Patient Communication during Cataract Surgery:

An EyeRounds Tutorial

Jason P. Brinton, MD and Thomas A. Oetting, MD

July 28, 2011

Introduction

Cataract extraction is the most common surgical procedure in the United States today with over 3 million cases performed annually. Patient expectations for cataract surgery have increased over the past several decades as surgeons have transitioned from standard extra-capsular techniques to a clear-cornea phaco-emulsification procedure. The surgery is quick and often under topical anesthesia. However, just because the surgery is faster now, doesn’t mean that patients are not as anxious as ever about the procedure and what is going to happen to them. The purpose of this tutorial is to offer some suggestions to assist the surgeon with the intraoperative portion of patient communication.

Background

Various studies have looked at a number of factors relating to the quality of the patient’s intraoperative experience, among them confidence, pain, understanding, satisfaction, memory, and reassurance.[Mokashi 2004] Three to 16.2% of patients who had cataract surgery with topical or retrobulbar anesthesia reported they were frightened by the visual experience of the procedure.[Tan 2005] Fear may lead a patient to become restless or uncooperative. The language and conduct of the operative team has been demonstrated to have a meaningful effect on these parameters. In one study, handholding by a nurse was shown to produce a significant decrease in patient epinephrine levels and in the number of patients reporting intraoperative anxiety.[Moon 2001] A second study showed that a hand massage five minutes before cataract surgery led to a decrease in patient levels of epinephrine, norepinephrine, cortisol, blood pressure, pulse, and reported anxiety.[Kim 2001] In a third study patients were allowed to use an electronic patient-controlled alert device that allowed them to level of anxiety related to their cataract extraction procedure.[Mokashi 2004] In addition to discussions that take place in the exam lane, some surgeons have sought to familiarize the patient with cataract surgery in advance of their procedure by allowing them to watch a surgery live. Some ambulatory surgery centers have an operating room setup that allows patients contemplating cataract surgery to watch live surgery through a window to the operating room or by video feed. Other surgeons may refer patients to websites such as www.eyerounds.org to familiarize them with process of undergoing cataract surgery.

What follows are some suggestions on how to communicate with patients while performing cataract surgery. For a video of informed consent for cataract surgery see the following link: http://cataractsurgeryforgreenhorns.blogspot.com/2009/01/consent-for-cataract-surgery.html

"Do I Have Cancer?"

Your patients are listening. They listen to the words we use and tone of our speech. They hear how you treat your staff and expect professionalism.

A patient experience from several years ago illustrates how a single word uttered in the operating room, taken out of context, can result in a significant misunderstanding. In this case Dr. Oetting was operating with one of the senior Iowa residents. Toward the end of the case the anterior chamber temporarily shallowed and for a moment the two surgeons discussed several conditions that could lead to this finding. Among those mentioned was "malignant glaucoma," also known as aqueous misdirection. The temporary shallowing ended up being inconsequential and the case was completed without incident.

When the patient returned for his postoperative month one visit he asked if he could speak with Dr. Oetting in private. The patient then queried, "when are you going to tell me about my cancer?" The patient had heard the adjective "malignant" in the operating room and spent the next four weeks believing that he had a cancer about which his surgeons had not informed him.

The words and tone of voice we choose in the operating room contribute to the patient’s overall experience. When balanced with appropriate silence, they provide comfort to the patient, allow for a greater measure of involvement in their medical care, and promote safety.

Steps of Cataract Surgery with Suggestions on Patient Communication

Preoperative, day of surgery

Retrobulbar anesthetic injection:

Surgical prep

Draping

Microscope Light

Lid speculum placement

Incisions

Intracameral lidocaine

Viscoelastic

Malyugin ring insertion

Capsulorhexis

Hydrodissection

Phacoemulsification

Cortical removal

Placement of intraocular lens implant

Removal of viscoelastic

Wound Closure

End of the Case

Some additional suggestions:

References

Kim MS, Cho KS, Woo H, Kim JH. Effects of hand massage on anxiety in cataract surgery using local anesthesia. J Cataract Refract Surg. 2001;27(6):884-90.

Mokashi A, Leatherbarrow B, Kincey J, Slater R, Hillier V, Mayer S. Patient communication during cataract surgery. Eye (Lond). 2004;18(2):147-51.

Moon JS, Cho KS. The effects of handholding on anxiety in cataract surgery patients under local anaesthesia. J Adv Nurs. 2001;35(3):407-15.

Tan CS, Au Eong KG, Kumar CM. Visual experiences during cataract surgery: what anaesthesia providers should know. Eur J Anaesthesiol. 2005;22(6):413-9.

Suggested Citation Format: Brinton JP, Oetting TA. Patient Communication during Cataract Surgery: An EyeRounds Tutorial. Eyerounds.org. July 28, 2011; Available from: http://www.EyeRounds.org/tutorials/Communication-Cataract-Surgery.htm