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

• What they may be thinking
  • I will never keep this straight
  • Why so many drops?
  • What are these drops for?
• What to say
  • "We will give you a printed instruction sheet and the nurses will go all of the drops after the surgery."
    • Topical anesthetic drops: this drop will numb the eye for your comfort but may sting for a few seconds.
    • Antibiotic drops: this drop is to prevent infection.
    • Steroid drops: this drop is for your comfort.
    • Dilating drops: this drop is to open the pupil and expose the cataract and may blur your vision.

Retrobulbar anesthetic injection:

• What they may be thinking
  • I thought this was not going to hurt?
  • Is that a needle?
  • Why are we doing this?
• What to say
  • "Look straight up at the ceiling and try to keep both eyes open. This is the hardest part of the procedure but will make everything else pretty easy. You will feel a poke in your eyelid followed by pressure around your eye as the numbing medicine starts to work."

Surgical prep

• What they may be thinking
  • I can feel this on my skin I thought I was numb
  • What is she doing now?
• What to say
  • "This cold solution helps clean the eye to prevent infection. You may feel this on your skin but don’t worry your eye is numb."

Draping

• What they may be thinking
  • Will I be able to breath?
  • What is she doing now?
• What to say
  • "These sheets are to keep the eye clean during surgery; it is really just a fancy paper towel so you can breath right through it. Plus you will have a lot of oxygen flowing from this nasal cannula. So really you will have more air than usual."

Microscope Light

• What they may be thinking
  • It is so bright!
  • How long will this last?
• What to say
  • "At first the microscope light will be very bright and then you will get used to it. We will also give you some medicine to help make the light less bright."

Lid speculum placement

• What they may be thinking
  • Am I supposed to keep my eye open?
  • What is she doing now?
• What to say
  • "This is a soft device that keeps your eye open so you don’t have to worry about blinking" (consider avoiding the term speculum, especially in female patients who may have encountered this word in its ob-gyn context).

Incisions

• What they may be thinking
  • When will they really get started?
  • Will it hurt?
  • What is she doing now?
• What to say
  • "We are getting started now and everything is going great."

Intracameral lidocaine

• What they may be thinking
  • That hurts I thought I was numb!
  • What is she doing now?
• What to say
  • "Here is the rest of the medicine to get you the rest of the way numb you may feel a sting while I put it in and then you will be all the way numb."

Viscoelastic

• What they may be thinking
  • The microscope light is bright!
  • Then the light goes dim. Am I going blind?
  • What is she doing now?
• What to say
  • "This medicine makes the light less bright."

Malyugin ring insertion

• What they may be thinking
  • I can feel some pressure, is this going to really hurt?
  • What is she doing now?
• What to say
  • "You may feel some pressure inside your eye on this step don’t worry it will just last a second."

Capsulorhexis

• What they may be thinking
  • How is the surgery going?
  • What is she doing now?
• What to say
  • "The surgery is going great and this is a very delicate part and i would like you to hold very still for a minute or so."

Hydrodissection

• What they may be thinking
  • I can’t follow the light any more, what do I do now?
  • What is she doing now?
• What to say
  • "it may be hard to follow the light now so just try to look up at the ceiling."

Phacoemulsification

• What they may be thinking
  • What are those funny noises
  • Are we making any progress yet?
  • I feel fluid by my ear is that blood!?
  • What is she doing now?
• What to say
  • "Now we are using the machine that removes the cataract you will hear some funny noises and voices. During this part we use a lot of water so don’t worry if you feel some fluid."

Cortical removal

• What they may be thinking:
  • How much longer
  • Something seems different, is everything OK?
  • What is she doing now?
• What to say
  • "The main part of the cataract is out and we’re 2/3 of the way done and are just removing some of the soft parts of the cataract."

Placement of intraocular lens implant

• What they may be thinking:
  • I can see some funny shapes
  • I am feeling some pressure
  • Am I going to see yellow forever now?
  • What is she doing now?
• What to say
  • "This is the most interesting part as we are going to place the artificial lens. You may feel some pressure as we place the lens which will look like an amber crystal. Can you see it? It will give you very clear vision."

Removal of viscoelastic

• What they may be thinking
  • What is she doing now?
• What to say
  • "We are removing a protective jelly from around the lens implant and are almost done."

Wound Closure

• What they may be thinking
  • Wow that was fast!
  • Why do I need a suture (if they did)?
  • What is she doing now?
• What to say
  • "We’re nearly done. I’m checking to see if your wound can seal itself. It looks like we need to place a suture to keep the eye secure. You may feel a little poking sensation as we place the suture to close the wound. Everything is going great."

End of the Case

• What they may be thinking
  • What do I do now?
  • When do I see her again?
  • Why is everything so blurry?
• What to say
  • "We are all done and your surgery went great. Your vision will be blurry for a few days as the drops wear off and the swelling goes away. We will see you in four to 5 hours and make sure your pressure is okay. Thank you for holding so still."

Some additional suggestions:

• Use "anticipatory reassurance." Consider what the patient may be wondering about as you talk to them.
• It is important to gauge how much information the patient wants to hear as you go along.
• Talk to patients you trust and ask them what the experience is like.
• If you have a problem let the patient know the case is going to take a little longer and briefly why.

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