Eyeworld

106 September 2016 by Michelle Dalton EyeWorld Contributing Writer Patient satisfaction It's a scientific unlikelihood that LASIK satisfaction rates will ever reach 100%. "We don't have a foolproof way to screen for personal- ities, and it is human nature not to be 100% satisfied," Dr. Waring said. "Even with the outstanding lasers we have today, healing processes are unique to each patient and can be difficult to predict long term." What it may take, he said, is improved metrics, understanding of epithelial and stromal remodeling processes, and intraoperative aber- rometry. "We're still basing our outcomes on Snellen acuity—a technology first described in the 1800s," he said. Instead, he suggested clinicians start working with advanced diag- nostics at quality of vision and "start looking at retinal image quality with double-passed wavefront. Look at the light, and analyze exactly what image is falling on a patient's retina. That's what will allow us to surpass 20/20 and get into 20/15, 20/12 super vision ranges with the next generation lasers, such as topogra- phy-guided LASIK and the higher resolution wavefront LASIK," Dr. Waring said. In the Schallhorn analysis, 1,617 (63.9%) were very satisfied, 686 (27.1%) were satisfied, 100 (4.0%) were neither satisfied nor dis- satisfied, 94 (3.7%) were dissatisfied, and 33 (1.3%) were very dissatisfied. 1 But the key for Dr. Durrie is how many respondents would have the surgery again if necessary: 2,396 patients (94.7%) responded affir- matively, 2,442 patients (96.5%) would recommend the procedure to their family or friends, and 2,410 patients (95.3%) thought the surgery improved the quality of their life. 1 The authors attributed lower patient satisfaction to worse postop binoc- ular uncorrected distance vision, the presence and severity of visual symptoms, or postop spectacle/con- tact lens use, among others. Dr. Durrie does "in-depth pa- tient satisfaction surveys on our pa- tients. The most important question you can ask is if the patient would refer a relative or friend. In the last two quarters we've had a 100% positive response rate." He attributes these stellar results to patient selec- tion—preoperatively every surgeon spends about 20 minutes with the refractive arena, Dr. Cummings said. Figure 1 shows how predictable today's surgery is. "Our safety data for losing two or more lines of distance visual acuity in our myopic group (base- line vision ranging from –12 D to –0.5 D) is 0.5%, and the number gaining two or more lines is 3.9% at 6 months," he said. "We now have 88.4% remaining unchanged or gaining one line." In the Schallhorn study, preop manifest spherical equivalent ranged from –11 D to –4.88 D. At 5 years postop, 79.3% of eyes were within 0.50 D of emmetropia, 77.7% of eyes achieved monocular uncorrected distance visual acuity (UDVA) and 90.6% of eyes achieved binocular UDVA of 20/20 or better. "I expect 95% of patients to be 20/20 or better, and I expect 95% of them to be within 0.5 D," Dr. Durrie said. "If that's not happening, then I need to tighten my nomograms and my algorithms. There's a variation in wound healing, but anytime we see something where there is a scatter in the database, there is opportunity. It says to me that preop refractions might be slightly off or nomograms might be slightly off." Wellington Eye Clinic and Beacon Hospital, Dublin, agreed. "Our results are very similar, and when speaking to colleagues, this is what the current standard appears to be, i.e., better than what the older FDA studies found and much like Dr. Solomon's summary suggested." Daniel Durrie, MD, professor of ophthalmology, University of Kansas Medical Center, and founder, Durrie Vision, Overland Park, Kansas, said his group's results "are better than the ASCRS survey and Schallhorn et al., but we really concentrate on our metrics all of the time and are constantly improving them." The key to both studies, how- ever, is that surgeons should expect the majority of their patients to be highly satisfied and with very few retreatments, Dr. Durrie said. "Published literature should always be the minimum baseline be- cause the reviews are retroactive," he said. "We should be better now than we were 5 years ago." Refractive surgeons should compare their own outcomes to these long-term studies, and "if their outcomes aren't better, then they're not improving." For example, predictability and stability are excellent in today's Patient surveys indicate a higher satisfaction rate with better visual outcomes than studies have shown M odern LASIK surgery has some of the high- est patient satisfaction rates of any kind of surgery, and outcomes are better than what has been reported, according to some new research and expert opinion. At the 2016 ASCRS•ASOA Symposium & Congress, Kerry Solomon, MD, presented results from a systemic peer-review liter- ature search on LASIK published between 2008 and 2015. The meta-analysis showed uncorrected visual acuity (UCVA) of 20/20 or better could be achieved in 91% of eyes, and 99.5% were 20/40 or bet- ter. These results are "significantly better" than what had been reported in the Food and Drug Administra- tion studies. Schallhorn et al. 1 assessed patient satisfaction and quality of life (QoL) outcomes 5 years post- LASIK, and reported 91% were either satisfied or very satisfied with their outcomes. According to this anal- ysis, "uncorrected vision was the strongest predictor of satisfaction … five years after surgery, satisfac- tion with LASIK remained high and most patients reported that QoL was improved." 1 Further, the analysis showed that the vast majority of QoL issues could be alleviated by spectacle correction. Clinical experience Most high-volume refractive sur- geons have similar findings in their own practices. "Our personal clinical expe- rience mirrors that of the recent long-term patient-reported outcome data from Schallhorn et al. in a large series and also the updated trial study results. In most cases, our outcomes are even better than what they've reported," said George Waring IV, MD, associate professor of ophthalmology, director of re- fractive surgery, Storm Eye Institute, and medical director, Magill Vision Center, Medical University of South Carolina, Charleston. Arthur Cummings, MBChB, consultant ophthalmologist, EW REFRACTIVE "Real world" outcomes better than clinical trial data, LASIK reviews show Figure 1. Predictability with LASIK for –11.00 to –0.50 D. There were only a handful of outliers, illustrating the increased predictability of modern day laser eye surgery. Source: Arthur Cummings, MBChB

• Cover