Eyeworld

34 | EYEWORLD | DECEMBER 2023 ATARACT C ophthalmologist, Dr. Rai said. While cataract surgery is safe and can have a profound impact on a patient's quality of life, it is ultimately an elective surgery. With more advanced cataracts, the patient has already been symptomatic for some time and arrives at the consultation ready to proceed with surgery. "With respect to allowing the cataract to become more visually significant, the Lens Opacities Classification System III (LOCS III) is a great scale. With the most common subtypes of cataracts, a lower LOCS III grade cataract can be observed if the patient is tolerating the lens changes, while a higher grade cataract is ready for surgery," he said. "If we elect to observe a cataract, I ask the patient to monitor their symp- toms and return once they think their lifestyle is impacted. Typical early complaints include diffi- culty with night driving or frequently updating their spectacles due to shifting refraction and a drop in their best corrected visual acuity." Rom Kandavel, MD, thinks that as a patient, a good question to ask when considering cat- aract surgery is, "With my best pair of glasses, what vision problem do I wish to solve through cataract surgery?" As a surgeon, you may want to ask, "Is the vision limiting the patient's quality of life or their ability to perform daily ac- tivities the way they want to be perform?" If you can't find the answer to those questions, you probably shouldn't be operating on that patient, he said. "That is the premise of what I look for in a conversation. It's not a discovery when they need surgery. The vision is already impacting the patient's quality of life. The need to improve the vision should be obvious to the surgeon and to the patient." You never want to be in a posi- tion where you're telling the patient that they have a problem that they are unaware of. He added, "In the rare circumstance that a patient has a problem after surgery, like glaucoma or retinal detachment, the patient should look back and know they made a clear self-driven decision to improve their vision through surgery. "Patients will commonly know they are ready for surgery, but they'll still ask me, 'Do I need this surgery?'" It's not because they're not sure, but Dr. Kandavel said they want reassur- ance in order to move forward with their deci- sion. He will be supportive and positive. "I never do surgery on someone who I don't think it will help significantly." He also said that as surgeries become more routinely successful, physicians may become less mindful of the potential complications of a procedure. Operating on borderline cases can be less successful. "A good result, when evalu- ated in the context of moderate preoperative vision impairment, becomes unacceptable with a symptom such as mild halo after surgery. "I always tell residents that the patient's satisfaction with your surgery is not always linked to the result but to the process that you establish with the patient, earning trust over years of appointments," he said. "If you build that trust, not only do you have a more fulfill- ing career, but you also have a more successful one." When patients trust you, they are much more likely to put their faith in your recommen- dations because of that earned relationship. Dr. Kandavel said there are some reasons to operate sooner rather than later. One potential issue is cases with narrow angles. "In hyperopic patients who fail to have an angle improve- ment with laser iridotomy, cataract surgery can become medically indicated," he said. In a discussion of factors that could sway a surgeon or patient to have surgery done sooner, one of the most common is the desire of the patient to reduce spectacle dependence. He often coun- sels patients, "Don't do cataract surgery just to eliminate glasses because I cannot ensure that 100% of the time." However, there are some circumstances where less spectacle dependence can play a role. "If the patient has presbyopia and is a high hyperope or myope who has al- ready undergone vitreous separation, you could consider the desire to reduce spectacle depen- dence because there is also a significant quality of life improvement in those circumstances." Another example would be someone who is a long-time contact lens wearer with monovision. Those patients may not tolerate their mono- vision any longer, which can be unsettling. "If they desire to stay in functioning monovision and they no longer can, cataract surgery may be indicated," he said. Patients with glaucoma who are on multiple drops and have trouble taking them consistently may be another case in which to operate earlier, when combined with MIGS procedures to improve compliance. Dr. Rai said patients may present with co- morbid conditions that add complexity to their cataract surgery. Common ocular comorbidities continued from page 33

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