CATARACT EWAP MARCH 2024 9 and drive at night again. “For a while, I was seeing a lot of advanced cataracts, a lot of people who waited longer than they should have,” she said. Amandeep Rai, MD, has also found that coming out of the pandemic, there has been a noticeable trend toward patients presenting with more advanced cataracts. “The delayed access has certainly resulted in more patients presenting with advanced, visually significant cataracts in the last 2 years,” he said. “However, I do see a fair number of patients with milder symptoms who are referred from their optometrist for a surgical consult,” he said. “If they are minimally symptomatic, I will often ask them to follow up with the optometrist until the cataract becomes more advanced.” The decision to proceed with cataract surgery is jointly made by the patient and the ophthalmologist, Dr. Rai said. While cataract surgery is safe and can have a profound impact on a patient’s quality of life, it is ultimately an elective surgery. With more advanced cataracts, the patient has already been symptomatic for some time and arrives at the consultation ready to proceed with surgery. “With respect to allowing the cataract to become more visually significant, the Lens Opacities Classification System III (LOCS III) is a great scale. With the most common subtypes of cataracts, a lower LOCS III grade cataract can be observed if the patient is tolerating the lens changes, while a higher-grade cataract is ready for surgery,” he said. “If we elect to observe a cataract, I ask the patient to monitor their symptoms and return once they think their lifestyle is impacted. Typical early complaints include difficulty with night driving or frequently updating their spectacles due to shifting refraction and a drop in their best corrected visual acuity.” Rom Kandavel, MD, thinks that as a patient, a good question to ask when considering cataract surgery is, “With my best pair of glasses, what vision problem do I wish to solve through cataract surgery?” As a surgeon, you may want to ask, “Is the vision limiting the patient’s quality of life or their ability to perform daily activities the way they want to be perform?” If you can’t find the answer to those questions, you probably shouldn’t be operating on that patient, he said. “That is the premise of what I look for in a conversation. It’s not a discovery when they need surgery. The vision is already impacting the patient’s quality of life. The need to improve the vision should be obvious to the surgeon and to the patient.” You never want to be in a position where you’re telling the patient that they have a problem that they are unaware of. He added, “In the rare circumstance that a patient has a problem after surgery, like glaucoma or retinal detachment, the patient should look back and know they made a clear self-driven decision to improve their vision through surgery. “Patients will commonly know they are ready for surgery, but they’ll still ask me, ‘Do I need this surgery?’” It’s not because they’re not sure, but Dr. Kandavel said they want reassurance in order to move forward with their decision. He will be supportive and positive. “I never do surgery on someone who I don’t think it will help significantly.” He also said that as surgeries become more routinely successful, physicians may become less mindful of the potential complications of a procedure. Operating on borderline cases can be less successful. “A good result, when evaluated in the context of moderate preoperative vision impairment, becomes unacceptable with a symptom such as mild halo after surgery. “I always tell residents that the patient’s satisfaction with your surgery is not always linked to the result but to the process that you establish with the patient, earning trust over years of appointments,” he said. “If you build that trust, not only do you have a more fulfilling career, but you also have a more successful one.” When patients trust you, they are much more likely to put their faith in your recommendations because of that earned relationship. Dr. Kandavel said there are some reasons to operate sooner rather than later. One potential issue is cases with narrow angles. “In hyperopic patients who fail to have an angle improvement with laser iridotomy, cataract surgery can become medically indicated,” Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. LESSONS LEARNED Rosa Braga-Mele, MD, EyeWorld Cataract Editorial Board member: I have found that when dealing with complaints of quality of vision from MFIOL patients, it is important to listen but also show them what their near vision would be like without the MFIOL. I put up –2.50 trial lenses in front of their eyes while having them hold a Jaeger near card. Once they see what their up-close vision would have been like with a monofocal IOL, most will stop complaining about little issues. Also always let your patients know it can take up to 3–6 months for foreign body sensation to go away and neuroadaptation to take place with their new lenses.
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