August 2009

 

COVER FEATURE

 

challenging cataract cases

Navigating nerves in cataract patients


by Enette Ngoei EyeWorld Staff Writer

   

How to deal with the anxious

Nobody is ever keen to have to go through cataract surgery, much less the nervous cataract patient. But there are cooperative patients and then there are difficult patients who simply can’t help their fears. Luckily, there are steps a surgeon can take to help jittery patients through a smooth surgery. The most obvious and important first step is spending chair time with the patient. During consultation, assure him or her that being afraid is in fact normal and that you’re used to dealing with it, said Donald N. Serafano, M.D., associate clinical professor, University of Southern California, Los Angeles. If the patient is anxious about the details of the surgery, like how much it will hurt, how much discomfort there’ll be, or how bright the light will be, said Thomas A. Oetting, M.D., professor of clinical ophthalmology, University of Iowa, Iowa City; and chief, Eye Service, and deputy director, Surgery Service, VA Medical Center, Iowa City, the best thing to do is talk them through it.

“Telling them things like, ‘most patients find that the most difficult part of the surgery is removing the drape afterwards,’ gives them a sense of the level of discomfort afterwards,” he said.

They will understand that it might hurt a little bit when you pull tape off of your skin but realize that it’s not a big deal and something they can handle, he explained. Telling the patient that the amount of bright light is similar to when they had their exam also helps. Finally, he said, assure them that you’ll be talking to them during the procedure and helping them through it and that there will be availability of additional medicine by I.V. if they need more relaxation medicine.

Steven H. Dewey, M.D., Colorado Springs, Colo., finds that in his waiting room, post-op patients, who’ve had successful surgeries, sitting in the waiting area next to pre-op patients, can help in calming any nerves. “One of the nice things is to have somebody sitting there who just got through with the procedure who can then kind of provide the next patient with a perspective on how it happens or works,” he said.

Beyond just nerves

If especially anxious patients need that extra reassurance, Dr. Dewey said, “There are those patients who will more or less cheerlead your successes and will actually volunteer to talk with other patients about the procedure and we don’t use that resource really often but at the same time I think it’s a valuable one that’s assisted us in a couple of cases along the way.” Another good thing to do for patients who need a little bit more handholding than others, Dr. Oetting said, is to tell them that you want to hear all their concerns and help them understand what surgery will be like and then set another time to meet again when the dust has settled and when you aren’t harried by your schedule. It gets trickier if the patient is nervous because their only eye is undergoing surgery or if they have a family member who had a complication, or if they’re scared that they’re going to have a complication, Dr. Oetting said.

“If they’re nervous because in their other eye they had a complication like an infection or the lens was funny, then I think you have to work with them to explain why this is going to be different,” he added.

Tell the patient what you are doing to help them that couldn’t have been done before or how you are anticipating things to be different in this case because perhaps you’re using a different antibiotic or a different lens or a different technique for this eye than the other eye. It helps them understand why this eye isn’t going to be the same, he said. Show them you recognize that what they’re going through is tricky and give them some assurance that even though there’s some risk in the procedure, that you’re going to be with them through that and you’re going to help them should they need referral help if they do have a complication, he added.

Also, let the patient know that if they don’t have enough of a disability now and they want to assume that risk, that it’s ok, they can wait, they’re in charge of when things happen, Dr. Oetting said.

Recognizing who will need further attention

In identifying a patient who has more than the usual level of anxiousness, Dr. Serafano said often the technician who does the A-scan for his patients will have some difficulty with their cooperation like keeping their eye open or having them look where they’re supposed to look. “The technician will then leave a note saying, ‘patient very nervous, difficult A-scan’ and that gives me the clue that when it comes time for the surgery that this may be a patient who cannot cooperate and then I warn the anesthesiologist that the patient may need sedation.”

Detailing his general protocol with particularly anxious patients on the day of surgery, Dr. Serafano said, “When the patient checks in to the surgery center in the pre-op area, we might start the IV a little bit early so that the anesthesiologist can give them a little sedation so they’re not nervous waiting.”His team always reassures patients about marking the right eye and gets their cooperation by having them point to the eye. They initial the area around the eye to bolster their confidence. When they come into the surgery room the next hurdle to get over is finding out if they can have topical anesthesia, Dr. Serafano said. To test this, he said, “We have them lay down and look at the microscope light, some people can cooperate and calm down with just the mild IV sedation but other people still cannot cooperate and they want to close their eye, they want to roll their eye up, they can’t look at the target light.”

If a patient is going to cause undue risk to themselves by continuing with a topical anesthesia, Dr. Serfano said, he performs a peribulbar block, this way he doesn’t need their cooperation anymore and can give them a little more in the way of sedation.

In calming patients though, Dr. Oetting warns that surgeons should be careful not to over sedate patients. In his experience, when he has over sedated patients because they were nervous, it wasn’t that their nervousness that caused problems. It was patients falling asleep and waking up suddenly or being unaware of where they are and they move suddenly, he said.

Finally, Dr. Serafano said it’s important for the surgeon to remember that it’s really their responsibility to get the patient safely through the procedure, whether or not the patient is uncooperative.

Editors’ note: Drs. Serafano, Oetting, and Dewey have no financial interests related to their comments.

Contact information

Dewey: 719-471-4139, deweys@prodigy.net
Oetting: 319-384-9958, thomas-oetting@uiowa.edu
Serafano: serafano@gte.net

Navigating nerves in cataract patients Navigating nerves in cataract patients
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