“The older population is one that we can really serve and make the biggest difference,” says Robert M. Kershner, MD, MS, FACS. “The majority of our cataract patients are in their sixth, seventh and eighth decades of life. Their level of satisfaction for our efforts is among the highest. Thirty years ago, we waited to do surgery until it was absolutely necessary and there was no other alternative. The generation of surgeons prior to mine waited until the cataract was ripe. Our criteria for surgical intervention have changed over the years, and today’s threshold for surgery is more dependent upon the patient’s lifestyle than an arbitrary line on an eye chart. The criteria for proceeding with surgery in a patient who doesn’t drive and sits at home all day watching TV are obviously going to be considerably different from those of the 40-year-old who works late, travels and is having night vision problems.” Dr. Kershner is a professor and chairman of the Department of Ophthalmic Medical Technology at Palm Beach State College, and a consultant specialist in cataract and refractive surgery in Palm Beach Gardens, Fla.
He sees today’s 80-year-olds as yesterday’s 60-year-olds. They are active, healthier and living longer than previous generations. As the baby boom generation moves into the retirement years, its expectations may be higher than today’s elderly patients. “There are about 78 million of them,” says Dr. Kershner. “This is the generation that has always wanted everything and needed it right now. They are demanding. They believe they know what’s best, they know what they want and they usually get it. That’s quite a contrast from the retirement generation of a decade ago. A few years ago, we were performing 2.2 to 2.4 million procedures annually. The latest numbers are 3.1 to 3.2 million. These numbers are not because people are developing cataracts at an accelerated rate. It is because our technologies and our outcomes have improved dramatically and the population that can benefit is expanding.”
Understanding Your Patient
The first step in managing expectations in the older cataract patient is to get to know him as an individual. If the patient is retired, it is important to find out what he did as an occupation before retirement.
While many elderly patients are still active, some are not. It is important to sit down with each individual patient and ask about his needs and lifestyle. “Surgeons have to make a concerted effort to explore what their patients’ lives are like, what their day-to-day needs are, and what they want to accomplish by undergoing eye surgery,” Dr. Kershner says. “Surgeons often don’t take the time to do that. Older surgeons think they know this group (after all, we are all in the same boat), but they are wrong. Young surgeons don’t take the time to look up from their EHR screens to see who they are talking to. So much of today’s exam is delegated to ancillary personnel.”
He notes that, while a proper preoperative interview may add only two or three minutes to the exam for each patient, the time required to convince an unhappy patient that she made the right decision can take days, weeks or months. Perhaps the most important question you can ask a patient is what her typical day is like.
Dr. Kershner says that he sees the same mistakes being made over and over again when he consults with practices. “Many patients end up getting premium lenses when their needs are not going to be met by those lenses,” he says. “They are being talked into doing something just because they think they should or because the doctor sounds convincing. This is a formula for failure. If the patient’s needs are not addressed or their concerns discussed, your patient will seek out another physician or an attorney. The valuable lesson here is to listen to every patient, ask the right questions and hear what each patient’s needs are. As the professional in the equation, we need to inquire as to their day-to-day and light-to-dark visual needs. It may be difficult to take the extra time to do the preop interview properly, but it is time well spent, not just because it can land you in court if you don’t take the time, but because unhappy patients do not refer. With today’s social networking, they can share their unhappiness with the world.”
For some patients, a premium lens may not be the best solution. For example, if a patient plays golf, a multifocal lens may not be a good choice if the patient wants the best distance acuity. “Monovision is not particularly good for golfers because of the depth of field and stereovision needed on the green,” says Dr. Kershner. “On the other hand, if the person mostly reads on a laptop or Kindle and drives infrequently at night, then she will need the best vision in the intermediate to near range. Many surgeons feel they can do good surgery, and neuroadaptation will intervene to make up the difference between a clear, well-centered intraocular lens and dysphotopsias. But, adaptation can take months if it occurs at all. It is always better to frontload the patient time. It pays for itself down the road.”
Lisa B. Arbisser, MD, agrees that premium lenses are not for all patients. “When patients are asked to step out of the paradigm that Medicare has created and pay themselves, their expectations really skyrocket,” she says. “That’s part of why we should never be upselling people for that which they don’t understand and don’t need or want, because then they are likely to be unhappy. The whole concept of ‘converting’ people from standard to premium I think is a terrible disservice to ophthalmologists as well as to patients. We should really be looking for what is right for an individual patient according to what his or her goals actually are.” Dr. Arbisser is in private practice at Eye Surgeons Associates in Iowa and Illinois and an adjunct associate professor at the Moran Eye Center at the University of Utah.
She notes that there is no perfect implant, so patients will either be given blended vision or bilateral multifocal diffractive lenses. “Nothing is going to make them like they are 15 again so we have to manage their expectations as a result and make sure that it’s very clear what the trade-offs are, that they are not widgets, and that we are not God. Only then we can meet expectations most of the time,” she says.
Age Versus Attitude
Dr. Arbisser notes that managing patient expectations is often less about age and more about patient rigidity. “I think there are rigid people at age 50 and malleable people at age 85, so it’s less about age and more about attitude,” she says. “I always ask how patients feel about glasses. Would they be happy to have readers? Will they be willing to have prescription glasses they wear occasionally? Some people think glasses age them or are uncomfortable, and they are willing to do whatever they can to get rid of them, while others think they hide their bags and they wouldn’t be recognizable without them. I offer all the choices to 80-year-olds that I offer to 55-year-olds. There are still 85-year-olds on the tennis court, at least in Iowa. I am hesitant to recommend multifocals except to those people for whom it is so critical to be rid of glasses.”
She explains that patients must understand that there is a trade-off in general vision quality with multifocality, though it’s the only way the vast majority of patients can be truly independent of glasses for all daily activities. Many people can deal well with this reality. “Naturally, we carefully choose only patients with healthy eyes and visual systems for these implants,” says Dr. Arbisser. “Because we can’t predict the future, when implanting a diffractive lens in a younger person I’m mindful of the future risk of disease development. So, in fact, I’m more confident to offer multifocals to older patients who, once they are 80 or 85 and healthy, are unlikely to ever get macular degeneration or glaucoma and so will enjoy their spectacle-free bilateral multifocality indefinitely.”
She only implants multifocal IOLs in 9 to 10 percent of her patients, but she implants premium lenses in well over 30 percent because she believes that neutralizing astigmatism is a huge boon to all patients. “Even people who think they want to wear glasses and look better in glasses are well-served not to require them for function,” she says. “For this reason, I have done peripheral astigmatic keratotomy since [Florida surgeon James Gills] described it years ago, have embraced toric lenses since their inception, and enjoy trading finicky manual AK for the femto laser version today.”
Take Extra Time
Although today’s seniors may be more technology-savvy than previous generations, they are still traditional in many areas. They remember a time when doctors made house calls, and they may prefer to spend more time with the doctor than with ancillary staff.
“I take a more traditional approach with everyone, but especially with the older demographic,” says Robert Arleo, MD, in private practice in Ithaca, N.Y. “They want the MD to do more and the optometrist to do less, and I think they need a little bit of education to work through the reality of how things are structured now. They view the doctor/patient relationship in a more traditional way where the doctor makes the treatment decisions,” he adds.
Dr. Arleo notes that it is important to determine the patient’s primary complaint and focus on improving that complaint. This population can also be more difficult to manage because many of them have other eye conditions in addition to the cataract. For example, many older patients have dry eyes, glaucoma or macular degeneration. Any of these associated conditions can limit vision to some degree.
“Many patients think that cataract surgery is going to solve everything, which is not the case for most people,” he says. “I tend to shy away from multifocal lenses in this demographic. If they have been nearsighted, I really encourage them to remain at a functional level of nearsightedness unless there is a very specific reason to change that because they have lived with it for so long. I have had more people unhappy becoming emmetropic when they were nearsighted than leaving them somewhat nearsighted. I’m sensitive to that in everyone, but with the older population, it’s even more important not to rock the boat too much.”
In his practice, the main complaint in the older age group is difficulty driving. “So, we focus on making that better and not trying to make the patient 30-years-old again,” he says. In his practice, many patients are retired professors, so they often have very high expectations. However, he says that, while the baby boom generation believes that medicine fixes everything, the older population is more cognizant of the fact that they are older and are not going to have vision like they had 30 years ago.
He recommends delivering more and promising less. “You have to be careful about what you are promising about what they are going to get,” says Dr. Arleo. “If I have an engineering professor who is -6, you’re going to really have to twist my arm to not leave him a -3. Many of those people will be unhappy if you make them emmetropic. You may need to have different goals for them. When we do change their visual acuity, we have to really be clear about how it will affect their lifestyle. If a person is myopic but likes hiking, you may want to make him or her emmetropic. It takes a little more counseling than with someone who is 45 or 50.”
Surgeons in different parts of the country may encounter different patient expectations. For example, Dr. Arleo practices in a small city with two universities. “We have a disproportionate number of very educated elderly people. They are just as tech savvy as far as researching the docs as the younger people around here. However, that may be different in other parts of the country. I think it’s very specific to your location,” he says.
Snowbirds who spend part of the year in Florida or Arizona or those who relocate to more temperate areas are often engaged in more outdoor activities than those in other areas of the country, so they may value distance vision more than elderly patients in colder climates.
Dr. Arleo notes that surgeons need to be a little bit more careful about instructions with older patients. “Many of these people have hearing issues. Some might be having some dementia,” he says. “We are very careful about giving them specific instructions and making sure they understand everything. Many of them are juggling multiple medications, and they have multiple doctors. I think they need a little more TLC with the logistics of everything. Fix the problem, but don’t try to go for it too much.” REVIEW