Eyeworld

5 Supported by Abbott Medical Optics Inc., Alcon Laboratories Inc., and AcuFocus 5 postoperative enhancements have been an important tool in ensur- ing that patients ultimately get the outcome they want. Packages can be custom- ized to be all-inclusive (covering the total cost of enhancements) or offer discounted refractive touchups. A potential disadvan- tage of packages, however, is that patients may have even higher expectations. In contrast, some practices provide a more detailed list of à la carte options. However, in my experience, the more exhaus- tive lists can confuse patients. Maneuvers to mitigate refractive surprises by Richard Tipperman, MD need to weigh the strengths of available technologies in light of each patient's needs. Laser vision correction (LVC) is one of our best tools for fine-tuning refractions very effectively and predictably. I prefer to use LASIK for these procedures. Although some surgeons choose PRK for enhancements to avoid flap-relat- ed complications, PRK recovery is much more uncomfortable. Furthermore, LASIK offers a faster visual recovery. If the residual error is 4.00– 5.00 D or a patient has a thin cornea, I usually perform a lens exchange or implant a piggyback lens rather than performing LVC (Figure 3). Conversely, if a patient has weak zonules or a compromised capsule, a corneal refractive pro- cedure is more appropriate than a lens exchange. Limbal relaxing incisions are useful to address 0.50 to 0.75 D of residual astigmatism when the patient's spherical equivalent is close to plano. We can perform them easily in the office, and they are minimally invasive (Figure 4). With excellent strategies, surgeons can ultimately satisfy patients even when the initial outcome is less than optimal D espite our best efforts, refractive surprises occasionally occur after pseudophakic presby- opia-correcting surgery. To achieve optimal outcomes from enhancements, surgeons continued from page 4 If a patient has 1.5 D or more of residual astigmatism or the spherical equivalent is not plano, we use LVC to correct the astigmatism rather than a lens exchange. Weighing technologies Because residual refractive errors after cataract surgery usually are very small, it is less important Richard Tipperman, MD continued on page 6 Managing the technicalities I f we are meticulous in our preoperative measure- ments and surgical techniques, most patients will be pleased with their pseudophakic presbyopia-correc- tion outcomes and will not require touchups. Howev- er, how can cataract surgeons who provide advanced tech- nology IOLs but not LVC satisfy their patients if refractive surprises occur? One option is to offer patients who sign up for these procedures a voucher for a discounted LVC touchup with a colleague. Patients who do not require an enhancement can transfer the certificate to a friend or relative for a dis- counted LVC procedure. This can be a win-win-win situation—for patients, who are pleased with their discount; for cataract surgeons, who can count on a colleague to perform occasional LVC enhancements; and for refractive surgeons, who gain ad- ditional patients. Surgeons need to present options clearly so patients can readily understand them. We keep it relatively simple, and I think many practices are taking this approach. We offer two basic packages, based on pa- tients' visual goals. Patients may opt for distance-only correction or a range of distance and near correction. However, your practice setting should guide your choices. Surgeons in a medical retina practice that also performs cataract surgery are less likely to have patients who qualify for presbyopia-correcting IOLs. Therefore, à la carte choices may be more appropriate. Packages must also make sense in terms of profitability and costs. For example, surgeons with a high enhancement rate should factor that into the equation. By committing to exception- al treatment, surgeons can deliver the visual results presbyopic patients expect. Surgeons may choose to bundle options to make it simpler for patients to under- stand and to deliver a seamless spectrum of care. Reference 1. Trattler WB, et al. Cataract and dry eye: Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) Study. ASCRS•ASOA Symposium & Congress, San Diego, March 2011. Dr. Yeu is assistant professor, East- ern Virginia Medical School, and in private practice, Virginia Eye Con- sultants, Norfolk, Virginia. She can be contacted at eyeu@vec2020.com.

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