As the most common ophthalmic surgical procedure, cataract surgery has offered hope to patients worldwide who would otherwise eventually go blind. Cataract surgery is generally safe; however, it has associated risks and complications. Therefore, patients require adequate information before they make an informed decision on whether to undergo or forgo surgery. Counseling prospective patients on both the risks and benefits is important for medicolegal, moral, and ethical reasons.

The most common cause of ophthalmic malpractice litigation is cataract surgery, and the number of claims has increased over the years.¹ Courts in the United States and Europe have specified the information that patients should have prior to surgery, including a description of the treatment and its alternatives, its inherent risks, and the postoperative course.^2,3

Counseling is also important for ethical reasons; it respects patients' autonomy and their right to make decisions regarding their own treatment. However, ophthalmologists are also expected to provide guidance and expert advice on whether the benefits of surgery outweigh the risks. Although all patients should be advised on these topics, counseling is especially important for certain groups with demanding visual requirements or the potential for poor visual outcomes. For example, poor outcomes may occur due to coexisting ocular pathologies such as age-related macular degeneration. The manner of counseling also varies according to cultural norms. For instance, in some societies, patients expect doctors to play a large role in the decision-making process.

TOPICS COVERED DURING COUNSELING
There are many possible complications of cataract surgery, and it is impossible to be absolutely exhaustive under the time constraints in a busy clinic session. However, certain essential information must be provided to the cataract patient prior to surgery. Patients should know what cataract surgery will involve, from the preoperative assessment, type of anesthesia, and intraoperative procedures, to the postoperative recovery period.

Preoperative care. Information given regarding the preoperative period should include (1) biometric assessment, (2) systemic examination to determine anesthetic risk, and (3) expectations for the day of the surgery. For No. 3, for example, it would be beneficial to tell patients that a family member or friend should accompany them the day of surgery because their operated eye, which could be patched, affecting their mobility. They may also feel the effects of intraoperative sedation for several hours after surgery.

Surgical process. The major steps of cataract surgery should be reviewed, preferably with the aid of short videos or animations. The choice of anesthetic (topical or injected) and the use of intraoperative sedation should be discussed with the patient, either by the ophthalmologist or in conjunction with an ophthalmic anesthetist.

IOL options. With the ever-increasing range of available IOLs, the choice of lenses—monofocal, multifocal, accommodating, aspheric, and toric—should be discussed with the patient. However, the ophthalmologist must guide the patient in his choice and also exercise his clinical judgment as to what types of lenses are most suitable for the individual. This is especially important with multifocal IOLs. A thorough discussion of the patient's lifestyle and priorities are essential before the doctor and patient can jointly reach a decision on whether a given IOL is suitable. With an increasing emphasis on refractive outcomes, the option of astigmatic correction with toric IOLs or limbal relaxing incisions should also be covered.

Complications. There are many possible intra- and postoperative complications, which are usually listed on an informational sheet available to the patient prior to surgery. However, the ophthalmologist should also highlight common or sight-threatening complications, such as posterior capsular rupture, endophthalmitis, retinal detachment, and residual refractive error.

Postoperative care. The patient should be made aware of the frequency and duration of postoperative visits, the time to visual recovery, and the need for postoperative eye drops. Finally, the patient should have the opportunity to ask questions and clarify with the surgeon any doubts he may have.

Many centers that practice cataract surgery give patients an informational booklet summarizing the points mentioned above. It is also helpful to provide patients with a short video or animation sequence so that they can see the steps of surgery and review them with their families. Such videos are commercially available or can be produced in-house.

THE SOCIAL SIDE OF COUNSELING
Although preoperative counseling is typically thorough in discussing the clinical aspects of cataract surgery, counseling usually does not cover the less technical aspects of the surgery. Be sure to discuss with patients what they will experience before, during, and after surgery. Many patients have no idea what to expect during the procedure and often rely on anecdotal experiences from friends who have already undergone cataract surgery. Some of this information is based on false assumption and may give patients an inaccurate idea of what the procedure is like.

An important area to cover is the potential for intraoperative visual experiences. Several studies have shown^4,5 that most patients under local anesthesia (80% to 100%) experience at least light perception during cataract surgery. On the other hand, up to 20% of patients may experience loss of light perception, either transiently or throughout the surgery.⁵

Patients may also experience other visual sensations, such as flashes, colors, movement, and changes in brightness. They have also reported seeing surgical instruments, hands and fingers, and even the surgeon. Patients who expect not to see intraoperatively may become frightened when they encounter unexpected visual sensations; other patients who lose light perception may believe that some complication has occurred. Between 3% and 19% of patients are frightened by their intraoperative visual sensations.⁵ This is clinically relevant because fear may lead to a surge in the sympathetic nervous system, resulting in hypertension, tachycardia, ischemic strain on the heart, and panic attacks. Take extra caution with the elderly, who may have significant comorbidities. A frightened patient may become uncooperative during surgery, and sudden movements can lead to surgical complications. Even if none of these scenarios occur, a frightening experience would likely decrease patient satisfaction.

We suggest that preoperative counseling may reduce fear caused by intraoperative visual sensations.⁵ A randomized, controlled trial of patients in the United Kingdom and Singapore showed that preoperative counseling reduced the mean fear score of patients who were frightened.⁶ In another randomized study of 850 patients undergoing phacoemulsification, preoperative counseling significantly reduced both the percentage of frightened patients and the mean fear score (presented at the American Academy of Ophthalmology Annual meeting, New Orleans, Louisiana, 2007). Do patients value this extra counseling? In a study performed in India, 73% of patients who were frightened felt that counseling on potential visual sensations would have reduced the fear they experienced.⁷ Some patients have indicated that they find their intraoperative visual sensations beautiful, and those who were counseled were more likely to say this than those who were not forewarned.

CONCLUSION
As patients become more knowledgeable, the expectations placed on ophthalmologists will undoubtedly increase. The method of counseling should be tailored to the individual and his expectations because the most important consideration is that the patient have adequate information for his needs. Proper preoperative counseling has the potential to help patients prepare for surgery and increase their satisfaction with the entire process.

Colin S.H. Tan, MBBS, MMed(Ophth), FRCSEd(Ophth), practices in the Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Dr. Tan states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +65 63577726; fax: +65 63577718; e-mail: Colintan_eye@yahoo.com.sg.

Wei Kiong Ngo, MBBS, practices in the Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Dr. Ngo states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: wkngo@hotmail.com.

Edwin M. Gay practices with the National Healthcare Group Eye Institute, Singapore. Mr. Gay states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: newid84@yahoo.com.sg.

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2. Lanckton AV. The contours of informed consent. Surv Ophthalmol. 1996;40:391-394.
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7. Rengaraj V, Radhakrishnan M, Au Eong KG, Saw SM, Srinivasan A, Mathew J, et al. Visual experience during phacoemulsification under topical versus retrobulbar anesthesia: results of a prospective, randomized, controlled trial. Am J Ophthalmol. 2004;138:641-648.