EW CATARACT
39
May 2017
by Lisa Brothers Arbisser, MD, John A. Hovanesian, MD, and Nicole Fram, MD
a DMV test without glasses, to wear
normal, non-prescription sunglasses
when you're outside, so you can do
things like go out for a walk, swim,
or play tennis and see clearly, watch
TV, and see fairly well without glass-
es. To do this, we need to correct
your astigmatism.
"Astigmatism happens when
the curvature of the eye has an oval
shape instead of being perfectly
round. It just kind of puts every-
thing out of focus. You have a signif-
icant amount of astigmatism."
Sometimes I show an image of
the corneal topography to empha-
size this, especially if the patient has
low manifest astigmatism but high
corneal astigmatism.
"Without correcting your
astigmatism, you will still see much
better because we are correcting
your cataract, but you will need
glasses to have clear vision beyond
arm's length—to pass a DMV test, to
watch TV comfortably, and so forth.
"If we do correct your astigma-
tism, I expect you should be able
to do most of those things without
glasses.
"You do need to understand
there are limitations to how perfect
we can make your vision. You may
still need glasses for some things
that are difficult to see like driving
at night or seeing small captions on
the TV."
Here we talk about co-morbid-
ities like dry eye, age-related mac-
ular degeneration, and epiretinal
membranes and how they will affect
vision.
"You WILL also need glasses to
see things up close like computer
work or reading your phone or other
material.
"There is a cost to correcting
your vision with a toric lens that is
not covered by insurance. The good
news is the major costs of cata-
ract surgery ARE covered by insur-
ance. Cataract surgery costs per
eye. That's because we have to pay
for an operating room, an anesthesi-
ologist, nurses, supplies, and there's
the cost of my time. Those items are
covered by insurance. The portion
we chose the standard implant to
replace, your cataract your vision
will be blurred with your glasses off
at all distances. Medicare covers this
basic surgery so you can see again
with glasses. If we use the toric lens,
which is not covered by insurance,
your vision will be clear at distance
(or wherever we chose) with your
glasses off. If you would like to
be less dependent on glasses after
surgery and can afford to spend your
money in this way, a toric lens is the
best choice to get the most benefit
from your cataract surgery. The only
added risk is that because no one
can achieve what we aim for 100%
of the time despite all the special
testing, care and experience, if you
are not sufficiently satisfied with
the result we might require another
minor surgery to make it perfect. I
personally would choose a toric lens
if I had astigmatism as you do."
John A. Hovanesian, MD
Clinical instructor, Jules Stein Eye Institute,
UCLA, Los Angeles
Naturally, every patient is different.
Other co-morbidities besides cata-
ract can change significantly how
I explain toric implants. Generally,
I only offer torics to patients with
>1.25 D of corneal astigmatism,
where I find toric implants work
better than limbal relaxing incisions.
Below is my verbatim explanation to
the "typical" patient.
"While we're correcting your
cataract, we also have the opportuni-
ty to correct your vision by putting
your glasses prescription into your
implant. That would give you the
ability to have distance vision—pass
Astigmatism and toric lens selection
What's my line? Pearls for effective patient communication
Physicians share advice on
effectively communicating
with patients
This column was developed as a
practical guide to honing or modifying
your own patient communication skills.
I offer my patter and ask colleagues,
experts in their fields, to detail their
own conversations with patients. Craig
Piso, PhD, an industrial psychologist
specializing in eye care, introduced this
column.
Lisa Brothers Arbisser, MD
Adjunct professor, John A. Moran Eye Center,
University of Utah, Salt Lake City
I say, "You have astigmatism. This
is not a disease, it's just that the
shape of your eye is not round like a
basketball but steeper one way and
flatter the other like a football."
I keep a spherical topography
map to show them compared to
theirs. Then I say the following:
"If this were a map of hills and
valleys you can see the red shows
the steep part which bends light
more in one direction than the
other making your image blurry. The
blurriness can be sharpened with a
hard contact lens to force the eye
into a round shape—glasses with
more focusing power in one direc-
tion than the other, operating on
the front cornea to change its shape
or, as I am recommending to you, by
correcting it with a special implant
during cataract surgery called a toric
lens. When we remove your own
cloudy lens—your cataract—you
will see clearly with glasses on. If
continued on page 40
H
ow do you increase the probability
that a patient will say "Yes" to your
recommendation for toric Implants
for astigmatism correction when you deem
such an option to be in the patient's best
interest, rather than settling for standard,
insurance-reimbursed lenses for their
cataract surgery and accept any ongoing
need for eyewear? Psychologically, it's un-
reasonable to expect people to take the risk
of veering off the well-worn path for treat-
ment, especially more personally expensive
treatment, as long as they remain confused
and/or filled with fears and doubts!
Effective, ethical discussion to gain
positive influence in this regard is a result
of communication that follows these
principles:
1) Information is power…when it is fact-
based, timely, relevant, and helpful—every-
one appreciates feeling empowered when
they better understand vital information.
2) A picture is worth 1,000 words…so
make use of models, graphs, and pictures/
images to augment and clarify your verbal
explanations.
3) Metaphors and analogies deepen our
understanding and memory…so translate
your medical/surgical explanations into
more familiar images/objects and relation-
ships.
4) A gap in expectations is the root of all
conflict…be sure to set clear, realistic
expectations to avoid subsequent patient
disappointment, and lean toward un-
der-promising and overdelivering regarding
their visual outcomes.
In the following scripts offered by
three well-established ophthalmologists,
try to recognize each of these communi-
cations pearls for gaining helpful, positive
influence and increasing patient receptivity.
Understanding and incorporating such
pearls into your own script is likely to help
your patients better understand and feel
comfortable with your recommended premi-
um lens recommendations.
Craig N. Piso, PhD,
What's my line? editor
