Publisher’s note: We’re delighted to be posting this clinical piece by a talented COA in our network, Maria Razumovich Kordit. Maria was honored last year with a Local Eye Site/JCAHPO scholarship. This is a very helpful article for other COAs, COTs ,and Ophthalmology professionals about how you can ensure surgical success. We also want to encourage eye care employers to read the article for better understanding around the staffing and training required to get the best outcomes.

Common Topography and IOL Master Mistakes: How a Technician’s Approach to Testing Can Significantly Impact a Patient’s Pre-and-Post Surgical Status

If you are a technician in a practice where a physician is a practicing surgeon, your ability to properly interview a patient and conduct tests can significantly alter a post cataract extraction refractive state. When a patient is unsatisfied with their post-surgical refractive state, it is the doctor that takes on the stressful responsibility of handling this patient, however, there is a high chance it was the technician that inaccurately conducted the testing. This often skews the doctor’s great surgical skills by providing him with inaccurate numbers. Our topography readings and IOL scans help the doctor determine the surgical plan with the patient, and our inaccuracies can create these unhappy post-operative patients.

As our industry becomes busier and days get filled with more patients to accommodate heavy schedules, we tend to take shortcuts to stay on time and flow patients to the doctor. Such a sacrifice can later create refractive surprises from IOL and corneal miscalculations, ultimately taking more time away from the doctor to resolve.

As technicians, we must overcome two issues that can lead to an abnormal ocular surface, which creates a risk for inaccurate keratometry readings: identifying the patients who have dry eyes and the patients who wore contact lenses in the past (especially if you see they have Keratoconjunctivitis Sicca). These become extremely critical when patients are selecting an advanced technology lens such as a toric or multifocal IOL. Our preoperative testing enables the surgeon to make judgment whether a patient is a candidate, evaluate contraindications, observe things that were not visible on the slit lamp exam, and cohesively portray the expectations to the patient.

Contact lens wearers, especially those who currently or historically wore RGP’s, should be carefully pre-tested. Each physician has a recommendation of how long they want a patient to be without contact lens wear prior to testing (some say for RGP’s one to three months, for soft lenses between one to four weeks). This “request” to the patient has no severity in the patient’s mind, as they do not understand that a little incorrect topography reading can significantly alter their visual acuity results. As a technician, you must be an advocate for your doctor and make sure patients understand they must follow these recommendations. In addition, you must also be a good detective when the patients return to clinic for testing to make sure they followed the recommendation. A patient will always be too scared to be truthful due to worry of upsetting the physician, sense of urgency to get the surgery over with faster, or just plainly think it’s inconsequential to hold back information. Instead of just taking the patient in to do tests, you must thoroughly question the patient to make sure they didn’t wear their contacts within the recommended time frame.

Dry eyes are another major issue that creates significant problems for the patients and the physician. I will never forget when I was learning to use the IOL Master, I saw a patient’s keratometry, axial length, and topography readings fluctuate significantly from just the lack of, or excess of, blinking. Assorted studies have proven that a dry eye can alter an IOL Master keratometry and anterior chamber depth readings by +/- 1D change in postsurgical refraction.

What can you do as a technician?

  1. Don’t just aimlessly click buttons, select a lens, print off the results and pass on to the doctor. Take a moment to look at the numbers – do they make sense? Is there variability? If there are discrepancies, it is a sign that you must repeat the test.
  2. Prior to each test make sure to lubricate the eye. Avoid artificial tears that have polyvinyl alcohol as an ingredient. Some people can get immediate side effects such as inflammation, which will cause a temporary change in vision. Also avoid gel tears, or anything that you know has dense viscosity. This will build a fluid layer on top of the cornea that can skew the axial length and anterior chamber calculations. Furthermore, it will create false topography readings. Remind patients to not become paralyzed from concentration and ask them to blink frequently prior to you starting your next reading.
  3. Patients who have dermatochalasis and ptosis will create a “curtain” on the top portion of the topography reading. While this is unrelated to cataract surgery directly, we still need to be concerned with helping the doctor create the best outcome for a post-surgical result. A patient may choose to have a blepharoplasty surgery a few years after cataracts whether it is a medical necessity or cosmetics. If you see a patient with this diagnosis, and especially if they are doing specialty lenses, speak to your surgeon to see if he wants the lids taped. Taping the lids will create full cornea surface area readings and can properly account for irregularities in the cornea. Studies have shown that after ptosis repair, corneal topography demonstrated a reduction in average keratometry of 0.15 ± 0.47 diopters (D) and in corneal astigmatism of 0.26 ± 1.12 D . If a patient got a toric lens and later proceeded to have ptosis surgery, their final visual acuity might be impacted.

It is important to remember that if at any time you feel you are unable to complete a test to the best capacity due to an uncooperative patient, or feel like something is off with the test results, don’t stay silent. Go to a head technician, nurse, or medical professional at the clinic (O.D./M.D.) and make sure they are aware of the issue. People’s quality of life can be affected by our mistakes and we cannot afford to be careless in our approach to this very responsible position.

Maria Kordit is currently working as an ophthalmology technician at Manhattan Eye, Ear, and Throat Hospital, NY. Maria has worked as a technician and administrative assistant in various optometry and ophthalmology settings for the last seven years. After receiving a part time job as a contact lens assistant during her undergraduate years at the University of Washington, Seattle, she has fallen in love with this specialty in medicine. Currently, Maria is pursuing a Master of Health Care Policy and Administration at Columbia University in order to transition into a policy and administrative career incorporating public health, with a goal of focusing on the current lack of national health literacy standards and effective population health management between providers.

Sources:
[1]https://www.ncbi.nlm.nih.gov/pubmed/26751993