February 2008




Patient questionnaire focuses the discussion

by Rich Daly EyeWorld Contributing Editor



Latest changes to the IOL questionnaire aim to better inform both the patient and the surgeon

A freely available questionnaire that has provided guidance to patients and surgeons prior to intraocular lens procedures continues to evolve.

The patient questionnaire, developed by Steven J. Dell, M.D., two years ago and made available to ASCRS members in 2006, provided a framework for patients and physicians to discuss realistic expectations and the capabilities of various types of intraocular lenses. A revised version was made available to surgeons by Dr. Dell in August 2007.

The changes, based on feedback from surgeons who have used the questionnaire, aimed to simplify it and make it easier for patients to understand. Also added was a question about whether the patient has any interest in paying an additional amount of money to reduce his or her spectacle dependence.

“It pretty quickly hones in on what the patient wants to achieve in terms of spectacle independence post-op,” Dr. Dell said. “Most importantly, it alters the patient’s expectations because after he is done filling out the survey, it becomes obvious to him that perfect vision under all viewing circumstances and all lighting conditions is really not possible.”

The seven-question, one-page survey includes questions asking patients to identify the vision distance range at which they most desire spectacle independence, and to identify the vision range at which they would accept wearing glasses post-op.

The questionnaire, given to patients to answer before their first visit with the surgeon, educates patients that components of IOL surgery mandate compromises and choices by the patient.

As an education tool, the survey simplifies the first patient-physician discussion and “focuses” patients on which distance range they most want good uncorrected vision. If good uncorrected distance vision is the goal, a limbal relaxing incision or a toric IOL will be needed to correct corneal astigmatism.

“If the patient wants to see well at a distance, as well as intermediate and near, then that merges into a discussion regarding presbyopia IOLs,” Dr. Dell said.

His office provides the questionnaire to every new patient who seeks cataract treatment or a refractive lens exchange consultation. His technicians who initially assess patients also provide the questionnaire to older patients who appear to have poor vision, even if they have not yet been diagnosed with cataracts.

“There is a tremendous amount of information that has to be exchanged between the patient and the surgeon when it comes to presbyopia-correcting IOLs,” said David F. Chang, M.D., clinical professor, University of California, San Francisco, who has used the questionnaire for two years. “This questionnaire is a very useful and time efficient tool to facilitate that.”

The idea for a questionnaire that targeted refractive lens patients stemmed from research by William F. Maloney, M.D., associate clinical professor, University of California, Irvine, who studied the use of questionnaires for cataract surgery patients. Dr. Dell has customized his approach to limit it to a single-page, simplified questionnaire targeted at presbyopia-correcting IOLs.

The educational function of the patient questionnaire has reduced the complexity of Dr. Dell’s cataract and refractive lens exchange consultations. Although he continues to discuss the procedure options with patients “for as long as it takes,” the document has helped reduce the length of the average consultation from 20 minutes to as little as 5 minutes.

In addition to simplifying the educational role of physicians, the survey can allow good surgery candidates to self-select. One survey question asks patients to mark where their personality falls on a range between “easy-going” to “perfectionist.”

Such a query posed by a written questionnaire may provide more honest responses and patients won’t take it personally, as they might if a doctor posed the personality question seemingly “out of the blue,” Dr. Chang said. “Interestingly, two of my most difficult multifocal patients who both had a strong sense of entitlement had actually refused to complete the questionnaire preoperatively,” he said. “In retrospect, this might have been a warning sign of a passive aggressive attitude.”

Dr. Chang slightly modified the questionnaire to further orient it toward cataract patients. Right above the personality scale is a similar scale that allows cataract patients to rate their desire to be spectacle independent, by placing a mark along the range between the two extremes of “prefer glasses at all times” to “I hate glasses.” He also wrote a general handout that explains the option of presbyopia correcting IOLs at extra cost, and for which some, but not all patients are good candidates. This is mailed along with the Dell questionnaire to every patient making an appointment for a cataract evaluation. “After studying the handout and completing the questionnaire at home, most interested patients have already given some thought to their refractive priorities and have a basic understanding of the options by the time of their visit,” said Dr. Chang. “The questionnaire, in turn, quickly provides me with a lot of information at a glance, and allows me to immediately cut to the chase”. He recommended that every surgeon develop his own introductory handout, customized to the approach and focus of his practice.

Editors’ note: Drs. Dell and Chang have no financial interests related to the questionnaire.

Contact information
Dell: 512-327-7000, sdell@austin.rr.com
Chang: 650-948-9123; dceye@earthlink.net

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