Eyeworld

EW FEATURE 48 Patient satisfaction • December 2015 AT A GLANCE • Vet patients appropriately before surgery to assess how a premium IOL might suit them. • If a patient is unhappy, listen and let him or her know you are an advocate for what is needed. • Try to determine if a patient is still neuroadapting or if the concern involves a surgical or other intervention. • LASIK enhancements, limbal relaxing incisions, IOL exchange, and IOL rotation are common options to improve the patient's vision postoperatively. • Patients need time to neuroadapt; it typically takes 3–6 months. by Vanessa Caceres EyeWorld Contributing Writer Dr. Macsai also advises waiting 3 months, and even at that point, she favors making the most noninvasive intervention possible. Sometimes, an IOL exchange is necessary. Certain tools available to sur- geons can help with outcomes and patient satisfaction. For example, Dr. Masket uses custom wavefront exci- mer laser treatment with diffractive multifocal IOLs. He also has intra- operative aberrometry to further customize surgical outcomes. Role of neuroadaptation Neuroadaptation can throw a curve- ball to the most optimistic patient or surgeon. "Some will see unbe- lievably well. Others will say they're having a hard time getting used to their new focal point," Dr. Berdahl said. "Neuroadaptation is probably the most unpredictable part." Three to 6 months is the usual amount of time for neuroadapta- tion to develop. "In my experience, if patients have not neuroadapted within the first 6 months, they will not adapt," Dr. Macsai said. At that point, surgeons should make sure the posterior capsule is clear and the ocular surface is pristine. issues, assuming emmetropia. "If those are the issues and they are otherwise satisfied, I encourage them to tough it out and see how they do," he said. If the patient complains about distance vision, again assuming em- metropia, then Dr. Masket is more concerned that an IOL exchange could be necessary. In either situa- tion, he reminds patients he is there to help. "I always let them know I'm willing to exchange at any time it's not tolerable," he said. Residual refractive error can be a common reason for unhappiness, and that's something that can be corrected with a LASIK enhance- ment, Dr. Berdahl said. Other problems include IOL decentration, anterior basement membrane dystrophy, and posterior capsule opacification, Dr. Berdahl said. Ocular surface issues could also play a role in dissatisfaction, which would require helping the patient to restore the ocular surface to optimal conditions, Dr. Macsai said. The timing for making any corrections is usually around 3 months, Dr. Berdahl recommended. In fact, Dr. Masket will let patients know that in a U.S. Food and Drug Administration clinical trial, 94% of patients selected a multifocal IOL again—but that means 6% did not. That curve of unhappiness should temper how you describe lenses to patients as well. "I think it is best to never be absolute with patients. Not all will respond in the same manner to technology," said Marian Macsai, MD, chief of ophthalmology, NorthShore Univer- sity HealthSystem, and professor of ophthalmology, Pritzker School of Medicine, University of Chicago. When meeting with unhappy patients, listen carefully. "If they are unhappy, I let them know that I'm their advocate," Dr. Masket said. "The first thing I want to do is understand what they are telling me. I want them to know I care about their problem," said John Berdahl, MD, Vance Thompson Vision, Sioux Falls, S.D., and medical director, South Dakota Lions Eye Bank. Any necessary work postoperatively is included in the price that patients paid before surgery, he added. Detective work When listening to an unhappy mul- tifocal IOL patient, you'll naturally want to get to the bottom of their dissatisfaction. For example, cer- tain lenses may have vision-related limitations that both surgeon and patient should keep in mind, Dr. Berdahl said. You'll also want to distinguish what might be an initial issue with neuroadaptation versus a problem that will require a surgical correc- tion. This is one reason that timing of complaints is essential. If a patient complains more about near vision or that they are seeing halos, Dr. Masket puts them in the category of neuroadaptation Helping unhappy premium IOL patients A primer for clearer vision and better patient satisfaction A key step to help avoid unhappy premium IOL patients postoperatively is to get to know the patient well preoperatively, said Samuel Masket, MD, in private practice in Los Angeles, and clinical professor of ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles. Consider their current refractive error and their vision-related needs. Personality and occupation play roles as well. "Know their goals, and let them know [in advance] what the technology can and can't do," Dr. Masket advised. Even with the best vetting, it's likely that some patients will not be satisfied with their vision after a multifocal or toric IOL implantation. someone around age 50 to 60 look- ing for vision correction is placed on the "dysfunctional lens track," and those over 60 with complaints about daily activity put on a "cataract track." Putting patients on these tracks is important because this process can be time-consuming for technicians and patients, and this can help to streamline everything, Dr. Waring explained. Going forward, Dr. Waring expects the trend toward using such high-tech educational tools to continue. "There is a whole new generation of advanced diagnos- tics coming for functional vision testing along with the maturation of electronic medical records," he said. This, along with femtosecond lasers for cataract surgery, advanced IOLs, and intraoperative aberrome- try, make for a great opportunity to help patients in every stage of their life. "This is what my father, George Waring III, MD, always called vision for a lifetime," he said. EW Editors' note: Dr. Gatinel has financial interests with Alcon (Fort Worth, Texas), Bausch + Lomb (Bridgewater, N.J.), Nidek (Fremont, Calif.), and PhysIOL (Liège, Belgium). Dr. Waring has financial interests with Abbott Medical Optics (Abbott Park, Ill.), AcuFocus, Alcon, and Visiometrics (Barcelona). Dr. Alió has no financial interests related to this article. Contact information Alió: jlalio@vissum.com Gatinel: gatinel@gmail.com Waring: georgewaringiv@gmail.com By the book continued from page 46

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