March 2015

 

CATARACT

 

Whats my line?: Pearls for effective patient communication

Anisometropia decoded


 
 

Information is power when it is clear, accurate, relevant, and helpful. Therefore, physician communications are vital to relationship and rapport building. The most successful ophthalmologists are those who generate both outstanding medical/surgical outcomes and tremendous patient satisfaction and loyalty. When you communicate face-to-face, ideally with complete presence and good eye contact, about two-thirds of the messages patients receive are nonverbal (e.g., facial expressions, bodily posture, tone of voice). So in addition to communicating good information, which is intellectual, make full, effective use of your nonverbal signals, which express your feelingsthe combination having the positive effect of more fully empowering your patients.

The second facet of an empowering communication style is affirming your patients right to select the treatment option of his or her choice. The most influential approach typically takes place in 3 steps: 1) educating the patient regarding all possible treatment options, including probable risks versus rewards, objectively and without apparent prejudice; 2) deliberating the cost/benefit of each option; and ideally at the patients request, 3) weighing in with your treatment recommendation. First listen to the patients wants, needs, hopes, and fears, and then share your medical/surgical recommendation. Your ability to gain patient confidence and commitment regarding your treatment suggestions is enhanced simply by adopting one of Stephen Coveys The 7 Habits of Highly Effective People: Seek first to understand, then to be understood. The following language samples shared by 3 expert ophthalmologists clearly reflect these principles of patient empowerment and, therefore, effective rapport building.

Craig N. Piso, PhD, Whats my line? editor

 

One of the many non-scientific skills that I wished I had learned but was never taught in medical school is effective patient communication. In addition to protracted chair time and patient dissatisfaction, we all understand how much unnecessary harm can be done by poorly worded communication. Lisa Arbisser, MD, EyeWorld Cataract Editorial Board member, has volunteered to lead a new EyeWorld column that explores how we can better communicate with our patients. For every installment, Lisa will pick a clinical topic on which we must regularly communicate with our patients. In addition to discussing how she words the explanation, she will invite colleagues to add their communication pearls. Lisa has also enlisted psychologist and author Craig Piso, PhD, to collaborate with this ongoing column. Craig is president of Piso and Associates, a nationally recognized consulting firm specializing in professional development in the healthcare arena. His insights as a non-physician specialist will be important.

Lisa was one of the busiest and best cataract surgeons in the country before retiring last year from the multi-subspecialty group practice that she founded in Iowa approximately 30 years ago. She is a popular lecturer and author and past president of the American College of Eye Surgeons. However, a lesser known distinction is that she is the daughter of celebrity psychologist Joyce Brothers, PhD. Known for being an eloquent speaker and gifted surgical teacher, I am delighted that Lisa will be bringing her experience and seasoned communication skills to this new column.

David F. Chang, MD, chief medical editor

In this column, 3 physicians share how they discuss this scenario with patients: You need to use a soft contact lens for the first time for the bilateral high myope having an IOL in just one eye.

Lisa Brothers Arbisser, MD

Adjunct associate professor, Moran Eye Center, University of Utah, Salt Lake City

I prefer to discuss this eventuality ahead of time with the unilateral cataract ammetropic patient. I start by saying the following: We have some choices that I must explain so we can plan together for your best result after your cataract surgery. You have a visually significant cataract in only one eye, and that eye must have surgery if you ever hope to see well with it. The other eye sees well with glasses or contacts and therefore does not currently require surgery for best vision. If I take advantage of the side effect of cataract surgery by choosing an implant to make that eye see well without glasses, it will no longer get along with your unoperated eye. Assuming we achieve this goal with your new implant, the image you see from that eye will be a normal size. Due to the laws of optics, the other eye, which needs thick glasses to see clearly, will have a smaller image through the glasses prescription. The brain cannot use both eyes together when the images are different enough in size, and this will cause you to see double. We call this anisometropia. I have written this word down for you so you can Google it if you choose. When we wear a contact lens the power needed to focus light is closer to the eye than in glasses. The laws of optics make the image less minified or in other words, it is not changed as much. I show with my hands the distance from the eye and the image sizes.

This then will allow the two eyes to work together. Because of these facts, if we aim to see distance with the operated eye without glasses (called emmetropia), there will be no pair of glasses that you can wear at all after surgery, and you will have to always be wearing a contact lens in your unoperated eye in order to see with 2 eyes at once or to have depth perception. This is why you have a decision to make. Basically we have 3 options: Number 1: If you have always been happy with glasses then we can choose to make the eye with the cataract nearsighted to match the other eye. This will solve your immediate problem of blurred vision due to cataract but will not help you to see without glasses any better than you have before. Even when the other eye develops a cataract, that eye will need to be made nearsighted to match the first eye. Unless you opt for additional refractive surgery in the first eye (3 surgeries rather than 2), you will always wear glasses for nearsightedness. This is the most conservative choice as it does not require any surgery for your eye that has no cataract until it is necessary, and it is hard to predict when that might be.

Number 2: Knowing you will need to wear a contact lens most of your waking hours, especially if you have been doing this anyway and were comfortable with it until now, we can plan to aim for no distance glasses (emmetropia) in your cataract eye now. This means you may have 2 contacts for your unoperated eyeone for distance with readers as needed over the contact (leaving the other eye bare). When you like, you can also have a contact lens for intermediate or near vision giving you blended vision with less dependence on glasses for most daily tasks. If you like this idea but arent accustomed to a contact lens, we can have the unoperated eye fit with a contact now so you can see if it is manageable and then make your decision. If the patient has been using the cataractous eye for near as part of a monovision contact strategy for years, I will aim for 1.75 in the cataract eye rather than emmetropia as long as the patient knows he or she will need a contact in the unoperated eye for distance from then on.

Number 3: We schedule both the cataract surgery in the one eye and a refractive surgery in the good vision eye. I discuss LASIK vs. refractive lens exchange as appropriate. Assuming all goes well with the cataract surgery and we reach our refractive goal, we will plan for the RLE within a week or so of the first eye surgery. We then discuss the various options of bilateral emmetropia, blended vision with monofocal IOL, or multifocal lens bilaterally. This choice gives you relief from the poor vision the cataract has caused and also gives you a refractive goal for less dependence on glasses and contacts into the future. In my experience, once you see how easily the cataract surgery can go, you wont put up with dependence on the contact for long and will be begging for surgery in the second eye if we aim for emmetropia in the first. Given the risks of surgery [I discuss increased risk of RD due to high myopia; if there is a unilateral cataract due to disease or injury, the discussion has already taken place], you need to be the one to decide if you wish to postpone any risk to the sound eye and restore your previous condition in glasses or choose one of the other options.

Thomas A. Oetting, MD

Professor of ophthalmology, University of Iowa, Iowa City

I would tell patients: Now that we have decided to do cataract surgery on just one of your eyes, we have another issue to discuss. We have to decide what power intraocular lens to place. One option is to simply leave you nearsighted like you are now, making it so the operative eye after surgery matches your unoperated eyes need for glasses. This will make wearing glasses easy because the strength in both of the spectacle lenses will be about the same. I pause to make sure they understand. I continue, The other option is to place an intraocular lens during surgery that will allow you to see well far away without spectacles. This will be a nice long-term solution as eventually you will need cataract surgery in the other eye, and then we could make it so you dont need glasses to see far away with either eye. However, during the period of time between surgeries we would have an important issue with this option. If we place the intraocular lens so you dont need any spectacle power to see far, you will have one eye that still needs a lot of spectacle power and the other eye, which we operated on, that needs very little spectacle power. The optics of having one strong lens and one weak lens in spectacles can be awkward. The eye with a lot of spectacle power will see smaller images, while the eye with the artificial lens and little spectacle power will have larger images. At this point, I have the family members look at the patient in her glasses and show how her eye looks smaller.

To counteract the awkward spectacle problem if you choose this option, you will need to wear a contact lens in the eye we did not operate on. This matches it up optically with the operative eye and eliminates the awkward problem of a high power lens in just one spectacle lens.

However, as you have never worn contacts before we will have you see one of our optometrists and make sure you can comfortably wear a contact lens before the surgery so we are sure this is even an option for you. In summary, the decision is a little tough. You could go for a long-term homerun and wear a contact lens in the unoperated eye while you wait a few years for the cataract to develop in that eye. When it develops, we could place an intraocular lens with the cataract surgery then so you wont need correction in either eye to see far away. Or if you dont mind wearing glasses, we could set the intraocular lens in our surgery so you are about as nearsighted as now and just plan on continuing to wear glasses as you always have. You dont have to decide now. You can think about it for awhile. Here is my card with my email. Let me know some time before the surgery so I get the correct lens ready for you.

Richard J. Mackool Jr., MD

Mackool Eye Institute, Astoria, New York You have a cataract in your right eyethat is why you have poor vision and glare. We can remove the cataract and give you good distance vision, but you will need glasses to see the computer and read with the right eye after surgery. Your left eye is very nearsighted, meaning you can see things without glasses when you hold them very close to your eye. After surgery on your right eye, your 2 eyes will be very different, with the right eye clear in the distance and the left one clear at near. Unfortunately, glasses will not work for you after surgery since the right and left eye need such different prescriptions. A contact lens for your left eye will allow you to see clearly in the distance and your eyes will work together after surgery if you wear one. I suggest we have you try a contact lens before surgery to make sure you are able to use it. If you are happy with the contact lens we can proceed with cataract surgery to give you distance vision in the right eye. I start with the statement above. I then ask patients if they have any questions, and try to make sure they understand that glasses will not work for them. Patients will often ask why a contact lens will work while glasses will not. At this point I ask them if they have noticed that their eyes look smaller through their glasses when they look in the mirror than they do without their glasses. Surprisingly, many highly myopic patients will say they have not noticed. If a family member is in the room I ask them to look at their relative with the glasses flipped up and then down. Once the family member is on board I show the patient in a mirror. Once the patient and a family member understand this concept, it is easier to explain that not only does the eye look smaller through the glasses, but the world looks smaller to the eye through the thick glasses. I then tell them that after surgery the eye that has no prescription will see things as larger than the eye with the thick eyeglass, and therefore glasses will make them unbalanced. I explain that contact lenses work differently so that the 2 eyes see things as the same size.

Contact information

Arbisser
: drlisa@arbisser.com
Mackool: richardmackool@aol.com
Oetting: thomas-oetting@uiowa.edu

Anisometropia decoded Anisometropia decoded
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