Typically, outcome measures such as visual acuity and refractive error are used to assess the quality of cataract surgery postoperatively. However, psychological factors and the patient's expectations can have a major impact on postoperative patient satisfaction, especially in patients who receive multifocal, toric, or other premium IOL models and even more so in those undergoing clear lens exchange for presbyopia. Therefore, an important key to success is accurate patient selection and early detection of the warning signs of a difficult patient—one who may never be pleased with his or her postoperative results and may also need more rigorous informed consent.
To illustrate the discrepancy between medical and patient-reported outcome variables, we present two case studies with dissimilar postoperative satisfaction.
PATIENT NO. 1: BILATERAL CATARACT
A 62-year-old woman with bilateral cataract received a diffractive multifocal IOL in her right eye. Feeling disturbed by the asymmetry of her vision because of the residual cataract, and due to the appearance of halos, she decided to undergo surgery for the left eye as planned. I implanted the same multifocal IOL, and her postoperative UCVA was 6/5 in the right eye and 6/6-2 in the left. Her near vision was J 1-2 in the right eye and J1 in the left.
Despite her good distance and near visual acuities, the patient was dissatisfied, complaining of worse distance vision in her left eye compared with her right. Moreover, she saw halos and reported the presence of rings when she closed her eyes. Follow-up consultations resulted in long discussions with this unhappy, dissatisfied patient. We reached a consensus to explant and replace both IOLs with monofocal lenses. The patient was moderately satisfied with good distance vision and the use of reading glasses.
My take-home message: Do not underestimate the value of patient screening, because difficult patients before surgery remain difficult after surgery. More rigorous screening may have revealed that this patient was not only over-critical about her vision but that she had other problems that interfered with her judgment of visual perception. Looking back, it would have been better to explant the first multifocal IOL when the patient complained about her postoperative results, rather than proceeding with the second implant.
PATIENT NO. 2: AGE-RELATED
A 75-year-old man with moderate dry age-related macular degeneration (AMD), bilateral cataract, and moderate hyperopia in both eyes presented with a visual acuity of 6/30 in the right eye and 6/60 in the left. The patient said that he felt socially isolated due to difficulty engaging in his hobbies. He mentioned that even a little improvement in vision would be helpful.
I implanted two monofocal IOLs to provide good distance UCVA for his most favored hobbies, cycling and hiking. Despite visual outcomes of 6/12 in his right eye and 6/24 in his left, the patient was extremely happy, saying he noticed great improvement in his vision. This patient probably had lower expectations than the first patient, partly because of the intensive informed consent and discussion that took place before surgery. When the result exceeded his expectations, he was overwhelmed by the outcome.
My take-home message: Under-promise and over-deliver appears to be a good strategy for setting patient expectations.
These two case studies depict how postoperative patient satisfaction depends on more than visual acuity results. Sometimes patients have relatively poor visual acuity after cataract surgery but are satisfied with the outcome. On the other hand, some patients are never satisfied with the outcome, even if it appears to be near perfect from a medical perspective.
The psychologists Fillip and Ferring introduced a classification scheme (Table 1) that can be applied to cataract surgery. In this scheme, patients are categorized into one of four groups based on their measured and subjectively rated visual outcomes.
- Fortunate: patients with good visual acuity and good subjectively rated vision;
- Unfortunate: patients with poor visual acuity and poor subjective rating;
- Satisfaction paradox: patients with poor visual acuity but good subjective rating; and
- Dissatisfaction dilemma: patients with good visual acuity but poor subjective rating.
The fortunate group is by far the largest category in cataract surgery, and usually ocular comorbidities such as AMD or glaucoma are the main reasons for patient categorization in the unfortunate group. The satisfaction paradox group consists of patients who show positive thinking and possibly a belief in destiny. These patients are satisfied with visual outcomes even though their measured visual acuity may be poor. They may have relatively good functional vision due to a large depth of focus that can provide moderate distance and near visual acuity, such as in the case of uncorrected corneal astigmatism. Patient No. 2 belongs in this group. When we encounter this patient, it is best to support his or her enthusiasm and satisfaction.
Patients in the dissatisfaction dilemma category, such as patient No. 1 in this article, pose the greatest challenge to the surgeon. These patients typically present with minimal to moderate cataract, preoperative emmetropia, and poor mental health or depression. They are often perfectionists with neurotic and overcritical personalities such as teachers and psychologists, or they have vision-critical professions, such as artists or designers, that require good vision and contrast sensitivity for their work. There are some warning signs when dealing with this patient category. The first indicator is if the patient makes comments or asks questions about the guarantee for good postoperative visual outcomes and the safety of cataract surgery. Another alarm should sound for patients who admittedly adapt their expectations based on the postoperative outcomes of friends and family members who underwent cataract surgery before.
MAXIMIZING PATIENT SATISFACTION
Several factors can lead to insufficient postoperative visual function despite good visual acuity, such as low contrast sensitivity due to higher-order aberrations or glare resulting in compromised UCVA or dysphotopsia. These issues may lead to low patient satisfaction.1
Every patient has a different expectation for visual function improvements after cataract surgery, just like the two patients in this article. The overall take-home message here is that an individualized and empathic discussion with the patient during the informed-consent process is the key to patient satisfaction. Active listening can unmask patients with unrealistic expectations and challenging personalities. Additionally, questionnaires that also act as checklists may aid in preselecting patients, shortening consultation times, focusing patients' expectations on realistic results, and preparing patients to accept that most techniques and IOLs require compromises.
Reducing expectations is easier than improving postoperative outcomes. In the case of presbyopia-correcting IOLs, discussing the patient's visual goals and clearly defining the terms near, intermediate, and distance vision by giving examples relevant to patients' daily activities such as reading in telephone directory, working on the computer, or seeing traffic signs can narrow expectations to a realistic level.
Patient satisfaction is multidimensional and dependent on a variety of factors. In addition to the medical outcomes of visual acuity, contrast sensitivity, and general health, patients' perspectives on the preand postoperative processes significantly affect their overall satisfaction.2
Accurate biometry and lens power calculation are important for patient satisfaction, but so too are an exploration of patients' needs and preferences, a reasonable choice of IOL, a well-performed surgical procedure, and sufficient follow-up. Most important, the value of high-quality care, empathy, and a good staffpatient relationship should not be underestimated. The efficiency of the entire treatment process and the clarity of competence during this pathway are crucial factors for overall satisfaction.
In the 1980s, Donabedian and coworkers described patient satisfaction as the discrepancy between patients' expectations and their experience.3 The higher the patient's expectations and the lower the quality of experienced services and outcome values, the lower the resulting patient satisfaction.
A good candidate for cataract surgery has realistic expectations for visual improvement after cataract surgery. Ideally, this candidate can focus on the type of vision that is the most important for his or her daily life. The patient must also be honest about the aspects of vision on which he or she may be willing to compromise. For presbyopia-correcting IOLs, we have found patient motivation to be the most important key to success,4 probably because the most motivated patients tolerate visual compromises such as contrast sensitivity loss, glare, and other dysphotopsias.
Oliver Findl, MD, MBA, is Director of Ophthalmology at the Hanusch Hospital, Vienna, Austria, and a Consultant Ophthalmic Surgeon at Moorfields Eye Hospital, London. He is also the Head of the Vienna Institute of Research in Ocular Surgery, Hanusch Hospital, Department of Ophthalmology, Vienna, Austria. Dr. Findl states that he has no financial interests in the products or companies mentioned. He may be reached at e-mail: email@example.com.
Sophie Tatzreiter, MD, practices at the Vienna Institute for Research in Ocular Surgery, Hanusch Hospital, Department of Ophthalmology, Vienna, Austria. Dr. Tatzreiter states that she has no financial interest in the products or companies mentioned. She may be reached at e-mail: firstname.lastname@example.org.
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