Adapting to the changing climate

March 21, 2013

Adapting to the changing ophthalmic climate is what has enabled our profession to successfully meet the optometric needs of our patients. Optometry is much like the peppered moth of Great Britain, which originally had light coloration that effectively camouflaged it against the light-colored lichens attached to the trees-only to witness the Industrial Revolution create widespread pollution and the demise of the lichens. The peppered moths rested on blackened soot and, through evolution, the population of dark-colored or melanic peppered moths thrived in place of the aforementioned light moth. This optometric melanism is evidenced in the co-management of our cataract patients, and as witnessed in the evolution of the moth, the strong-minded ODs will flourish.

 

Adapting to the changing ophthalmic climate is what has enabled our profession to successfully meet the optometric needs of our patients. Optometry is much like the peppered moth of Great Britain, which originally had light coloration that effectively camouflaged it against the light-colored lichens attached to the trees-only to witness the Industrial Revolution create widespread pollution and the demise of the lichens. The peppered moths rested on blackened soot and, through evolution, the population of dark-colored or melanic peppered moths thrived in place of the aforementioned light moth. This optometric melanism is evidenced in the co-management of our cataract patients, and as witnessed in the evolution of the moth, the strong-minded ODs will flourish.

Optometric melanism is related to the paradigm shift in surgical outcomes. One does not have to look further than cataract surgery to see that a patient is no longer satisfied with the ability to just perceive bright color and shape without spectacle assistance. Patients now expect remarkable uncorrected vision. Refractive surgery has also seen a shift from the satisfied patients being able to function without spectacles, as evidenced by the radial keratometry inconsistencies and seemingly satisfied patients, to the expectation of a 20/20 or better outcome from the first day visit.

As in the example of the peppered moth, the Industrial Revolution brought amazing change and advanced technology, but the industrial soot left a dark cloud. The cataract surgeries of today must be viewed from “refractive-colored glasses” to help co-manage these lightly colored, like the moth, cataract patients. There are strategies that can be employed in this optometric melanism, which will help you and your patients in the exam lane.

  • Chief complaint: This may be the biggest melanistic change optometrists have to overcome: the desire to solve all of our patients’ complaints. The chief complaint can often be mistaken for a statement of fact. Comments such as: “I have halos at night,” “My intermediate vision is not very good,” and “Street signs are not that sharp,” can and should be regarded as your patient telling you the status of her eye. This is not consistent with having a problem that needs resolving.

Try this the next time you go into a post-operative visit. Do not mention anything about the chief complaint and solely focus on the results of your evaluation. For example, a 1-month post-operative patient with 20/20 UCDVA OU and J2 UCNVA OU has the beginnings of a great result. Focus your attention on how well she is doing visually, what you want her to do with her medications, and when you will see her back. In this scenario, if the patient was truly bothered by the chief complaint, she will stop you and ask for a resolution, or at least a time frame on when the complain will be resolved. As reported by AMO1 and Alcon2 in their QOL FDA studies, more than 90% of patients were satisfied, so the likelihood of needing to address the chief complaint is minimal.

  • Two eyes are better than one: Staying with our evolutionary theme, we have evolved (or intelligently designed, depending on your point of view) with both eyes working in tandem. Therefore, we see better, or at least as good as the best eye, with both eyes open and in the same gaze. Pre-operatively, you should counsel patients who may have convergence insufficiency, amblyopia, or strabismus about improved quality after the surgery. Always binocularly test your patients post-operatively. Medico-legally, you need to know the individual eye’s outcome. However, in practice it is more important to know how the eyes work in the real world. When talking to patients about their outcomes, they look to you as a barometer of their success. Therefore, the true measure of vision is achieved only by both eyes working together. Now, if your patient has one eye that is not doing as well as the other, see the last pearl before you say anything.

  • Time: As Einstein pointed out, it is all relative. Timing of the surgery makes a huge effect on the results. Modern surgeries are mostly free of micro-cystic edema or striae, although the more recalcitrant cataract may induce some swelling. Yet there still may be some mild corneal edema that will create blur, haze, and often more halos. Moreover, approximately 20% of patients have subclinical cystoid macular edema,3 which may also contribute to the patient’s perception of decreased vision. The post-operative period needs time to remove this inflammation, and setting your expectations around 4-6 weeks is a good practice. Remind patients that the final surgical results can take time, and although they are off to a good start, it may takes weeks for the quality to be there.

  • More Time: The phrase “more time” should become part of your vernacular. Because adaption to slight refractive changes may take weeks to many months, you should not see your patients back on a weekly basis. Much like following a glaucoma patient, the change may be slow, so stretch out your post-operative visits to months rather than the common weekly visits. However, schedule a follow-up visit. A patient who may perceive she is not doing well needs your reassurance and guidance, and therefore should be on your recall list. It can often be worse to avoid these patients, even if nothing can be done at the moment, than to see them without resolve.

  • Scratching the surface: We cannot talk about optometric melanism without mentioning the ocular surface. Picture the windshield of your car after you just had it washed. Now imagine that same windshield after you drive through a mud puddle. Just like your car’s windshield, the surface of the eye needs protection. With the eye, clarity is limited by the increased osmolarity and inflammation. Cataract surgery induces inflammation, which in turn creates a greater inflammatory load on your patients. The cognition of this reality and our ability to treat this menacing condition is all the more important with our new-found evolution of refractive cataract patients.

While the peppered moth has adapted to change using industrial melanism, our optometric melanism will enable us to adapt to new paradigm shifts. However, unlike the moth that is camouflaging for survival, we need to display our traits like a male peacock.ODT

References

Tecnis Multifocal Foldable Acrylic Intraocular Lens [package insert]. Santa Ana, CA: Abbott Medical Optics Inc.

AcrySof IQ ReSTOR IOL [package insert]. Alcon Laboratories, Fort Worth, TX.

Rotsos TG, Moschos MM. Cystoid macular edema. Clin Ophthalmol 2008; 2(4):919-930.