, as this further clarifies understanding. In the exam room, Dr. McCabe uses diagrams of ocular anatomy and a large model eye to explain the cataract and the surgery. 

She conducts her exam and biometry visit separately, which gives her time to optimize the ocular surface and gives the patient time to think about their lens options. Patients feel less sales pressure when they don’t have to make an immediate decision, she said. 

Dr. Chang also discussed the counseling process in his consultative practice. He recorded himself explaining the three IOL categories and the four zones of their camera on a 5-minute video that is posted on his website and is also shown while the patient is dilating. Before the consultation, Dr. Chang also tries to educate patients through handouts that are mailed or accessed via his website. Patients are asked to complete the Dell questionnaire before their consultation, which prompts the patient to contemplate, articulate, and prioritize their wish list in advance.

Before the patient returns home, they receive a specific handout about the IOL that was selected and/or discussed. Dr Chang has personally written these FAQ handouts, which are part explanatory and part informed consent. 

When the appointment is made, Dr. Chang mentioned the importance of asking patients to bring family members along for the consultation. He always invites patients to record the discussion on their phone. “This improves comprehension and retention, while reducing call backs and misunderstandings,” he said. “Because advanced technology IOLs are a significant financial investment, this helps other family members to subsequently learn about the options that were discussed.”

Dr. Chang personally discusses the extra costs with patients because this helps him to better tailor and direct the discussion. If it’s clear that they cannot afford a premium lens, he reassures the patient that they’ll still get a great outcome. “If they immediately say that the adjustable IOL is not in their budget, there’s no point describing this option in detail, and we may explore a less expensive option that can still meet their goals,” he said.  

Also during the session, Patti Barkey, COE, Immediate Past President of ASOA, spoke from the administrator’s point of view on “Problems We See ‘On the Back End’ and How the Physician Can Help ‘On the Front End.’” At the end of the day, our goal is to get patients as educated and as qualified as possible, she said. They often know how much they’re going to spend. If someone is not satisfied, it’s usually a communication issue. She shared some problem scenarios and potential solutions.

Problem: The patient doesn’t feel special all the way through the process.
Solution: It’s important to celebrate the patient’s choice and outcome all the way through the process. Don’t forget to “rave” about results. The patient wants to hear they made the right choice. 

Problem: The patient isn’t 20/happy.
Solution: Document early on for the team the set outcome visual goals for the patient. Allow the patient to voice concerns with the “right person.” Many times the patient complains to the technician but when in front of the doctor, doesn’t want to complain. 

Problem: The patient is lost to follow-up before the process is complete.
Solution: If the surgeon isn’t seeing the patient postoperatively, it is important that an emphasis is placed on the need to complete the “process.”

Problem: The patient is raving to the doctor about their experience, and the moment isn’t memorialized.
Solution: Get a picture. Get the patient to approve sharing their comments. Happy patients attract more happy patients, but it’s hard to get the doctor/patient thrill after the fact.

Problem: Return trips to the OR.
Solution: Often the patient doesn’t “own their complications.” Help the staff by reviewing risks, benefits, and complications thoroughly and reminding the patient if needed.

Problem: Balances due after surgery.
Solution: Develop a team that understands the importance of collecting all patient fees up front so that patients don’t feel “nickeled and dimed.”

Keep in mind that the consumers have choices, Ms. Barkey said.

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About the sources

Patti Barkey, COE 
CEO 
Bowden Eye & Associates
Administrator
Eye Surgery Center of North Florida
Jacksonville, Florida   

David F. Chang, MD 
Altos Eye Physicians
Los Altos, California 

Cathleen McCabe, MD
Chief Medical Officer
Eye Health America
Sarasota, Florida

Richard Tipperman, MD
Attending Surgeon
Wills Eye Hospital
Philadelphia, Pennsylvania 

Relevant disclosures

Barkey: None
Chang: Alcon, Carl Zeiss Meditec, Johnson & Johnson Vision, RxSight
McCabe: Engage Technologies Group 
Tipperman: Alcon 

Contact

Barkey: pattibarkey@hotmail.com
Chang: dceye@earthlink.net
McCabe: cmccabe13@hotmail.com
Tipperman: rtipperman@mindspring.com