Eyeworld

54 | EYEWORLD | JULY 2023 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Joseph Ling, MD Laser Eye Center of Silicon Valley San Jose, California James Loden, MD Loden Vision Centers Nashville, Tennessee BEST PRACTICES W hen performing one of the many refractive procedures available today, the surgical experience doesn't end when the surgery is over. Surgeons often have to follow up with patients, helping them through the postop experience, and sometimes providing touch-ups. Two physicians discussed how they handle the refractive postop experience, how to manage patient expectations, and diagnostic tools that help them. The postop experience begins right at the end of the surgery, said James Loden, MD. The doctor should be communicating with the patient that the procedure went well, if it did. If it didn't, you need to share that as well, he said. "Part of setting the preliminary postop experi- ence is by saying 'You did great' or 'We did have a little complication, but we fixed it,' or in those rare cases, 'We broke a capsule and we're going to have to do a second surgery.'" Being very communicative is key, he said. The second step is providing instructions before the patient leaves the surgery center, Dr. Loden said. It's important to give clear and con- cise instructions of expectations and what the patient will experience over the next 2–3 hours and what they experience the next morning when coming in for the day 1 visit. The postop visit depends on the procedure, and Dr. Loden said he won't always see each patient immediately after surgery, though he does prefer the chance to see the patient and set expectations. He added that it's also important to identify if the patient may be harder to sat- isfy. In those cases, you can have them see the operating surgeon and set the expectations and timelines to get the patient happier quicker. With LASIK, he said that almost every pa- tient is 20/20 on the day 1 postop exam, but it's still important to set expectations for the next week. There could be a little glare or halo, but those will usually go away. Joseph Ling, MD, said he likes to see most patients 1 day after a refractive procedure be- cause there are many things that can occur over the day after surgery. For LASIK specifically, he said it's important to ensure that the flap isn't mispositioned, and for LASIK, PRK, and SMILE, he said you want to make sure that the interface is clear. DLK can occur in the first 24 hours when there's a lot of inflammation, he said. These are things that can easily be treated early on, but if you don't see patients at 1 day out, these can get worse. For ICLs, he said it's important to make sure the pressure looks good the day after surgery. It's an intraocular surgery, so he's concerned about inflammation, TASS, and infection, he said, adding that these are things the surgeon would want to catch early. "The sooner you see it, the sooner you can treat it, and the better the outcome," he said. Most of these patients are quite functional the next day, Dr. Ling said, so it's also a good time for celebration and to see if they're happy. For those who aren't seeing well at day 1, it's about reassurance so they're not sitting at home wondering why they're not seeing great. "For all my patients, I counsel them about the most common things to expect," Dr. Ling said. "You want to focus on the relevant expec- tations and not go over every possible thing. The consent can cover everything else." He said that the common things for LASIK are the potential need for a second treatment, accuracy, residual refractive errors, and com- mon side effects. The same goes for SMILE. "For PRK, I counsel patients that they will need to wear a contact lens for the first week, and the vision will gradually get better," he said. With ICLs, Dr. Ling said you can expect the patient to be functional starting at day 1 following surgery. Vision dramatically improves with the ICL due to the fact that we're not touching the cornea, he said. "The cornea is pristine, even immediately after surgery. Almost all my patients are 20/40 or better immediately after ICL surgery. The next day is when they get to 20/20 or 20/15," he said. Side effects may include glare or halo, and Dr. Ling said most pa- tients will notice these issues, but they generally disappear over the course of the first month. He added that patients should be aware of residual refractive error, and he will also men- tion possible issues with positioning of the lens or exchanging the ICL for a different size. Dr. Ling finds that patients are most con- cerned about potential side effects. For pa- tients who had LASIK or SMILE, they are also The refractive postop experience

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