Why patient education is bit like fortune telling

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

I saw a new patient today complaining of redness, itching, and burning. When asked how long she had been feeling these symptoms, she reported it had been since cataract surgery. She reported seeing her surgeon about her eyes and was told the surgery was successful and shown the door. That was nine months ago.

She regrets having surgery, even though she is 20/20 unaided. She dislikes her surgeon and previous optometrist and tells anyone who asks about it. I cannot be sure she did not leave negative posts on Yelp, Facebook, and Healthgrades.com after she unloaded her negativity on my office staff. That is why I treat ocular surface disease-even in non-symptomatic patients-prior to surgery. Also, I don’t like to look like an idiot.

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High patient expectations

Let’s consider how not treating a patient prior to referring her for cataract surgery may be problematic (and make me look like an idiot). Even mild ocular surface disease (OSD) can alter tear film, changing the keratometry readings used to determine the intraocular lens power. A 0.50 D shift in the keratometry power can affect the residual refractive error. When significant, a larger error can result.

If you travel back in time to when I graduated from optometry school, this is not a huge problem. Back then, we used air puff to measure intraocular pressure, used glaucoma drops four times per day, and everyone wore glasses after cataract surgery. 

In 2016, our patients have higher expectations. Patients want to be spectacle free, particularly when their neighbor or friend from church was able to do so after cataract surgery. 

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Another reason to treat OSD is ocular surgery’s tendency to exacerbate it. This can result in a list of problems that, honestly, I prefer to avoid. Paying specific attention to surface conditions at the one-week postoperative visit will demonstrate this. If you like patients to whine about fluctuating vision, foreign body sensation, red and itchy eyes, ignore it. Even mild OSD will slow incision healing time, slow edema clearance, and reduce patient satisfaction. Worst case scenario for untreated OSD is infection following cataract surgery. Not surprisingly, this ranks number one on my list of things to avoid. 

Next: Don't get thrown under the bus

Don’t get thrown under the bus

Consider the fact that your preferred cataract surgeon will also assess the ocular anterior segment and note the less than ideal environment. Referring a patient with anterior basement membrane dystrophy with irregular astigmatism, a pterygium-inducing astigmatism, or severe blepharitis will end well only if you are lucky with stockpiles of good karma. 

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Possible scenarios include: 

1. The surgeon fails to address it, and the patient proceeds with surgery.

2.  The surgeon notes the problem and suggests treatment, delaying the surgery, and the patient wonders why you did not mention it. The surgeon thinks you might be an idiot.

3.  The surgeon throws you under the bus. 

Option 1 says something about the surgeon’s skills. Option 2 erodes the relationship of the patient as well as the doctor with you. Option 3 indicates you should find another surgeon after attending 10 hours of CE on OSD. All should be avoided for various reasons, except for the 10 hours of CE on OSD. If given by an Optometric Cornea, Cataract, and Refractive Society (OCCRS) member, it is spectacular. 

Next: Fortune telling

Fortune telling

A colleague of mine once told me that informing the patient what would happen in the future would strengthen the patient’s confidence in me. Holding back information about his health would erode it.

I prefer to educate patients about what I see during slit lamp examination, educate them about why it needs to be addressed, and attempt to improve the situation prior to surgery. I know this is shocking, but I talk during my exams. I talk a lot, and not just to my scribe. I talk to the patient about what I see. I do not want to be the doctor who saw the patient last and did not tell him about clinical findings that his new doctor found. I much prefer to be the doctor who calmly mentions clinical findings relative to his complaint and determines the best treatment. I feel smarter in this scenario. I prefer to feel smarter.

Part of my patient education includes fortune telling. What can the patient expect from treatment? How will her symptoms resolve, and what do you expect to see when she returns? I typically describe the treatment in baby steps. It took years for the clinical findings to be present. Treatment will take considerable time.

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When patients experience what you predict, their confidence in you grows. They are more likely to come back, and they are more likely to be compliant with their treatment. For the patient with anterior basement membrane dystrophy and cataracts, I address his corneal health using a hyperosmotic drop QID with doxycycline for 30 days. I set his cataract consult appointment for one month. By the time he sees the surgeon, the corneal epithelium is improved, and ocular inflammation is reduced. I include my assessment of the ocular surface disease treatment in my referral letter to ensure the surgeon is aware of my findings. 

For the patient with a pterygium, I demonstrate the lesion using topography. I educate my patient that I will schedule a consult to determine if her cornea needs to be addressed prior to cataract surgery and why it is important that we correct problems on the cornea. Mebomitis, blepharitis, and chronic dry eye need to be addressed early on, as well. And anterior segment photos are invaluable to patient education. 

After my clinical exam, I decide to whom the patient will be referred. I describe what may take place and instruct the patient to call me at any time with questions. If everything goes as I described, he will not call. If it does go as I described, or he has concerns, I hope he calls me. If he calls, I address his concerns and take another stab at fortune telling. Then, I see him postoperatively to ensure his OSD does not go unnoticed or untreated.

Treat ocular surface disease prior to surgery. Tell the future. Don’t be an idiot.

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