Eyeworld

EW FEATURE 58 by Jena Passut EyeWorld Staff Writer Managing unhappy refractive patients When managing expectations early doesn't help, doctors may be re- quired to take extra steps to soothe an angry post-op patient "One of the things the surgeon has to do is assess the patient, how flexible he is, and how well he is grasping some of the issues," he said. "If the patient is not, the sur- geon should postpone the surgery or even not do it if the patient has un- realistic expectations. That's where a good staff person can alert you. I pay attention to my staff, and if I get a warning signal from them, I will often turn these people down." But what if there was no indica- tion pre-op that the patient's expec- tations were too high and he or she might be unhappy no matter what? Again, it's not enough to fall back on the numbers and post-op test results that indicate the patient's vision is fine or better. "It doesn't matter what the pa- tient's visual acuity is; it doesn't February 2011 Challenging refractive cases October 2011 AT A GLANCE • Get to know the patient's expecta- tions early on to decide if they are reasonable, experts advised • Understand that a patient's percep- tion of vision loss is real to him, and treat him accordingly • Unhappy patients can be encour- aged to seek a second opinion • Giving a patient his money back after surgery does not mean that the surgeon is guilty of wrongdoing, the experts agreed I t's interesting to note that 36% of respondents do not perform LRIs. The most common reason stated for not per- forming them—poor predictability with current techniques. Femtosecond arcuate incisions hold some promise to improve astigmatism outcomes. As baby boomers are moving into the cataract realm, we will be seeing more pa- tients who have had previous refractive surgery. Due to the complex nature of these IOL calculations, we will need to be addressing more enhancements. Most commonly, respondents will lift a flap at any time following a previous LASIK surgery, while some of the members will lift early and perform surface ablation later. A minority of respon- dents will perform surface ablation at all times. Of note, LASIK volumes have remained flat or declined more often than increased in the past year. The majority of respondents feel refractive lens exchange has come of age. –Kerry Solomon, refractive editor T he main concerns of the 1/3 of ophthalmologists that do not perform LRIs are the technique or the results, which suggests a real opportunity for toric IOLs and femtosecond arcuate incisions as an alternate treatment for astigmatism associated with cataracts. While 1/3 of surgeons will lift all flaps for LASIK enhancement, about 50% now perform PRK over the flap when enhancements are over 12 months post-LASIK. Only 14% of sur- geons always do PRK enhancements after LASIK; however I expect this number will rise as the inverted side cut of the femtosecond lasers make flaps harder to lift. When 75% of surgeons report no change or a decrease in LASIK volume, there must be very poor market conditions as refractive surgeons are notoriously optimistic about LASIK volume. While not specifically addressed in the survey question, RLE for hyperopia is more mainstream; RLE for high myopia is still controversial because of the potential for retinal detachment. –Louis Probst, refractive editorial committee member Monthly Pulse Keeping a Pulse on Ophthalmology T he refractive surgery is over and the patient's visual acu- ity is 20/20. The entire process, from the initial meeting to the recovery room, was a bona fide success, ac- cording to the surgeon. So why is the patient in the sur- geon's office 2 weeks later complain- ing bitterly that his vision is "ru- ined"? Not much will befuddle a good surgeon more than dealing with a post-surgical patient whose results look excellent on paper but who in- sists his vision does not meet his original expectations. There are several ways to handle such a dilemma, according to three experts who spoke to EyeWorld. First, Richard L. Abbott, M.D., San Francisco, immediate past chair- man of the board of Ophthalmic Mutual Insurance Co., said surgeons may head off this type of complaint through managing and understand- ing their patients' expectations early on. "Any time you pay out-of- pocket, that raises the bar for expec- tations," he said. "What we as physicians and refractive surgeons think of as successful may not be in the mind of the patient. That could even be 20/20 or 20/15 vision. "It really depends on what the patient's expectations were going into the surgery and how well that was managed and explained to the patient, either by the staff or by the physician." A thorough pre-op exam can de- tect which patient will not be a good candidate for the elective surgery, both in terms of the patient's eye health and personality, Dr. Abbott said. 62% of respondents thought refractive lens exchange was becoming more mainstream 52-67 Feature_EW October 2011-DL33_Layout 1 9/29/11 4:51 PM Page 58

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