Eyeworld

34 | EYEWORLD | WINTER 2025 ATARACT C Contact Braga-Mele: rbragamele@rogers.com Ledoux: dledoux@specialized pediatriceyecare.com Rowe: susannah.rowe@bmc.org Shah: madhura.shah7@gmail.com Relevant disclosures Braga-Mele: None Ledoux: None Rowe: None Shah: None "We don't have a mechanism to acknowledge that there's a difference financially when taking care of these patients." She said she gets emails every week from patients around the U.S. who can't find a sur- geon to perform cataract surgery in their home- town. The result is a hollowing out of access. "These patients are covered by Medicaid, but if there's no reciprocity, they can't get surgery in Massachusetts. Transporting them across states is traumatic and often unfeasible." Dr. Ledoux said patients with mild to mod- erate cognitive delays and mental differences should be incorporated into their community ophthalmic and optometric practices. "We don't want to see people's lives decline because of unrecognized conditions that are easily inter- venable like cataracts," Dr. Ledoux said. Dr. Shah recalled her department getting an email inquiry from the family of a woman in her 30s with special needs. They were having trouble finding an ophthalmologist in their Los Angeles suburb who would approach the sur- gery. Dr. Shah thinks ophthalmologists should get more exposure to cases involving patients with disabilities during residency so they might be more comfortable caring for them once in practice. "Once while on call, I saw a 13-year-old with a developmental delay," Dr. Shah said. "I think we all get very nervous and fall back to what we're taught to do in medical school, which is again that very rigid outline of how we're supposed to attain information. … I'm so grateful to have had this experience because instead of getting nervous, I view it as a liber- ating kind of thing. … We're going to gather all the clues that we can. And if we don't have any objective data, that's OK because we'll try to understand how they're experiencing the world around them. Even if that's different informa- tion, we'll use it to come to the same kind of questions about diagnosis and treatment that we would have otherwise." A call to surgeons To surgeons across the country, Dr. Rowe offered this message: "We need to do better. This is a national problem. There are thou- sands of patients like this who deserve access to high-quality care." incision surgery, for these patients she will still use a suture at the end of the case. Another issue is drops. Dr. Braga-Mele said too many drops (an antibiotic, steroid, and non-steroidal) can be challenging for the patient and their caregivers. Dr. Braga-Mele said a com- bination drop, avoiding an NSAID altogether, or intracameral antibiotics could be considered. Barrier 3: economic disincentives and lack of confidence limiting access Perhaps the most entrenched barrier is systemic: Economic structures in many ways disincentiv- ize care for patients who fall outside the surgical norm, Dr. Rowe said. "There are very real economic barriers," she added. "Cataract surgery reimbursements are going down. Exceptions for complex surgery don't apply to these patients because they're tied to specific intraoperative tools, not time or expertise." A neurodiverse patient's surgery might require more than 2 hours, yet reimbursement is the same as a more typical case, Dr. Rowe said. continued from page 33 From Dr. Shah Observe how the patient interacts with their surroundings. Go out to the waiting room to get the patient yourself and watch them as they walk back with you. Observe their gait, if they shake your hand, etc. From Dr. Ledoux Suture them all. You don't want to worry about eye rubbers or accidental trauma. Consider dropless cataract surgery. Shield them for longer. If there is posterior haze present at the end of the case, consider performing a posterior capsulorhexis to avoid a later YAG. Have shiny or spinning objects in your office to help a patient focus so you can get a look at the retina. Pearls for patients with disabilities

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