Eyeworld

EW CATARACT 34 June 2015 What's my line?: Pearls for effective patient communication visor over their brow, blocking the light from the ceiling illumination, which always makes the negative dysphotopsia briefly disappear. This assures them of the veracity of my explanation. I then say, "Although 30% of people will notice this, less than 1% are bothered long term. Modern surgery involves opening the front bag of the cataract, removing the cloudy protein, polishing the back bag, and placing the man-made lens in this bag. Over time and with healing, the bag shrinks around the new lens, decreasing the space for the unwanted stray light rays to enter and protecting the lens edge so it gets less glinty. This may cause the images to go away completely. One more reason so few people are bothered for long is that the brain is a smart organ that learns to tune out noise and tune in information. "For the very small percentage of people who are bothered long term there are surgical solutions but they are not without risk. I would be happy to discuss these details further and would expect to hear if you have an ongoing problem. "So don't let it strike fear in your heart if you notice these imag- es; there's nothing wrong that needs attention. Your goal is to ignore them as best you can, knowing they will likely either disappear or fade from consciousness unless you look for them actively out of curiosity. Do you have any questions, anything that's not well understood?" It is very important that the whole staff understands this issue and that the patient hears the same explanation from the staff and the doctor. Lisa Brothers Arbisser, MD Adjunct associate professor, Moran Eye Center, University of Utah, Salt Lake City When patients complain of dyspho- topsia, we must first be sure they are not retinal in origin. Full confron- tation fields and the assurance that positive dysphotopsias are only experienced with eyes open, not closed, is sufficient, along with the classical temporal arc of the negative dysphotopsias. I explain to patients: "Even the most modern technology cannot ex- actly mimic the young natural lens that God or nature gave us. Before your cataract developed, causing your lens to get cloudy, the lens let almost all light go through with- out bouncing back. Our man-made materials, which allow you to see so clearly, are most often made of a type of plastic called acrylic. This substance is more reflective than the natural crystalline lens. Although most of the light goes through, some bounces back, causing what we call 'unwanted visual images,' interpret- ed by the brain as glints or glimmers or a curved dark shadow to the side. About 30% of people will notice this after uncomplicated cataract surgery, sometimes in just one eye and some- times in both. "Even though your pupil is this big [I show them a small circular opening with my fingers] and the lens is this big [also demonstrat- ed as much larger] certain rays of light, mostly from above, can come through the pupil and bounce off the edge of the implant, resulting in an image that isn't really there like the image in the mirror isn't real." I then check their side vision by confrontation, showing them how this virtual image doesn't block their vision at all. If they are aware of the image while we are talking in the lane, I will place my hand like a Pseudophakic dysphotopsia continued on page 36 T hree expert ophthalmologists share here how they communicate with patients experiencing dysphotopsias following successful cataract surgery and where no pathological etiology is found. Since forewarned is forearmed, notice the use of anticipatory guidance—setting non-threatening expectations preop—so patients are less likely to become unduly alarmed postop. As you read their suggest- ed verbiage for handling these symptoms when no pathology is present, be looking for their skillful use of these helpful com- munication principles: 1) Our perception defines our reality: It makes no sense to argue with patients about what they are seeing or experienc- ing since, like beauty, it is subjectively perceived in the eye of the beholder. Accordingly, normalizing their experience, and thus validating their report, will calm most patients and liberate them to follow your lead, rather than battling you to make their point. 2) What we focus upon tends to expand: The more a patient becomes anxious about any unwanted visual images and, therefore, remains visually fixated upon them, the more likely it is that these symptoms will continue because such preoccupation interferes with neuroad- aptation and their typical cessation over time. 3) Self-fulfilling prophecy: Once a patient understands and accepts the expecta- tions you've set, they become psycholog- ically invested in making your predictions come true, at least unconsciously, which explains a great deal about the efficacy of pharmacological placebos. There- fore, ophthalmologists can tap into this unconscious process by setting positive, reality-based expectations in order to mobilize the patient's psyche to augment the desired outcomes. Craig N. Piso, PhD, What's my line? editor Susan M. MacDonald, MD Director of comprehensive ophthalmology, Lahey Clinic, assistant professor, Tufts University School of Medicine, Boston After a successful cataract surgery, we anticipate happy patients, yet with dysphotopsias patients seem unimpressed with their new vision and are unhappy, focusing on these new peripheral visual symptoms. This can be a frustrating experience for both the patient and the oph- thalmology team. Patients can be made to feel as if their symptoms are "all in their head" and they are being dismissed. The ophthalmology team can judge the patient as a com- plainer and ungrateful. It is a setup for miscommunication, misinforma- tion, and an unhappy patient. One of the most important things the ophthalmologist can do is lead by example and set the tone of how this patient is to be treated. When I hear a patient is "complaining or being picky" about streaks or peripheral glare, I remind myself and my team that these are legitimate concerns, and the patient may be afraid and worried. It is our responsibility to help this person with our kindness, patience, and explanation. Giving the patient an oppor- tunity to describe the symptoms is useful. I then ask a few pertinent questions to hear what they are worried about and to further classify positive or negative dysphotopsias. I will then let them know that we are going to evaluate their eye and make sure there is no serious condition, such as retinal detachment, causing the symptom. I will follow this with a thorough exam of the anterior and posterior segment. Once I have determined there is no underlying pathology, I share this information with the patient: "There is good news. Your eye is healthy and I am happy to report I did not find any retinal pathology such as a detachment, peripheral tumor, or neurologic lesion causing visual field loss." I spend time on this because it is important to emphasize the positive and to try and reduce anxiety and fear. I will then explain what a dysphotopsias is and give a basic description of the optics of the eye. I will remind the patient of our preop discussion about the visual system and the limitations of lens tech- nology. I say that many people will

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