FROM SURGEON TO PATIENT Charles Slonim, MD, (left) has experience on both sides of the OR table after he had cataract surgery several years ago. Here, he operates on a patient while volunteering in Haiti following the 2010 earthquake.

I've spent more than half of my 30-plus years in surgery performing cataract cases, and currently counsel my oculoplastics patients on their cataract options as well. I gained even more insight into the mindset of cataract patients after I became one several years ago.

I was diagnosed with early cataracts at the age of 50 after noticing halos around the bright OR lights. My vision had always been good (20/20+), but I noticed a new blurriness and haziness. It seemed like I was looking through wax paper. After much research and a lot of thinking, I decided to undergo cataract surgery.

Since I've been on both sides of the operating microscope, I can say there are several things that help enhance a patient's overall experience during cataract surgery. Likely to top the list? Minimizing anxiety and discomfort and perfecting post-op vision. Let's take a closer look.

1. Deal with delays
After I chose my surgeon and scheduled my procedure, the nervousness started to creep in. I know just how bad things can get, despite the low risk of complications from cataract surgery. When I arrived at the center and waited in pre-op, I tried to keep my nerves in check by reminding myself that today's cataract cowboys (and cowgirls) move quickly, sometimes completing a case every 10 to 15 minutes. Even a minor issue could cause a backup.

However, I'm an outlier. Most patients aren't aware of turnover times and what goes on behind the scenes. If a patient is prepped and left waiting, their minds automatically go to the worst-case scenario. As a patient waits (including me), the anxiety can crescendo.

Aside from small comforts (see "Other Tidbits to Enhance Your Patients' Experience"), there is another simple solution to calm delayed patients: Keep them informed. While having the surgeon personally update the patient is the best option, a nurse doing regular pre-op rounds works well, too.

If there's a delay, be honest about why and try to make the patient more comfortable. For example, a nurse could say, "Sorry, Ms. Smith. There was an administrative delay with one of the previous cases, so we'll have you in the OR in about 20 minutes. In the meantime, can I get you a warm blanket?" It's a small gesture, but it goes a long way.

SMALL COMFORTS
Other Tidbits to Enhance Your Patients' Experience

There are several other little comforts that make a big difference in your cataract surgery patients' satisfaction:

• Personalized pre-op. It's slightly daunting to see 5 patients in pre-op all with your doctor's name on signs affixed to their beds. Great, I'm one of 5, patients may think. Instead consider discreet designations (color-coded signs are one idea) to show which patient belongs to each surgeon.
• Warm blankets. If you aren't letting patients wear street clothes during the procedure, you're in the minority. Some facilities only make patients take off their tops and wear hospital gowns; others let patients wear their own loose, comfortable clothing in the room. Whatever your policy, keep in mind that patients may still get chilly even if they're wearing more than those paper-thin gowns, so consider offering warm blankets.
• Education. While I had the chance to shadow my surgeon in the OR before my surgery, your patients will rarely have that option. Instead, consider filming a cataract surgery (with legally appropriate patient consent, of course) or creating a presentation to walk patients through the procedure. You could post it on your website or show it during pre-op counseling.

— Charles Slonim, MD

2. Explore the IOL offerings
Back when I performed cataract cases, the goal was to get patients as close to 20/20 as possible without the need for glasses. Most understood that if they had astigmatism, or wore bifocals, they would still need glasses post-operatively. Those days are gone. Patients want near-perfect vision — and surgeons can deliver that request.

A large part of this innovation is due to premium toric and multifocal intraocular lenses (IOLs). Before my surgery, my visual acuity was very good. I used reading glasses, but never had issues with distance vision. So when I studied my IOL options, I considered multifocal (presbyopic) IOLs. While traditional lenses can correct only distance vision, these lenses improve both distance and near vision.

While I liked the idea of not having to carry around my readers, I wanted to know exactly what the lenses entailed. I studied the choices at a trade show, looked at the studies and sought out ophthalmology colleagues who considered multifocal IOLs when they underwent the procedure. Since there are minor concerns about irregularities and halos with the lenses — and I work under bright OR lights for a living — I ultimately chose a standard monofocal IOL.

For patients who are sick of carrying around their glasses, or those with astigmatism that traditionally were left with suboptimal post-op vision, premium IOLs are an attractive option. This is especially true for astigmatism patients, since toric lenses are now one of the most popular ways to correct the problem.

Since these lenses can tack on an additional out-of-pocket cost of $1,500 to $2,500 per eye, they may be attractive to you as well. However, make sure your patients are aware of the risks, since there is a small percentage of patients who still need glasses after surgery.

Often, informed patients are willing to take that risk. However, an uninformed patient will likely be very unhappy that she paid premium prices for a less-than-premium outcome. For your toric lens patients, you may want to minimize this risk of less-than-perfect vision by adding corneal refractive procedures to your facility or partnering with a LASIK center to offer post-op touch-ups.

3. Make post-op compliance easier
Patients typically must use antibiotic, steroidal and non-steroidal eye drops several times a day for as long as 3 to 4 weeks after cataract surgery. Since I was young and healthy (and knew firsthand the consequences of missed drops), compliance wasn't an issue. For many of your patients, though, that's not always the case.

Dropless surgery involves an intraoperative injection that eliminates the need for post-op drops. This cuts down on patients' out-of-pocket expenses and their need to follow a strict post-op regimen. The dropless technique does increase your case costs, though, and has not been proven to dramatically improve outcomes. However, it could help reduce infections and complications caused by compliance problems, making everyone involved a little happier.

While some surgeons go dropless for all of their cases, the technique is really beneficial for certain populations: patients at high risk of complications or infections, who live alone, are older (70+) and have a history of problems with compliance.

LASER CATARACTS Patients are drawn to the blade-free precision of the femtosecond laser.

4. See if a laser is right for you
I remember when the phaco machine was the hot new thing in cataract surgery. For years, patients would come to me and mistakenly say that they wanted their eyes done "with the laser." While I had to explain that phacoemulsification wasn't a laser, it demonstrates a relevant point now that laser cataract surgery is actually an option. Patients almost always want cutting-edge technology … especially when a laser is involved.

While laser cataract surgery wasn't a possibility when I underwent surgery, the promise of blade-free precision can be a draw to many out-of-pocket patients. Research on the benefits of laser versus non-laser surgery is still limited. However, patients who have the option often choose the technology, sometimes simply because it sounds like a higher quality of care. Additionally, some femtosecond lasers now also let a surgeon perform LASIK, which can be very attractive for docs and patients determined to get perfect post-op vision.

Before adding the laser to your facility, do a cost analysis to find out if purchasing the pricey technology is worth it to your facility. Many smaller centers may find they don't have the volume necessary to turn a profit with the $500,000 laser plus a per-use fee. In those cases, you might consider leasing or outsourcing.

The people that might make the biggest impact on your decision, though, are your surgeons. If they are performing laser cases at other facilities, or are eager to use the technique, simply having the technology available can keep you in the race. If patients know that their doctor can go to facility X for laser cataract surgery or facility Y for a standard procedure, many will go with that first choice.

5. Consider new refractive technology
My surgery was relatively straightforward. But today's refractive cataract patients have 2 other options on the market that may help improve their outcomes: intraoperative aberrometry and digital marking systems.

Intraoperative wavefront aberrometry helps reduce residual refractive error. The system measures a patient's refractive power intraoperatively to confirm or revise the surgeon's IOL power choice or perfect your arcuate corneal incisions (when appropriate), enhancing overall accuracy.

Digital marking systems work a little differently. During standard pre-op biometry measurements, these systems create a high-resolution, digital reference image of the eye. After determining the optimal IOL and/or incision placement, the system overlays a digital "map" in the surgeon's microscope, or helps guide the femtosecond laser.

While both systems can be helpful, mainly in astigmatism cases, research on the effects is still limited. Instead, just as with laser surgery, the decision to add these technologies often comes down to patient and surgeon demand. If your docs offer patients the choice of new technology for enhanced refractive outcomes at one center vs. a standard procedure at yours, they'll likely want the perceived "best" option even if it comes at a higher price. Patients say it all the time: I only have one set of eyes. They may not know what it means when their surgeon says "intraoperative wavefront aberrometry," but they definitely understand when he adds, "This will improve your vision."