JUL 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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July 2013 EW CATARACT 21 The art of advanced technology IOLs Homage to, and hidden secrets of, the "Dell Questionnaire" by Richard Tipperman, MD Richard Tipperman, MD T he eponymously described "Dell Questionnaire" (DQ) is familiar to most if not all anterior segment surgeons. Originally created in 2004, Steven Dell, MD, developed questions to self-survey patients considering cataract surgery in order to help with the counseling process involved in IOL selection. By trying to formalize and standardize the process in which patients are evaluated, Dr. Dell deserves great credit (or indeed, homage). In this article I'd like to explore "hidden secrets" of the Dell Questionnaire—this includes information and educational benefits of the DQ that are not necessarily obvious at first glance. Hidden secret #1: The patient who will not complete the questionnaire On occasion patients will refuse to complete the DQ saying, "I need to speak to the doctor first." This is often a strong indicator of a patient with a sense of entitlement for whom "the rules don't apply." These patients can be quite challenging to provide care for. If a patient is not willing to comply with a simple request to complete a less than one page survey, how compliant will he/she be with the rest of the care regimen? Hidden secret #2: One of the biggest benefits of the DQ is not in the information that it provides but rather that it begins to get patients thinking about their visual function at different distances. As anterior segment surgeons we think about functional vision and working distances all the time—it is always an issue and discussion for every patient undergoing cataract surgery. For the average patients it is something that they never think about and so anything that begins to make them aware of these issues is helpful. Think about this for yourself. We rarely self-query or "inventory" ourselves about details of our day-today life and end up taking so many things for granted. If you were to self-inventory the 10 things in your household (outside of family members or pets) that are most important to you, what would they be? A photo album? Some sort of keepsake? Other items of personal importance? Regardless of what you chose, the exercise of thinking about what things are important forced you to go through a mental inventory of things you likely hadn't thought about for some time, while stratifying them added relevance and importance. "I really should take better care of that (insert important personal item here)." It is no different when patients are queried about their visual function. The average patients never think about vision at different distances, they just think they "can" or "can't" see. By helping them think about vision at different distances, it allows them to "inventory" their visual function and also begin to realize the importance and value of vision at multiple distances. Hidden secret #3: The query "Mark yourself on a scale from perfectionist to easygoing" provides tremendous amounts of information, but not about what most ophthalmologists think. Most ophthalmologist assume that this is a litmus test for how "good" or "bad" a patient will be regarding candidacy for a presbyopia- correcting IOL (PC-IOL). Nothing could be further from the truth. The most perfectionistic, obsessive compulsive patient is still extremely happy with an excellent result, and the most easygoing, laissez-faire patient will still be dissatisfied with a poor result. As an example, engineers tend to be viewed by ophthalmologist as "perfectionists," and many would consider them poor candidates for PC-IOLs. In my experience, they tend to be excellent candidates because they listen to and also understand the issues of "technology tradeoffs," which is a common concept in much of engineering. Easygoing patients are often the "pre-sold" patients who come in telling you how great they heard you are and how they know "soand-so" who you operated on and is thrilled with the multifocal IOL. The "pre-sold" patients already know what they want, often don't listen to any of the preoperative education, and have already made their mind up about their technology choices. Because they potentially go into surgery with a poorer understanding, they have the potential to be less satisfied. With regard to candidacy, however, the "perfectionist/easygoing" scale is helpful in determining how challenging the patient might be to care for postoperatively IF he/she happens to be one of the rare dissatisfied patients with a PC-IOL. In this instance, a dissatisfied patient with an easygoing personality is usually easier to work with than a "perfectionist" patient. Personally, however, I've found that "perfectionist" patients also tend to be realists, and a frank discussion preoperatively regarding appropriate postoperative expectations and management strategies if the patient is dissatisfied makes things much easier. Final hidden secret: The Dell Questionnaire is flawed. How could a column that pays homage to a questionnaire also describe it as flawed? In reality all questionnaires and surveys contain some type of bias or flaw. Merely querying people can influence their response. Understand that this is not a criticism as all surveys contain some element of bias. Somewhat like the famous "Schrodinger's cat," just asking people questions affects how they answer them. Statisticians and behavioral scientists spend great effort to develop surveys that are statistically sound. My own personal belief is that the original DQ had a significant bias in what range it described "intermediate" and "near vision" tasks. Computer may be mid-range for some patients and near for others— the same is true of shopping. In our own vision survey we've shortened this aspect of the survey to make it simpler for patients. We now present the three following questions: 1. After cataract surgery I would prefer to function for distance without glasses. Yes or No 2. After cataract surgery I would prefer to function for near tasks without glasses. Yes or No 3. After cataract surgery I would prefer to function at both distance and near with minimal dependency on glasses. Yes or No. When presented in this simplistic fashion, patients can easily understand for themselves the benefits of visual function at different ranges. Then in the surgical consultation the physician can discuss individual patient needs in greater detail. EW Editors' note: Dr. Tipperman is affiliated with the Wills Eye Institute, Philadelphia. Contact information Tipperman: rtipperman@mindspring.com

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