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EW FEATURE 36 in this conversation, including what type of lens the patient is receiving, cost issues, and the possibility for patient dissatisfaction after the surgery. Richard Tipperman, MD, Wills Eye Hospital, Philadelphia; William Trattler, MD, Center for Excellence in Eye Care, Miami; and Kevin Waltz, MD, Eye Surgeons of Indiana, Indianapolis, weighed in on this topic. Do you discuss this preop with all patients? Dr. Tipperman said that he discusses the possibility of enhancements with patients who express a strong desire for a specific refractive out- come. "I do not routinely discuss this, but it is likely a good idea," he said. He knows some surgeons who have patients sign waivers indicating that they understand that results can vary on a patient-to-patient basis and may not be exactly as a patient desires. "Fortunately, if patients wish to have their post-refractive outcome adjusted, this can usually be done with laser vision correction, but there are additional costs for this," he said. Dr. Tipperman added that for multifocal IOL patients, particularly ones with significant astigmatism, it might be necessary to have a discus- sion before surgery. "I explain that they will need to cover just the facility fee costs," he said. "We price our toric and multifocal patients so that it includes touchups," Dr. Trattler said, "so this is not usually a preoperative conversation." "Our day-to-day goal is be on target, so if the subject is broached with patients, it's a simple point that if the outcome ends up over- or undercorrected, it can be fine- tuned postoperatively." Dr. Waltz discusses these possi- ble refractive enhancements with certain patients, adding that it becomes more apparent depending on the patient if this is going to be a good option. For example, someone with cataracts who is 20/60 and does not care if they wear glasses is not a patient who is going to want refrac- tive enhancement postoperatively. He will discuss this with pa- tients who are getting a toric lens because they are obviously paying extra to get a refractive outcome, so there needs to be an enhancement strategy in place for them. Dr. Waltz added that these patients cannot be surprised with the enhancement strategy after the fact. This strategy also applies to patients getting multifocal or ac- commodating lenses. Patients need to be aware that there is a possibility Keratorefractive enhancement of pseudophakes July 2014 T he topic of this Monthly Pulse survey was "Keratorefractive enhancement of pseudophakes." We asked, "In your experience, what's the most common cause of patient dissatisfaction with multifocal IOLs?" The majority of respondents said residual refractive error, with poor quality of vision as the second most popular answer. For a presbyopia-correcting IOL patient with residual myopia (–1.25 @ 4 months) dissatisfied despite new glasses, more than half of respondents would perform LASIK/PRK/mini-RK themself. For a presbyopia-correcting IOL patient mildly dissatisfied due to residual astigmatism (–0.50 + 1.00 x 180), the majority would do LASIK/PRK themself; performing an LRI in office was the second most popular answer. Finally, we asked survey participants to describe themselves, and more than 65% said they implant presbyopia-correcting IOLs and do needed keratorefractive enhancement (KRE) themself. Monthly Pulse Keeping a Pulse on Ophthalmology Depending on the patient, a surgeon may want to discuss refractive enhancement preop W hen handling keratorefractive enhancement in pseudophakic patients, it may be necessary for a surgeon to discuss a patient's options and counsel him or her about the necessity of refractive enhancement preoperatively. There are a number of factors to consider AT A GLANCE • Not all patients will end up needing keratorefractive enhancement, but it is important to have a plan in place that patients know about beforehand to avoid last minute surprises. • Patients who need counseling include those with previous laser vision correction, monovision patients, and those receiving multifocal, accommodating, or toric lenses. • Many surgeons include some of the price in premium procedures and may have the patient pay a facility fee or wrap it into the total cost. by Ellen Stodola EyeWorld Staff Writer Counseling patients about refractive enhancement 30-37 Feature_EW July 2014-dl_Layout 1 6/30/14 8:42 AM Page 36

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