What Optometrists Should Know About Collaborative Care in Cataract Surgery | Eyes On Eyecare

What Optometrists Should Know About Collaborative Care in Cataract Surgery

by Danielle Kalberer, OD, FAAO, Jay L. Schwartz, DO, Jeffrey Martin, MD, and Marc Bloomenstein, OD, FAAO

For optometrists to provide the best possible outcomes for our patients, it's imperative that we cultivate strong relationships with local cataract surgeons. In this course, we discuss what optometrists can do to ensure excellent collaborative care.

5.0 (3 ratings)
Updated Apr 27, 2021
25 min
1 quiz
What You'll Learn
  • Understand the importance of collaborative care in cataract surgery
  • Learn which information is most important for a surgeon to know
  • Practice methods for explaining cataract surgery and IOL options to patients

Introduction

As optometrists, it is imperative to cultivate symbiotic relationships with local cataract surgeons in order to provide our patients with the best possible outcomes. It is also important for us to keep up with the newest technology and be educated on products, procedures and protocols in order to promote the best option for each individual patient. The optometrist and ophthalmologist each play an important role in the successful evaluation and management of cataract surgery patients. When the care team is able to work together in a collaborative way that is really when we are able to take care to the next level. In order to explore this topic further, we have interviewed three doctors well-versed in collaborative cataract surgical care.

At the Schwartz Laser Eye Center in Phoenix, AZ, Jay L. Schwartz, DO and Marc Bloomenstein, OD, FAAO practice collaborative eyecare treating LASIK, cataract, and other ophthalmic patients. Jeffrey Martin, MD is a managing partner at SightMD in New York state and assistant clinical professor of ophthalmology at SUNY Stony Brook. Drs. Schwartz and Martin are both board-certified ophthalmologists specializing in LASIK and cataract surgery.

*Drs. Schwartz, Martin, and Bloomenstein are paid consultants of Johnson & Johnson Surgical Vision Inc.


Collaborative care and cataract surgery

What is collaborative care in cataract surgery?

Collaborative cataract care refers to the sharing of a patient's care between an optometrist and ophthalmologist, particularly when it comes to cataract patients. Of course, part of this collaborative effort is for the optometrist to identify those patients who would potentially benefit from cataract surgery and partner with a surgeon for referral—but it should not end there! Dr. Martin has had a deep-rooted sense of collaboration between optometry and ophthalmology within his practice since his father, founder of SightMD, had established this type of care from the beginning. Dr. Martin views the optometrist as a primary eye care provider and makes an analogy of cataract surgery to heart surgery; the cardiac surgeon does not then become the primary doctor, the primary care physician remains so after the procedure is complete. Dr. Martin has found the in-house optometrists serve as a bridge to outside optometrists. This has helped him introduce a more successful relationship between like-minded optometrists with the ophthalmologists in the practice. Dr. Schwartz works alongside three optometrists at his practice; he also feels having experience working with in-house optometrists creates a continuum type of experience that is beneficial for the patient.

Three requirements for collaborative care

According to Dr. Martin there are three main points of collaborating in the care of cataract patients. The first being the medical care portion. The second is the compliance and legal portion. The plan for collaborative care needs to be clearly explained to the patient- including how the care will be shared and the fee schedule. If the patient does not understand their own responsibilities related to follow up, this can lead to poor compliance, poor outcomes and potential issues for the involved doctors. The third, and most important, component is that it is the patient’s choice to receive care this way. Not all collaborative care setups are the same and not 100% of patients are going to want it; if the patient does not feel comfortable then it’s not pursued. If it is, there needs to be complete transparency of the plan and each party's responsibilities.

Finding the right collaborative care partner

It is important to find a surgeon who you feel comfortable working with and who you share the same mindset with. Dr. Bloomenstein recommends finding a practice that exhibits the same attitude and mentality as your practice and a surgeon who describes procedures and protocol in a similar manner. He also recommends visiting the surgeon’s office to observe the workflow and process. This allows you to explain it to your patient accurately and ultimately make them more comfortable at the evaluation. If you are comfortable with and confident in the referral the patient will be too!

Once you make the referral, following up with pamphlets or brochures about the technology or the surgeon’s practice is helpful. Dr. Bloomenstein feels this really bolsters these recommendations. It gives the patient some information to consider at home, discuss with their family and have some awareness and understanding of before their consultation.


Lens options

How to discuss lens options with patients

Dr. Bloomenstein enjoys talking about the lens options with patients and getting them excited about the opportunities available. Asking patients questions about their lifestyles and preferences is key: what do they enjoy doing? What is important to them? What is their occupation? Would they be satisfied with some glare at night to have good vision at all ranges? Is night vision more important than being glasses-free at near vision tasks? Do they frequently drive at night?

Additionally, Dr. Bloomenstein notes that it is important to define what “reading” means for the patient—do they read paperback books held close to their face, or a tablet placed on their lap? Do they spend more time doing computer work than reading, and do they work on a laptop or a desktop? The goal is to find a way to personalize the patient’s vision, since individuals do not work the same way. While there may be certain limitations and optometrists should be wary of making specific lens recommendations before the surgeon’s evaluation, optometrists today are in a position to offer more patients reduced spectacle wear post-surgery.

Dr. Martin recommends that optometrists familiarize themselves with the lens options and procedure choices to give an introduction to what will be discussed in more detail at the cataract evaluation. It is beneficial to the ophthalmologist when the optometrist has been working with the patient for some time and has an idea of the patient’s desires, personality, or hobbies as well as knowledge of their ocular history. Dr. Martin feels that an optometrist making a “strong recommendation” based on these factors assists his decision-making process. Similarly, Dr. Schwartz appreciates if the optometrist introduces the options and concepts; however, he warns that setting expectations that are too specific can lead to patient disappointment and distrust.


TECNIS Eyhance Highlight Box 4.8.png

Visit https://www.jnjvisionpro.com/Eyhance to learn more.


How optometrists can make a recommendation

Optometrists can make a strong recommendation by getting to know the patient and collecting information that would be beneficial in the decision making process. For example, hobbies, occupation, time spent reading versus night driving, anxious or laid back personality. Having the patient demonstrate where they habitually read and keep their computer is helpful as well.

There are several important components of patient education for the optometrist to cover. First, making sure the patient understands their refractive condition (especially presbyopia and astigmatism) and the basics about cataracts. For patients who might not know that they have astigmatism, it’s especially important to explain why that might be the case. Astigmatism can occur on the cornea or the lens in such a way that nullifies the magnitude of the astigmatism. However, when discussing cataract surgery, it’s crucial to define the corneal astigmatism to patients since we are removing the lenticular astigmatism. In cases like this, corneal topography can be used to show patients their corneal astigmatism and what they can expect postoperatively.

This should be followed up by a discussion of the options relevant to their refractive status, such as a toric lens for astigmatism, laser treatments to nullify some of the corneal astigmatism, or a combination of both. This introduces the concepts and terms the surgeon will later bring up. This is an opportunity for the optometrist to set expectations at an appropriate level so there is still room for the surgeon to maneuver in making an appropriate lens choice without disappointing the patient.

The tools we have in our toolbox include monofocal IOLs, accommodating IOLs, multifocal IOLs, and extended depth of focus IOLs. All of these options now have toric versions available. Current research suggests that while â…“ of patients have greater than 1D of cylinder, only about 25% are receiving toric IOLs.5 This is an opportunity for optometrists to really educate patients since residual astigmatism can hinder success with IOLs in general. Presenting the options for astigmatic correction, LRI or arcuate incision, toric IOLs, or postoperative glasses or contacts, lays the foundation for incorporating the proper refractive correction into the surgical plan.


Lens choice and surgical options

How ophthalmologists identify the “right” lens

Dr. Schwartz makes his intraocular lens choices based on a patient's desires and ocular history. Patients with greater degrees of astigmatism and regular astigmatism are candidates for toric IOLs, which are specially designed to correct astigmatism through different powers in different meridians of the intraocular lens. During surgery, the lens is aligned in the eye so that the lens is oriented appropriately.

As an additional example, a patient with macular degeneration may not be the best candidate for a certain multifocal lens, while a patient with an immaculate macula and an interest in maintaining reading vision might find a multifocal or extended depth of focus (EDOF) to be a great option.

Left: Monofocal IOLs are used to restore vision for one area of focus—usually distance. Reading glasses will still be needed for intermediate and near activities. Right: Extended depth of focus IOLs provide high-quality continuous vision for activities without glasses overall—from near to intermediate and distance. Reading glasses may still be necessary for very small print.

While a multifocal IOL works by splitting light between two distinct focal points, an EDOF lens, TECNIS Symfony™, distributes light across a range of distances. This is what creates the extended depth of focus with a continuous range of clear vision. If an EDOF lens is being considered, it's essential to have a discussion about neuroadaptation. With this type of lens the brain needs some time to acclimate to the optics. By explaining the technology to the patient in advance we are setting up for better success postoperatively.

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* TECNIS Multifocal IOLs provide distance and near vision (ZLB00 and ZMB00) or distance and intermediate vision (ZKB00). In combination, the lenses can provide a full range of vision.

Understanding laser cataract surgery

According to its proponents, femtosecond laser technology is a customized treatment plan that is more precise, and more gentle than the manual procedure. In FSL assisted cataract surgery (FLACS), the laser does the work of a surgical blade, making incisions in the tissue on either side of the cornea to access the cataract. In FLACS, the femtosecond laser breaks the lens up before entering the eye for easier phacoemulsification, which breaks up the cataract and vacuums the pieces out of the eye. Because it requires less energy for lens fracturing, FLACS causes less inflammation and allows for faster recovery.6

Overall, laser cataract surgery offers a smoother procedure and tends to give patients more confidence in the surgical outcome. When discussing the difference between laser and traditional cataract surgery, Dr. Martin will explain the options and the precision of laser cataract surgery, and will discuss the costs associated with astigmatic correction of laser cataract surgery. According to Dr. Martin, most cataract cases benefit from laser cataract surgery, like the CATALYS® Precision Laser System, and really the only time it would not be as beneficial is in a patient with historical corneal pathology, where the prognosis is guarded to begin with.7,8

The CATALYS® Precision Laser System

When Dr. Martin approaches the subject of laser cataract surgery versus manual, he explains the aforenoted benefits but lets the patient know it's “okay” to still choose the manual route. For some patients, the financial burden is just not doable and he lets them know that manual cataract surgery is still a safe and effective procedure. As he puts it for his patients “laser didn’t make a bad procedure good, it made a good procedure better.”7

Videos like this one are excellent tools for patient education, particularly if they can be made available to patients to view at their leisure.


Preoperative and postoperative care

In collaborative care, an optometrist’s role extends beyond the referral to cataract surgery. As mentioned earlier, the referring optometrist’s knowledge of their patient’s history and needs is crucial information to relay to their surgeon; additionally, the optometrist plays a crucial role in postoperative care.

From preoperative

The surgeon’s preoperative evaluation usually involves a thorough ocular health exam on top of the refractive portion and lens selection. Dr. Schwartz does rely on findings provided by the referring optometrist; however, he still repeats most testing to make himself more comfortable with the case. Dr. Martin also performs a thorough ocular health exam on the patient, focusing on any areas the optometrist has pinpointed on the referral form. After the thorough evaluation, a conversation of risks, benefits and options takes place.

To postoperative

Dr. Martin will continue to follow the patient until he feels like it’s safe to transfer care to the optometrist. The common postoperative follow-up schedule is one day, one week, one month, three months, six months, and one year. Dr. Schwartz generally likes to see the one-day and one-week postoperative patients himself. In particular to check their intraocular pressure, lens position, and level of pain. The vision can fluctuate since there is still swelling, especially one day after surgery. One-month and three-month postoperative follow-ups are generally performed by the managing optometrist. At this time, the majority of healing has occurred and if there is any residual inflammation it can be treated and managed by the optometrist (with surgeon consultation as needed). If post-surgical cystoid macular edema is present or the refractive error needs major adjusting, then the optometrist will send the patient back to the surgeon. Dr. Bloomenstein suggests discussing with the surgeon how and when they plan to make any adjustments; for example, do they like to have the patient acclimate for 30 days then re-visit? It may also be helpful to know at which point your surgeon prefers to do YAG-Capsulotomy if and when the time comes.

Treating OSD before surgery

It is especially important for both the optometrist and ophthalmologist to do a thorough preoperative exam for premium IOL cases to help avoid unexpected outcomes. Any treatable ocular health issues need to be addressed before going forward in order to increase the success rate. Ocular surface disease, including meibomian gland dysfunction, is a big one. This will need to be well-controlled before surgery in order to obtain accurate readings for topography, keratometry etc. This can be done by creating a regimen of lubrication, lid hygiene, and considering TearScience® LipiFlow® treatment if needed.

Additionally, an intact corneal surface aids in the healing process. Dr. Martin notes that this is a point of collaborative care like anything else. He will confer with the referring optometrist about how they would like to handle the treatment plan. Dr. Bloomenstein makes sure ocular surface disease is treated before proceeding and explains to patients that we can make the best lenses and do the safest surgery but if the ocular surface isn’t clear, it is “muddling” all the other hard work. A healthy ocular surface allows ophthalmologists to identify and utilize the best lens for the patient’s desired outcome.

Even simply identifying OSD prior to surgery can make the surgical experience much smoother for both patient and surgeon—not to mention bolstering trust in the patient-doctor relationships, including between that of patient and optometrist.


Unhappy surgical patients

What causes unhappy surgical patients?

The biggie—unrealistic expectations! The surgeon can fully and thoroughly explain the risks, benefits and limitations of every technology and sometimes that still just isn’t enough. This can be a combination of the patient not listening or simply being overwhelmed by the amount of information.

One step Dr. Schwartz takes regarding this, that optometrists can do as well, is to take detailed notes of what was discussed during the consultation to reference later on in a “remember when we talked about? I jotted it down in my notes . . . ” fashion. One particular example he mentioned was when utilizing a premium lens in a patient who had an essentially perfect surgical and visual outcome. This particular patient still didn’t feel “quite right” despite having been educated on halos at night and neuroadaptation after the procedure (up to a year after surgery). Dr. Schwartz took time to re-educate and have a discussion with the patient, who then decided to wait it out a bit longer to see how he adapts.