Thinking refractively in terms of ocular surgery

As optometrists, we think about refractive endpoints for glasses and contacts daily but rarely think about it in terms of ocular surgery. Having been fortunate to work with surgeons whose goal was to maximize the uncorrected vision with each surgery, cataract or corneal.

While this may not be achievable every time, we reassured the patient that we had their best result in mind by touching on it during the preoperative discussion. Doing this certainly impresses patients, and it will most likely impress the surgeon you work with as well.

State of the lens

During my exams in patients 50 years and older, I will comment on the state of the lens.  “A baby cataract” or a “toddler cataract” will later become “time for cataract surgery”.  I often put the idea of cataract surgery in their mind early, particularly in a toric lens would be beneficial, or if they have never fully appreciated their progressive lenses.  If they are interested in premium lenses, best to discuss the additional fees in general early on, and then it is less of an issue when they need surgery.

I often put the idea of cataract surgery in their mind early, particularly if the patient is in a toric lens that would be beneficial, or if they have never fully appreciated their progressive lenses. If they are interested in premium lenses, best to discuss the additional fees in general early on, and then it is less of an issue when they need surgery.

Prior to referral for surgery, consider the refractive endpoint. Many default to distance correction, and target plano. But that may not be the best for -4.00 myope who reads in bed every night or builds model rockets.  

What is the best endpoint for the patient? Ask if they want to see the TV or read without glasses, or if they want to replicate their monovision that they have been successful with in contacts with cataract surgery. Determine this prior to surgery to avoid an unhappy patient. Discussing it years before surgery is required gently opens the door for further discussions later.  

Considering surgery

If a patient expresses interest in a presbyopic correction, consider a demonstration of monovision or a multifocal prior to referral to the MD. This may include a short monovision or multifocal trial in the office or overnight. If the trials fail, then a discussion of monofocal vs. accommodative lens is beneficial. The point is you are trying to determine what the patient will be happy with after surgery, and ruling out options prior to surgery.

Once you consider the patient’s goal for surgery, asses if the eye is ready for surgery.  Treat OSD, lid disease, and corneal issues prior to referral to ensure accurate keratometry readings. Get their osmolarity down if it is increased. Severe EBMD or Salzman’s degeneration may benefit from a corneal treatment prior to cataract surgery. Again, doing this years prior to cataract surgery is in the patient’s best interest.  

Treatment of the tear film in dry eye patients can save you up to a 0.75D error after a vision correction procedure. Do not get caught addressing residual refractive error after treating their dry eye and causing a refractive shift making their uncorrected vision worse.  This will ruin your day, I promise. Treating the patient prior to surgery when they perceive their vision to be blurry, getting improved measurements yielding a better endpoint may take longer, but the patient will thank you.  

While working in an optometric referral center, I found a topography titled, “bad map” by a surgeon. The technician reported that the surgeon told her to ignore the “bad map” and wrote the note. Not surprisingly to anyone who knows me, I found the patient, repeated the map and treated their ocular surface disease. Four weeks later, we had improvement in the anterior basement membrane dystrophy and the best-corrected vision. The patient delayed surgery for a year and revisited me periodically to ensure control of the ocular surface.   

It is not uncommon for patients with a refractive surgical history to present saying, “the surgery wore off,” or to request a LASIK enhancement. I strongly recommend a full work up to ensure you determine the cause of their complaint and avoid referring for the wrong reason. All that work impressing your favorite surgeon will be for naught if you miss a macular hole, epiretinal membrane, or mild ectasia. All post-refractive’s should have topography prior to referral for surgery, and I dilate all patients within three months of referral to avoid the awkward situation of the surgeon having to tell you a mistake was made.  

If the patient is a Cl wearer, mention the need to discontinue their CLs long before referral for cataract surgery. This is especially important if they have no glasses, or if the patient has an emotional meltdown at the thought of wearing spectacles. The need to discontinue the lenses varies with surgeon and type of lens. Only after wearing spectacles for the allotted time should IOL measurements be performed.    

Consider the timing of surgery prior to referral as well.  Patients with high astigmatism or high anisometropia after one eye has been surgically corrected will have difficulty waiting on the second eye surgery. Those CL wearers will want their surgery one week apart.  Communicate this to the surgeon.

Select the surgeon based upon your relationship with the MD, proximity for the patient, and the surgeon’s surgical skill. Listen to what patients say when they return post-operatively. Note that not everything a patient says is true. Reported issues can be communicated with the surgeon’s staff such that you are letting them know the patient thought there was an issue, rather than blaming the staff for wrongdoing.   

Starting the conversations early allows the patient to consider options, and ready themselves for a smoother procedure with a better outcome. Happy patients, happy surgeons, and less chair time overall make for a great day.