5 easy steps in cataract co-management

Reviewed by Mitch Ibach, OD and Damon Dierker, OD.

The members of the Baby Boomer Generation are living longer than their predecessors and an increasing demand for health care services goes hand-in-hand with healthy aging. Mitch Ibach, OD, and Damon Dierker, OD, reported on the impact this population has on eye care and how ODs can work together with surgeons to handle how the 2 groups manage cataracts using a 5-step plan. Drs. Ibach and Dierker are from Vance Thompson Vision, Sioux Falls, SD, and Eye Surgeons of Indiana, Indianapolis, respectively.

The current landscape in cataract surgery shows an upward swing in the number of surgeries that are being performed in increasingly younger patients by an increasingly small number of surgeons, they commented. The estimate is that by 2030, about 5 million cataract extractions will be performed annually at a workload of 600 cases per surgeon.¹

“The role of ODs is only getting bigger and bigger, with 6.5 million referrals and about 1 million co-managed,” Drs. Ibach and Dierker emphasized.

Step 1: Are my cataracts matured?

Insurance defines matured cataracts as those causing symptomatic impairment of visual function that is not corrected with a tolerable change in glasses/contacts, lighting, or non-operative methods that results in restrictions on patient activities. However, the visual examination conducted in near-perfect conditions may not reflect the actual impairments the patient is experiencing.

Drs. Ibach and Dierker suggested asking the patient about the quality of night driving with glare and starbursts, the need for additional light to read, the need to change the spectacle refraction annually, and reductions in image quality.

Step 2: Education and expectations

They advised that ODs identify any ocular co-morbidities in their patients, i.e., ocular surface disease, corneal/retinal/optic nerve pathologies, poor dilation, pseudoexfoliation glaucoma, and cataract type, as well as systemic diseases and use of systemic and topical medications. Information should be recorded regarding ocular trauma and previous surgeries, contact lens wear, and any history of uveitis.

ODs should provide patients with information on the cataract surgery options for achieving vision at all distances, which includes a review of the surgical risks and the preoperative referral and co-management process.

Step 3: 2-way communication with the surgical team

The pertinent patient information gathered by the ODs should be provided to the surgeon preoperatively. Postoperatively, the surgeon who performed the cataract surgery should provide a co-management release letter that provides a detailed description of the ocular status and scheduled follow-up appointments with the referring OD, postoperative medication regimen, and other follow-up appointments.

Step 4: Postoperative surprises

When intraoperative complications occur, i.e., poor dilation, iris prolapse, zonular weakness and intraocular lens decentration, and capsular tears, close attention is paid to these patients.

The routine postoperative evaluations occur on the first postoperative day, 1 week postoperative, and 1 and 3 months postoperatively, when the visual acuity and intraocular pressure (IOP) is measured, and a slit-lamp evaluation is performed. High and low IOPs are treated appropriately on day 1.

Refractive surprises can surface during the postoperative period in the form of a missed distance or near target. Refractive surprises should be approached with patience to allow neuroadaptation, and can be treated with optical correction, IOL exchange, and/or laser vision correction.

Between day 1 and week 1 postoperatively, a retained lens fragment may become evident with inferior focal edema and/or elevated IOP; the cases can be monitored with an increase in the steroid dose or removal of the fragment. If endophthalmitis develops, emergent care is required.

At 1 month postoperatively, rebound iritis is possible when the steroid is stopped; aggressive treatment is needed with a long taper over 4 months. Posterior capsular opacification (PCO) can develop from 1 to 3 months postoperatively and small central YAG laser performed as needed.

Cystoid macular edema can develop in the postoperative period and calls for topical non-steroidal anti-inflammatory drugs and topical steroids for at least 1 month as an initial step in most cases.

Step 5: Treating the Unhappy Patient

The common complaints are refractive error, ocular dryness, PCO, positive dysphotopsias, and poor near vision or the patient may be visually demanding.

Refractive errors are the most common and are handled successfully with formula and aberrometry help, recognition that multifocality and astigmatism may compound the error, laser enhancements, and in a patient with an extended-depth-of-focus IOL, the recommendation is to push the plus during refraction.

Dryness, the second most common complaint, is managed with lubricants, medication, thermal pulsation, punctal plugs, and omega 3 supplements.

Drs. Ibach and Dierker offered the following conclusions:

• Be involved in the perioperative care.
• Don’t wait for 20/40 cataracts; send a referral letter that focuses on preoperative preventatives.
• Don’t play the blame game; embrace new/newer intraocular lenses that increase spectacle independence.
• Don’t shy away from calling/communication with surgeons; suggest treating with minimally invasive glaucoma surgeries during the cataract procedure.

Reference

1. Lindstrom R. Future of cataract surgery seems promising. Ocul Surg News February 2021.

Mitch Ibach, OD: mitch.Iback@vancethompsonvision.com

Damon Dierker, OD: damon.dierker@esi-in.com

Mitch Ibach, OD

Damon Dierker, OD