Eyeworld

EW NEWS & OPINION 20 September 2015 choose standard cataract surgery, this football shape will remain and you will be as dependent on glasses or rigid contact lenses (which flatten the shape) as you have always been. We have a unique opportunity at the time of cataract surgery to correct this problem so you will likely see clearly at distance without glasses; depending on other choices that we will discuss, you will need glasses to read. We fix the astigma- tism, depending on the severity, either by changing the shape of the cornea for mild astigmatism with incisions or cancelling out the distorting shape of the natural cornea with a special implant called a toric lens. Remember that when we remove your cataract, we replace your natural lens (which has become cloudy) with a man-made lens called an intraocular lens or implant. The standard implant, which insurance covers, is like a sphere that cannot correct your astigmatism. The toric lens, an elective choice you pay for, has more power in one direction than the other to bend the light, like your glasses do for you now. This corrects the blur caused by astigmatism, making your vision clear without glasses. The toric lens is tailored for you according to many measurements. Other than the financial cost, the main issue is that you could still need some glasses for your very sharpest focus or another more minor surgery to adjust the toric lens position for the best outcome if you are dissatisfied. There is no other added risk of a toric lens beyond that of standard cataract surgery. I even recommend this for people with one eye, and honestly, you couldn't drag me to cataract surgery without one if I had astigmatism. Keep in mind when my assistant discusses the finances with you that with glasses ON you will see the same with or without the toric lens; it's with glasses OFF that you have an opportunity to see the world clearly with the toric lens. This is why it is an elective choice on your part." The conversation goes more in depth in the rare case of latent or irregular astigmatism. Lisa Arbisser, MD Adjunct associate professor, Moran Eye Center, University of Utah, Salt Lake City I tell patients: "Now that we have decided you need cataract surgery to see better, I want to explain a choice you have to make regarding your surgery. Your eye is shaped in a way that you need glasses to see clearly at all distances because you have astigmatism. Astigmatism means that your eye is not a sphere like a basketball but is curved more steeply in one direction and more flatly in the other like a football." I show this explaining the 2 directions with my hands. "This causes light to be distort- ed as it travels through the front watch glass of your eye, the cornea, and makes a blurry picture for your brain to see. This is why you require glasses with more power to bend the light in one direction than the other to see clearly." I then show them their topog- raphy. "This test that measures your eye's shape is like a map of hills and valleys. The hot (red) colors are like the top of the mountain, and the warm (blue) colors are like the bot- tom of the valley. You can see this hourglass picture that defines your football shape." I make that same hand gesture showing the steep and the flat. I then show them a spherical topog- raphy. "This is what it looks like if there is no astigmatism. If you Explaining astigmatism and its correction with a toric IOL or corneal relaxing incisions Communicating astigmatism and its treatment W e can better influence patients who are appropriate premium IOL and/or laser-assisted cataract surgery candidates to "pull the trigger" for such largely uncovered services by first understanding their emotional mindset and then through the skillful use of relevant communications. The first emotional factor is hope, which requires 2 conditions to be generated: 1) a sense that selecting this upgrade is personally important; and 2) sufficient confidence that she/he will be satisfied with the outcome and not have buyer's remorse. Therefore, anything we do to increase the personal meaningfulness of having the upgraded product/procedure supports its importance. On the other hand, anything we do to increase a patient's con- fidence completes the second requirement and further supports his/her hope. Sufficient hope then engenders the emotional energy a patient requires to cross the tipping point that enables him/her to pay any finan- cial and/or emotional toll willingly—sale completed! Increasing patient confidence depends largely on how much she/he trusts the provider, trust also having 2 necessary but insufficient conditions alone: 1) we are deemed to be competent, including a great reputation for generating consistently good outcomes; and 2) the perception that the provider and those supporting her/him are of good character, especially that we are honest, we have the patient's best interest at heart, our motives are authentic/pure, and we are reliable. While the content of the following verbiage samples from 3 proficient ophthal- mologists focuses on product/procedural options for astigmatism correction, look for the trust engendering pearls embedded within each style. Craig N. Piso, PhD, What's my line? editor James A. Davison, MD, FACS Wolfe Eye Clinic, Iowa We start by introducing the concept of upgrades in uncorrected vision performance after surgery. We send a brochure that explains that the options need to be presented as part of the informed consent process even though they are not covered by insurance or Medicare. It describes cataracts, IOLs, toric IOLs, pres- byopia-correcting IOLs, and laser vision surgery. We list the price for each option and ask patients to tell us whether they might be interested in being less dependent on glasses through one of these upgrades if they were found to be eligible. If they don't want to talk about it at their consultation and just want to wear glasses after surgery, we ask that they circle "No," but if they want to talk about it with us, they circle "Yes." If they circle "Yes," we get Pentacam (Oculus, Arlington, Wash.) images (which are non-re- imbursable) in addition to the usual workup. If a person has significant keratometric astigmatism as defined by the Pentacam's total corneal refractive power (TCRP), we discuss how it will affect their postoperative uncorrected vision quality. We start by reviewing the eye model and explain that the cornea and lens are the parts of the eye that provide focus (Figure 1). Then we explain the analogy of a basketball as a non-astigmatic surface, where the radius of curvature is the same in any direction, while with a football continued on page 22 What's my line?: Pearls for effective patient communication

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