
Cornea, Cataract and Refractive Surgery Management
Thinking Refractively The Optometric Cornea, Cataract and Refractive Society is a refractive-based group, but we are not focused solely on LASIK. While optometrists often think about refractive endpoints for glasses and contacts, they are less familiar with maximizing visual aspects of ocular surgery. However, they will find that examining and commenting on the state of the lens for patients 50 years and older will increase familiarity with cataract surgery for both themselves and the patient. “A baby cataract” or a “toddler cataract” will later become “time for cataract surgery.” Starting the conversation early with patients means they will not be shellshocked to hear the term “cataract.” Make sure to educate patients needing toric lenses early to make the discussion prior to referral easier. Premium lenses are more attractive when the patient has years to consider their options and save the required funds. An important aspect of comanagement is consideration of the refractive endpoint. Most surgeons default to distance correction, targeting plano. But myopes may prefer to remain nearsighted and wear correction for distance. We know our patients best and need to look out for their visual needs. Determine this important consideration prior to surgery to avoid extremely unhappy patient postoperatively. Discussing this option years before surgery allows patients to carefully consider their options and feel more reassured when the cataract requires extraction. In addition, fitting patients in multifocal contacts is an excellent method to demonstrate multifocal intraocular lens options. Demonstration of monovision or a multifocal correction should be initiated prior to referral to the MD. When discussing surgical endpoints, patients with a refractive surgical history are in particular need of extra education. After LASIK, many patients think all visual problems are the result of LASIK, or can be fixed with an enhancement. When cataracts develop, post-refractive patients should be educated that the IOL measurements are affected by the previous surgery. They will be less shocked or angry if they suffer a postoperative refractive surprise, if the possibility of blurred uncorrected vision was discussed prior to surgery. Remember that contact lens wearers must discontinue their lens wear prior to cataract surgery. This may be problematic if the patient does not have spectacles. The time needed to discontinue the lenses varies with surgeon and type of lens. Discontinuation must be completed prior to testing for IOL measurements, including keratometry and biometry, for proper measurements. Only after wearing spectacles for the allotted time should IOL measurements be performed. Discuss the timing of surgery with patients prior to referral. For some, the limits on bending, lifting and swimming may be problematic. I once told a patient the day after surgery, “You can’t swim or hot tub for two weeks.” He responded with, “But I clean hot tubs for a living.” I promptly called his supervisor. While travel is not contraindicated, it should be discussed to avoid issues later. Timing of the surgery may also need to be addressed, as patients with high astigmatism or high anisometropia will do better with minimal time between eyes. Communicate this to the surgeon in the referral letter or when scheduling surgery. Starting the conversations years before referral enables the patient to consider options, and ready themselves for a smoother procedure with a better outcome.

Cornea, Cataract and Refractive Surgery Management

Thinking Refractively

The Optometric Cornea, Cataract and Refractive Society is a refractive-based group, but we are not focused solely on LASIK. While optometrists often think about refractive endpoints for glasses and contacts, they are less familiar with maximizing visual aspects of ocular surgery. However, they will find that examining and commenting on the state of the lens for patients 50 years and older will increase familiarity with cataract surgery for both themselves and the patient.

“A baby cataract” or a “toddler cataract” will later become “time for cataract surgery.” Starting the conversation early with patients means they will not be shellshocked to hear the term “cataract.” Make sure to educate patients needing toric lenses early to make the discussion prior to referral easier. Premium lenses are more attractive when the patient has years to consider their options and save the required funds.

An important aspect of comanagement is consideration of the refractive endpoint. Most surgeons default to distance correction, targeting plano. But myopes may prefer to remain nearsighted and wear correction for distance. We know our patients best and need to look out for their visual needs. Determine this important consideration prior to surgery to avoid extremely unhappy patient postoperatively. Discussing this option years before surgery allows patients to carefully consider their options and feel more reassured when the cataract requires extraction. In addition, fitting patients in multifocal contacts is an excellent method to demonstrate multifocal intraocular lens options. Demonstration of monovision or a multifocal correction should be initiated prior to referral to the MD.

When discussing surgical endpoints, patients with a refractive surgical history are in particular need of extra education. After LASIK, many patients think all visual problems are the result of LASIK, or can be fixed with an enhancement. When cataracts develop, post-refractive patients should be educated that the IOL measurements are affected by the previous surgery. They will be less shocked or angry if they suffer a postoperative refractive surprise, if the possibility of blurred uncorrected vision was discussed prior to surgery.

Remember that contact lens wearers must discontinue their lens wear prior to cataract surgery. This may be problematic if the patient does not have spectacles. The time needed to discontinue the lenses varies with surgeon and type of lens. Discontinuation must be completed prior to testing for IOL measurements, including keratometry and biometry, for proper measurements. Only after wearing spectacles for the allotted time should IOL measurements be performed.

Discuss the timing of surgery with patients prior to referral. For some, the limits on bending, lifting and swimming may be problematic. I once told a patient the day after surgery, “You can’t swim or hot tub for two weeks.” He responded with, “But I clean hot tubs for a living.” I promptly called his supervisor. While travel is not contraindicated, it should be discussed to avoid issues later. Timing of the surgery may also need to be addressed, as patients with high astigmatism or high anisometropia will do better with minimal time between eyes. Communicate this to the surgeon in the referral letter or when scheduling surgery.

Starting the conversations years before referral enables the patient to consider options, and ready themselves for a smoother procedure with a better outcome.