Gary Wörtz, MD: Open. Outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz.

Batman and Robin, Bonnie and Clyde, Hall and Oates, Wayne and Garth, and Gary and John. That’s right, a well-oiled cataract-retina tag team joins the ranks of the most famous duos in history. All kidding aside, there is something to be said for partnerships formed between cataract surgeons and their retina colleagues. In this episode of Ophthalmology off the Grid, I talk to Dr. John Kitchens, a retina specialist here in Lexington, Kentucky, and my posterior segment counterpart in the OR. We’ll explore what’s unique about our relationship and how we joined forces to provide the best outcomes possible for our patients.

Speaker 1: Ophthalmology off the Grid is supported by Ilevro from Alcon.

Gary: This is Ophthalmology off the Grid with Dr. Gary Wörtz, and today I have with me Dr. John Kitchens. John, I just want to say thank you very much for taking a little bit of time out of your evening and talking to me about stuff that we actually do a lot together, which is a lot of fun, which is operating in tandem as a cataract and retina duo. With that being said, John, thanks for coming on the program.

John Kitchens, MD: Hey, thanks for having me, Gary, appreciate it.

Gary: Yeah, absolutely. Just as a little bit of background, John and I have been working together, what would you say, probably close to five to six years at this point?

John: Gosh, it seems like longer, but yeah, I’d say we’ve been at least 5 years.

Gary: Yeah, so I’ve had the real privilege and benefit of having just a tremendous retina group here in Lexington to refer patients to, and John and I have really hit it off and become good friends, just really through work and also through some other activities here in Lexington, just being ophthalmologists and trying to take good care of patients. Through our time working together, we’ve really, I think, come up with a unique relationship that’s allowed us to take care of patients maybe in a little bit of a unique way. As we were just kind of discussing this the last time we were in the operating room together, I said, “You know, maybe this is something that other cataract surgeons and perhaps other retina doctors around the country would find beneficial, to really discuss what’s the best way for a cataract surgeon and a retina surgeon to work together to give patients optimal results.”

On your side of the equation, John, when you have a patient who’s either post cataract surgery or someone who you’re about to do surgery on, but you see that they have a cataract, what are the things that really go through your mind either in regards to when patients should have cataract surgery, or how cataract surgeons can perhaps set you up for better success in taking care of these folks?

John: Well, you know, Gary, I think the biggest thing is really communication. I love the fact that I can just text you about a patient and send you a one-line text message. A lot of times, I use voice dictation in the room with the patient, I say, “Hey, you know what, if you have a question about things, let me just text Dr. Wörtz and see what he says. The thing is that you’re always getting back to me about these patients and always very good at communicating what you find out about the patient, what you’re thinking.

For me as a retina specialist, I’ll tell you, partnering with a great cataract surgeon really enhances your patients’ outcomes and your patients’ experience. I certainly feel like anybody that we’re going to operate on would benefit from being pseudophakic because, to be honest with you, when we do a vitrectomy on a patient, they’re going to get a cataract more often than not, and having that cataract out of the eye, even potentially before we operate on them, just makes our surgery easier. It makes it more reliable for the patient, it gives us a better view into the back of the eye. There’s a lot of reasons to want to have that patient have their cataract taken out prior to their retina surgery.

Oftentimes, we’ll get these patients that have an epiretinal membrane or some other macular problem, vitreomacular traction, and a cataract. In a lot of instances, they’re actually sent to the cataract first, and what you guys are really good at, and good cataract surgeons are really great at, is picking up the fact that hey, could be multifactorial. A lot of times, I’ll talk to those patients and I’ll say, “You know what, you’ve got this epiretinal membrane, you’ve got a cataract, in my mind, it could be 50/50. Your reason for your 20/50 or 20/80 vision may be a little bit of both. But you know what, let’s take the cataract out first and see where you’re at. Then, if you need macular surgery, great, but since it’s a little higher risk proposition, maybe we should go ahead and do the cataract surgery first.” Knowing that there’s a cataract surgeon that’s there, will listen to that, and get that cataract done is fantastic, and it’s so reassuring.

Now, there’s other times when we’ll look at somebody and go, “You know what? This epiretinal membrane looks visually significant, but I also think that for me to do the best surgery, I need to have that cataract out of there, and I also think that the patient’s going to do better with the cataract out of there.” That’s when it’s really synergistic to be able to pair up with somebody like yourself to go in and say, “Hey, you know what? Take that cataract out first, and, at the same time, I’ll go in and I’ll do my vitrectomy and my membrane peel.” I’ll know that I’m going to have a good, clear cornea without a lot of edema, I’m going to have a good view, a well-placed IOL.

To be honest with you, a lot of times, those are the patients that we see back in a week and they’ve gone from 20/80 to 20/40, and I know that that 20/80 to 20/40 is because of their cataract surgery. It’s really only about 8 to 10 weeks later when they really see the benefit of their epiretinal membrane surgery, but guess what? They get that wow effect. They’re coming in and very rarely, as retinas specialists, do we get hugs at 1 week. We may get them at 8 to 12 weeks, but we don’t get them at 1 week. When I pair up with someone like yourself and do the cataract combined procedure, we get those impressive results and we get those immediate returns, where the patient is just wowed.

Gary: John, you know, you’re making me want to maybe go back and do a retina fellowship. If I got hugs for 20/40 at 1 week, I would think that something had happened, that the world had stopped spinning on its axis. Usually, I’m getting the knife in the back if it’s 20/40 at 1 week, so definitely a difference in patients that we’re taking care of. I do know what you mean, it’s really setting up expectations and when patients do see a real noticeable improvement in their quality of vision, they are absolutely thrilled with it, and we definitely see that.

What I’ve found really helpful, and just from a practice pattern standpoint is those subset of patients who either have a cataract that is so opaque, white, black, brown, you name it, that you can’t see to the back. Maybe they have silicone oil in the eye, and you’ve not seen the retina in a while. Or, on the flipside, it’s someone who definitely has macular pathology such as a patient with VMT or an epiretinal membrane and a visually significant cataract. If I were that patient, if it could be offered to have immediate sequential cataract surgery and a vitrectomy with a membrane peel, that’s just so attractive. It’s less running around for their family, it’s less time off work, it’s really just doing the right thing for the patient.

I’m not a vitreoretinal surgeon, so I can’t offer that, and you know, if we can pair together and we can provide that for the patient, I will say, we do this generally once or twice a month on a handful of patients, and you know, I really can tell from the patients and their family that they’re really thankful. They understand that we’re doing something that’s a little bit unique and we’re really trying to put them at the top of our pyramid of care. They’re very, very appreciative of that. Is this something that you know of a lot of other guys around the country that are doing? I know it’s not totally unique, but I do feel like the fact that we can get in there and get a potentially, a cataract and a retinal procedure done in short order, I think that’s really helpful for those subset of patients.

John: I think that it does happen, but a lot of times, it happens in practices that are already established, that have a cataract person and a retina person, or practices that are academic, hence they have a lot of residents or fellows that may do the cataract surgery and then the retina person does the retina surgery. I know of very few, Gary, that actually take two separate, disparate practices and have such synergy where you can pair the cataract person who has the idea of what I want, and that’s what I appreciate is the fact that if I have a patient who let’s say has silicone oil in their eye, and I say to you, “Hey, I don’t know,” and I do this via a dictated letter, so it’s very easy to do, “I don’t know if this patient’s going to have their oil out or not. I can’t see into the back of their eye,” but I say, “You know what, I want you to take the cataract out and let me take a look in.” You’ve got them aphakic, with a capsule intact and everything such as that, I look in and now, for the first time in a year, or maybe two years, I’ve been able to see the back of their eye, because they’ve had oil in their eye and this cataract.

I go, “You know what? This patient’s not going to have this oil out because I don’t feel like the retina’s going to stay attached.” I can then look at you and go, “Hey, you know what, we’re going to keep the oil in, put a lens in appropriate for them having oil in their eye.” You’ve already done everything, you’ve done the leg work on the calculations to know, here’s the calculation that will offset the refractive difference between oil and clear vitreous. This is what we’re going to put in. A surprising number of people who have retained silicone oil in their eye long-term, that have attached maculas, that have 20/200 or better vision, because they have the right IOL in their eye. I don’t want to have a patient that has to come back and get a +5 prescription because basically you put a standard pseudophakic IOL in their eye. I want a patient that’s going to come back and get the very best vision uncorrected and then we can talk about adding a magnifier or adding other low-vision aids to them, as far as that goes. That’s just really reassuring.

Gary: Well, and you know, I’m going to credit Warren Hill for helping me with that, so if there are docs out there who are dealing with a lot of patients who have silicone oil in their eye, and thanks to John and his tremendous retina population, I’m probably doing silicone-filled eyes, at least three or four a month at this point. Not a ton, but enough to …

John: That’s not always a compliment, by the way, for a retina person, you’re doing a lot of silicone oil-filled eyes. But we have a lot of bad diabetics here in Kentucky, so …

Gary: Absolutely, and those are … in no way did I mean that, but this is a patient population who, as you mentioned, we take care of a lot of people who are really just sick patients, sick diabetics, and that’s the only hope they have for keeping the retina attached. For docs out there, for cataract surgeons who are considering taking out cataracts in silicone-oil filled eyes, Warren Hill has a great website that you can search and he has some resources on there, but the rules of thumb are this: If you have a patient with silicone oil in their eye, you want to make sure you’re doing biometry on the appropriate settings.

If you have an IOLMaster or Lenstar, you need to choose the setting that says “silicone oil-filled eye.” Then, if the silicone oil is going to stay in the vitreous, you can basically just use that calculation as is. Now, if you do the calculation and they have silicone oil in their eye and then that is going to be removed, you have to really make an adjustment for that. That’s something that you have to calculate on a case-by-case basis. Vice versa, if you have a patient who may be getting silicone oil placed in their eye, and, at the time of measurement, they do not have silicone oil in their eye, you’re going to have to add a lot of power to that lens, potentially up to 5.00 to 8.00 D of power. There’s a lot of thinking that has to go into this, and so I’m happy to help with cases, if that’s ever needed, because again, John and I are taking care of a fair number of patients on a monthly basis who need that, and so I’ve had a little bit of practice with it. It is something that you kind of have to think through every time.

John, just to switch gears a little bit, one thing that I find extraordinarily valuable in having a retina person around is, number one, those in-between cases where I’m looking at a cataract, and I think, you know, is it the retina? Is it the cataract? Maybe they’ve got some macular degeneration? and I think, man, they’re 20/50. This cataract is getting worse, I can definitely tell they have some cataract but I’m not really sure that they’re going to get that wow effect if I take the cataract out, or I just want a second opinion to help reassure the patient that they’re getting optimal care. Also, honestly, just to get your opinion as to whether the visual loss is coming more from the cataract or more from the retina. What do you find when you’re getting referrals such as this from cataract surgeons who are just wanting that second opinion or reassurance to say. Would you agree that this is ready? Or, give me the thumbs-up or thumbs-down.

John: I tell you, Gary, I think the biggest thing is that it’s never harmful to ask. I mean, I can tell you that we have seen a number of patients with cataract surgery, multifocal IOLs primarily, that are not happy. The main reason is because they have macular pathology that was not addressed beforehand. Setting those patient expectations are really huge, and that’s why seeing those patients with any kind of macular process, epiretinal membrane, vitreomacular traction, dry AMD with some drusen or some atrophy is really kind of the most important thing because I think just the fact that you refer that patient establishes with them, “Hey, you know what, I’m not just here to take your cataract out; we’re here to provide comprehensive care for your eye.”

It also sets their expectations from the standpoint of “Hey, you know what, I may have something else going on.” It’s important the way we talk to those patients, to be able to say, “Hey, look, you have this thing going on in your eye, and I think you’re going to benefit from cataract surgery, but realize that if you don’t get back to 20/20, this is why.” From my standpoint, when it’s an in-between thing, I would always defer to having the cataract taken out first. Saying, “Hey, you know what, if we need to come back and do something else to fix your retina, that’s great.” If it’s obvious, we want to do a combined case, but if it’s not so obvious, I would say, “You know what, it’s safer, it’s easier, go ahead and have Dr. Wörtz take out your cataract, and then, if you don’t see better, then we’ll do your macular pucker or your macular traction or whatever it may be.”

I’m always surprised, 80% of those patients that have combined pathology and it’s up in the air that we say take the cataract out first, 80% of them do not need a vitreoretinal procedure after that because they come back and they’ve improved by a couple lines and they go, “You know what? My vision’s better, I feel great, I’m able to read, I don’t necessarily think I need that retina surgery.”

Gary: Yeah. You know, what I find is that in the whole scheme of taking care of patients, it seems that anything you find or anything that you diagnose preoperatively, is the patient’s problem, and anything that you find postoperatively, at least in the patient’s mind, is something that you did to them or caused. I didn’t come up with that, I’ve heard that from a number of docs throughout the years. It really is a true statement. I think by calling a time-out and sending someone for a second opinion, it really does allow them to realize their eye is different. One thing I always say is, “It seems that everybody’s neighbor was 20/20 and had a painless surgery and is like a miraculous cataract surgery.”

It’s nice when you can educate somebody, say “You’re not just like your neighbor, you’re not just like the average cataract patient, and these are the reasons why, and I’d like you to go see this doctor, I’d like you to see Dr. Kitchens, to really get another opinion about what’s the best course.” When you do that, I feel like it builds trust with the patient, it sets appropriate expectations, and it also allows a neutral third party, such as yourself, to really advise whatever you feel like is best. That way, I don’t feel like I’m in any way pushing the patient into a procedure that they may or may not want or may or may not benefit from, and I feel like I’m doing the boy scout thing and really doing the right thing for the patient.

John: Absolutely, and it’s, like I said, so much easier for us to operate on a pseudophakic patient versus a phakic patient. I tell our fellows oftentimes, Gary, I say, “You know what, our job is to keep the patient out of the OR. If we do our job, patients that are borderline on needing surgery won’t need surgery.” I love operating, it’s my favorite thing, but more importantly, I never look for surgeries to do. That’s why I like having the fact that we can get the cataract out and make sure that that takes care of their problem, that’s great. The worst thing ever is to go in and do an epiretinal membrane surgery and the patient drops from 20/60 to 20/100 because their cataract, and you only get them back to 20/60. I would much rather take that 20/60 patient and make them 20/40 and then go “Okay, now let’s address your epiretinal membrane,” or “Let’s watch you,” and the patient’s better.

Gary: Well, let’s explore that a little bit, maybe on a different subset of patients. When I was in residency, it seemed like there were just a number of patients who were complaining of floaters. This is just a chronic thing that we all experience, and it seemed like since that time with the advent of smaller-gauge, 25-gauge vitrectomies, faster surgeries, safer surgeries, that more and more patients who have bothersome floaters end up actually getting a really nice result by having their floaters removed.

The reason I’m trying to tie this I in is a lot of times we think about retina patients in terms of people who have poor visual potential or some compromised visual potential. Sometimes, these are patients, especially the floater patients or the patients with vitreous floaters, are patients who have normal retinas who may have a multifocal lens or may have a nice refractive result from a cataract surgery, but they’re actually really absolutely bothered by their floaters. And, to be honest, I’ve sent a couple of those patients to you, you’ve taken care of them and I’ve really been astounded at the improvement in their quality of vision, their quality of life that that provides. This is really the flipside of that coin, but it really is a problem that I think now is being adequately addressed by surgical intervention. What are your thoughts about that? Taking care of patients who are actually really bothered by their floaters and providing a surgical solution?

John: You know, Gary, I tell you, it’s one of those things that’s kind of the redheaded stepchild of retina, is vitrectomy for floaters. I’ll tell you that I think there’s a few pearls for taking care of these patients. The first thing is obviously patient selection; you want to make sure that this patient is bothered by their floaters. You want to ask them, and preoperative screening is huge for these patients. You want to basically say to them, “Hey, you know what, do you have problems driving? Are you worried about driving because you lose cars in the floater? The floater distracts you from what you’re seeing as far as that goes, and you just don’t feel comfortable reading or you don’t feel comfortable doing those activities of daily living?” If they respond positively that that happens and that happens 80 to 90% of the time? Then you realize they’re very impactful, and some of those patients, in fact, most of those patients, are the happiest patients I have.

It’s hard to operate on a 20/20 eye, you know, I mean for you all, operating on a 20/20 cataract or whatever, is almost impossible. For us, we look and many of these patients are 20/20, 20/25, but they’re profoundly affected by this and they’ve been told time and time again, “We can’t do anything for you, don’t think about surgery, it’s too dangerous.” Realistically, with small-gauge surgery—25-gauge, 27-gauge surgery—where you don’t have to suture most of these wounds, and considering these patients already have a posterior vitreous detachment, where you’re not now worried about inducing a posterior vitreous detachment, where you can cause tears peripherally and things such as that. They really are very straightforward cases.

I often tell the patients, especially if they’re pseudophakic, I always hesitate to operate on the phakic patients because I know I’m going to give them a cataract, and I’ll tell them that. I’ll say, “You know, I’d love to take out your floaters, but honestly, I’m going to give you a cataract, and that’s a whole other subset of problems.” I’ll talk to these patients, and I’ll say, “You know, look, I can go and I can do this procedure, and I think there’s a 95% chance we’ll get rid of your floaters to a significant degree, and you may want your other eye done.” I’ll tell you, 95% want to have their other eye done after we get done with that, especially in those pseudophakic patients.

I also think, as a clinical pearl, that there’s something about those multifocal IOLs. I don’t know if it’s the multifocality or if it’s the expectations of the patient, but those patients are more bothered by floaters and actually may benefit more from a vitrectomy for the floaters, in those cases. I don’t want to basically say, “Hey, you know what, you should do floaterectomies for all your floater patients.” I certainly think for those patients who are profoundly bothered by the floaters, you’ve given them 4 to 6 months after the onset of the symptoms for those to clear up and they haven’t, and that are pseudophakic are the ideal candidates for a vitrectomy for floaters.

Gary: You know, I think those are great pearls, and I think just kind of in summary of all of this, I think just having a retina person or a cataract guy on the other end of the phone that you know is not going to leave you hanging. From my standpoint, I never want to send a patient to you who has had a multifocal and has macular pathology and vice versa, I don’t want to take out a cataract in someone who may have had a vitrectomy that I didn’t know about or was compromised in other ways. I can say I’m just so thankful to have such a great retina doc in town that I can refer patients to. Patients benefit from having these kind of conversations and having thoughtful care. With that being said, John, I just want to say thank you for the care you’ve provided to my patients, the opportunity to operate on your patients, and also just for coming on the program tonight.

John: Thanks, Gary, the feeling is definitely mutual, and I think that all of the listeners of this can realize that there is so much synergy that can happen between anterior segment and posterior segment that can really make it fun and enjoyable and can benefit our patients.

Gary: That’s it for this episode for Ophthalmology off the Grid. If you’d like to hear more episodes, visit itube.net/podcast. This is Dr. Gary Wörtz. Thanks for tuning in.

Speaker 1: Ophthalmology off the Grid is supported by Ilevro from Alcon.