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Put patients first with refractive surgery


We now live in the age of refractive cataract surgery. As optometrists, we think daily about refractive endpoints for glasses and contact lenses. But few think about it in terms of ocular surgery.

We now live in the age of refractive cataract surgery. As optometrists, we think daily about refractive endpoints for glasses and contact lenses. But few think about it in terms of ocular surgery.

I have been fortunate to work with surgeons whose goal was to give each patient the vision he wanted without this glasses with each surgery, even PTK and transplants. This was, at times, a lofty if not unreachable goal, but the fact that we discussed it reassured the patient that we had his best result in mind. I firmly believe this philosophy can help grow our practice and improve your referral surgeon’s impression of you as well. I try to maximize my patients’ vision at each encounter. Here’s how. 

Before referral

Prior to referral for surgery, I consider the endpoint. Many default to distance correction and target plano. But that may not be the best for every patient. Consider the -4.00 D myope who reads in bed every night, or builds model airplanes competitively. I admit I see more than my share of these rare hobbies in the engineering capital of Huntsville, AL. What is the best endpoint for these patients? Determine this prior to surgery to avoid an unhappy patient. Ask if they want to see the TV or read without glasses, or if they want to replicate the monovision that they have been successful with in contact lenses. 

If a patient expresses interest a presbyopic correction, investigate monovision or a multifocal prior to referral to the MD. This may include a short monovision or multifocal contact lens trial in the office or overnight. Staff can apply lenses and remove them to avoid the dreaded I&R. If the trial fails, 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.

Next: Assessing ocular health


Assessing ocular health

Once you consider the patient’s goal for surgery, assess if the eye ready for surgery. Treat ocular surface disease, lid disease, and corneal problems prior to referral to ensure accurate keratometry readings. Get her osmolarity down if it is increased.

Severe epithelial basement membrane corneal dystrophy (EBMD) or Salzman’s degeneration may benefit from a corneal treatment prior to cataract surgery. Retinal problems such as mild epi-reitinal membranes (ERMs) may require a referral to retina prior to the date of the cataract evaluation and is best done with a letter making it clear for what you’re referring to each doctor.

You may need to call your cataract surgeon to ask who he uses for retina referrals to ensure they will work together. 

Is your patient a contact lens wearer? She needs to discontinue the lenses for a period of time, which may vary by surgeon. And this makes patients crabby. Only after wearing spectacles for the allotted period of time should intraocular lens (IOL) measurements be performed.

You do not want to be the OD who refers the patient with contact lenses, obtains the wrong keratometry measurements, and has to explain that to the patient. “The surgeon should have known that” will not make your day any better when this patient is 20/30 in your chair. The patient will blame you because you fit her lenses.    

Next: Timing is everything


Timing is everything

Consider the timing of surgery prior to surgery as well. Patient with high astigmatism, high anisometropia after one eye has been operated on, and contact wearers will want their eyes operated on one week apart. The world will not involute if you ask the surgeon to do the eyes one week apart. If he says no, you win bonus points for asking and thinking of the patient.

Select the surgeon based upon your relationship with him, proximity for the patient, and his surgical skill. I do not know any OD who refers to a particular surgeon based upon his Christmas gift. Some fruit does not get you far with me-neither does chocolate or free CE. If you are good surgeon with great people skills and a good staff, you are my go-to surgeon in your specialty. 

So what does all this effort get you? Happy patients and a surgeon who likes to work with you because you are a good doctor. I would rather have a patient excited one-day post-operatively than chocolate any day. 

Related Videos
DanIel Fuller, OD, FAAO Dipl., FSLS, discusses augmenting corneal thickness in thin keratoconus corneas during corneal cross-linking via FDA-approved hypotonic riboflavin during SECO 2022.
Jake Weber, student at Southern College of Optometry.
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