Eyeworld

EW FEATURE 42 Keratorefractive surgery August 2015 AT A GLANCE • Improperly set patient expectations and poor patient selection are two factors that can lead to unhappy refractive patients. • Refractive lens exchange is a good option, although not always the go-to option in a practice. • Screening tools like topography, optical biometry, and OCT are extremely valuable for refractive patients. by Ellen Stodola EyeWorld Staff Writer should be proficient in the use of to- ric IOLs, LRIs, and multifocal IOLs." Surgeons using refractive lens exchange should be able to fine-tune the refractive results with corneal re- fractive surgeries, like LASIK or PRK. Those with a high complication rate or whose postoperative refractive results are not at least 85% +/–0.50 D may not be the best individuals to perform RLE, Dr. Hoffman said. "This, however, is mostly dependent on the expectations of patients with- in their particular market." "Refractive lens exchange is an option that should be on the table," Dr. Berdahl said. "In our practice it's a good option, but it's not our pri- mary go-to option except in select circumstances." A refractive lens exchange may be particularly beneficial for those around 50 years of age who are hyperopic, he said. With modern cataract surgery and a number of new technologies, surgeons can address the problem of presbyopia better than they were able to before, but it's still not perfect, and the new technology does come with a price. Unhappy refractive patients "The most likely reason for unhappi- ness is improperly set expectations," Dr. Berdahl said. Surgeons need to be certain that patients understand what they're going to get and what they're not. Don't gloss over potential side effects, he said. It's important to dis- cuss issues like glare and halos and the chance that there will be a need for an IOL exchange. If the anatomy and physiology of the eye is not pristine, discuss that and make sure the patient understands, he said. "The second thing that leads to unhappiness is poor patient selec- tion," Dr. Berdahl said. It's import- ant to be aware of patients who may have a personality type that can't tolerate the imperfections that come with every technology. For example, he said a subtle epiretinal membrane is not compatible with multifocality. Meanwhile, irregular astigmatism on the cornea does not work well with toric lenses. "If we're not being diligent or screening for it or we believe that the technology is robust enough to handle these imperfec- tions, we're setting our patients up Role of refractive lens exchange and management of unhappy refractive patients Before a refractive procedure, it's important to know what factors can cause unhappy patients, the best tools, and how a refractive lens exchange may be valuable A lthough a refractive lens exchange (RLE) may not be the first choice for many surgeons, it can have value in the refrac- tive practice. It's important to know its role and to be able to evaluate refractive patient expectations ahead of time to eliminate some of the unhappiness and complications that can occur. Screening tools can help with this, as can a thorough discussion with the patient prior to surgery. Richard S. Hoffman, MD, clinical associate professor, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., and John Berdahl, MD, Vance Thompson Vision, Sioux Falls, S.D., discussed when they use refractive lens exchange and other guidelines for patients in the modern cataract refractive practice. The role of refractive lens exchange RLE is an important but not es- sential part of a modern cataract refractive practice, Dr. Hoffman said. "It is essential to offer this if you are a refractive surgeon, but a cataract surgeon can elect to refer these out to someone else," he said. "Surgeons who perform these procedures for disappointment," Dr. Berdahl said. Dr. Hoffman said the most com- mon reason for unhappy patients is unrealistic expectations. Another is- sue may be the inability to commu- nicate intelligently with the patient. Screening tools Dr. Hoffman uses a variety of screening tools, starting with cor- neal topography to rule out surface pathology, angle kappa, irregular astigmatism, and pupil size. "There is no substitute for the physician talking one-on-one with the patient since many times this will reveal unreasonable expectations," he said. "In addition, this gives the surgeon the ability to attempt to reset the patient's expectations and feel out whether a particular patient will be happy with a mediocre result or unhappy with a good result." He added that it's a good idea to perform macular OCT to rule out subclinical retinal pathology, such as epimacular membranes and macu- lar edema that might not be visible with a 90 D examination. "This is especially important for RLE with multifocal IOLs," he said. Dr. Berdahl said there are 3 essential tools he uses for screening. These include topography, optical biometry, and OCT. Additionally, tools like wavefront aberrometry, the HD analyzer (Visiometrics, Terrassa, Spain) or iTrace (Tracey Technolo- gies, Houston) can be helpful. Guidelines for tolerance of error and acceptable outcomes Dr. Hoffman recommended having postoperative residual astigmatism less than 0.75 D for refractive mul- tifocal IOLs and less than 0.50 D for diffractive multifocal IOLs. Addi- tionally, getting the postoperative sphere less than 0.50 D is usually fine, he said. An acceptable outcome is a happy patient, he added. "I have had patients with what I considered mediocre results with a postopera- tive refractive error of –0.75 D who were thrilled with their results," he said. "I have also had an occasional plano patient who was unhappy because one eye saw 20/15 and the second eye was 20/20." For this rea- son, patient selection is incredibly important. Being thorough can help the surgeon maximize patient satis- faction. "A full work-up including automated keratometry, topography, manifest refraction, complete slit lamp and biomicroscopy, retinal OCT, and a discussion regarding dysphotopsias, enhancements (and their cost if any), and potential When screening refractive patients, it's important to rule out conditions such as anterior basement membrane dystrophy. Poor patient selection is one of the leading causes of an unhappy patient. Source: John Berdahl, MD

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