Cataract surgery

[Zarniwoop]

Looking for curbside advice....

What should I look for when selecting cataract surgeon? Fellowship trained doc or generalist? Are there different procedures or technologies I should be looking for, or is the procedure very standardized? Thank you.

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[TheLesPaul]

you want someone who offers all the available technologies, so that they can choose the one that is best for you.

 

[Dusn]

I’d disagree with offering “all of the available technologies.” Most of those technologies are marketing gimmicks and have a primary goal of making the surgery ineligible for Medicare reimbursement so that a higher out of pocket cost can be charged. Personally I’d want a surgeon that does not push “premium” IOLs or “lasers” for cataract surgery so that they can make more money from out of pocket procedure or please referring optometrists who expect a co-management fee. The one exception to this would be for a toric IOL if there’s astigmatism.

 

[TheLesPaul]

I'm not a cataract surgeon, but I think the notion that all premium lenses are useless is a bit misguided....certainly there is an argument for LAL and other newer tech. And technology is iterative. Nothing is perfect in the beginning but perhaps each version is better than the version before and we don't know the utility of these things unless we try them.

There's a difference between "pushing" a premium lens vs identifying the patient's surgical goals and finding the best match.

 

[Zarniwoop]

Thank you for the above advice.

I imagine the best way to pick a cataract surgeon (or any surgeon) would be to know the opinion of the scrub nurse and others who directly observe the surgeon in the OR.

Since that is something most people can't find out what should a patient look for in a cataract surgeon?
Fellowship training?
Academic vs community setting?
Other?

 

[mjohnsonets]

Thank you for the above advice.

I imagine the best way to pick a cataract surgeon (or any surgeon) would be to know the opinion of the scrub nurse and others who directly observe the surgeon in the OR.

Since that is something most people can't find out what should a patient look for in a cataract surgeon?
Fellowship training?
Academic vs community setting?
Other?

Maybe ask the surgeons you're considering if they've ever done cataract surgery on another cataract surgeon?

 

[Slide]

My two cents, but ask the specialists that the cataract surgeon refers out to, especially those that handle their complications. We often have an inkling of who we don't want doing our phaco if we need it done.

 

[LightBox]

The busiest surgeons are typically the best. If one does 30 cataracts in a day, that surgeon must be relatively decent at it.

And btw, the LAL+ is hands-down the best IOL out there. Expensive and a lot of work in the few weeks afterwards, but definitely worth the investment!

I have no financial incentives for LAL btw 🙂

 

[RetinaDude]

Yeah a busy cataract surgeon is usually a great cataract surgeon. If I hear of a cataract surgeon who takes 30-40 minutes per case, then I’m not letting that doc operate on me. If there’s a cataract surgeon who regularly does 10 minute cataracts, then that doc has skills and is usually pretty darn good.

 

[i-doctor]

1)Experience is everything. You want a cataract surgeon at their peak age. Preferably one in their 40’s to mid-50’s
2) High volume , quick cases as discussed above
3) Local optometrists know who is good, and obviously the scrub nurses

 

[TheLesPaul]

Do you really think OR staff knows what's up? They really only care about speed, I don't think they have a good sense for postoperative outcomes because they never see the patients afterwards. They definitely won't know if you have hit the refractive target more often than not

 

[Dusn]

The best information would come from residents or former residents who have worked with the surgeon.

I’d also prefer to go to a surgeon who gets referred the more complex anterior surgical pathology.

But this info would be hard for a non-ophthalmologist to obtain and would be more limited to academically affiliated surgeons.

Unfortunately I have seen a few high volume surgeons, even ones who work in top ophthalmology academic institutions and give national talks about how to perform surgery, who are awful surgeons (but had excellent outreach and marketing, and thereby got referrals).

 

[i-doctor]

Unfortunately I have seen a few high volume surgeons, even ones who work in top ophthalmology academic institutions and give national talks about how to perform surgery, who are awful surgeons (but had excellent outreach and marketing, and thereby got referrals).

Yes, true, but even subpar surgeons improve simply by high volume.

 

[solitude]

Yes, true, but even subpar surgeons improve simply by high volume.

Dusn's assertion, I find is actually pretty common. However, there are some caveats that make it hard to discern exactly what is going on without sitting and watching somebody operate for a while. Some high volume surgeons avoid hard cases because they take more time and don't pay well, so those surgeons actually aren't very good if you have a tough case. Some take on the hard cases but do them in haste, and poorly. Some are good surgeons but have lots of complications because they run 2 rooms and their resident or fellow is next door making mistakes on half of their patients. Some have a higher absolute number of complications, but a lower relative number of complications, by virtue of doing high volume and taking on the hard cases which will result in more complications by their very nature.

 

[i-doctor]

I agree that it’s very hard to judge any cataract surgeon unless you are on the inside (such as an O.D. who does the surgeon’s—and also fellow surgeons’— post-op care, the retinal surgeon who handles the complications, etc.) There are so many variables. Even a bad night of sleep the evening before surgery is a variable.

 

[Zarniwoop]

So I had 2 consultations for the surgery with 2 of the highest recommended docs in the area. One works for a multispecialty clinic, and the other for a private ophtho group.
Here are the answers I got from them to the following questions:
1. Do you ever need to refer your post-op patients anywhere for complications?

Both answered the same. They never have any complications and all patients are very satisfied. Should this already be a hard stop and I consider them to be liars?​

2. How do you remove the native lens?

Multispecialty guy: always use scalpel​

Ophtho group guy: always use laser​

3. What implants do you use?

Multispecialty guy: a variety (but does not use LAL and didn't mention other premiums)​

Ophtho guy: almost LAL exclusively​

4. Have you ever done surgery on a cataract surgeon?

Both said their colleagues are too young, so no.​

Both highly rated in community, but with 2 different approaches. Should I consider their lack of fessing up to errors a red flag and keep looking?
I didn't make an appointment at the closest academic center, since it is 2 hours away and no one in the chat recommended the academic route.

Thank you for your input!

 

[eyeeye_captain]

So I had 2 consultations for the surgery with 2 of the highest recommended docs in the area. One works for a multispecialty clinic, and the other for a private ophtho group.
Here are the answers I got from them to the following questions:
1. Do you ever need to refer your post-op patients anywhere for complications?

Both answered the same. They never have any complications and all patients are very satisfied. Should this already be a hard stop and I consider them to be liars?​

2. How do you remove the native lens?

Multispecialty guy: always use scalpel​

Ophtho group guy: always use laser​

3. What implants do you use?

Multispecialty guy: a variety (but does not use LAL and didn't mention other premiums)​

Ophtho guy: almost LAL exclusively​

4. Have you ever done surgery on a cataract surgeon?

Both said their colleagues are too young, so no.​

Both highly rated in community, but with 2 different approaches. Should I consider their lack of fessing up to errors a red flag and keep looking?
I didn't make an appointment at the closest academic center, since it is 2 hours away and no one in the chat recommended the academic route.

Thank you for your input!

*Disclaimer: not medical advice

There is no such thing as a surgeon without complications.

The second guy is up-charging everybody. If you want to pay extra for new technology, that’s fine, but it doesn’t improve outcomes much, if at all. I pray that guy isn’t in my region so I don’t have to clean up the post-op problems that “never happen.”

 

[Slide]

So I had 2 consultations for the surgery with 2 of the highest recommended docs in the area. One works for a multispecialty clinic, and the other for a private ophtho group.
Here are the answers I got from them to the following questions:
1. Do you ever need to refer your post-op patients anywhere for complications?

Both answered the same. They never have any complications and all patients are very satisfied. Should this already be a hard stop and I consider them to be liars?​

2. How do you remove the native lens?

Multispecialty guy: always use scalpel​

Ophtho group guy: always use laser​

3. What implants do you use?

Multispecialty guy: a variety (but does not use LAL and didn't mention other premiums)​

Ophtho guy: almost LAL exclusively​

4. Have you ever done surgery on a cataract surgeon?

Both said their colleagues are too young, so no.​

Both highly rated in community, but with 2 different approaches. Should I consider their lack of fessing up to errors a red flag and keep looking?
I didn't make an appointment at the closest academic center, since it is 2 hours away and no one in the chat recommended the academic route.

Thank you for your input!

Wow the audacity at saying they have no complications. Either they haven’t operated enough or are lying.

 

[LightBox]

Just DM me the names and I'll let you know whether either of them are any good.

 

[dantt]

Lol same as light box.

Not even the LAL reps have a good argument what the laser adds.

 

[LightBox]

Lol same as light box.

Not even the LAL reps have a good argument what the laser adds.

I love femto-assisted cataract surgery and would definitely have it on my own eyes when the time comes. Especially for white/dense cataracts, shallow chambers (where the CCC is a PIA to create), etc. The "softening" of the cataract with femto definitely makes it easier to fracture with my usual chopping maneuvers.

However, a few thousand dollars is not going to impact my finances, while it definitely can hurt some of our patients' finances. I always tell my patients to spend the money on the lens first (e.g. LAL) and then on femto if they really want the full Monty. I tell them if any of these extra expenses are going to significantly deplete them, then just stick with standard everything (with the usual caveats of wearing glasses afterwards). But you'd be surprised by how much disposable income patients have and how much many want to spend before they die.

 

[dantt]

I love femto-assisted cataract surgery and would definitely have it on my own eyes when the time comes. Especially for white/dense cataracts, shallow chambers (where the CCC is a PIA to create), etc. The "softening" of the cataract with femto definitely makes it easier to fracture with my usual chopping maneuvers.

However, a few thousand dollars is not going to impact my finances, while it definitely can hurt some of our patients' finances. I always tell my patients to spend the money on the lens first (e.g. LAL) and then on femto if they really want the full Monty. I tell them if any of these extra expenses are going to significantly deplete them, then just stick with standard everything (with the usual caveats of wearing glasses afterwards). But you'd be surprised by how much disposable income patients have and how much many want to spend before they die.

Most practices I know "bundle" femto with their premium options. I agree regarding disposable income. If dentists can charge 50k for veneers, why can't we charge for good vision for life?

 

[LightBox]

Most practices I know "bundle" femto with their premium options. I agree regarding disposable income. If dentists can charge 50k for veneers, why can't we charge for good vision for life?

Agreed. LAL+ is the real deal. Every patient I've done so far is 20/20 or better for distance and at least J2 for near. Every...single...one. I've even had some 20/10 eyes! It really is remarkable.

 

[hello lady!]

Agreed. LAL+ is the real deal. Every patient I've done so far is 20/20 or better for distance and at least J2 for near. Every...single...one. I've even had some 20/10 eyes! It really is remarkable.

What do you do in a few years when there's eventual refractive drift? LASIK touch up every few years?