BSM Connection

eLearning Course

Preparing Patients for

Cataract Surgery

By: Roger Steinert, MD,

and
Jane Shuman, COT, COE, OCS

2010, BSM Consulting

All Rights Reserved.
Preparing Patients for Cataract Surgery

Table of Contents

OVERVIEW ................................................................................................................................ 1

OPPORTUNITIES FOR PRACTICE EFFICIENCY ..................................................................... 1

THE ROLE OF THE SURGICAL COORDINATOR ..................................................................... 2

TRAINING THE SURGICAL COUNSELOR ............................................................................... 3

PATIENT COUNSELING: CATARACT SURGERY .................................................................... 5

SUCCESSFUL COMMUNICATION WITH THE PATIENT ........................................................ 11

CONCLUSION .......................................................................................................................... 12

APPENDIX

Exhibit 1: Frequently Asked Questions Regarding Cataract Surgery ............................. 14

Exhibit 2: Sample Pre- and Post-Operative Instructions ................................................ 15

Exhibit 3: Sample Surgical Checklist ............................................................................. 16

Exhibit 4: Sample Patient Letter..................................................................................... 17

COURSE EXAMINATION ......................................................................................................... 18

2010, BSM Consulting

Preparing Patients for Cataract Surgery

OVERVIEW
Cataract surgery is among the most frequently performed surgical procedures in the United States today,
boasting an extremely high success rate. However, to the patient who relies greatly on his or her eye
sight for independent living, cataract surgery can be a frightening proposition. The best way to alleviate
this fear is to have systems in place that convey a consistent message to the patient throughout the
evaluation, counseling, and surgical processes. The consistent message should be, Our practice
standard is to give you the best care possible.

Practices everywhere must be prepared to accommodate a growing number of surgical patients. As

surgical efficiencies are implemented and procedure time is reduced, surgical facilities will be able to
operate on an increasing number of patients; however, the same efficiencies may not exist in some
offices, thus creating a logjam. According to the National Eye Institute, an estimated 20.5 million
Americans age 40 or higher currently have a cataract in at least one eye. This number is expected to
1
reach 30.1 million by 2020 .

As the number of potential surgeries grows, it is estimated that the number of ophthalmologists will
decline, causing an increased waiting period from the time of diagnosis until the date of surgery. Although
the ideal wait time for cataract surgery is not benchmarked, it has been determined that patients who
waited more than six months for cataract surgery suffer a greater degree of vision loss, a reduced quality
2
of life, and an increased number of falls.

OPPORTUNITIES FOR PRACTICE EFFICIENCY

Effective practice systems begin with the staff member that answers the phone. Patients often will call,
stating they have been diagnosed with a cataract and are being referred for surgery. This is an
opportunity to extend an immediate appointment for the first available slot without delay. For those
practices with regular referral sources, this can be accomplished by allocating specific slots in the
schedule for referred cataract patients. These patients have already been informed that surgery is likely.
If a patient cannot be seen within days, he or she is likely to contact competitors who may be more
obliging and be able to schedule an appointment more quickly. Imagine the repercussions when a patient
shares his or her experience with another potential patient. It is important that the patient encounters a
warm, accommodating welcome to the practice.

A pre-determined number of slots may be held for new surgical patients until several days in advance of
the appointment day, at which point the remaining slots can be used for last-minute additions. Each
practice should have a prepared list of questions to ask the caller prior to the appointment, such as Are
you having any visual discomfort or light sensitivity? In some offices, potential surgical candidates can be
directed to the practices website, where medical history forms can be completed in advance of the
appointment. If the practices surgeons perform multifocal and/or accommodating lens implants, the initial
conversation is an opportunity to educate the patient about this option, thereby providing time for the
patient to consider all options in advance of the appointment. Alternatively, when time allows, a new
patient packet can be sent out for completion in advance of the appointment.

Someone in the practice must analyze the patient schedule regularly and adjust the available slots
accordingly. Modifications may need to be made in the master schedule to accommodate the growing
number of cataract patients. Practice revenues are greatly dependent on surgical revenues; therefore, it
is important to maximize the office schedule.

1
National Eye Institute citing Archives of Ophthalmology 2004; 122:487-494
2
The Consequences of Waiting for Cataract Surgery: A Systematic Review, CBC News, Canadian Medical Association Journal;
April 24, 2007; p. 1285
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Preparing Patients for Cataract Surgery

As surgeons, ophthalmologists understand that serious

health issues or family emergencies can cause cases
to be cancelled. However, efficient processes can
reduce cancellations to keep the surgical schedule
filled and to assure both the doctor and the patient that
no detail is left undone. To implement efficient
processes, it is recommended that each practice have
one or more surgical coordinators, depending on the
size of the practice, the patient load, and the number of
surgeons. In smaller practices, surgical counselors may
perform other functions in addition to surgical
coordination; however, each staff member in both the
medical office and surgical facility is important in Employing a dedicated surgical coordinator will
maximizing the patients medical and surgical significantly improve the quality of care a practice
experience. can offer patients.

THE ROLE OF THE SURGICAL COORDINATOR

The surgical coordinator acts as the liaison between the physician, the hospital or surgery center, and the
patient. Whether the surgery is done at a hospital or in an ambulatory surgical center, the surgical
coordinator is responsible for the following:

Describing the patients diagnosis and CONTRIBUTORS TO THE PATIENTS

procedure to be performed SURGICAL EXPERIENCE

Obtaining written consent for the procedure Receptionists (Telephone, Front Desk, Check-out)
Technicians
Scheduling the surgery
Scribe
Scheduling all pre-operative appointments Surgical Coordinator

Ordering the IOLs Physician/Surgeon

Ensuring the paperwork arrives at the
facility well in advance of the surgical date
Arranging transportation to and from the
surgical facility
Surgical Facility Staff
Anesthesiologist and Anesthesia Staff
Patients family and support system
Patient

Discussing insurance and personal financial obligations

Providing written pre-operative and post-operative instructions

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Preparing Patients for Cataract Surgery

TRAINING THE SURGICAL COUNSELOR

In order to accomplish such a myriad of tasks, the surgical
coordinator must have systems in place to track all occurrences for
each patient related to the upcoming surgery (see Exhibit 3: Sample
Surgical Checklist,) and be familiar with the guidelines of each
facility in which the surgeon operates. The responsibilities outlined
above are discussed in greater detail in the sections below.

1. The surgical counselor must have knowledge of not only

the diagnosis of the patient, but also of the procedures to
be performed, the risks and benefits of the procedure, and
the pre-operative and post-operative expectations and
instructions. This information can be obtained in a number
of ways; however, having the opportunity to follow a patient
through the surgical process is often very helpful. This
observation provides the surgical coordinator with the ability
to share firsthand knowledge with patients who are about to
undergo cataract surgery. With the patients permission, the
surgical coordinator should follow a patient through the
entire process: check-in, anesthesia, surgery, and Equally important is providing the
surgical coordinator the opportunity
postoperative care at the surgical facility. The end result is
to follow a patient through the
that the surgical coordinator will be better prepared to surgical process. This observation
accurately answer patient questions and to assist in the will provide the surgical coordinator
setting of realistic expectations. with the ability to share firsthand
knowledge with patients who are
2. To become familiar with cataract diagnoses and surgical about to undergo cataract surgery.
procedures, the surgical coordinator should use a variety of
resources available to enhance the learning process. Information can be obtained online and in
books written at a level appropriate for lay people. In addition, videos and animations can be used
to review the procedure, lens options, and associated risks and benefits. Shadowing another
surgical coordinator and surgeon provides an opportunity to observe what is said and how it is
said.

3. The surgical coordinator should have an understanding of the documentation requirements for
cataract surgery. Medical necessity for cataract surgery must be clearly documented in the
patients medical record. While the criteria may vary among insurance carriers, it is a general rule
of thumb that the best corrected vision must be 20/50 or worse when tested at distance or with
the Brightness Acuity Meter (BAT) set on medium. This must be measured with the patients best
corrected vision. In addition to visual acuity requirements, limitations in activities of daily living
caused by decreased vision must also be documented. Patients whose best corrected vision is
better than 20/50 will also have medical necessity for cataract surgery providing their activities of
daily living are impacted and documented. Staff members and doctors should be familiar with
their local Medicare policies.

4. As cataract surgery has evolved and become more

complex with the recent addition of premium
intraocular lenses, the surgical counselor must
have knowledge of the alternatives to traditional
cataract surgery and be able to explain the
advantages and disadvantages of each, although it
is the surgeon who determines a patients medical
candidacy. These new premium lenses include
toric, multifocal, and accommodating intraocular
lenses. In practices that insert a high volume of
these lenses, one surgical coordinator may assume The role of the surgical coordinator has
responsibility for the counseling of all patients become more complex with the recent
considering a premium intraocular lens. Although addition of multi-focal IOLs.
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Preparing Patients for Cataract Surgery

the surgical preparation and procedure are the same, patient expectations and the costs are quite
different. Therefore, more time may be needed to clearly explain the differences in order that the
patients expectations are realistic. The surgical coordinator must be familiar with the functionality
of each of the premium lenses and, more specifically, the lens(es) each surgeon in the office is
implanting. In some practices, surgeons may implant only one model, while another surgeon
might embrace all available models. At the time of this writing there are three FDA approved
multifocal IOLs (ReStor, ReZoom and Tecnis) and one accommodating lens (Crystalens), with
pending FDA approval of the accommodating Synchrony lens expected soon. Each lens has
different properties in the three focal zones of distance, intermediate, and near. This technology is
a rapidly changing one as there are more lenses being developed. If a premium lens is
recommended by the physician, every patient should be provided information regarding
advantages and disadvantages of each lens type so that an informed decision can be made.

The presbyopic, or premium, lens was the first instance in which the Centers for Medicare and
Medicaid Services (CMS) approved separate billing to the patient for services related to the
refractive function of the implant (premium lenses). These charges include additional physician
services and lens costs above and beyond the usual payment from Medicare for a monofocal
intraocular lens. The reason for this ruling is that the premium lenses are refractive, and refractive
services are not covered under Medicare and most third-party payers.

5. The surgical coordinator must have knowledge of the different requirements of the various
facilities in which the surgeon operates. If the surgeon operates at both a hospital and at an
ambulatory surgery center (ASC), the surgical coordinator may find the processes similar, yet
very different. They may be alike in that patients must have pre-operative clearance, spend time
in the pre-operative and post-operative areas, and usually leave feeling hopeful about their vision.
Differences may be related more to the size and scope of the facility.

As an increasing number of ASCs are being built, ophthalmologists are finding that single
subspecialty venues are able to provide quality care more efficiently than local hospitals where
any number of surgeons may be operating on various organs simultaneously. Hospital nursing
and surgical staff may not be familiar with the details of eye surgery, slowing the process as they
try to answer patient questions with which they may not be familiar. Because of these variations,
it is critical that the surgical coordinator be able to answer patient questions and concerns fully
and to set realistic expectations for the procedure being scheduled.

The typical ASC has multiple operating rooms dedicated to a high-volume surgeon during a
specific block of time (the hours regularly saved for a particular surgeon). These rooms may be
connected by the sterilizing area, thereby allowing the surgeon to move from room to room with
minimal disruption. Historically, the ASC turn-over time (the amount of time necessary to
prepare the operating room for the next patient) is minimal. While the surgeon is in one room, the
other room is turned over, and the patient positioned on the operating table. As a result, the
surgeon often can perform significantly more surgeries in one session, thus reducing wait time for
patients and improving patient satisfaction. Knowledge of the surgical flow assists the surgical
coordinator in preparing the surgical schedule for maximum efficiency and to limit the patients
time in the facility. Communication between the physician, the facility, and the surgical
coordinator or scheduler is of critical importance in efficient scheduling for all parties involved (the
surgeon, the facility, and the patient).

According to James Yates, MD, President of the American Association for Accreditation of
Ambulatory Surgery Facilities, patients experience less stress navigating an ASC than a hospital
because the admissions desk, waiting room, staging area, and operating rooms are generally
closer to each other than in the hospital setting. Other advantages include modern facilities,
3
nearby parking, and personalized service.

3
http://www.physiciansnews.com/cover/705.html

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Preparing Patients for Cataract Surgery

PATIENT COUNSELING: CATARACT SURGERY

The counseling of a patient prior to any surgical
procedure is critical in setting expectations of the
patient. Through patient education regarding the many
facets of cataract surgery, the patient is able to obtain
a realistic expectation of the procedure recommended
and its risks, benefits, and alternatives. According to
Teisch et al., Expectations regarding visual
functioning after cataract surgery are very high and, in
most cases, such expectations are fulfilled. In selected
cases, more comprehensive counseling may reduce
the discrepancy between expectations and actual
4
outcomes of cataract surgery. Almost a decade later,
Chet Pager found patients have highly unrealistic
expectations surrounding cataract surgery. He also
The purpose of surgical counseling is to assure the
emphasizes the importance for physicians to control
patient that cataract surgery, at least from the patients
their patients expectations. Controlling patient point of view, can be a simple, easy process.
expectations may be more effective than improving
5
patients postoperative outcome in terms of maximizing patient satisfaction.

The decision to have elective eye surgery is always the patients decision. For people who are
experiencing visual difficulties with their activities of daily living, this is an easy decision to make. For
others whose vision loss has been slowly progressive, this decision is more difficult. They may be
squeamish about surgery in general (or eye surgery in particular), feel they will inconvenience others, or
dont notice a problem, even though the vision change and glare sensitivity are documented.

A life-style questionnaire is often given to the patient for completion. This questionnaire not only assists
the surgeon in determining the suitability of a patient for cataract surgery and/or a premium lens, but it is
also helpful in the patient counseling process. This life-style questionnaire should include the prioritization
of visual needs for work and other daily activities as well as examples of activities at each distance, i.e.,
driving, computer usage, reading, and other close-up activities such as needlepoint, etc. Many practices
also have added a questionnaire developed by Stephen Dell, M.D., that identifies the patients degree of
perfectionism. Patient responses on this questionnaire provide the physician additional information to use
in developing the optimal surgical plan for a specific patient.

The patient must be guided to make an intellectual decision rather than an emotional one. Once the
recommendation for surgery has been made, and risks, benefits, and alternatives have been discussed
by the surgeon, the patient often is referred to the surgical coordinator, who will know the surgical
availability and can begin the process of educating the patient regarding the procedure and its expected
results. The purpose of patient counseling is to educate the patient as to his or her diagnosis, the
procedure recommended, and to reiterate the risks, alternatives, and benefits of cataract surgery to the
patient. Also included in the discussion should be pre-operative appointments, pre-operative and post-
operative instructions, post-operative expectations. The patient counseling process will often result in the
scheduling of a surgical date that is acceptable to both patient and physician.

4
Teisch JM, Steinberg EP, Cassard SD, Schein OD, Javitt JC, Legro MW, Bass EB, Sharkey P.; Preoperative functional
expectations and postoperative outcomes among patients undergoing first eye cataract surgery. 1995. www.archopht.ama-assn.org
Arch Ophthalmol, Oct 1995; 113: 1312-1318
5
Pager, Chet K.; Expectations and Outcomes in Cataract Surgery http://archopht.ama-assn.org/cgi/content/abstract/122/12/1788
Arch Ophthalmol. 2004;122:1788-1792
2010, BSM Consulting 5
Preparing Patients for Cataract Surgery

PATIENT COUNSELING
The patient counseling process often includes these 10 steps.
Step 1: Establishing Rapport
Step 2: Discussing Risks, Alternatives, and Benefits
Step 3: Discussing the Potential Outcome of Surgery
Step 4: Discussing the Diagnosis and Surgical Procedure
Step 5: Discussing the Patients Financial Responsibilities
Step 6: Obtaining the Patients Informed Consent
Step 7: Providing Pre-Op and Post-Op Instructions
Step 8: Discussing Post Operative Expectations
Step 9: Scheduling Pre-operative Testing and Appointments
Step 10: Summarizing

The above mentioned steps in the patient counseling process are discussed in detail below.

Step One: Establishing Rapport

The first stage in the patient counseling process is establishing a rapport with the patient. It is important
for patients to know that the surgical coordinator understands their problem, cares about them, and is
competent to help them. The coordinator must discover if the patient is interested in proceeding with the
discussions relating to cataract surgery. The surgical coordinator must make certain that the patient is at
ease and able to focus all attention on the conversation. If the patient is preoccupied, the entire
conversation will be of little benefit and a patient counseling appointment should be scheduled in the
future.

Step Two: Discussing Risks, Alternatives, and Benefits

Counseling the patient about the surgical risks, benefits, and alternatives often falls to the surgical
coordinator; however, for compliance purposes, the physician should also review risks, benefits, and
alternatives with the patient. There may be individual considerations that could potentially impact the final
outcome, such as other ocular or systemic conditions. Working as the physicians agent, the surgical
coordinator must project confidence and knowledge surrounding the surgery. A discussion regarding the
surgeons recommendations as to type of intraocular lens should be included at this point in the
counseling process. Both the benefits and risks of each alternative recommended by the surgeon should
be thoroughly discussed. For example, if a patient has large amounts of astigmatism, the surgeon may
recommend either astigmatic keratotomy or a Toric intraocular lens. Thorough discussion as to how this
procedure or special lens would benefit the patient must occur. From a risk management perspective,
there also needs to be a disclaimer stating the patient was informed of these additional options and either
chose to have a refractive implant with a patient self-payment component or declined the option.

If any type of premium intraocular lens is recommended, then the financial responsibilities of both the
insurance company and the patient must be clearly established.

Step Three: Discussing the Potential Outcome of Surgery

The third phase in the patient counseling session is to provide an expectation of the surgical experience
and potential for improved vision and lifestyle. It is important to discuss any patient conditions that may
limit the patients potential for improvement in vision (for example, macular degeneration). Other
discussions of visual improvement from cataract surgery may be related to the activities of daily living
documented in the chief complaint or the life-style questionnaire. Shared patient experiences often
alleviate a patients concerns through the use of support groups comprised of former surgical patients
who have offered to speak with others, patient testimonials, or video recordings.
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Preparing Patients for Cataract Surgery

Two common questions to expect are:

How well the patient can expect to see?

How soon following the procedure will the patient achieve the expected vision?

Under no circumstances should any member of the team answer those questions with a measurable
number, such as 20/25 or better. Rather, it is better to indicate that cataract surgery has the highest
success rate of all eye surgeries performed. According to the Eye Surgery Education Council, the
success rate of cataract surgery runs at a steady 98%.

Step Four: Discussing the Diagnosis and Surgical Procedure

The fourth step of the patient counseling process is to actually open the discussion regarding what a
cataract actually is and what can be done to alleviate the problems caused from cataracts. Show and
tell items can be extremely helpful when counseling patients. This may include written or video patient
education materials or a list of online resources. It is also effective to have a model eye and a sample
intraocular lens available to use when describing the procedure. If family members are present, the
patient should be encouraged to include them in the counseling session. HIPAA regulations require a
notation in the record as to who was present and what was discussed in the session. It is also helpful to
document the relationship to the patient and, if additional related conversation is likely, the family
members phone number.

The following information regarding the surgical procedure should be discussed with patients:

Provide an estimation of time, both the total amount of time to plan on from arrival to departure
and the average surgical time.

Inform the patient that many people will ask for clarification as to which eye is the operative eye.
This question is asked merely to confirm the accuracy of the surgical plan. In fact, the area above
the surgical eye is likely to be marked for additional confirmation of the operative eye.

Discuss expectations relating to anesthesia. Many patients are under the misconception they will
be asleep during the surgery. In rare cases this is true; however, the majority of cataract
surgeries are performed using topical anesthetic with an additional medication provided to reduce
anxiety. Remember, anesthesia guidelines for ANY procedure prohibit patients from operating a
motor vehicle for 24 hours following surgery.

Instruct the patient to make arrangements for transportation, both to and from the surgical facility.
Many patients may be concerned they will not find the hospital or ambulatory surgery center on
time on the day of surgery as it may be located in a town with which they are unfamiliar or in the
big city. It is the responsibility of the surgical coordinator to calm these fears and assure patients
by providing detailed driving instructions (in large print) and a clear map. To alleviate some of the
fears related to location of the facility, the counselor might suggest that the patients driver take a
test drive to the facility before the day of surgery.

o Some offices or ASCs may provide transportation on the day of surgery, if necessary.
When doing so, CMS regulations stipulate the patient be accompanied or have a written
exemption from the surgeon as is outlined below:

Q-0267 416.52(c) Standard: Discharge. The ASC must - (3) Ensure all patients are
discharged in the company of a responsible adult, except those patients exempted
by the attending physician. Interpretive Guidelines 416.52(c)(3) Unless the
physician who is responsible for the patients care in the ASC has exempted the patient,
the ASC may not discharge any patient who is not accompanied by a responsible adult
who will go with the patient after discharge. ASCs would be well-advised to develop
policies that address what criteria a physician should consider when deciding a patient

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Preparing Patients for Cataract Surgery

does not need to be discharged in the company of a responsible adult. Exemptions must
be specific to individual patients, not blanket exemptions to a whole class of patients.

The surgical coordinator must be aware of the transportation policies of each surgical
facility used by the practice. Because of cost, time, distance, etc., many practices
exercise discretion in deciding to whom they offer this service.

Step Five: Discussing the Patients Financial Responsibilities

Patients need to have a full understanding of the financial responsibilities related to their cataract surgery.
Confirmation of insurance benefits is important, as pre-authorization of surgery is often required by
insurance carriers. There may be co-pays for the surgical facility and additional charges for pre-operative
evaluations. Patients are much more comfortable when realistic financial expectations are set.

If premium intraocular lenses are an option, it is important to discuss the financial implications to the
patient. Printed materials should be provided so the patient has both the time and information to make an
informed choice. The partial elective nature of this option mandates this discussion which should occur
early in the counseling process and should include any financing options available. When the premium
intraocular lenses were first introduced, there was speculation that only high-income patients with greater-
than-average disposable income would opt to have premium lenses. Recent surveys indicate, however,
this is not the case. Patients of all income brackets wishing to be spectacle-free are finding the means to
achieve that goal. Often the adult children of the patient encourage their parents to choose the premium
lens, and some offer to pay for the premium lens choice. Cataract patients are encouraged to discuss
these choices with their family members prior to making a decision. All office staff should be aware of any
financing alternatives available, although the detailed conversation should be left to the surgical
coordinator or business office representative.

Step Six: Obtaining the Patients Informed Consent

Consent forms should be presented only after the patient understands all of the risks, benefits, and
alternatives of the recommended surgery. As previously mentioned, both the surgeon and the surgical
coordinator must review this information with the patient, and the patient should have an opportunity to
read the consent form. Obtaining the patients consent is more than just signing the form; rather, it is the
result of a successful counseling session. The patients signature on the consent form indicates the
patients understanding of all of his or her obligations (pre-operative appointments and testing, post
operative instructions, and financial responsibilities), the responsibilities of the practice and surgeon, and
the risks, benefits, and alternatives of the surgery.

Step Seven: Providing Pre-Op and Post-Op Instructions

Patients must have a clear understanding of all pre-
operative and post-operative instructions, not only
for their own comfort, but also to maximize the
patients surgical outcomes. If instructions are not
clearly understood, patients may forget to use the
eye drops necessary for the healing process. These
instructions should be provided not only verbally by
the surgical coordinator, but also in writing so that
patients can review the instructions as needed.
Though the pre-operative and post-operative drug
instructions vary from surgeon to surgeon, patients
are often expected to use an antibiotic eye drop and
a non-steroidal anti-inflammatory eye drop prior to
surgery.
INSTRUCTIONS FOR INSTILLING EYE DROPS
1. Hold the bottle between the thumb and forefinger.
2. Brace the thumb on the bridge of the nose.
3. Pull gently on the lower lid of the surgical eye with
the opposite hand.
4. Look up and make as large a pocket as possible.
5. Squeeze the bottle to land a single drop in the
pocket of the lower fornix.
6. Refrigerate the drops, if needed, so that the
patient can feel the cool substance touch the eye,
providing assurance that the drop is correctly
placed.

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Preparing Patients for Cataract Surgery

Post-operatively, a steroid eye drop is usually added. Since the schedule of instillation of eye drops
changes throughout the post-operative period, it is important to clearly document this information in
writing for patients.

Most patients are concerned about the need for eye drops before and after
surgery. Some patients may express discomfort with instilling eye drops and
may not have anyone to assist them with the drops. Other patients may have
arthritic hands or be afraid of missing the eye, thus wasting expensive,
necessary medications. The surgical coordinator can alleviate the patients
fears and provide the patient with some suggestions to assist in the use of
drops. The patient may be given some mild artificial tears with which to
practice. In addition, it may help to explain that reclining on pillows will provide
optimal support while instilling drops. A suggested process of instilling drops is
explained below:

The standard of care for most major surgery is to discontinue anticoagulants

(such as Plavix, Coumadin, etc.) several days prior to surgery. This is not
necessarily the case for cataract surgery, particularly when a topical anesthetic
is used. Consequently, the guidelines surrounding this will vary among Most patients are concerned
surgeons and facilities. Occasionally, the patients general health condition about the need for eye drops
supersedes the facilitys rules, and patients may be instructed not to before and after surgery.
discontinue their anticoagulant medication. In most cases, patients are
instructed to restrict their food intake for several hours prior to surgery; however, this information is also
specific to facility or anesthesia requirements.

On the morning of surgery, the patient is instructed to thoroughly cleanse the area around the operative
eye. Keeping this area clean in the period immediately preceding and following surgery will assist in
reducing the risk of post-operative infection. Therefore, it is imperative patients wash their hands prior to
touching the eye area or instilling medication before or after surgery.

Step Eight: Discussing Post Operative Expectations

Depending on the anesthetic and mydriatics used prior to surgery, the patient should be prepared for
potential symptoms in the days immediately following surgery. Commonly communicated concerns
include:

Headache

Double vision

Dilated pupil

Blurred vision

Patients are cautioned to call the office immediately if any of the following symptoms occur:

Flashes and/or floaters

Pain

Redness

The patient should expect to be seen for post-operative follow-up several times during the post-operative
period. The schedule of these appointments varies from surgeon to surgeon and from patient to patient.
There is a 90-day post-operative period in which all appointments related to the surgery are included.

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Preparing Patients for Cataract Surgery

Note: See Exhibit 1 for a sample of Frequently Asked Questions Related to Cataract Surgery and Exhibit
2 for a sample of Pre and Post Operative Instructions. These forms can be modified for surgeon-specific
requirements.

Step Nine: Scheduling Pre-operative Testing and Appointments

Multiple appointments may need to be scheduled to prepare the patient

for surgery. It often is more efficient for the surgical coordinator to make
all of these appointments rather than rely on the patient to do so. When
scheduling pre-operative appointments, it is important to allocate
sufficient time to process lab work, receive the forms from the primary
care doctor, and to allow the surgeon to review all information, calculate
intraocular lens powers, and complete the surgical plan. Although these
pre-operative appointments may be confirmed at a later date, written
notification should be provided to the patient, with a copy maintained in
the record until the surgical event. Please note the deliberate use of large
print on the attached sample patient letter to help ensure that patients
with reduced vision can easily read the letter (see Exhibit 4: Sample
Patient Letter).

The following is a list of possible appointments that may need to be made

prior to the patients surgery:

History and Physical: There are strict guidelines that require a

The task of communicating
history and physical exam within 30 days prior to the patients important information falls to
surgery. The history and physical is often completed by the everyone in the office, not just
surgeon; however, in some cases, because of the patients the surgical coordinator.
medical condition, the surgeon may require medical clearance The office staff should have an
from the patients primary care physician. understanding of the role of the
surgical coordinator.
A-Scan/IOL Master/Corneal Topography/B-Scans: Patients must undergo additional testing to
provide the surgeon with information to complete the patients surgical plan. Measurements of
axial length of the eye as well as corneal measurements (sometimes including corneal
topography), are needed by the physician in order not only to determine the power of the
intraocular lens implant but also the type of implant that would best meet the needs of the patient.
Different practices utilize different types of equipment (A-Scans, IOL Master, etc.) for these
measurements; however, regardless of the equipment, it is critical that the measurements are
performed accurately. Inaccurate measurements can adversely affect the results of the cataract
surgery. Determined by practice flow and the anticipated surgical date, this testing may or may
not be performed on the day the decision for surgery is made. If performed on the same day, the
amount of time the patient remains in the office can be quite lengthy. The surgical coordinator
should explain the reason for the measurements and the procedures involved in obtaining the
measurements. If immersion scans are the standard for the practice, the patient should be
instructed not to wear eye make-up the day of the test. All contact lens wearers should be
instructed to remove contact lenses at least 48 hours prior to the A-Scan appointment.

Facility/Anesthesia Pre-Operative Appointments: Some facilities require a pre-operative

anesthesia appointment; however, many facilities handle anesthesia pre-operative questionnaires
via the telephone, so no appointment is necessary.

Step 10: Summarizing

The final counseling stage is to test patients for comprehension by listening to their comments, answering
questions in a calm manner, and observing their confidence in the setting and the surgeon. It is likely the
patient will have heard a friend or family members recollection of a surgical experience. This often
provides the patient with confidence to proceed with surgery. Occasionally a patient has heard about
complications from cataract surgery; therefore, these patients may need additional reassurance which
can be accomplished by reiterating the high success rate associated with cataract surgery.
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Patient counseling can be time consuming, but it is necessary in order to explain the procedure
adequately. Therefore, attention must be paid to where these conversations will occur. Ideally, the
surgical coordinator should have a quiet office dedicated to patient counseling and scheduling of surgery
and pre-operative appointments. Unless the office has a surplus of vacant exam rooms, patient flow will
be disrupted if the surgical candidate is allowed to remain in the exam room, since the doctors rooms
would have been reduced by one.

SUCCESSFUL COMMUNICATION WITH THE PATIENT

The task of communicating important information falls to COMPONENTS OF SUCCESSFUL
everyone in the office, not just the surgical coordinator. COMMUNICATION
The office staff should have an understanding of the role
of the surgical coordinator. Staff may be able to field Non-directive Questions
some questions after an internal training session is held
Skills of Attention
to share the answers to patients most frequently asked
questions (see attached Exhibit 1: Frequently Asked Confirming Questions
Questions). Otherwise, all queries should be directed to
Paraphrasing
the surgical coordinator. Training staff to work as a team
imparts a feeling of confidence in patients as they sense Summarization
the entire office works together in the interest of their
surgical outcome. Language and Culture

Communication can be difficult in a medical setting, and not everyone is a comfortable communicator.
Communication requires give-and-take dialog, and everyone must both listen as well as communicate
verbally. Successful communication requires interaction. It is a behavioral science that requires a
minimum of two people for success. There are many components that comprise successful
communication. These components are discussed below.

Non-directive questions: The non-directive question asks for more than a yes or no response. It
allows for elaboration and/or explanation. This type of interrogatory concerns itself with the
who/what/when/where/why of a situation. These questions can be used to focus on the patients
concerns and to identify any problem areas that must be investigated more fully. These questions
actively engage the patient in conversation. Examples of non-directive questions include:

o Would you please tell me more about that?

o You say you have trouble reading your piano music. How long has that been a problem?
What other difficulties have you noticed?

Skills of attention: To communicate well, the speaker must be able to concentrate on the person
being addressed. In a multi-tasking environment, it is easy to forget to make eye contact, smile,
and focus on the person. For communication to be effective, it is necessary to pay attention to
one person at a time without distraction. Examples of this include:

o Eye contact: Look at the person at whom the conversation is directed. If family members
are present, make sure they are included in the gaze from time to time. This
demonstrates interest and implies they are a participant in the patients care. Eye contact
is an important enforcer of continued interest. Additionally, it allows for a momentary
evaluation of comprehension. Random assessments allow for clarification.

o Posture: The body language of the participants is a language of its own. Relaxed, but
intentional positioning communicates sustained interest. This positioning might include
leaning forward across a desk or using a semicircular arrangement of chairs. It is
important to learn to read others signals. Crossed arms may indicate resistance while an
elbow resting on the other hand with fingers on the cheek may signal receptiveness and
consideration of what is being proposed.

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Preparing Patients for Cataract Surgery

o Following: Indicate you have heard what the patient has said by asking a question,
nodding, or making comments such as, I see. Chances are good the patient has noted
your interest and will continue the train of thought.

Confirming questions: Confirming questions limit discussion by simply asking for a yes or no
answer. This is in direct contrast to non-directive questions which are used to gather information
and encourage discussion. This interrogatory technique is used to direct conversation elsewhere,
seek agreement or disagreement, and limit or conclude a particular discussion. The most useful
places to use confirmatory questions are to verify the benefit of the shared goal (i.e., surgery to
improve vision and daily living activities). In this scenario, the patient must first indicate there is a
problem and recognize surgery will improve the situation. This type of question is often preceded
by paraphrasing or summarizing the patients words. Some examples of confirmatory questions
are as follows:

o You mentioned you are afraid of eye surgery. Would it help to speak to a patient who
has had this operation? This style will confirm the common goal and move toward
closure.

o Shall we schedule the surgery? This serves to conclude the discussion.

o Do you have someone to drive you to the ASC or hospital? This directs the
conversation. It could be that the patient was focused on a particular point and simply
needed to be steered in another direction.

Paraphrasing: Paraphrasing is a powerful listening tool that demands concentration on the part
of the staff member. To paraphrase, you repeat the essence of what has been said. This
demonstrates you have been listening to the patients comments and hearing what is important in
order to make an informed decision. If paraphrased in an accurate, concise manner, the patient
may hear his/her comments crystallized. Lastly, paraphrasing indicates that what was said was
understood to be correct. If not, the patient will clarify any misconstrued thoughts or comments.

Summarization: Summarization is similar to paraphrasing. This technique also requires

concentration and listening skills. The difference is that summarization includes the entire
conversation, while paraphrasing is directed toward several specific comments. In order to
summarize coherently, notes may need to be recorded during an extensive conversation.

Language and culture: Language and cultural differences may make conversation difficult.
Perceptive staff members must adapt to these situations; however, it may be necessary to
reschedule the patients consultative appointment to allow ample time for the counseling session.
If there is a language barrier, it is often helpful to reschedule the appointment so that an
interpreter or family member can be present to facilitate understanding of the procedure and the
options for the patient. Cultural diversity in patients may be less evident. Some societies and
religious beliefs shun surgery of any type; others believe two people of opposite gender should
not be alone in a room. In todays multicultural world, the staff is presented with a wide variety of
differences, some very subtle. It is, therefore, important to be sensitive to cultural diversity and to
work together with those patients to provide a positive, successful surgical experience.

CONCLUSION
Thoroughly preparing the patient for his/or cataract surgery is of critical importance not only to the comfort
and confidence of the patient, but also to maximizing the patients opportunity for the best surgical
outcome possible. A dedicated surgical coordinator provides an important role as liaison with the
surgeon, the patient, the office staff, and the surgical facility. This cooperative teamwork can significantly
improve the quality of care offered to patients and of the surgical outcome as well. With proper
preparation of the patient for cataract surgery, the practice conveys its commitment to the patient for
excellence in patient care.

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Preparing Patients for Cataract Surgery

APPENDIX

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Preparing Patients for Cataract Surgery

EXHIBIT 1: Frequently Asked Questions Regarding Cataract Surgery

What is a cataract? A cataract is a thickening and clouding of the natural lens of the eye. It is generally
slowly progressive in nature. Your vision has reached a point that everything is blurred at distance and at
near; you may also be sensitive to glare and the headlights of oncoming cars.

How long is the surgery? The surgery itself is very brief, although you should plan to be at the facility
for several hours.

Why will I be at the facility so long? You will check in and be taken to the preoperative area where
nurses will review your medical history and the anesthesiologist will begin to prepare you and your eye
for the surgery. Prior to surgery, several people may ask you to confirm which eye is the surgical eye.

What must I do before my cataract surgery? As we get closer to your surgical date, we will review all
the steps necessary prior to surgery. We will provide it to you in writing as well, so you will have
something to refer to.

Will my activities be limited? Only the more strenuous activities will be limited and only for a short
period of time.

I have never used eye drops before. What if I miss my eye? That is a common concern. The best
way to instill drops is to recline on some pillows, putting your head back. Hold the bottle between your
thumb and index finger, bracing your thumb on your nose. Look at the ceiling and pull down the center of
the lower lid, making a pocket. Squeeze the bottle until one drop enters the eye. It may help to keep the
bottles in the refrigerator because when you feel the cold temperature contact your eye, you will know the
drop is in. If you prefer, your drug store may sell devices to help you direct the drops into the eye.

When can I drive after cataract surgery? When you feel up to it and your vision is adequate to drive
safely, but not before 24 hours have passed at the earliest. If glasses are needed for distant vision, you
will need to wait for these.

Can I eat the day of surgery? We must follow the guidelines determined by the surgical facility.

Will I be asleep during surgery? No, but you may be given something to relax you.

Why do I need a physical exam and testing? We must follow the guidelines determined by the surgical
facility. Because this is a surgical procedure, we need to be assured that you are in good health to
withstand the operation.

Will the doctor perform surgery on both eyes at the same time? No, we only operate on one eye at a
time.

Will I need glasses after the surgery? That depends on the lens choice. We will explain your options to
you.

What about my current glasses? They wont work any longer. However, if you will be having the
second eye done in the near future, and you feel awkward using one eye to see, you can substitute
window glass (no prescription) for the first surgical eyes lens.

How long do I have to wear the shield/patch? Usually, just at night for a short period of time.

Will I have a 20/20 result? No doctor will guarantee this. Much of the final outcome is determined by any
other eye conditions you may have.

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Preparing Patients for Cataract Surgery

EXHIBIT 2: Sample Pre- and Post-Operative Instructions

Please note: These are samples for the purposes of this module.
Protocols vary widely; check with your surgeon to develop surgeon-specific guidelines.
BEFORE SURGERY
Arrange for someone to be with you after your operation and to bring you to the office the next day.
Generally you do not have to discontinue products containing aspirin and ibuprofen. Your surgeon will
review your medications and instruct you if any modifications are to be made.
If you use Pilocarpine eye drops or gel, please discontinue using those 48 hours before surgery in the
operative eye, only. Use all other eye medications as directed.
Please familiarize yourself with your insurance benefits, including copayments, and deductibles. We will do
all we can to ensure maximum payment. However, policies vary. Some require pre-notification from the
subscriber; others need a second opinion before surgery.
THE DAY OF SURGERY
Do NOT have anything to eat or drink for eight hours prior to surgery, unless otherwise directed.
Your doctor will inform you if you should take your daily medications in the morning with a small sip of
water.
Dress in loose, comfortable clothing, leaving valuables at home.
Wash your face as usual; do not wear make-up or nail polish.
DURING SURGERY: What to Expect
You will be asked to don a surgical gown.
An IV will be started in your arm; you will receive many eye drops in the operative eye.
Just prior to the surgery, you will be given a sedative through the IV. It will help you to relax, although you
will still hear people around you. Once its effects are felt, you will be given a local anesthetic to prevent you
from feeling any pain.
Expect monitors to be placed on your chest and finger; a blood pressure cuff will be attached to your arm.
You may leave the operating room with a light shield over your eye and be taken to the recovery room
where you can expect to be given something to eat and drink.
AFTER SURGERY
(Note: These are guidelines only; check with your surgeon for specific preferences)
SHAMPOOING: May be done following the first post-op visit.
BATHING: Shower or bathe as usual. Protect your eye by keeping it closed, head back in the shower or
tub. Keep a towel nearby and wipe your eye gently before opening it.
DRIVING: Your doctor will determine when you may resume driving. Plan on having someone bring you to
the office for your first appointment.
GLASSES: Depending on the procedure, you may get a prescription as soon as the second post-op visit. In
some cases, a temporary glasses prescription is given on the first day if there has been a large shift in your
prescription.
WORKING: Check with your doctor about returning to work. It will vary according to the type of work you do.
SWIMMING: Avoid swimming for at least 2 weeks after surgery.
LIFTING: Refrain from lifting anything heavier than 10-15 pounds until clearance is received from your
physician.
EXERCISE: Because of the wide variety of exercise regimens, you should check with the doctor or staff
about your specific routine.
After surgery, feel free to read, write, watch television, etc. You cannot harm your eye by using it in this manner. In
general, you can expect to return to most of your normal activities in moderation the day after surgery. Please call
the office with any questions.

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Preparing Patients for Cataract Surgery

EXHIBIT 3: Sample Surgical Checklist

Note: Attach to patient chart. Keep copies of pertinent communications with record until one-day PO
appointment.
Patient Name:
Record Number:_____________________________ DOB: ______________

Doctor: ________ Facility: _______________________ DOS: _____________

Procedure: Complex Cataract: Yes / No Eye: RT LT

Date Scheduled Action Confirmation # or Name

Facility Notified

Office Pre-Op or N/A

A-Scan

PCP Pre-Op Exam

(Name and Address)
H&P Sent: Date of Exam:

Receipt of H&P

Post-Op Appt.

Transportation Arranged or N/A

Patient Notified

IOL Ordered

Surgery Confirmed

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Preparing Patients for Cataract Surgery

EXHIBIT 4: Sample Patient Letter (Note larger font)

Dear __________________:

Your eye surgery has been scheduled for____________. We

look forward to meeting your eye care needs.

Please report to the Day Surgery Unit on the third floor of XYZ
Hospital, located at 123 Hospital Way, Anytown, State. I will
personally call you several days prior to your surgery to inform
you exactly what time you will need to arrive. I am enclosing a
map and directions to the hospital for your review and
convenience.

I have made several appointments for you that are necessary

prior to the surgery.

Preop with ophthalmologist _______________________

A-Scan with ophthalmic technician:_________________
Preop physical with Dr. _____________ at _____ AM/PM

Please do not hesitate to call if you have any questions regarding

your surgery. I can be reached at 111-555-1234 extension 100.

Sincerely,

Your Name
Surgical Coordinator to Dr. ABC

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Preparing Patients for Cataract Surgery

COURSE EXAMINATION

1. The number of Americans to have a cataract in either eye is expected to reach:

a. 20 million in 2020.
b. 30 million in 2030.
c. 20 million in 2030.
d. 30 million in 2020.

2. When patients wait longer than six months for cataract surgery, their quality of life:

a. Improves.
b. Decreases.
c. Remains the same.
d. Varies according to the patient.

3. The surgical coordinator acts as a liaison between:

a. The patient and the doctor.

b. The doctor and the hospital or ASC.
c. None of the above.
d. Both a and b.

4. Before a patient is asked to sign an Informed Consent for Cataract Surgery, which of the following
should be discussed?

a. Risks of cataract surgery.

b. Benefits of cataract surgery.
c. Alternatives of cataract surgery.
d. All of the above.
e. None of the above.

5. For most Medicare carriers, which of the following qualifies the medical necessity of cataract
surgery?

a. < 20/50 vision.

b. Documented difficulties with activities of daily living.
c. Neither a nor b.
d. Either a or b.

6. What is the average success rate of modern cataract surgery?

a. 92%
b. 95%
c. 98%
d. 99%

7. The patient should expect to be asked to confirm the surgical eye during the pre-operative
process.

a. True
b. False

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Preparing Patients for Cataract Surgery

8. Of the following IOLs approved by the FDA, which is the accommodating lens?

a. Crystalens.
b. Rezoom.
c. Restor.
d. Toric.

9. In a precedent setting move, the Centers for Medicare and Medicaid Services (CMS) approved
balance billing for the refractive portion of the IOL. The rationale for this decision was based on
the following facts:

a. The practices need for revenue.

b. The fiscal needs of Medicare.
c. Medicare does not cover refractive services.
d. The patients desire to be spectacle-free.

10. During the patients post-operative period, which of the following types of eye drops may be
prescribed?

a. Antibiotic drops.
b. Anti-inflammatory, non-steroidal drops.
c. Steroid drops.
d. All of the above.
e. A and b.

11. Patients will always be asleep during the surgical procedure.

a. True
b. False

12. The post-operative period following cataract surgery is:

a. 10 days.
b. 30 days.
c. 60 days.
d. 90 days.

13. Patients are advised not to drive for 24 hours after surgery because of:

a. Anesthesia guidelines.
b. Poor vision.
c. Possible anisometropia.
d. None of the above.

14. Most cataract surgery today is performed under topical anesthesia.

a. True
b. False

15. Symptoms that occur during the patients post-operative period that require an immediate call to
the surgeons office are:

a. Dry eyes.
b. Blurry vision.
c. Flashes and floaters.
d. Headaches.

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