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What tools does your practice use to heighten awareness of the expanded scope of refractive surgery options for potential clients?
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Education starts with specialty training
Educating patients about the benefit and liability of the various options in refractive surgery was something the previous generation of ophthalmologists did not have to navigate. Awareness starts within the practice walls, with the surgeon and staff, and specialty training has become more valuable. The first LASIK surgeons learned in weekend courses; later, surgeons were trained in ophthalmology residency and in cornea fellowships. For today’s ophthalmologists pursuing the specialty of refractive surgery, training in a dedicated refractive fellowship program has become increasingly indispensable to proficiently navigating the accumulating array of modern lens and laser-based vision correction procedures.
Staff education represents the next most important step. Staff members need to see happy patients — and happy staff members — who have experienced the benefits of approaches from phakic IOLs to inlays and SMILE. Patient education about refractive options then begins with the first touchpoint, whether on the phone or a practice web page.
While the incidence of myopia and presbyopia expand, we have seen a commensurate expansion in our ability to correct these issues surgically. By increasing awareness around these options, we have the potential to deliver better results that are more personalized to patients’ individual vision needs and goals. These procedures do not supplant LASIK; rather, they supplement it. Educating the public about this new generation of procedures holds tremendous value for everyone in our community who wears glasses and contacts.
Offering the full scope of refractive surgery services is not for everyone. Surgeons who spend a majority of their time managing cataracts or who practice comprehensive ophthalmology may find it challenging to develop the processes, infrastructure and staff expertise necessary to offer procedures that are performed infrequently relative to LASIK. Our colleagues employed by corporate laser centers may also find it difficult to switch from the binary LASIK vs. PRK approach to the comprehensive refractive surgery approach due to limitations and barriers inherent in the corporate business model.
Jason P. Brinton, MD, is an OSN Refractive Surgery Board Member. Disclosure: Brinton reports he has a financial interest in Alcon, Abbott Medical Optics, Nidek and STAAR Surgical.
Analysis focuses on history, exam and diagnostics
There are three main categories I use when analyzing a patient’s situation: history, exam and diagnostics. I lean heavily on history and diagnostics. An exam, on the other hand, can appear normal, but there could be early lens changes that might limit a laser patient’s joy, if not identified. Early lens changes that are too early to call cataract can take years to become obvious at the slit lamp, yet are noticeable in other ways.
The first is history. I ask the patient how their nighttime image quality is with their best possible glasses or contact lenses. It is amazing how many early lens changes I find this way. I also learn about patient expectations. For example, during a refractive consult with a 58-year-old who thinks they are going to have LASIK, I ask: “If my laser helps you see at night with the same clarity that your glasses or contact lenses do, will you be happy?” By the patient responding, “I was hoping for better than that,” it helps me to understand that they may have early lens changes affecting their nighttime image quality. At that point, I rely heavily on diagnostics to help me with my decision of what to recommend.
It is important to realize that early nuclear sclerosis often does not affect a wavefront measurement. Light scatter is a better measure of visual quality than any other measurement we have. My favorite way to quantify light scatter is with the HD Analyzer (Visiometrics), which will quantify light scatter as it travels through the tear film, cornea, lens and vitreous. Thus, if someone has a normal light scatter measurement, called the Optical Scatter Index (OSI), you can be confident that their tear film, cornea, lens and vitreous are not affecting their image quality.
If the patient has a great nighttime image with their optical devices and all other aspects of the exam are normal, I can then proceed confidently with corneal refractive surgery or a phakic IOL. But if their nighttime image quality is reduced and their OSI is elevated, I need to figure out why. If their tear film, corneal topography and vitreous are normal, then I am really suspicious that they have early lens changes affecting their image quality and that corneal refractive surgery is not the best option.
Next, I like to use the iTrace Dysfunctional Lens Index to provide valuable information to support my suspicion that the index is elevated due to early lens changes. I also employ the Oculus Pentacam to measure lens density for further support.
Vance M. Thompson, MD, is an OSN Refractive Surgery Board Member. Disclosure: Thompson reports he receives lecture fees and is a consultant to Abbott Medical Optics and Alcon, is a consultant to Bausch + Lomb and Visiometrics, and receives lecture fees from, consults for and is an equity owner in AcuFocus.