Q&A: Discussing benefits, risks of options key to refractive surgery evaluations
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Key takeaways:
- An ICL may be a good option for patients with myopia of -3 and higher.
- Patients who are candidates for multiple procedures should be made aware of all their options before a recommendation is made.
Patients with myopia may qualify for several refractive surgery options depending on their age, lifestyle, corneal health and expectations.
To help patients feel more comfortable with surgery and increase their satisfaction after the procedure, it is important to inform them of all options and ensure that they understand the benefits and risks of each one.
To learn more about best practices for refractive surgery evaluations, Healio spoke with Neda Nikpoor, MD, a cataract, cornea and refractive surgeon at Aloha Laser Vision in Honolulu.
Healio: What does your typical workup for refractive surgery look like?
Nikpoor: First, we do a refractive questionnaire in which we ask for typical demographic information as well as lifestyle, hobbies, profession and medical history. Specifically, we ask patients about keloids, autoimmune disease, ocular herpes simplex virus, pregnancy and breastfeeding. We check uncorrected and corrected vision as well as refraction depending on age and use Pentacam (Oculus). In the past, we used epithelial thickness mapping, but for workflow reasons and due to staffing shortages, we now use it only on patients who really need it, such as those who have any irregularity of the anterior cornea or flag on Belin.
After that, we do a slit lamp exam to look for any sign of corneal scarring, dry eye disease or anything out of the ordinary. For patients who are presbyopic, we often do a monovision trial and talk about monovision or blended vision. We occasionally do a contact lens trial, but that is typically not necessary.
We also have a conversation about the risks and benefits of surgery to make sure patients do not have any unrealistic expectations or issues that might increase their likelihood of having a poor outcome or dissatisfaction after LASIK. I look for whether people are on multiple antidepressants or antianxiety medications because a study showed patients on three or more of these medications had a dramatically lower satisfaction rate after LASIK. If they are on one such medication, I take the time to talk to them further, assess their personality and determine whether they have had any difficulties with surgeries in the past. Many times, after I have shared the risks with patients who have anxiety or depression and are taking multiple medications, they are the ones who choose not to proceed. This is an important topic that needs to be addressed.
Healio: What are the most important considerations for patient selection?
Nikpoor: Important considerations include age, refractive error, lifestyle and expectations. Also, it is important to consider topography and ocular surface diseases such as dry eye. If we are looking at an ICL (STAAR Surgical), anterior chamber depth is an important consideration, and lens status and accommodation status are important for presbyopic patients.
Healio: How do you choose between an ICL or laser vision correction for patients with low to mid myopia?
Nikpoor: Sometimes I will choose an ICL for patients with low to mid myopia. I always choose an ICL for patients who have severe dry eye, or even those who have mild or moderate dry eye but I want to avoid any worsening. Even though there are data showing that PRK can be performed safely, I would far prefer to do an ICL for patients who have borderline or true keratoconus.
Even though it is off label, another scenario in which I will often recommend an ICL is for patients older than age 45 years who are moderate to high myopes getting close to cataract age to preserve their cornea and future lens options. Because older patients are more prone to dry eye, an ICL can reduce that risk compared with LASIK or PRK.
In a 20-year-old who is –3 D to –4 D with a normal cornea, I would usually do LASIK or PRK. But in an older patient who is over –5 D, I start to talk with them about an ICL as a better option.
Over -6 D at any age, I often recommend ICL over LASIK and do not routinely perform PRK that high. Over -8 D, I strongly recommend ICL and will avoid LASIK and PRK.
Healio: Are there indications for an ICL beyond patients who are not good candidates for laser vision correction?
Nikpoor: An ICL should be offered to every patient who is a candidate. We show patients a vision correction video that includes LASIK, PRK and ICL so they know their options. When patients are properly educated, the fear of having a flap in the eye usually goes away. However, some people still do not like the idea of having a flap in their eye, and there are options for these patients. PRK would be reasonable for patients wanting to avoid a flap because of fear or lifestyle concerns. If they are a good ICL candidate, it is completely reasonable to offer an ICL as well because it is a safe procedure and a great option. Surgeon fear should not stand in the way of offering an ICL to any patient regardless of their refractive error.
It is also reasonable to bring up the option of an ICL to any patient who you would recommend PRK to because not everyone can afford to take time off to heal from PRK. Even though patients are functional 5 days after PRK, it can take 1 to 3 months until they have sharp, clear vision. As an eye surgeon, if someone told me it was going to take that long for me to be able to see clearly, I would say that is not acceptable. Of course, not all patients have the same visual demands as an ophthalmologist, but you should respect patients’ wishes and what their needs are in terms of visual recovery.
There is a lot of misinformation and fear around LASIK in the community, so presenting patients with all their options may lead to better comfort in terms of their willingness to have a procedure vs. continuing to wear contacts or glasses. Even though it is the status quo, wearing contacts presents the risk for corneal blindness from contact lens-related infections. If patients have poor contact lens hygiene and express fear or concern around the risks of surgery, I make sure they also understand the risks of continuing to wear contacts because sometimes that gets lost in fear around the procedure. It is fine if patients choose not to have a procedure, but they still need to be informed on proper contact lens hygiene.
For more information:
Neda Nikpoor, MD, can be reached at drneda@alohalaser.com.
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