CLS AND REFRACTIVE SURGERY
Integrating Options for Refractive Surgery and Contact Lens Patients
A changed perspective has evolved on screening and referring patients for refractive surgery.
By Joseph J. Yager, OD, FAAO
Over the past few years, no part of our practice has taken as big a hit as refractive surgery. Formerly co-managing about 10 refractive surgery patients each month, we're down to just one or two. A laser surgery center in which I was part of a management team recently closed because of decreased volume.
Although the sluggish economy has contributed to this downturn, it can't take all the blame. Several other factors are at work:
- The "early adapters" willing to try something new who were candidates for LASIK have already undergone the procedure
- Many candidates may be waiting for insurance to cover the procedure, and that isn't likely to happen soon. Patients aren't spending discretionary income as they once did Bad press on safety issues has turned public opinion against the procedure, at least in the minds of more conservative patients
- A change in clinical thinking about LASIK and other refractive surgery procedures has occurred
I think this last factor is the most important. Our perspective today is that LASIK isn't as good a procedure as we once thought it was. We often see patients referred for post-op contact lens fittings after a poor LASIK result, and some of these patients are poor lens candidates.
This perspective has influenced our entire approach to refractive surgery, from if and when we suggest the procedure to initial patient screening and referral to a refractive surgeon.
Where We're Coming From
I work in a large contact lens practice in downtown Orlando that also has a high-end optical. Our practice is well-known for specialty fits such as keratoconus and bifocal contact lenses. Now I practice with two associates and 14 staff members.
From our solid patient base, and with our long-standing commitment to the latest healthcare technology, we developed a strong co-management program for refractive surgery patients. I became a managing team partner in a laser surgery center, and my job was to develop and sustain the OD referral network.
During the last few years we experienced a boom, something of a decline and then a virtual bust compared to our case volume in 2000. We also began to see more problems, most commonly night-time glare and corneal surface irregularities. The most severe complication that we've seen in our office is post-LASIK ectasia, a difficult condition to manage, similar to the challenges of fitting keratoconus patients. We fit these patients with large diameter GP lenses to mask astigmatism and achieved good initial results. Then the cornea would change, so the fit would change. Most of these patients were former soft lens wearers, so many were particularly disappointed with GP comfort. Not to mention that they had selected refractive surgery to eliminate contact lens or spectacle wear, not complicate or increase their dependence on vision correction.
These cases eventually reshaped our thinking on laser surgery. We continued to see many patients succeed with LASIK and, to a lesser degree, with PRK. But those who experienced less-than-positive outcomes felt truly debilitated by their new visual reality. We saw then that patient selection was more important than we had imagined.
Referring the Right Patients
We still strongly believe that laser vision correction must be part of your practice. It's the only way to retain patients who are good candidates and to ensure that they receive the level of surgical and post-op care that you would demand for yourself. But understand that only a small percentage of patients are good candidates. We've developed extensive patient selection guidelines, most of which focus on whom not to refer (see sidebar at left)
Our Perspective in Practice
The market for laser vision correction is small. Only about one in five patients make good candidates, and not all of those patients wish to undergo laser vision correction. We currently refer no more than two percent of our patients for refractive surgery.
Our patient questionnaire asks patients if they're interested in refractive surgery. Usually, we wait for them to ask about it. If we have a particularly good candidate, we might suggest it. We also suggest it to patients whom we suspect are noncompliant with their lens wear and care. Refractive surgery may be safer for these patients than continuing lens wear.
For contact lens patients who express an interest in refractive surgery, we first switch them to a 30-day lens. We're more likely to steer soft lens patients rather than GP patients toward refractive surgery because soft lens wearers can achieve a stable pre-op refraction after just two to three weeks of discontinuing lens wear. For interested patients under age 25, I often recommend corneal refractive therapy (CRT) because it's not permanent and they don't wear the contact lenses 24 hours a day.
Presenting Corrective Options to Patients
To inform our patients about various vision correction options, we provide pamphlets on "What's New in Contact Lenses" and "What's New in Refractive Surgery." Our staff plays an important role in educating patients about refractive surgery. We have one staff member, a high myope, who underwent LASIK in one eye and PRK in the other. She explains the procedures well and can address the issues between eyeglasses, contact lenses and refractive surgery. (As an aside, we have an employee who's a great candidate, but doesn't want to undergo surgery. She currently wears 30-day lenses.)
We proactively recommend refractive surgery to lens wearers whose lenses interfere with their jobs, such as policemen, firemen and healthcare workers. The best candidates are aged 25 to 43 with no dry eye and no need for "perfect" distance correction.
Co-managing Refractive Surgery Patients
Our co-management program for refractive surgery patients includes:
- Removal of contact lenses until the cornea stabilizes. We perform topography, pachymetry and wet and dry refractions. When a patient achieves two consistent findings, we consider him stable and refer him to a refractive surgeon
- The surgeon sees the patient once pre-op and then performs the surgery. Sometimes the surgeon will perform a one-day post-op appointment
- We sometimes see the patient one day post-op. We check the flap, look for inflammation and perform retinoscopy
- At one week post-op, we perform slit lamp, refraction, IOP and check VA
- We repeat this protocol at the one-, two-, three- and six-month visits
Recommend What's Best for Each Patient
In some ways, contact lenses and refractive surgery compete for the same "turf." Often the best contact lens patients are the best candidates for refractive surgery. Similarly, a cornea that's difficult to fit is usually also difficult to correct with laser surgery.
Consider your patients' needs when recommending a modality. Presbyopes who don't want to wear eyeglasses will be happier with a successful bifocal lens fitting than with surgery and post-op reading spectacles. We fit teenagers and those apprehensive about the risks of refractive surgery with CRT, and almost 100 percent stay with this modality.
In the end, only a small part of the market is truly competitive between contact lenses and refractive surgery. Most of the vision care market is more open to contact lenses.
Dr Yager is in group practice in Orlando, FL. He is a past chair of the cornea and contact lens section of the American Academy of Optometry and is the current president-elect of the American Academy of Optometry.
|Patients We Don't Refer for Refractive Surgery:|
Anyone under age 25 We feel these patients don't possess the maturity to fully comprehend the risks of refractive surgery. They may also experience future visual changes
Presbyopes These patients will still need reading glasses for near work
Myopes above 9.00D They usually don't achieve full correction and will still need spectacles or contact lenses
Low myopes (2.00D or less), especially those in their 30s or early 40s When they become presbyopic, they may prefer reading without correction
Hyperopes Laser surgery steepens the cornea. It's difficult to keep the optical axis in the pupil, and the result may be irregular astigmatism
Irregular corneas Corneal topographers reveal that many patients have a certain degree of irregularity in the corneal surface
Thin corneas (500µm or less)
Dry eye patients This condition often progresses as the patient ages, and laser surgery seems to accelerate that process
Long-term GP wearers These corneas may take up to one year to stabilize before surgery. Most GP wearers who undergo LASIK won't achieve acuity equal to what they had with their lenses
Visually critical people I mean patients who must try three to four lenses before they achieve the VA they want. We discourage them from refractive surgery because the outcomes aren't perfect
Any sign of cataract formation If the cataract changes, then the patient will become more nearsighted. It's also tougher to calculate IOL power post-refractice surgery.