Sep 15, 2020 • 20 minutes read

How to manage cataract patients

Introduction

Written by
Svein Tindlund

Cataract is something you probably see every week in your practice or store. Your patient typically has symptoms like slightly reduced visual acuity and a cloudy lens. It’s too early for surgery, so you suggest new glasses instead: “You have cataract, but it’s yet too early for surgery, so here are your new glasses. See you next time!” Or another scenario: your patient has dense cataract, and you refer them to the local eye clinic or hospital: “I’ll refer you to a good surgeon. We can talk about new glasses after surgery. Good luck!”

In this handbook, I’ll explain how you can provide the best care when your patient has cataract symptoms. It’s not complicated. There are some steps to get there, though, that come in handy to know. It’s about understanding what your patient thinks when you mention the word ‘cataract’ or ‘surgery’. It’s also about knowing what’s happening at your local ophthalmology colleague and the eye clinic or hospital.


Chapters

Five eye-openers to change your practice

01
Know your optics!

Let’s dive into understanding scatter and visual quality.

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02
Know the needs of your patient with cataract

How to decide if your clinical findings are relevant – or not.

Go to chapter
03
“You have cataract, but there is nothing to worry about…”

How to communicate about cataract without making your patient nervous.

Go to chapter
04
Know your local cataract care protocol in medicine

What you need to know about cataract surgery and how to manage the expectations of your patient.

Go to chapter
05
Become friends with the eye surgeon

How to refer at the right time and see the patient again after surgery.

Go to chapter
01

Know your optics!

Let’s dive into understanding scatter and visual quality.

When you diagnose cataract in a patient, it’s essential to know if there’s a match between what you see and what the patient sees. To start with, let’s avoid going into the shadowland of individual visual perception and psychological effects on patients’ and optometrists’ expectations, and take a look at what cataract is from an optical point of view.

There are two main models to explain how light passes through a lens. One is the good-old refraction, where we measure focal points and optical power in dioptres. A relevant effect of this is when a nuclear cataract increases the shape of the crystalline lens and thus shifts refraction into more myopic. The other model is how light particles are spread when photons interact with each other and collide with their surroundings. One effect of an interaction like this is called interference, which can only happen when there’s a high degree of symmetric obstacles. Cataracts don’t produce this. When the photons collide with their surroundings, like the small imperfections in an otherwise clear lens, it changes the direction of travel in an unorganised way. This is called light scatter and impacts visual quality.

Scatter is the key to understand cataract. Let’s have a look at the differences in your point of view and the patient’s point of view.

Imagine, you are in a foggy valley. In most cases, you can still see okay in front of you. The visibility won’t be super clear as the contrast is reduced. During daytime, you might experience glare, as you’re observing forward scatter of the sunbeams. To see what’s in shadows is tricky – even in daytime. Still, you can see well and move around. At night, the fog just makes everything much darker and visibility drops.

This is how the cataract patient experiences the incoming light through a foggy lens.

Example of forward scattering of sunlight illustrated by viewing it from within the fog. This is how a patient perceives looking through a lens with cataract.

Now imagine that you observe the same fog from a nearby hilltop. You’re probably not able to see the ground below at all, as it will be hidden behind the white mist. The brighter the sun above, the denser and whiter the fog below will look like. You’re observing backward scatter of the sunbeams.

It’s what you, as an optometrist, see when you bring the bright, sharp light from the slit lamp at the same foggy lens with cataract. What you see from the outside and what the patient observes from the inside of the eye might doesn’t match.

Fog as seen from above. The strong sunlight creates backward scattering that makes everything behind it hard to see. This can be compared to when you use the slit lamp on a crystalline lens with cataract.

What you see is what you get?

This phrase isn’t always true when it comes to cataract – because of the scatter. Ask yourself “is what I see in the slit lamp similar to what the patient experiences?” To check your findings, use other methods apart from trying to evaluate lens clarity only.

How’s the quality of the fundus image?

Taking a fundus image is a standard test and sends the same amount of light into the eye in a repetitive way every time. The light from the fundus camera passes the light through the crystalline lens twice and creates an image on what is behind it. This makes it a valuable objective indicator of image quality. If the image quality on the fundus image looks good, then the patient is less likely to experience significant symptoms of cataract. Note that this is only applicable for the white-light scanning fundus cameras. OCT and fundus cameras using scanning lasers, like OptoMap, can’t be used to evaluate optical quality this way.

Will this type of cataract cause problems for the patient?

You can only fully evaluate which type of cataract the patient has by dilating the pupil. All other methods are estimates only – useful sometimes, but not conclusive for a referral. As a rule of thumb is, we can say that the more central and posterior-positioned a cataract in the crystalline lens is, the more likely it will reduce vision and create symptoms for your patient. So, make sure you know how to grade cataract, e.g. by using the grading system for cataract from the World Health Organisation (WHO).

Future vision

Wouldn’t it be easier if we could measure the level of scattering in an eye and use this as the key measure for when to refer for surgery? Laser interferometry is probably the way to go. The technology exists but is not yet common to use, as it’s expensive and needs more validation studies. That said, the patient’s subjective experience will always be the most important trigger for cataract surgery, as vision is a subjective thing by nature. First, we should standardise the mapping process on the patient’s experience of their vision. That’s why you can find all about this in the next eye-opener.

02

Know the needs of your patient with cataract

How to decide if your clinical findings are relevant – or not.

Cataract surgery in healthy adults is defined as an ‘elective’ procedure, which means we’ll do the operation when the patient wants it. Understanding how the cataract eventually impacts your patient’s life is therefore crucial. No symptoms, no treatment. The only exception to this is if the cataract creates a too narrow angle – increasing the risk for narrow-angle glaucoma.

Questionnaires are the way to go

Questionnaires aren’t used enough in the world of optometry – as I see it. In comparison, other medical professions that also rely on subjective input, like psychologists and psychiatrists, make much more use of questionnaires. The reason is simple: using them is time-efficient, and just works well! A good questionnaire should be spot-on and guide you through the things you want to find out about your patient. As long as the questionnaires are validated by science, they’re the way to go.

World-class questionnaire: Catquest 9SF

This questionnaire is short and effective. The Swedish Cataract Register started it, and now it’s part of Europe’s biggest on-going project about collecting data on cataract surgery to improve outcomes: the programme EUREQUO run by the European Society of Cataract & Refractive Surgery (ESCRS). An important part of enhancing surgery outcomes is to make sure surgery is performed at the right time when it comes to patient needs. There are several questionnaires created in this project, and the Catquest 9SF will take you up one step in evaluating patients with visual challenges due to cataract.

Patient consent is always key

Even if your clinical observation says cataract, and the subjective questionnaire supports that there are symptoms that can be treated, you still need consent from your patient on a follow-up plan – regardless of if you refer the patient or not. Forms can never make a patient understand why your advice is the right one. So, it comes to your clinical communication skills in making sure the patient understands the need and can make an informed decision about a referral for surgery should be made or not.

Future vision

Ideally, we as optometrists should take greater responsibility when it comes to when we refer a patient to surgery or not. To deserve this position, we need to deliver consistent clinical quality and use methods that are known by ophthalmologists to improve health outcomes. The use of validated questionnaires is one step in this direction.

Further reading

Patient-reported outcomes (PROM) in the Swedish National Quality Registers

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03

“You have cataract, but there is nothing to worry about…”

How to communicate about cataract without making your patient nervous.

What you say and what a patient hears are often two different things. Eyes are priceless, and many patients get very nervous when you tell them they have cataract. That’s probably even more so in the Nordics, where the words for glaucoma and cataract in everyday language are very similar – and everyone knows that one of them leads to blindness, and the other one will need surgery. Both are pretty scary scenarios, especially if you don’t know which one it is.

Diagnosing is educating

If we want to deliver increased health outcomes in optometry, we need to take this part of our job seriously. A diagnosis that’s not followed by information about the eye condition will either lead to no change or will make the patient even more nervous. Give your patient the necessary information about the condition, and make sure they understand what it means, what it can cause, and what the practical actions should be. You don’t want the internet to be the only source of education for your patient – so make sure they see you as the provider of better eye health!

What you say and what a patient hears are often two different things.

Deal with your patient’s fears

It doesn’t matter that cataract surgery is the most common surgical procedure worldwide. The idea that someone else will use a knife in the eyes scares most people! There are two ways of dealing with fears of your patient. One is to increase their knowledge, so they feel smart and more positive. Be practical and fact-oriented when telling about cataract. The other one is to listen to your patient to understand where they are in their emotional thought process. They feel cared for if you recognise and accept their emotions. It’s good to know that one without the other is only half-way – so using both is the best option. You can train these skills to get better at dealing with your patient’s fears.

Professionalism is also how you express yourself

A patient won’t be able to understand your level of skills and knowledge, if you’re not able to express yourself in an understandable way. It’s about what you say and how you say it. And this is how a patient perceives professionals. Choose a patient-orientated approach in how you educate and communicate with the patient. There isn’t a one-size-fits-all way of delivering effective communication.

Future vision

Optometrists are educated to be the first point of contact when it comes to visual needs. Optometry organisations and most optical retailers also communicate that view. You can take the lead in creating or emphasising this perception in your local market, by making sure you’re not only delivering premium clinical service, but also by becoming a master in how you give advice to your patients. When it comes to diseases, cataract is a very achievable one to master. Your patients will value that you’re the go-to person for eye care and are in close contact with the local medical eye care community.

Further reading

This is my favourite book about health communication in eye care: Professional communications in eye care by Ellen Richter Ettinger

Go to website
04

Know your local cataract care protocol in medicine

What you need to know about cataract surgery and how to manage the expectations of your patient.

How many times have you sold a pair of progressive glasses that gives perfect visual acuity, but the customer does not find the glasses comfortable and wants a refund? In many cases this is a matter of expectations that aren’t managed properly. Outcomes after cataract surgery can also be like this, but remakes are tricky to do when it comes to surgery! Not impossible but surgeons rather avoid it... When you refer a patient for cataract surgery, you need to manage expectations of both the patient and the surgeon. A measure of success is when the patient says: “What you told me was the same as the surgeon explained. The outcome of the surgery is exactly as I expected it to be”.

Preparation is everything

People like to be prepared – and knowledge is crucial in preparation. Your patient must know what will happen at their first appointment after your referral. Will it hurt? Will they have to use eye drops? Are they able to see and drive a car after the examination? Will they do the surgery on the same day? Remember to inform about the possibility for dry eyes after cataract surgery, that can last from days to – in rare cases – years. It’s nothing complicated – they just want to know what’s going to happen. Make sure you know so that you can pass this information on.

What’s the surgery like?

Many patients will not need surgery straight away after you’ve referred them – you might see them again before. They will then probably have many questions about the upcoming surgery. Insight into the basic surgical procedure of phacoemulsification – including how the patient will experience it – is valuable and makes the bond between you as the educator and the patient stronger. Modern cataract surgery is quite uniform across the western world, as most hospitals and eye clinics use phacoemulsification as the surgery method. If you learn about this method, you can inform your patients better about the surgery.

Three messages about the cataract surgery that your patient will appreciate

  • The anaesthetics is done by eyedrops only and you won’t feel any pain.
  • The complete procedure is done in six to eight minutes
  • Sight-threatening complications after the surgery are extremely rare and can be managed.
A measure of success is when the patient says: “What you told me was the same as the surgeon explained. The outcome of the surgery is exactly as I expected it to be.

Know when to refer again after surgery

The first appointment after surgery is usually done by the surgeon. The optometrist or general practitioner can take care of the rest. Although it doesn’t happen often, you need to know which complications can occur, how they look like, and when to refer to the surgeon again. Key measurements are:

  • Is there any pain, light sensitivity and discomfort other than post-surgical dry eyes?
  • Is visual acuity normal?
  • Is pressure normal (within 30 mmHg the first week)?
  • Is there unusual inflammation, like red eyes or cells in the anterior chamber after day 3-7?

Future vision

Most treatment offers in healthcare are standardised. Cataract likely has one of the most standardised treatments internationally. For us that’s good, as it’s possible to learn how the treatment protocol is from end to end. By showing that you can add value by following these protocols, you’ll be valued by both your patients and your local medical community. The road to get there is to learn how the cataract protocol is, what are the key success factors, risks and how the local ophthalmology community wants to be helped with their high number of cataract cases. It’s about reaching out to them and getting to know them.

Further reading

Article ‘Evidence-based guidelines for cataract surgery: Guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database’, by Mats Lundström, Peter Barry, Ype Henry, Paul Rosen, and Ulf Stenevi.

Open pdf
05

Become friends with the eye surgeon

How to refer at the right time and see the patient again after surgery.

To deliver high clinical quality with high diagnostic precision is a goal we all want to achieve. In cataract care, this means learning how to diagnose cataract correctly and know when to refer for surgery. The story doesn’t end there, as most patients who undergo cataract surgery will need refractive care and new glasses in the years that follow. Taking care of their refractive needs is our key focus area. That’s why it’s essential to master how to get your patients back again after surgery.

Right time, right referral

Cataract is an elective procedure, which means that surgery will be done when the patient is ready for it. No eye surgeon will try to talk a patient into undergoing surgery if they don’t want to – except in very rare cases. It might take years before the patient’s ready for it. So, after your diagnosis, the focus is to take care of the patient’s refractive needs – until they are better off with surgery than with new glasses or filtering lenses. Then it’ll probably be easier for the patient to agree on that they’re ready for surgery – as a pair of new glasses or lenses will just add unnecessary costs.

Elective surgery means that it’s up to the patient to decide when it’s the right time for surgery. Professionals who are involved in this process should make sure the patient can make the right decision at the right time.

Befriend the eye surgeon

The surgeon needs to know if the patient wants the surgery or not. Of course, it’s always up to the surgeon and the patient to decide, but your input will help:

  • “I have followed the patient in the past five years for cataract. It’s now at a level that new glasses will not bring any benefits.”
  • “Since the point of detecting cataracts four years ago, we’ve had three consultations to follow how it developed. The patient now experiences reduced vision when driving at night and needs to spend more time in making sure small details are seen correctly during daytime, which bothers him/her. The patient is ready for surgery – if you too find that an appropriate solution to enhance his/her vision further.”

If you’re not sure if surgery is the right solution at that time, just be open about it to the surgeon. Simply state in the referral that you’re unsure if cataract surgery is the right choice at that point.

Nothing beats personal contact

To get to know more about cataract surgery, and get to know your local eye surgeon, ask if you can spend a day at the eye clinic to observe pre- and post-examinations and some surgeries. You’ll be able to inform your patients better if you’ve seen it for yourself. The surgeon knows that this will increase their clinical efficiency, as you’ll probably get better in only referring patients that are ready for surgery. They prefer referrals that lead to surgery – and not follow-ups. This goes together with us wanting to deliver refractive care until the time of surgery.

By establishing personal contact with the local eye surgeon, you’ll start a professional relationship to the benefit of all three – including the patient. This ‘bond of trust’ will also make it easier for the surgeon to refer the patient back to you after treatment. And, it benefits the patient as you’re the refractive expert. Let there be no doubt in your communication with the surgeon that you want to care for your patient until they are ready for surgery and want them referred to you afterwards. Most ophthalmologists see the value of shared care, but they might need to know you a bit better and experience that you are able to produce consistently high clinical quality.

Future vision

Wouldn’t it be nice if your local ophthalmologists could rely on that you, the local optometrist, are ready to take an extended responsibility when it comes to refractive care? I mean not only detecting and correcting refractive needs with products, but also to take part in the pre- and post-operative cataract work? The trust and position you can achieve in co-managing cataract patients are signs of your professionalism. There is also a monetary value in this which you shouldn’t underestimate. If you send good referrals, most likely you’ll later receive these referrals back again. Not only will you get back the patients you have referred for cataract surgery, but possibly also new customers. It’s about becoming famous for professionalism, right!

As optometry still isn’t considered a part of medical eye care, it’s up to you to decide if you want to take that position in your local area or leave it to someone else. To start involving yourself in the local cataract care, along with delivering excellent refractive care, is one way to start earning this position.

Further reading

Article ‘A Cataract Surgeon and the Referral Network: A Roundtable Discussion’, Collaborative Eye

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