EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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40 EW FEATURE February 2011 Refractive challenges and innovations August 2012 When patients strike an unhappy pose by Maxine Lipner Senior EyeWorld Contributing Writer AT A GLANCE • In eliciting the problem from unhappy patients, some practitioners attempt to drill down on a single problem • Many patients return years after surgery with complaints of recur- rent refractive error, which may be related to problems of aging such as presbyopia or cataracts • For some patients where surgery isn't an option, a neurological approach or even use of specialty contact lenses may be the answer for the interim How to change the refractive picture I t's the kind of thing that even the best practitioners occasion- ally face—the unhappy refrac- tive surgery patient straggling through the door. Managing these cases requires special care that can begin at the outset and a dedication that may stretch for years. Here's how you can strive to satisfy patients in even the most difficult cases. For Richard L. Lindstrom, M.D., adjunct professor emeritus, University of Minnesota, Minneapo- lis, managing the potentially un- happy patient begins even before any surgery takes place. "Those pa- tients who are normal risk patients, I simply tell them about the most common problems and then the Addressing continued from page 39 in clear lens exchange patients, es- pecially in cases of high hyperopia, because predicting IOL powers is "next to impossible" after the ker- atometry changes. Dr. Vukich also recommended using a scleral tunnel incision to minimize induced corneal astigmatism. "You want to tread as lightly as possible to avoid stretching," Dr. Donnenfeld said. Following cataract surgery, it's not uncommon to have an immedi- ate hyperopic shift of up to 2 D, "but don't be dissuaded by that," since the patient can go plano after 2 months or so, Dr. Donnenfeld said. Because of the significant higher order aberrations associated with these patients, he recom- mended using a negative or zero aberration lens. CXL? Dr. Majmudar said a newer, but somewhat controversial, potential treatment for these patients might be corneal collagen crosslinking (CXL), which "may improve the bio- mechanical stability of the cornea like we see in keratoconus." Early re- sults seem to indicate CXL may help alleviate the diurnal fluctuations in vision for these patients. No studies have shown CXL can change the hyperopic shift—yet, Dr. Donnenfeld said. "I've done CXL on about 20 patients with previous RK and found in patients with fewer in- cisions it's eliminated the diurnal fluctuations, but not so in those who had 8 or 16 incisions. In that latter group, however, CXL did re- duce the magnitude of the fluctua- tion." More importantly, no one's vision was adversely impacted after undergoing CXL, he added. For Dr. Vukich, the early anec- dotal results are promising, but "it's too early for any projections for- ward." "If you've done PRK, done cataract surgery, tried CXL, and the patient is still having issues, the only remaining option may be transplant," Dr. Majmudar said. EW Editors' note: The doctors mentioned have no financial interests related to this article. Dr. Majmudar is an investigator for the CXL Group. Contact information Donnenfeld: 516-446-3525, eddoph@aol.com Majmudar: 847-275-6174, pamajmudar@yahoo.com Vukich: 608-282-2000, javukich@gmail.com worst problems," he said. He makes them aware of potential problems as benign as the need for another treat- ment and as significant as a sight- threatening infection or post-LASIK ectasia. For the high-risk patient, he hones in on the specific finding that makes this particular case more com- plex. For significant dry eye patients, for example, he makes it clear that something like LASIK may worsen the condition. "We need to make them aware that they have a dry eye and that while in the majority of patients LASIK doesn't permanently make dry eye worse, in a small num- ber it does," Dr. Lindstrom said. Likewise for those with possible risk factors for post-LASIK ectasia, Dr. Lindstrom will go the extra mile and often switch the patients from LASIK to surface ablation and even obtain special informed consent. "In the future I think what we'll do with many of these patients is collagen crosslinking with simultaneous PRK, or perhaps LASIK or sequential PRK once the crosslinking has healed," he said. Karl G. Stonecipher, M.D., medical director, TLC Laser Eye Centers, Greensboro and Raleigh, N.C., takes a similar initial tact. "We always have a conversation before surgery that surgery is not perfect," he said. While his average risk for an enhancement is between .8 and 1.27%, he makes it clear that for some people, such as high myopes, this risk is significantly higher. "I say, 'Overall the risk of [patients] coming back for a touchup is about An example of flap striae 1%, but you're pretty nearsighted so we're probably going to be looking at a number like 7-8%,'" he said. "The same thing goes for astigma- tism." Through the early lens If a patient does return unhappy, Dr. Stonecipher does his best to emulate John Potter, O.D., vice president, TLC Vision Corporation, who is the go-to person for any problematic TLC cases. "What John says is that patients who don't get the outcome they want, whether it is a complica- tion related to healing that's beyond the surgeon's control or whether it is something simple like they are just not as happy as they think they should be, you've got to treat those patients with respect and listen to what their problem is," Dr. Stonecipher said. He builds on this and has devel- oped his own technique for eliciting the problem from patients who he finds often come in with a list of complaints. "I like to start the con- versation with, 'I'm a one fix-it doc- tor, and I'm going to fix one thing in you today,'" Dr. Stonecipher said. "I say, 'You know I'm only good at fixing one thing, and you're going