Cataract Surgery Report

Tips for improving cataract outcomes

Meet the demands of both patients and payers as they track quality measures.

By Jessica Ciralsky, MD, Edward Lai, MD

	About the Authors: Jessica Ciralsky, MD, is assistant professor at Weill Cornell Medical College, NewYork.
	Edward Lai, MD, is also an assistant professor at Weill Cornell Medical College. Disclosures: Dr. Ciralsky disclosed she is a consultant to Alcon. Dr. Lai has no financial relationships to disclose.

With recent advancements in modern cataract surgery, patient expectations have grown exponentially. Routine cataract surgery is increasingly viewed as a refractive procedure, and almost all patients expect to achieve 20/20 vision afterward without correction. Additionally, as Medicare and private payers more closely track outcomes and shift reimbursements from fee-for-service to quality measures, it is more important than ever cataract surgery be effective with predictable results. Physicians must constantly adapt to the continuously changing field by introducing new technologies and surgical techniques.

Optimizing patient outcomes and satisfaction with cataract surgery starts with setting and managing realistic expectations. In the modern era, where successful cataract surgery has become commonplace, many patients do not consider the risks involved. A frank discussion with patients is essential, focusing on the risks and benefits of surgery, with the appropriate modifications based on pre-existing pathology. Spending time with each patient preoperatively to understand each individual’s visual needs, motivation for cataract surgery, and expectations postoperatively is crucial.

This article reviews key steps physicians can take before, during and after cataract surgery to achieve the best possible result in each case.

PREOPERATIVE STEPS

Probe deeper in history and exam

A complete history and a thorough physical examination are some of the most important steps to achieve good outcomes with cataract surgery. We suggest you ask the patient about ocular symptoms, systemic diseases, past trauma, ocular surgery, the use of medications such as warfarin or tamsulosin, and her or his ability to lie supine. This information can be helpful when tailoring an approach to surgery.

During physical examination, screen the patient for coexisting pathology. Pay particular attention to the ocular surface, looking for disorders such as dry eye and map-dot-fingerprint dystrophy — disorders often overlooked and which cataract surgery can exacerbate. Failure to identify and treat ocular surface disease can result in reduced accuracy of keratometry and topography and may lead to incorrect IOL selection and treatment of astigmatism and ametropia.

We encourage aggressive optimization of the ocular surface prior to testing. Additionally, a thorough posterior segment examination looking for pre-existing retinal and/or optic nerve pathology is necessary to help set realistic visual expectations for the patient.

Obtain accurate measurements

In the modern era of advanced-technology IOLs, accurate biometry is critical. Consistent axial length measurements must be obtained, either with an immersion A-scan or with automated biometry such as the IOL Master (Carl Zeiss Meditec, Dublin, Calif). It is also important to acquire accurate and consistent keratometry readings, which you can take manually with a reliable, regularly calibrated keratometer or with an autokeratometer.

If axial length or keratometry measurements are inconsistent between the two eyes or do not correlate with the clinical picture, repeat scans, or measuring with multiple modalities may be necessary to confirm the measurements. Delay surgery until you obtain consistent, reproducible and high-quality measurements.

Postoperative endophthalmitis demonstrates corneal infiltration involving the surgical incision site.

As patient expectations have shifted toward improved refractive outcomes and spectacle independence after surgery, evaluating corneal astigmatism has become increasingly important. Uncorrected astigmatism is often responsible for decreased visual acuity postoperatively, so we must address it preoperatively. If the patient has significant astigmatism, corneal topography should be ordered to check the etiology and pattern of astigmatism.

Corneal topography is imperative before toric IOL implantation to rule out irregular astigmatism. If the patient has regular astigmatism, you can consider surgical corrections with either toric IOLs or limbal relaxing incisions. Familiarity with both techniques can greatly improve patient outcomes.

Select the correct IOL

Many of the commonly used IOL formulas are two-variable (axial length and keratometry) vergence formulas that rely on the accuracy of the biometry readings. Newer generation formulas incorporate multiple variables to more accurately determine effective lens position and aid in accurate IOL selection.¹ Becoming familiar with the different IOL formulas in your practice, customizing A constants and investing in newer-generation formulas can help achieve optimal results.

With the recent explosion of new IOL varieties, choosing an ideal lens model for a patient is no simple task. Familiarity with the advantages and disadvantages of various IOL models and matching them to each patient’s needs and expectations is essential. All IOLs require a compromise in terms of quality of vision, range of vision, contrast sensitivity, or glare and halos. An honest discussion about the trade-offs between each lens type helps set appropriate expectations for patients.

INTRAOPERATIVE STEPS

One step at a time

Good surgical technique and visualization are critical to ensure consistent, high-quality outcomes. All cataract surgery should be meticulous and highly controlled. Since every step in cataract surgery builds upon the previous one, each is equally important.

The patient and surgeon should both be positioned comfortably to avoid the need for future adjustment. Before starting the case, check equipment for function. Providing appropriate topical, retrobulbar or monitored anesthesia is also important for patient satisfaction and outcomes. A comfortable patient is usually cooperative.

The corneal wounds need to be reliably constructed with a watertight seal and unvarying induced astigmatism. To correct small amounts of astigmatism, construct the main corneal wounds on the steep axis.

Use optimal surgical techniques

Creating the continuous curvilinear capsulorrhexis should also be consistent and controlled. Aids such as trypan blue can help improve visualization when needed. Some IOLs specify ideal capsular size, so you must be comfortable constructing different sized capsulorrhexes to meet these needs. The ability to identify loose zonules when creating the capsulorrhexis is also important; this finding can also help in making appropriate adjustments later in surgery.

A variety of surgical techniques for cataract removal are at our disposal. We must weigh the pros and cons of each technique in each individual case. Regardless of the technique, you must remove the nucleus and cortex efficiently to allow for a less traumatic surgery and decreased surgical time, which in turn leads to fewer complications and faster recovery.

Adequately polishing the anterior and posterior capsule can help prevent anterior capsular contraction and posterior capsular opacification, respectively. Finally, we must ensure centration of the IOL. Thorough removal of the viscoelastic helps with postoperative lens centration. While adequate lens centration is especially essential with premium IOLs, decentration with a monofocal lens can be problematic as well.

POSTOPERATIVE CARE

Keep it simple and thorough

A patient’s perception of the surgical experience can influence how he or she perceives the surgical outcome. When the operating day is smooth and efficient, patient satisfaction tends to be higher. Time delays inevitably occur and although most patients are aware of this, communication with the patient is helpful.

The surgical experience does not end when the patient leaves the operating room. A smooth postoperative course is just as important. Postoperative visits should be thorough and efficient. Spend appropriate time addressing the patient’s questions and concerns.

The postoperative regimen should be simple and easy to follow with clearly written instructions. Typically, patients use a topical fluoroquinolone, NSAID and steroid postoperatively. Simplify the regimen as much as possible, and choose drops with less daily frequency if the patient’s insurance allows it.

Manage patient expectations

Patients often focus on appearance, comfort and vision after surgery to judge their outcomes. For this reason, I use a cut weck cell as my second instrument when performing the initial paracentesis and a second instrument in the paracentesis during main wound construction to avoid subconjunctival hemorrhage.

Inform the patient that some discomfort after the surgery is normal, usually in the form of a foreign-body sensation. Commonly, this is due to exacerbation of ocular surface disease; treat it accordingly with dry eye and blepharitis therapies.

Before we remove the eye patch, we tell the patient that vision is often imperfect for the first few days postoperatively. Of course, with improved surgical techniques and instrumentation, many patients achieve rapid visual recovery, often the day after surgery. For patients who have had complicated surgery, dense cataracts and/or pre-existing corneal disease, discuss a more realistic time frame for their visual recovery.

Post-recovery management

Even after they recover fully from the surgery, some patients will still be unhappy with the outcome. For these patients, it’s best to start with a discussion about what aspect of the vision is causing the dissatisfaction; this can often help focus the exam.

Before any further intervention, examine the ocular surface and treat existing ocular surface disease. Additionally, scan the macula with OCT to rule out subclinical cystoid macular edema. Examine the status of the posterior capsule to look for any opacification. With premium IOLs, proper centration of the lens on the pupillary axis is another important factor.

For residual refractive errors, if the patient is amenable, spectacle correction is the first step. If residual refractive errors persist and a patient prefers to be spectacle-free, consider laser vision correction.

A patient’s surgical experience starts with the first office visit. Accurate preoperative examinations and measurements, good surgical technique and appropriate postoperative management are keys to success. OM

REFERENCE

1. Holladay JT. Special considerations for cataract surgery after presbyopia correction. Cataract Refrac Surg Today. 2012;12 (9):40-44.