Lawrence H. Bloom

The issue of patient education has always been an important one to my practice. Educated patients are more likely to comply with prescribed regimens, achieving better outcomes and, as a consequence, tending to be more satisfied with their overall medical treatment. However, proper patient education often takes significant chair time. Without proper tools it can be difficult for patients to understand abstract concepts or complex anatomic descriptions.

Animated visuals

The LUMA software system (Eyemaginations) is an innovative forum for patient education that uses 3-D animated visuals and an interactive user interface to explain complex medical processes to patients in an engaging manner. It can be used in the exam room, applying draw-over-video technology and zoom features to clearly show patients how disease progression will affect their daily lives. It can be used during the consultation to highlight features and benefits of certain procedures or products, matching the patient’s lifestyle with the appropriate course of treatment. It can also be used in the waiting room, educating otherwise idle patients about different disease states and treatment options.

My office has benefitted enormously from dedicated patient education technology. We use it for all ocular disease conditions. For example, when new patients are referred to the practice with cataracts, macular degeneration or diabetic retinopathy, I can have my staff play specific animations with narratives that pertain to that condition. These can be shown to patients in the exam chair prior to my coming in or after dilation. By the time I get to see the patients, they have already seen a pictorial explanation showing the anatomy of their condition. We can therefore move on to more specific questions that will help them understand the disease and treatment options in greater depth.

If a patient comes in for an emergency exam due to flashes and floaters, I have to decide whether that patient has any significant retinal complications. Describing the anatomy of a posterior vitreous detachment can take a considerable amount of time. However, if we have already shown the patient the educational content on the subject in advance, the ensuing discussion is taken to a higher level, with a resulting clearer understanding by both patients and their families.

The ‘wow’ factor

The same exists with macular degeneration. If a patient needs to be started on supplements or see our retina specialist, it is much easier for the patient to understand after viewing the animation that explains the disease process. When I come into the room, I access the draw-over-video technology in the exam advisor to emphasize specific items. This creates a big “wow” factor for patients because it shows that we are technologically savvy while at the same time making it easier for them to understand their disease.

If a patient comes in with a corneal abrasion, I can pull up a picture of the cornea in the exam advisor and write on the touch screen, showing patients where their corneal abrasion is. The same is true with a stye. I can show an image of the lid and then draw on the screen to show how the blockage leads to the stye. LUMA has the ability to show the normal anatomy alongside the progressing disease, easily demonstrating how it changes over time.

Disease progression visualization

Another important feature is to show the disease progression from the point of view of the patient. For example, for a patient with cataracts, advanced images can show what the patient theoretically sees when trying to read or drive a car at night with untreated cataracts. We can then show the different treatment options. Should a patient have glaucoma, not only can the physician pull up a picture of a cross-section of the optic nerve, but also show the progression of optic nerve damage. This can be followed by an explanation of the different tests that a physician may choose to do. Animated educational content can show what an optical coherence tomography, visual field or other exam is like and why it is needed. When I see patients, all of this information is already fresh in their minds, and they are much more comfortable with the testing because they have a better understanding of what we are planning and why.

Diseases of the eye are particularly difficult for patients to understand because there is often no physical manifestation from the outside. Animated educational content allows me to document what we have gone over. I can note in patients’ charts that they have viewed specific content, making it unlikely that they will later say that we never talked with them about a specific disease or treatment. I can now perform the informed consent portion of my patients’ visits in a more efficient manner and be confident that they have a much better understanding of the procedure and risk-to-benefit ratio.

Web access

Another unique feature of my patient education system is that patients can access these informational animations on my website. When patients call in with a certain symptom or question, my staff can direct them to my website where they can watch the video before visiting the office. This is particularly helpful for family members of elderly patients who may not be able to come to the appointment but need to be involved with treatment decisions.

As a comprehensive ophthalmology practice, we see the whole spectrum of diseases and perform a variety of procedures. It is important on so many levels for patients to truly understand their own medical care. LUMA provides a level of patient education that would be impossible to reach without such advanced technology. My patients are better informed, more compliant with therapies and, therefore, more satisfied overall with their medical experiences. As a physician, I am able to use my time more efficiently within the office while at the same time enhancing my practice’s reputation and strengthening our referral base.              

Lawrence H. Bloom, MD, can be reached at Bloom Eye Associates, 525 Jamestown Ave., Suite 207, Philadelphia, PA 19128; 215-483-8444; email: lh.bloom@gmail.com.

Disclosure: Dr. Bloom has no relevant financial disclosures.

Staying ahead of the latest technology, surgical devices and procedures to hit the market can be a challenging, but often necessary, task for any refractive cataract surgeon looking to create the “premium practice.”

As one of the newest procedures being implemented into the field, femtosecond laser cataract surgery has brought with it quite a buzz. From whether or not to incorporate the procedure into one’s practice to how to properly charge patients for the service, the introduction of femtosecond laser cataract surgery has sparked a number of debates.

In light of this, Premier Surgeon posed questions surrounding the incorporation of this procedure to the PS250 in its latest survey. To see how the PS250 responded, click here. Additionally, if you’d like to weigh in on this subject yourself, find us on Facebook and leave us a comment. We’d love to hear what you have to say!

Keeping with the theme of technology, this issue also takes a look at how one physician has incorporated the “high-tech mentality” into designing and running an efficient surgical practice. See the latest Photo Feature spread, highlighting the practice of James S. Lewis, MD, found here.

– Cara Hvisdas
chvisdas@slackinc.com

Multifocal IOLs offer patients a broader range of functional vision for performing daily activities.

When we discuss the option of premium IOLs with our cataract patients, we typically mention that a major advantage for qualified patients is the ability to see simultaneously at multiple distances. This is often overlooked.

But we also should inform patients that premium IOLs such as the Tecnis multifocal (Abbott Medical Optics) and AcrySof IQ ReStor (Alcon) can increase functional vision by providing superior depth of focus, particularly in circumstances in which adequate light is present. More studies are needed to determine the scientific validity, but anecdotally, my patients are strongly in favor of their new vision, which allows them more stability.

For example, older patients are sometimes prone to falls that can have serious consequences, such as hip fractures. To help avoid falls, patients must rely on stereopsis and depth of focus to see objects in relation to each other.

This issue particularly is of concern at our California practice because multistory residences are the norm in the area (land is not cheap here). To safely accomplish daily activities and chores, our older cataract patients who are vulnerable to falls need the ability to clearly see all the steps of stairways and in proper relation to each other. These patients often live alone and must maintain independence of some fashion.

We have now studied these issues for about 5 years and have found that, particularly with an aging population, premium lenses have a huge role to play because of the variables involved with quality of vision. We continue to refine questionnaires for subjective input from patients, in addition to creating other types of clinical assessments to clarify the relationship among stereoscopy, functional vision and premium lenses.

When we compare vision correction options for most cataract patients, multifocal IOLs at this time seem best able to enhance daytime functional vision in at least three dimensions. It is also true, however, that multifocal IOLs can decrease contrast sensitivity in low lighting conditions, which is why we must also counsel our patients about the need to use adequate lighting. This is always a good safety tip for our older patients, even if they are not good candidates for multifocal IOLs.

Enhancing functional vision

With bifocals and trifocals, the brain first must select where to look (near or far). Because the patient cannot perceive multiple distances simultaneously, this can have a detrimental effect on the ability to make quick visual assessments and react accordingly. Compared with eyeglasses, multifocal IOLs give the patient the advantage of a stable and full visual field, including at the periphery.

Communication is the key

Surgeons must believe in the products they discuss. One reason we have a higher conversion rate in our practice is because I believe so strongly in the technology represented by premium IOLs. This confidence and passion for the technology are conveyed in all my discussions with patients. I never try to “sell” a patient on premium IOLs, but I do believe each patient has the right to be fully informed about risks and benefits represented by new technology, especially when that technology might improve functional vision beyond any other options that are currently available.

In addition to positioning premium IOLs well within the practice, however, effectively communicating the benefits of improved functional vision might even help patients who are unhappy with their premium IOL outcomes or those who have good postoperative visual acuity but say they are unhappy with their premium lenses.

First, I recognize these patients may not have been aware that whatever natural multifocality they had before surgery would be forever lost after their natural lens was removed. Patients may not fully grasp the meaning of what sight would be like with a monofocal IOL compared with a multifocal IOL. I show them what true monofocality looks like by placing a pair of –2.5 D spectacles on them to duplicate the sight a monofocal IOL provides — typically, excellent distance vision and extremely blurry near vision.

Once patients see for themselves what a monofocal IOL really is and the limitations in how they will view the world for the rest of their lives, they have a much better perspective. They also are better able to appreciate the fuller range of vision that a multifocal IOL provides, even if there are certain side effects such as mild glare and halos at night. It is important to inform patients that these same side effects also can occur with monofocal IOLs but that they are more likely to occur with multifocal IOLs.

Of course, multifocal IOLs are not right for all patients. I would never advise use of multifocal IOLs for a truck driver whose occupation depends on many hours of night driving. And for those patients who do opt for a multifocal IOL, I caution them to be extra careful while driving at night.

For most patients, however, we have found the benefits of multifocality and improved functional vision tend to outweigh any possible side effects related to glare and halos.

Lens selection

I prefer multifocal IOLs, namely the single-piece Tecnis and ReStor multifocal IOLs, but I do use all of the premium lenses in my practice, including the Crystalens (Bausch + Lomb). This lens provides reasonable blended vision; however, I am not convinced it gives the same stable, around-the-clock consistency and range of vision as multifocal IOLs.

In my opinion, the material and aspheric optics of the Tecnis platform are unmatched in terms of the ability to provide sharp, full-color vision. I have also developed a great deal of confidence in the ability of the Tecnis multifocal to meet the expectations of patients who want excellent near and reliable intermediate vision. For distance, both the Tecnis and AcrySof also have the ability to correct low levels of spherical aberrations, which improves functional vision in conditions such as night driving.

Of course, the prospects for new and continuing improvements in IOLs continue. While multifocal IOLs achieve excellent outcomes, they are based on principles that divide light into multiple foci, which is physiological. This technology does not duplicate the way the eye sees naturally and therefore has certain limitations.

We look forward to adopting even newer technology as it becomes available, such as dual-optic accommodating IOLs, which will provide more physiologic vision and better contrast sensitivity. For now, however, the current technology of new-generation multifocal IOLs offers cataract patients a much fuller range of vision than previously possible.  

Ehsan Sadri, MD, FAAO, FACS, can be reached at Atlantis Eyecare, 361 Hospital Road, Suite 327, Newport Beach, CA 92663; 949-642-3100; email: esadrii@gmail.com.

Disclosure: Dr. Sadri has no relevant financial disclosures.

Mitchell A. Jackson

Fifth in a series of the top 10 reasons for poor premium IOL outcomes and how to remedy them.

The etiology of visual loss in cataract surgery can be multifactorial, including but not exclusive to ocular surface disease, such as dry eye, blepharitis, allergy and epithelial basement membrane dystrophy; regular and irregular astigmatism; keratoconus and forme fruste keratoconus; pre-existing retinal pathology, such as epiretinal membrane, age-related macular degeneration and diabetic retinopathy; posterior capsular opacification; and cystoid macular edema.

Any of these problems becomes even more magnified in a premium patient paying premium prices for premium IOL technology. Astigmatism and PCO management were addressed in the third and fourth part of this 10-part series, and ocular surface disease will be addressed in the next issue.

Diagnosing CME

Cystoid macular edema (CME) is the most common cause of significant visual loss in patients without pre-existing disease and was readily underdiagnosed until more frequent use of postoperative optical coherence tomography testing began allowing for earlier detection. The current definition of CME includes an ophthalmic appearance of a cystic yellow fovea, petaloid leakage on fluorescein angiography, any visual deficit including metamorphopsia and decreased contrast sensitivity.

Angiography is the gold standard, but Flach has published that macular thickening correlates better with vision loss, and visual acuity does not always correlate with degree of angiographic leakage. Angiography is useful, however, to confirm the presence or absence of CME. OCT provides a much faster, easier, safer and even better look at retinal structure and is especially helpful for determining preoperative retinal pathology, such as epiretinal membrane, age-related macular degeneration and diabetic retinopathy, and postoperative CME diagnosis and monitoring of therapeutic response.

Onset of CME is typically not seen until around 4 to 6 weeks postoperatively. Pathophysiology of CME includes inflammation, surgical trauma of ocular tissue, retained lens fragments, vitreous traction, photic toxicity and possibly pharmacology (epinephrine, tamoxifen). High-risk patients include diabetics (even without diabetic retinopathy), as well as those with previous central or branch retinal vein occlusion, epiretinal membranes, uveitis history, previous CME, CME in fellow eye, previous ocular surgery and prolonged operative time. The decision to perform premium IOL surgery should be reassessed based on a patient’s risk factors to develop CME.

Treatment

Treatment of CME can be primarily addressed based on the inflammation etiology model: Topical steroids and NSAIDs work synergistically at the arachidonic acid cascade level to reduce inflammation. NSAIDs primarily act on the cyclooxygenase pathway (COX-1 and COX-2) by decreasing prostaglandin formation, and steroids act on phospholipase A2 by decreasing arachidonic release.

There are a number of U.S. Food and Drug Administration-approved NSAIDs and steroids for pain and inflammation after cataract surgery, including Bromday (bromfenac ophthalmic solution 0.09%, Ista Pharmaceuticals), Acuvail (ketorolac tromethamine ophthalmic solution 0.45%, Allergan), Nevanac (nepafenac ophthalmic suspension 0.1%, Alcon) and Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon).

A large prospective, randomized, double-masked, multicenter trial showed statistically significant less clinical CME and less mean retinal thickening on OCT in patients taking NSAIDs and steroids combined vs. steroids alone in low-risk patients — those typically receiving premium IOL technology. In my premium IOL patients (low-risk CME cases), I begin topical NSAID therapy 3 days before surgery and continue it 4 weeks postoperatively.

OCT is an excellent way to guide withdrawal of NSAID therapy. I always perform OCT at the 1-month postoperative visit to be sure there are no subtle CME changes prior to NSAID withdrawal. The main precaution with topical NSAID therapy is to avoid usage in patients with severe dryness and/or unstable autoimmune disease so as to avoid corneal melts. These latter patients are not typically candidates for premium IOL technology, anyway. With patients who typically develop CME that is unresponsive to steroid-NSAID combination therapy, referral to a retinal specialist for intravitreal steroid and/or anti-VEGF therapy may be indicated.

Recognizing high-risk CME patients, efficient cataract surgery and prophylactic topical NSAID usage will regularly give your premium patients a visual outcome free of CME.

Stay tuned for managing the ocular surface in your premium IOL patient in the January/February 2012 issue.     

References:

Flach AJ. The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. Trans Am Ophthalmol Soc. 1998;96:557-634.

Wittpenn JR, Silverstein S, Heier J, Kenyon KR, Hunkeler JD, Earl M; Acular LS for Cystoid Macular Edema (ACME) Study Group. A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. Am J Ophthalmol. 2008;146(4):554-560.

Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; 847-356-0700; fax: 847-589-0609; email: mjlaserdoc@msn.com.

Disclosure: Dr. Jackson is on the speakers bureau for Ista, Allergan and Alcon.

John A. Hovanesian

Meibomian gland disease, referred to synonymously as evaporative dry eye, is one of the most common causes of dry eye throughout the world. In fact, it is believed that while between 50% and 70% of older patients in our medical practices have at least some degree of dry eye, approximately 70% of dry eye involves at least some degree of meibomian gland disease.

Despite these numbers, the problem remains that the most effective treatment we know of — the use of warm compresses on the eyelids — is a practice many patients do not follow. Most doctors and patients agree that this method is successful because it applies heat to the meibomian glands, which are not flowing. The difficulty, however, is that patients do not stick with it, and that because we are applying heat from the outside of the eyelid, which is insulated from the glands themselves by the anterior lamella, the heat is dissipated by the time it reaches the gland.

Another method to make blocked glands flow again is to massage and squeeze them. Unfortunately, this is difficult for a patient to do on his or her own because of the amount of pressure needed, the lack of knowledge regarding the anatomy of the gland, and the potential damage to the external structure of the eye that could result from such applied pressure.

New forms of treatment

There are now several technologies being used in the field for the treatment of meibomian gland disease. They include the Maskin Meibomian Gland Intraductal Probe (Rhein Medical) and an off-label use of intense pulsed light, both of which probe the oil glands blocked in meibomian gland disease to help resume normal flow.

Our focus in this segment of State of the Art, however, is the U.S. Food and Drug Administration-approved LipiFlow Thermal Pulsation System (TearScience) and the accompanying LipiView Ocular Surface Interferometer. Unlike the other options, the LipiFlow system has been rigorously tested by the FDA for its efficacy and safety.

How it works

LipiView is the diagnostic portion of this pair of devices, designed to objectively look at the production of tears and how robust they are. It is designed to not only give doctors a view of who has genuine meibomian dysfunction, but also to give the patient an objective measure of how serious the problem is. The test, which takes less than 5 minutes, also gives the doctor a chance to follow therapy over time and measure its effectiveness.

The LipiFlow pulsation system is the therapeutic arm of the pair, used in a 12-minute in-office procedure under topical anesthetic. The device applies localized heat from the inside of the eyelid and then compresses the glands through programmed, pulsed pressure without putting pressure on the globe itself.

Because a premium practice largely centers itself on surgical procedures to enhance vision, there are several reasons these devices will be useful. It is well documented that even a mild degree of tear film instability, particularly in the meibomian gland, is disruptive to vision. Patients judge their surgical result based on their vision, regardless of whether the vision is affected by the lens implant, the refractive outcome or a dry ocular surface. So, we have to treat the whole patient, and these tools will allow us to do just that.

Payment

At this stage, there is no mechanism or coding system for these procedures to be billed to insurance, and they are likely to be considered non-covered benefits by commercial insurance and Medicare.

The out-of-pocket cost for treatment in both eyes will be nearly $1,000. This is a significant upfront investment from patients; however, when taking into account other factors, such as the amount of money patients invest in not just over-the-counter lubricant drops, but also in medications such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and AzaSite (azithromycin ophthalmic solution 1%, Inspire Pharmaceuticals), this is not as overwhelming a financial burden. The cost for these devices is not much higher, particularly if we can obtain at least several months of benefit.

In premium practices, the LipiFlow Thermal Pulsation System will likely be another welcome tool.

Conclusion

No treatment in the complex world of dry eye is going to be a panacea that relieves all symptoms completely. But we welcome to our armamentarium a treatment that has been shown to provide some long-lasting benefits in well-selected patients.

It remains to be seen how prolific the adoption of this technology will be, and as usual, that will depend upon how well it works. We have respectable but early-stage data at this point, and further studies are under way to help us understand the clinical application of these devices.

The implications for LipiFlow, if it works well and we can determine the best application of it, are large because of the looming public health problem that is meibomian gland disease, as well as the fact that there are few treatments for it. These devices are a welcome addition even as financial aspects and efficacy are fine-tuned.      

John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com.

Disclosure: Dr. Hovanesian is a consultant and member of the medical advisory board to TearScience, the maker of LipiFlow.

Uday Devgan

Cataract surgery is arguably the most powerful refractive surgery because the new lens implant can correct just about any degree of hyperopia, myopia, astigmatism and even presbyopia at the time of surgery. Highly myopic patients, with preoperative refractions of –10 D or more, are often the happiest because a lifetime of nearsightedness is finally cured with successful cataract surgery. However, these myopic eyes pose challenges and additional risks during surgery and in the perioperative period.

Patient expectations

Myopic patients often use their natural nearsightedness, and if they are corrected for plano they need to understand that their ability to see a few inches away from their face will be lost. Because IOL calculations are less precise in eyes with extreme

refractions, patients with high myopia should understand that while the cataract surgery can correct much of the myopia, its primary purpose is to correct the cataract, and the refractive effect is a secondary benefit. These patients may need a second surgical procedure to fine-tune the postoperative refractive result. In addition, there are increased risks of complications such as retinal lesions, which could limit the visual recovery.

Preoperative evaluation

Because of this increased risk for retinal complications, the preoperative exam should include a careful examination of the retina for any breaks, holes or weakness, as well as any macular pathology. The highly myopic patients may also have myopic macular degeneration, epiretinal membranes or other significant changes (Figure 1). These may limit the postoperative vision achieved and may influence the development of postoperative complications such as cystoid macular edema. If any posterior segment issues are noted, referral to a vitreoretinal colleague for treatment is recommended prior to cataract surgery.

In addition to the typical cataract evaluation, care must be taken to accurately assess the retinal status and measure the axial length of the eye. Highly myopic eyes often have a posterior staphyloma, which can generate an erroneously long axial length when measured with the standard A-scan ultrasound. This would cause an error in lens calculations and residual postop hyperopia, resulting in an unhappy patient. Using an optical method for measurement tends to be more accurate because it measures directly at the fovea.

The IOL calculation methods, particularly the two-variable formulae, are less accurate at the extremes, and this is particularly true for very myopic eyes. Of the two-variable formulae, the SRK/T tends to perform particularly well, as do more complex formulae such as the Haigis and Holladay 2. A postoperative refractive goal of a mild amount of residual myopia, such as –0.5 D to –1 D, can be helpful to avoid a hyperopic surprise.

Certain IOLs have a significantly different design, and therefore A-constants at lower IOL powers and minus IOL powers. This variability in the A-constant of the IOL across these power ranges accounts for some of the difficulty in achieving accurate postoperative results. In general, the A-constant increases as the IOL power is lower, which leads to selection of a higher dioptric implant to lessen the odds of a postoperative hyperopic surprise. In other words, there is a strong tendency for a postoperative hyperopic surprise in these patients, so aim for some residual postoperative myopia.

Surgical technique

The advantage of cataract surgery in myopic patients is the larger anterior chamber depth, which allows more working room during phacoemulsification. However, the infusion pressure from the phaco handpiece can cause overinflation of the anterior chamber and a tendency to push the entire lens-iris diaphragm posteriorly. With an overly deep anterior chamber, surgery becomes difficult and uncomfortable for both the surgeon and patient. To address this issue, the infusion pressure can be decreased by lowering the bottle height; however, this will result in less inflow of fluid and a higher tendency for surge.

A better solution is to break the reverse-pupillary block by making sure that there is fluid flow under the iris to equalize the anterior and posterior chamber pressures. By neutralizing this pressure gradient, the cataract will not be pushed so deeply within the eye and adequate infusion pressure can be used. I prefer to use the chopper to slightly tent up the iris at the pupillary margin to establish a channel for anterior-posterior fluid flow. Alternatively, a single nasal iris hook can be placed for the duration of the surgery (Figure 2).

Myopic patients are at a higher risk for postop retinal detachment if there is tension or traction on the vitreous base during surgery. The primary culprit is allowing the anterior chamber to collapse when removing the phaco probe or irrigation and aspiration probe from the eye. Once the anterior chamber collapses from lack of infusion, the posterior capsule and vitreous have a tendency to move anteriorly, often quite abruptly and significantly. This can be avoided by one simple technique: Fully inflate the eye with viscoelastic via the paracentesis prior to removing the phaco probe or I&A probe from the eye. At the end of the procedure, once the IOL has been placed into the capsular bag, remove the viscoelastic completely and use balanced salt solution via the paracentesis to keep the eye pressurized as the I&A probe is withdrawn. These techniques will prevent collapse of the anterior chamber, increase patient comfort and lessen the risks.

Postoperative management

The postop refraction in myopes can take time to stabilize due to the variation in effective lens position as the capsular bag shrink-wraps around the IOL. During this period, inflammation can be controlled using topical steroids and NSAIDs. During the postoperative period, a repeat dilated fundus examination is indicated to search for possible retinal breaks or weakness that may have been created during surgery.

Finally, keep in mind that there may be a large degree of anisometropia between the eyes, so performing timely surgery on the fellow eye will minimize the imbalance. While patients will be functionally emmetropic after bilateral cataract surgery, they will always have the elongated axial lengths and retinas that need to be followed on a regular basis and referred to a vitreoretinal colleague for any noted changes.

While cataract surgery in myopic patients can pose a variety of challenges, these patients tend to be among the happiest of all. In a safe, efficient surgery that takes just minutes, their cataract is removed, their myopia is treated and they can now enjoy a lifetime of excellent vision.        

Uday Devgan, MD, FACS, FRCS, is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills. He can be reached at 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax: 310-388-3028; email: devgan@gmail.com; website: www.DevganEye.com.

Disclosure: Dr. Devgan has no relevant financial disclosures.

Y. Ralph Chu

Case presentation: The patient is a 75-year-old man who presented with gradual painless, progressive, decreased vision that interfered with his ability to read and to see street signs when driving during the past few years. He has a history of keratoconus and is having a harder time wearing his rigid gas permeable contact lenses due to increased discomfort.

Uncorrected visual acuity is 20/200 in the right eye and 20/400 in the left eye. Visual acuity with his contact lenses in is 20/60 in the right eye, 20/70 in the left eye and 20/50 in both. Best corrected vision without the contact lenses in is –5.50 +1.00 ×165 yielding 20/50 vision in the right eye and –6.00 +0.50 ×030 yielding 20/60 vision in the left eye. Brightness acuity testing under medium light is 20/100 in the right eye and 20/200 in the left eye.

IOP is normal. Slit lamp examination reveals corneal ectasia in both eyes, as well as 2+ nuclear sclerosis and cortical changes in each lens. There are some small drusen and retinal pigment epithelium changes noted in each eye, but the patient has a normal 0.2 cup-to-disc ratio.

1. The patient has known keratoconus and cataracts that are now interfering with his vision. What lens options would you discuss with him?
2. If you would choose a toric lens, how would you discuss this with the patient?
3. How long would you have this patient out of contact lenses before calculating the IOL power?

Approach 1: John Bello, MD

This has the potential to be a complicated case with a possible unpleasant surgical outcome if it is not first discussed at great length with the patient.

First, I would want to know what the keratometry readings are and how stable they have been for as far back as possible to establish the stability of the cornea. This also assumes the recent decrease in vision is due to the cataract.

I would have the patient remove his hard contact lenses for at least 3 weeks and then perform keratometry readings on a weekly basis, for at least 3 weeks, until I feel they are stable. Then I would discuss the choice of a standard IOL vs. a toric IOL. I know the vendor doesn’t promote the use of toric lenses in keratoconus, but there is a possibility of using them, based on the corneal stability and the patient’s risk tolerance. If the cornea is unstable, one may consider pre-treating the cornea with an Intacs insert (Addition Technology) and/or corneal cross-linking.

The possible postop complications would consist of an unstable cornea, indicated by changing keratometry readings, which would create a worsening of his astigmatism. This may require an IOL exchange with a standard monofocal implant if a toric implant was initially selected.

Approach 2: Lance S. Ferguson, MD

Although this individual’s topographic maps suggest pellucid marginal degeneration (“kissing birds”), the precise pigeon-holing of the diagnosis is moot. The ectasia is obvious at the slit lamp, and he shows a high degree of irregular astigmatism in the central 3 mm.

Before any operative intervention, I would recommend that this patient undergo corneal cross-linking, even though his age of 75 years suggests he may already have had an adequate dose of UV. Not only should this preclude any ectatic progression with its associated unstable refractive problems subsequent to cataract extraction, but it may also create the opportunity for safer consecutive PRK should any significant spherical or cylindrical error remain. One may also consider Intacs to stabilize the topography prior to cross-linking.

After the cross-linking, I would follow serial topography with the RGP contact lenses discontinued until there was no change in the maps and select an Alcon toric IOL based on the most consistent A-scans and keratometry readings in the central 3 mm. I would advise against any incisional techniques to reduce cylinder.

During the preop stabilization period, I would arrange a consultation with a retinal specialist to assess the OCT findings suggestive of a retinal pigment epithelium tear or detachment, and if possible, perform potential acuity meter measurements. Irrespective of the potential acuity meter findings, I would counsel that the ultimate level of visual acuity in the left eye could nevertheless remain limited and that surgical refractive accuracy in both eyes is compromised by his underlying corneal condition. Finally, I would emphasize that our goal is not perfection but rather to reduce his dependency on contact lenses and improve his overall visual sensorium.

Approach 3: John D. Sheppard, MD

This patient has two decisions: First, do I want correction now? And second, am I willing to undergo multiple sequential procedures to obtain the best possible result? Due to acuity loss and glare disability, I would advise our patient to stop driving until correction is undertaken. Immediate ocular surface optimization, punctal plugs, nutrition, lid hygiene and directed appropriate measures are essential to eventual precise biometry and surgical success. When axial punctate keratopathy is eliminated and after at least 4 weeks of RGP-free time in the worst eye, axial length and keratometry readings can be taken.

If successful extended RGP wear is not possible and the patient is willing to consider a corneal collagen cross-linking procedure with at least 6 more months of follow-up care, sequential surgeries can be recommended. This idealized strategy would allow a quiet ocular surface, stabilized keratometry, minimized irregular astigmatism, and the best possible chance for obtaining an emmetropic IOL calculation. With corneal cross-linking, our patient also has the best chance of enjoying a contact lens-free life or using soft lenses and avoiding RGP dependence.

If urgency is paramount or the patient wishes to avoid multiple procedures, a best-shot calculation and IOL under these moderately steepened corneas is reasonable if patient expectations match. At 75, the prospects of severe rapid ectasia and steepening are minimal because the patient displays a mild, later-onset keratoconus phenotype. Many milder keratoconic patients are pleased with distance-correction monofocal IOLs bilaterally and a good refraction. If preop keratometry shows a clear-cut axis and only moderate distortion, the astute patient can be counseled regarding the advantages of a toric IOL, understanding that 20/20 uncorrected visual acuity is not obtainable.

Dr. Chu’s response

This case illustrates the difficulty of achieving accurate refractive outcomes in patients with keratoconus and cataracts. In my opinion, this would be an ideal situation for using intraoperative wavefront aberrometry to determine whether a toric IOL would be the best option and at which axis to place this IOL at the time of surgery.

The patient in this case presentation has not yet proceeded with surgery at this stage. 

John Bello, MD, can be reached at Advanced Vision Specialists, 7447 W. Talcott Ave., Suite 406, Chicago, IL 60631; 773-775-9755; fax: 773-775-4306; email: nancy@johnbellomd.com.

Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 9117 Lyndale Ave. S., Bloomington, MN 55420; 952-835-0965; fax: 952-835-1092; email: yrchu@chuvision.com.

Lance S. Ferguson, MD, can be reached at Commonwealth Eye Surgery, 2353 Alexandria Drive, Suite 350, Lexington, KY 40504; 859-224-2655; email: lferguson@commonwealtheyes.com.

John D. Sheppard, MD, can be reached at Virginia Eye Consultants, 241 Corporate Blvd., Norfolk, VA 23502; 757-622-2200; fax: 757-622-4866; email: docshep@hotmail.com.

Disclosures: Drs. Chu, Bello, Ferguson and Sheppard have no relevant financial disclosures.

James S. Lewis, MD, and The Eye Institute of Salus University

Creating the premium practice means staying “ahead of the pack” in a number of areas, not the least of which being the technology aspect of ophthalmology. At The Eye Institute of Salus University, James S. Lewis, MD, has done just that, creating a high-tech yet inviting environment for his patients.

“I’ve been interested in imaging, particularly video imaging, even before I started my practice,” Dr. Lewis told Premier Surgeon. “It’s the perfect match because ophthalmology lends itself to the creative use of optics, ultrasound, laser interferometry and laser techniques.”

Dr. Lewis’ love of technology can be seen in every aspect of the well-appointed office. Within the waiting areas, patients watch educational videos on large-screen, high-definition LCD and plasma monitors, and each surgical procedure is recorded to DVD using top-of-the-line cameras so patients can view their surgery at home. Images by Peter Olson Photography.

Paul M. Stubenbordt

I need to focus on this topic because I, like many of you, recognize that customer service has declined even more during the last few years, especially after the recession hit in 2008. The practices that invest in customer service and offer an amazing experience for patients seem to be thriving, whereas practices that do not invest in customer service are not doing as well.

The world we live in today is predicated on what patients expect and what we deliver. To patients, delivering above and beyond equals great customer service. As much as I would like to write an article on the overall picture of customer service, I am limited to so many words and will have to break it down into a series. Without further ado, Part 1: The telephone.

Making a first impression

You only have one chance to make a first impression. Think about it. In your ophthalmology practice, a first impression frequently takes place over the telephone. Unfortunately, many practices fall short when it comes to handling the phones and greeting patients with a smile. Sure, they have excuses, such as short staffing, patients checking in or out while the phone is ringing, staff members at lunch or on break, patients being rude, and so on. But ask yourself, how important is it for you, as a patient, to hear a warm and friendly voice or see a smile? It is crucial to receive that clear affirmation that says, “Yes, you are in the right place, and we are glad you came.” It is your first impression, and it leaves a lasting impression, whether over the phone or in person.

Greeting with a smile

Although answering the phone is a seemingly simple task, in my experience, relatively few practices do this correctly. Many practices’ staff members answer the phone by saying, “Doctor’s office,” without even giving the name of where the patient is calling. These same practices often receive befuddled responses or silence over the phone because they have failed to initiate dialogue. The proper way to answer the phone is, “Thank you for calling Smith Eye Associates, this is Megan, how can I help you?” It only takes 5 seconds to say it right, and it is worth it. Let the patient hear your smile through the telephone. Remember, when cataract patients call your office, they are nervous; they need a friendly voice on the other line to say they have called the right place and that everything will be A-OK.

Know your stuff

Although staff members answering the phone may not work as ophthalmic technicians, they should have a basic knowledge of ophthalmology and surgical techniques. Recently, I was visiting a fairly busy cataract practice in the Northeast. A cataract patient who was referred from a local optometrist called in, and she wanted to know how cataract surgery was performed. The practice’s front desk receptionist told the patient that she would have all of her questions answered during their appointment. OK, fair enough, but this patient was nervous and asked again for vague details of what they should expect. The phone receptionist, frustrated, huffed out, “Hold on.” Three minutes later, a technician answered the call and gave a full explanation. She simply said, “If you have a cataract that is disrupting your vision, we’ll remove it in a 15-minute procedure that requires no shots, no stitches, and recovery time is so fast you’ll be able to drive to your postop visit the very next day.” As a consultant, I was impressed. The front desk receptionist, who had been working with the practice for 10 years, should have taken notes.

Also, make sure whoever answers the phone is educated about new technologies, such as femtosecond laser cataract surgery, even if your practice does not offer it.

Hold that thought

Another tragedy I experience repeatedly is practices putting patients on hold. Sure, sometimes we put someone on hold, but anything longer than 30 seconds is undesirable. Many practices will answer the phone and say, “Smith Eye, please hold.” Several minutes might go by before the phone staff comes back to the patient, and, of course, many patients will simply hang up and call back — or call a competitor.

If you need to put patients on hold, ask them if they would please hold momentarily, wait for their response, and then place the call on hold. Something like, “Thank you for calling Smith Eye Associates, this is Megan, would you mind holding for just one moment?” Use the proper greeting and the patient will understand and be more willing. Whatever you do, make it a brief moment, less than 30 seconds if possible.

Optimize the patient’s time

Patients appreciate when a doctor’s office of any sort respects their time. Your practice wants the patient’s experience at your office to be as comfortable and seamless as possible. One way of saving time for you and your patients is by having your patients complete all new patient forms prior to their initial appointment. When new patients come to your office, they are given paperwork requiring them to list insurance information, medications, family history, etc., taking up 15 minutes or more.

Instead of having your patients wasting their time in an uncomfortable environment and filling up your waiting room, refer them to your website and have them download and complete the forms prior to their visit. Think seniors don’t use the Internet? Think again. In 2010, the Pew Internet and American Life Project reported that 42% of seniors older than 65 used the Internet, as well as a whopping 78% between ages 50 and 64.

Now, some patients may say that they do not have a printer at home. You can also have your web designer code the forms so the patient can complete and submit the forms online. Then your office can have them printed out and ready for the patient’s signature upon arrival.

Listen to your patients

Most of us think we are really good listeners, but many of us drastically overestimate our ability in this skill. Have you ever called someone, started talking and then realized that they had not been listening? With the distractions of patients checking in and out, the other line ringing, and checking your Facebook status, listening to patients on the phone can be difficult. The brain is a single-cell processor, and it is impossible for anyone to truly multi-task. When people call, they want to be heard, so stop what you are doing and listen. As you improve this skill, you will realize that the person on the other line is pleased, and you will be involved with fewer miscommunications.

Tips for the telephone

• Answer within three rings.
• Use the proper greeting.
• Let the patient hear your smile.
• Leave patients on hold for less than 30 seconds.
• Direct patients to your website for new patient forms.
• Listen.
• Be educated on various services your practice or your competitors have to offer.

Conclusion

Spending time improving your practice’s customer service and telephone skills is extremely important. Improvement in these facets of your practice will have a big impact on your business.

In the next article, we’ll take a look at internal customer service skills:  how to greet patients and how all those little things matter.

Paul M. Stubenbordt can be reached at Stubenbordt Consulting Inc., 104 Houston St., Suite D, Roanoke, TX 76262; 682-831-0900; fax: 682-831-0903; email: paul@stubenbordt.com.