Eyeworld

52 | EYEWORLD | DECEMBER 2021 by Liz Hillman Editorial Co-Director About the physicians Thomas Clinch, MD Eye Doctors of Washington Washington, D.C. Ella Faktorovich, MD Pacific Vision Institute San Francisco, California Neda Nikpoor, MD Aloha Laser Vision Honolulu, Hawaii R EFRACTIVE lagophthalmos and counsel these patients about the potential for greater dry eye and the need for postop artificial tears. If a patient were to have higher order aberrations, which Dr. Clinch identifies with the WaveLight Topolyzer Vario Diagnostic Device (Alcon), he has performed Contoura (Alcon) treatments on post-LASIK patients to reduce ab- errations. The physician needs to explain to the patient that treating higher order aberrations can have variable outcomes. He usually advises against treating higher order aberrations if the patient's procedure was done a long time ago and they're functioning reasonably well. Dr. Nikpoor noted that she will set the appropriate expectation by telling patients it may take two or three treatments to achieve the final result. "Time tends to heal a lot of the aberrations in both that the cornea will respond and the brain tends to neutralize some of the aberra- tions," Dr. Clinch said. Dr. Faktorovich shared the reasons she finds for unhappy post-LASIK patients. There are patients whose outcomes don't align with their expectations. A good example of this is when a patient with mixed astigmatism also has signifi- cant accommodation, she said. "We can operate on MRx, but their vision will worsen over the years as they lose their accommodation. Or we can operate on CRx and they will be nearsighted initially. In this case, they may need to do vision therapy," Dr. Faktorovich said. Dr. Clinch said he's a big proponent of mild monovision in the pre-presbyopic, myopic patient. From an expectations standpoint, he said hyperopic patients need to be counseled preop that their convalescent period might be longer and they might experience nighttime visual disturbances for a longer period of time compared to their myopic peers. Highly myo- pic and/or myopic astigmats also could have a longer convalescent period, and they should be told they might need a touch-up. Other unhappy patients, Dr. Faktorovich said, are those who feel like the surgeon doesn't have time for them or is dismissive or defensive. There are also patients who may need help understanding what's normal during the healing process, she added. A patient unhappy after LASIK—thank- fully, as Neda Nikpoor, MD, put it, there are not many. LASIK was estab- lished by the PROWL studies 1 as safe and effective with a high level of sat- isfaction, but there are patients who are unhap- py with their outcomes, though rarely. Why this happens and how to best manage these patients is what Dr. Nikpoor, Ella Faktorovich, MD, and Thomas Clinch, MD, shared with EyeWorld. More than 95% of participants in the PROWL study were satisfied with their vision after LASIK. According to analysis by the FDA, some patients developed problems after the procedure, including visual disturbances such as starbursts, glare, halos, or severe dry eye. The studies found that less than 1% of patients had difficulty performing their usual activities due to any symptoms that developed postop. Reasons for unhappy patients Dr. Nikpoor said she could think of less than a handful of patients who were unhappy after LASIK. One was a man in his early 40s who was beginning to experience the symptoms of early presbyopia. She had offered to leave him a little myopic in his non-dominant eye, but he chose to see perfectly at distance in both eyes. His distance vision postop was good, and he could still read J1-plus uncorrected, but he said it felt more difficult to see near. "You could tell that he was struggling to deal with the fact that he was 40 now, and this was unmasking that," she said. Dr. Nikpoor said she has had a couple of patients experience "rainbow glare." Evidence suggests that the majority of these cases dimin- ish with neuroadaptation over time, and Dr. Nikpoor and her partner Alan Faulkner, MD, have found that to be true in their experience. Dr. Clinch said he has had this experience, too, and time resolves most cases of rainbow glare. He also said pulsed doses of topical steroids can be effective. Another side effect that could result in an unhappy patient is dryness. Dr. Clinch said patients with dryness preoperatively should be treated and counseled that it could get worse during the postop period, as should patients who spend a significant amount of time looking at screens. He said physicians should look for The unhappy LASIK patient COMPLICATED CASES

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