EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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46 by Michelle Dalton EyeWorld Contributing Writer LASIK/keratorefractive surgery August 2014 Measuring outcomes key to practice growth with laser vision correction The 2014 ASCRS Clinical Survey was completed earlier this year with the participation of 1,501 ophthalmol- ogists. The survey contained 134 questions on clinical opinions and practice patterns of ASCRS members. Each month, EyeWorld will highlight a few questions from this year's survey and have experts weigh in on what the responses mean. This month's inaugu- ral column reviews some of the practice trends in laser vision correction. The two survey questions and answers to the right are discussed: T here is no doubt that laser vision correction (LVC) is one of the most commonly performed elective surgeries in the world. When LVC first started, the goal was simply to "take people with really thick glasses and allow them to wear thin glasses," said Jason P. Brinton, MD, clinical assistant professor of oph- thalmology, University of Kansas. Today's lasers can help patients attain levels of vision they could not achieve with glasses or contacts. Seeing 20/20 postop is a given—but defining "20/happy" or "20/ecstat- ic" is not as easy, Dr. Brinton said. When it comes to assessing surgical success, several important factors come into play that many surgeons do not measure, he said. Assessing LVC outcomes In response to the 2014 ASCRS Clin- ical Survey question "How are you currently assessing successful laser vision correction surgery outcomes in your practice?" the survey found that 21% of surgeons performing laser vision correction do not have a standardized way of assessing successful outcomes. "There are very formal ways of assessing outcomes, for instance, entering data into national database programs," said Christopher E. Starr, MD, FACS, associate profes- sor of ophthalmology, and director of refractive surgery, Weill Cornell Medical College, New York. Dr. Starr said most surgeons measure out- comes in a less formal manner, by keeping a personal database of all preop vs. postop data points includ- ing satisfaction levels, refractive er- ror, astigmatism, uncorrected vision, and topography, among others. An additional data point from the survey revealed that 72% of U.S. surgeons and 57% of surgeons outside the U.S. routinely utilize 20/20 UCVA as a successful target- ed outcome for most of their laser vision correction patients. "As we increasingly observe out- comes better than 20/20, due to the technology advances we have seen with LVC in the last several years, we have started to ask the question, 'Does patient satisfaction increase with improvements beyond this previous conventional standard?' It certainly does," Dr. Brinton said. Durrie Vision (Overland Park, Kan.), where Dr. Brinton recently worked (he has since joined Hunter Vision in Orlando, Fla.), implement- ed a patient satisfaction survey and found a linear increase in patient satisfaction as uncorrected vision improved from 20/20 to 20/16 and 20/12.5. "One way we assess outcomes is to ask how likely patients are to refer a family member for a procedure," he said. "Even small amounts of residual refractive error can make a difference in how happy patients are." On a related note, when ASCRS members were asked if they would perform refractive surgery on one of their immediate relatives if they had clinically significant refractive error and no significant contrain- dications, 87% indicated that they would do so. Dr. Starr said limbal relaxing incisions can have a "significant impact" on decreasing corneal sensation that may exacerbate dry eye postoperatively and therefore lead to patient dissatisfaction. If a postop patient is dissatisfied with visual quality, dry eye "often is the root cause of these transient visual disturbances." Implementing standardized measurements does not need to be as detailed as some suggest, which may explain why some practic- es overlook this critical factor for practice development, Dr. Brinton said. It can be something as simple as calculating if the patient's postop uncorrected vision is better than the patient's preop best corrected vision—dubbed an "efficacy ratio." Practices that want to grow volume are going to have "to com- mit to, and take responsibility for, better refractive outcomes," he said. "They're going to have to be able to assess outcomes across the range of refractive candidates. If someone sees 20/16 with glasses, 20/25 post- op may not be appropriate if a small correction can get them to 20/16." Most importantly, Dr. Brinton said, practices and surgeons need to quantify, not just qualify, their LVC results. "You won't stay in business very long if you have bad outcomes IMPORTANT SAFETY INFORMATION FOR CENTURION® VISION SYSTEM CAUTION: Federal (USA) law restricts this device to sale by, or on the order of, a physician. As part of a properly maintained surgical environment, it is recommended that a backup IOL Injector be made available in the event the AutoSert® IOL Injector Handpiece does not perform as expected. INDICATION: The CENTURION® Vision System is indicated for emulsification, separation, irrigation, and aspiration of cataracts, residual cortical material and lens epithelial cells, vitreous aspiration and cutting associated with anterior vitrectomy, bipolar coagulation, and intraocular lens injection. The AutoSert® IOL Injector Handpiece is intended to deliver qualified AcrySof® intraocular lenses into the eye following cataract removal. The AutoSert® IOL Injector Handpiece achieves the functionality of injection of intraocular lenses. The AutoSert® IOL Injector Handpiece is indicated for use with the AcrySof® lenses SN6OWF, SN6AD1, SN6AT3 through SN6AT9, as well as approved AcrySof® lenses that are specifically indicated for use with this inserter, as indicated in the approved labeling of those lenses. WARNINGS: Appropriate use of CENTURION® Vision System parameters and accessories is important for successful procedures. Use of low vacuum limits, low flow rates, low bottle heights, high power settings, extended power usage, power usage during occlusion conditions (beeping tones), failure to sufficiently aspirate viscoelastic prior to using power, excessively tight incisions, and combinations of the above actions may result in significant temperature increases at incision site and inside the eye, and lead to severe thermal eye tissue damage. Good clinical practice dictates the testing for adequate irrigation and aspiration flow prior to entering the eye. Ensure that tubings are not occluded or pinched during any phase of operation. The consumables used in conjunction with ALCON® instrument products constitute a complete surgical system. Use of consumables and handpieces other than those manufactured by Alcon may affect system performance and create potential hazards. AEs/COMPLICATIONS: Inadvertent actuation of Prime or Tune while a handpiece is in the eye can create a hazardous condition that may result in patient injury. During any ultrasonic procedure, metal particles may result from inadvertent touching of the ultrasonic tip with a second instrument. Another potential source of metal particles resulting from any ultrasonic handpiece may be the result of ultrasonic energy causing micro abrasion of the ultrasonic tip. ATTENTION: Refer to the Directions for Use and Operator's Manual for a complete listing of indications, warnings, cautions and notes. © 2014 Novartis 4/14 CNT13017JAD-A THE C ATARAC T REFRAC TIVE SUITE BY ALCON U.S. Non-U.S. Overall We don't have a standardized way of assessing outcomes 22.5% 20.5% 21.1% Uncorrected visual acuity; we look at the percent of patients with 20/20 or better UCVA 71.7% 57.3% 63.6% Uncorrected visual acuity; we look at the percent of patients with 20/16 or better UCVA 12.3% 17.3% 15.3% Ratio of patients with postop UCVA better than preop BCVA 13.8% 15.7% 15.0% Patient satisfaction ratings 50.7% 52.4% 51.7% Visual quality contrast sensitivity testing 2.2% 16.2% 10.4% How are you currently assessing successful laser vision correction surgery outcomes in your practice? LASIK increases dry eye in >10% patients U.S. Outside U.S. Average 61.1% 74.4% 67.7% LASIK increases dry eye in >40% patients U.S. Outside U.S. Average 28.5% 30.5% 29.5% Source (all): 2014 ASCRS Clinical Survey 2014 ASCRS Clinical Survey In what percentage of your patients do you believe that LASIK has significantly increased the level of postoperative dry eye?