Eyeworld

EW FEATURE 94 Challenging cataract cases • October 2017 As a final piece of advice, Dr. Hart said it's important to talk to, not over, the patient, regardless of the level of dementia. "It's easy, because they don't talk back, to cut them out of the informed consent, but I think it's important to keep them involved and let the family see that you're keeping them involved because it's the right thing to do," Dr. Hart said. "Because they can't express them- selves, we don't know exactly what's going on inside their mind. We have to treat them like we would any other human being." EW Reference 1. Ishii K, et al. The impact of cataract surgery on cognitive impairment and depressive men- tal status in elderly patients. Am J Ophthalmol. 2008;146:404–9. Editors' note: Drs. Matossian, Mac- Donald, and Hart have no financial interests related to their comments. Contact information Hart: j.c.hartjr@sbcglobal.net MacDonald: Susan.M.MacDonald@lahey.org Matossian: cmatossian@matossianeye.com important for these patients. While monovision or a multifocal could be useful if the patient is likely to lose reading glasses, Dr. MacDonald stressed the importance of good depth perception. Postop care and other considerations With dementia patients, Dr. Matos- sian said she'll often do a "double prep," expanding the area where she applies betadine and also using SteriLid (TheraTears, Ann Arbor, Michigan) because sometimes their hygiene might not be as well ac- counted for. She used to put in one suture just in case patients forgot they were not to rub their eye. For the last few years, however, she's been using ReSure Sealant (Ocular Therapeutix, Bedford, Massachusetts) instead. "I also place a plastic shield over their eye when they leave the OR; I don't do that for my typical cataract patients. They wear it home while the eye is still numb since I don't want them to touch their eye. I rec- ommend the shield be used during naps and every night for a mini- mum of 7 days," Dr. Matossian said. Dr. MacDonald has all of her cataract patients where a shield for a week. Both Drs. Hart and Matossian said they make sure the patient has someone who will help them remember their drops or instill the drops for them. However, because some patients might fight instilla- tion of these drops, Dr. Matossian said in her more confused patients she will use an intracameral antibi- otic and steroid combination requir- ing only a topical NSAID, the latter of which she noted is branded and only requires one drop a day. "I decrease the drop burden to the patient postoperatively," Dr. Matossian said. Dr. MacDonald said she'll consider subconjunctival delivery of antibiotics and steroids as well if she fears noncompliance. "I try to keep it as simple as possible," she said. "I'll work with the family to try and figure out how we can taper them off any drops as quickly as possible." What about other consider- ations such as immediately se- quential bilateral cataract surgery (ISBCS)? Dr. Hart thinks there are several very real barriers to its imple- mentation in any patient, whether or not the patient has dementia. These include the risk for TASS or endophthalmitis occurring in both eyes, less reimbursement, and, he noted, medical malpractice doesn't cover it. Dr. Matossian said she doesn't do ISBCS, but added that sometimes she'll do just one of the cataracts. "Most of the time, just doing the one eye is all they need because then they can see well enough to navi- gate, see their food," she said. There may be patients who are not good candidates for cataract surgery at all, such as patients with serious medical conditions or who cannot follow commands, Dr. Ma- tossian said. Dr. Hart said it might not be worth going through surgery for a patient who is near the end of life. "At the end of the day, the days of doctors telling patients what to do are long gone. We're in a part- nership with our patients and their families, and we try to help them make good decisions and explain to them the options. These are not easy answers," Dr. Hart said. medication is better than more. The more anesthesia we give them, the more confused they become." Dr. Hart expressed a similar sen- timent. "As much as possible, less is more, but ultimately, you're doing anesthesia so that you can have a safe surgery," he said. On the vein of keeping the patient calm, Dr. Hart provided a couple of other simple tips for the OR. "Have a running commen- tary, calm demeanor, talk with the patient," he said. "I also tend to like the CRNA to hold the patient's hand. Before we drape the patient, she will explain that she's going to be there holding their hand and if there is an issue, they should squeeze her hand and that will be our clue to respond right away. It's something we try to do with every- one because it is very calming." Both Drs. Matossian and Mac- Donald said they will tape the head of dementia patients who they fear might get confused during the sur- gery and try to move. Reflecting on refraction Target refraction is of particular im- portance in this group. As Dr. Hart previously stated, he thinks these patients are less likely to need clear distance vision, making intermedi- ate vision important. As such, Dr. Hart targets patients for slightly myopic, rather than plano. Dr. Matossian pointed out that these patients, if wanting to read or do near tasks, might have trouble remembering where they put their reading glasses. For this reason, she said she has used multifocals in some dementia patients. "They're not driving so halos and starbursts are not a big problem for them, and this way they don't have to rely on glasses," she said. Dr. Hart said multifocal IOLs for these patients would be the prefer- ence "in a perfect world," but the expense and the likelihood of other ocular comorbidities usually pre- clude them from being multifocal candidates. Dr. MacDonald said she thinks maintaining good distance vision is Special continued from page 93 " At the end of the day, the days of doctors telling patients what to do are long gone. We're in a partnership with our patients and their families, and we try to help them make good decisions and explain to them the options. " —John Hart, MD

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