For many years, much of the culture and history of ancient Egypt was shrouded in mystery, due in large part to researchers’ inability to translate Egyptian writing. This all changed with the discovery and translation of the Rosetta Stone, which gave researchers and the ancient Egyptians a common language—Greek—to help the former better understand the latter.
Similarly, over a decade ago, when presbyopic intraocular lenses began to appear, neither patients nor their ophthalmologists spoke the same language, and it took surgeons large chunks of chair time to provide the many details and definitions the patients needed just to understand the basics of presbyopic IOL surgery. In response, Austin surgeon Steve Dell devised a preop patient questionnaire to act as an ophthalmic Rosetta Stone of sorts—getting patients on the same page as their doctors. Recently, Dr. Dell rewrote the questionnaire to keep pace with changes in cataract surgery. In this article, we’ll take a look at the changes and how they improve the preop patient/doctor interaction.
Dr. Dell explains the specifics of why he came up with the questionnaire in the first place. “Prior to the introduction of presbyopic IOLs in 2004, we really had a pretty simple discussion with most of our cataract surgery patients,” he says. “It was limited to the decision about whether to have their postop vision set mostly for distance or mostly for near, and spectacle independence wasn’t nearly as common a goal as it is now. Also, our refractive surgery offerings at that time were limited just to AK to try to provide good distance vision, so it was really a discussion about if the patient wanted to have good distance vision or wanted to wear glasses for everything. Then, when presbyopic IOLs came onto the scene, it was great. I had participated in some of the FDA trials of these lenses, and patients were excited about the new opportunities. However, their introduction created a massive logjam in my clinic because these consultations were now taking up all kinds of time. It was a situation that needed to be changed.
“I tried using counselors, videos and the like, but inevitably the patients still needed a discussion with a surgeon to go over their various options. Also, I wanted to develop a common vocabulary with the patients quickly. For instance, when I say, ‘intermediate vision,’ I know that I’m referring to a computer screen’s distance. A patient, however, might think I mean a TV set that’s 10 feet away, as opposed to ‘distance’ vision, which might be a mile away. And all this needed to be communicated quickly.” To accomplish this, the questionnaire was born.
The original Dell questionnaire was aimed at succinctly explaining the concept of cataract surgery or refractive lens exchange, explains Dr. Dell, and then to force the patient to prioritize his postop visual goals, using clear definitions of distance, intermediate and near tasks.
“The questionnaire then began to explore the various levels of visual compromise that the patient would be willing to accept in pursuit of these goals,” he says. “For instance, would they accept giving up stereopsis/depth perception? Would they be willing to put up with some dysphotopsias? We wanted to understand their thoughts about such compromises before even beginning the discussion.
“We also put in a personality test,” Dr. Dell continues. “In it, the patient rates his personality on a scale from easygoing to perfectionist. However, though these questions were helpful, we found the real utility of the questionnaire was its ability to get both of us on the same page very quickly. We established a common vocabulary, of course, but the patients knew—even before they met me—that some sorts of compromises might be required. Just the act of filling out the questionnaire, reading the questions, tells them that maybe they can’t have everything they imagined without any form of visual compromise. It alters their expectations a little bit, making for a much simpler discussion.”
The New Questionnaire
Even though the questionnaire proved effective, the changing world of refractive-cataract surgery led Dr. Dell to revamp it and make the new version available to his fellow surgeons. Following are the key modifications and areas Dr. Dell focuses on when a patient fills out the questionnaire.
• Key differences. “We updated the terminology to reflect current methods of accessing reading material,” Dr. Dell explains. “So, we talk about things like tablets, smartphones and e-readers. Those things didn’t really exist in 2004 when we first published the questionnaire.
“We also included a self-test for the patient’s habitual reading distance,” Dr. Dell adds. “With this, the patient uses the physical piece of paper the questionnaire is written on as a rough ruler to estimate how far from his face he typically holds the reading material. We validated this method in our clinic over a period of several months and patients were quite good at estimating whether it was one vertical paper length, 1.5 or two. This is an important question, because we now have a variety of presbyopic lenses with different add powers. We have extended-depth- of-focus lenses that are geared more toward intermediate, accommodative lenses that are better for intermediate and some multifocals that allow patients to read very close.”
The design of lenses has changed slightly over the intervening years, too, so questions regarding adverse events changed, too. “We’ve upgraded the descriptions of dysphotopsias to include starbursts, which are more of an EDOF-type phenomenon as opposed to halos and rings, and we’ve slightly reduced the severity of dysphotopsias to reflect the improved performance of modern presbyopia-correcting IOLs.” Also, in terms of logistics, if a surgeon would rather present the questionnaire digitally, such as on a tablet or laptop, Dr. Dell says he or she can use a calibrated piece of string for the estimation of the reading distance.
• Important question(s). Though the questionnaire was created so that each question is important in its own way, Dr. Dell says he finds his eyes seeking out certain questions. “I actually look at the first question, ‘Are you trying to achieve good vision without glasses at distance, mid-range and near?’ ” he says. “They then have to make a selection for each of these distances. I also pay a fair bit of attention to question three, which some patients find difficult to answer: ‘If you had to wear glasses after surgery for one activity, for which distance would you be most willing to wear them?’ They then are forced to pick distance, mid-range or near. Their response can be very telling, and you sometimes get an answer that completely surprises you. For example, we sometimes get a patient who currently has good distance vision without glasses, but who really wants to be nearsighted—they’d really prefer to read up close. It’s an unusual request, but I’ve seen it many times. And, if they do provide a weird answer like that, it stimulates a conversation about that issue, which is good. Having such a conversation after they’ve already had their surgery is very awkward—‘I really wanted X but you gave me Y.’ That’s not good.”
• Red flag responses. Certain responses to the questions can be a cause for concern. “When I review the completed questionnaire, there are some things that are worrisome,” Dr. Dell says, “such as when the patient actually refuses to fill it out. This can be a warning sign that they’re obstinate. We also see people who change their minds many times during the course of filling it out. These patients will cross out an answer, select a new one, but then go back and re-select their first answer. This is a little concerning as well. Some people fill out the questionnaire in a way that lets you know they don’t really understand what they’re reading. They appear to be completely confused about it. However, this can be helpful because it tells you that you’ve got more work to do to educate the patient on what his options are. This confusion will often take the form of contradictory answers. There are also the patients who write editorial commentary about the questions in the margins, and those who mark up the page to correct my—already correct—grammar.”
Ultimately, Dr. Dell says the questionnaire helps make a weighty decision easier for both patient and doctor. “The thing is, as a cataract surgeon, you’re sometimes making important, lifetime-long vision decisions with a patient you’ve only known for about 10 minutes,” he says. “The questionnaire helps you quickly suss out what this person is about and what his vision needs are.” REVIEW
Click here for a downloadable version of the latest questionnaire for use in your practice.