Refractive surgery, including procedures like laser assisted in-situ keratomileusis (LASIK), small incision lenticule extraction (SMILE), and photorefractive keratectomy (PRK), have provided millions of patients freedom from glasses or contact lenses.
Laser vision correction affords great success, with one study showing a total of 98.5% of patients were either satisfied or very satisfied with their surgery, and 98.5% considered their main goal for surgery was achieved.1
However, even with continued advancements in technology and surgical techniques, some patients may experience dissatisfaction with their outcomes. The retreatment rates after LASIK have been reported to vary from 4.7% to 37.9%. The amount of residual myopia is more commonly found in high myopes, who require retreatment procedures more often than in lower myopes.2,3,4
In this article, we will explore best practices for managing patients disappointed with their refractive surgery results, along with potential solutions to address the most common complaints.
Potential side effects follow refractive surgery
The first thing we must do as refractive surgeons is to understand our patient’s disappointment. The dissatisfaction does not always stem from poor vision, but other side effects that can occur due to refractive surgery.
Obviously, when the vision is poor, this creates the most noticeable issue. Taking the extra time to sit with your patients to understand what it is they need to be addressed is the first and most important step in correcting the problem.
Let’s review the various factors that can cause disappointment in a refractive surgery outcome:
- Suboptimal Visual Acuity: Patients may experience residual refractive errors. Any remaining myopia, hyperopia, or astigmatism can lead to blurred or fluctuating vision.
- Visual Symptoms: Issues like glare, halos, starbursts, or ghosting can affect vision quality, particularly in low-light conditions.5
- Dry Eye Symptoms: Some patients may develop dry eye syndrome post-surgery, resulting in discomfort, irritation, and fluctuating vision.6
- Regression: In some cases, the initially achieved correction may regress over time, necessitating retreatment or adjustment.7
- Unrealistic Expectations: Misalignment between patient expectations and achievable outcomes can lead to disappointment, especially if patients were expecting perfect vision without the need for glasses or contacts.
For a deeper dive into potential complications of refractive surgery, check out 3 Major Complications in Refractive Surgery Residents/Fellows Should Know!
Best practices for managing disappointed refractive surgery patients
1. Empathetic communication
Establishing open and empathetic communication with patients is paramount. Acknowledge their concerns, validate their experiences, and reassure them that their well-being is a priority.
Take extra time to really assess the situations where they feel their vision is limiting them. We must remember to always care for our patients; they should not feel abandoned or dismissed.
2. Thorough evaluation
Conduct a comprehensive evaluation of the patient's visual acuity, refractive status, corneal topography, and ocular surface health to identify any underlying issues contributing to dissatisfaction.
3. Educational counseling
Provide patients with a clear understanding of their current visual status, including any residual refractive errors, visual symptoms, or dry eye issues. Educate them about the factors contributing to their dissatisfaction and realistic expectations for potential improvements.
Provide them with thoughtful and written instructions on what can be done to improve their vision and outcome.
4. Collaborative decision-making
Involve patients in the decision-making process regarding potential treatment options. Discuss the risks, benefits, and limitations of various interventions, allowing patients to make informed choices based on their preferences and goals.
5. Tailored treatment plans
Develop individualized treatment plans based on the specific needs and concerns of each patient. Consider factors such as the type and severity of refractive error, ocular surface health, and previous surgical history when recommending interventions.
Treatment and management of a missed refractive target
We must also look at how to address these common complaints. Looking for potential solutions can vary patient by patient, and therefore, each situation must be approached carefully and thoughtfully.
Let’s review how to approach each one:
Residual refractive errors
A common approach is to provide our patients with laser enhancement surgery.2,3 It has been reported that 85% of enhancement procedures were performed within 1 year of the primary LASIK, and the 1-year incidence of retreatment was 10.5%.8 For patients with significant residual refractive errors, enhancement surgery may be considered to fine-tune the correction and improve visual acuity.
Another option is to provide contact lenses or glasses. This is usually done in a temporary fashion to provide correction to provide improved vision while patients consider further interventions. It is important to allow the eye to have enough healing time after laser vision correction before jumping to enhancement surgery.
You must ensure refractive stability so you know exactly what you are treating. The average recommended time between enhancement treatments (e.g., 3 to 6 months for LASIK, 6 to 12 months for PRK). For this, glasses and contact lenses provide a good temporary fix.
Visual symptoms (glare, halos, etc.)
The most important approach for visual symptoms is prior education to the patients, especially those at higher risk of having visual symptoms (i.e., large pupils, larger ablations, etc.). However, using advanced laser platforms that offer pupil-optimized treatments aims to reduce visual symptoms by minimizing higher-order aberrations.
Neuroadaptation strategies can also be employed to encourage patients to gradually increase exposure to challenging visual environments, to help minimize symptoms over time. Other techniques like using miotic drops can help to minimize glare and halos at night by decreasing the pupil size and limiting the peripheral corneal light rays, which are responsible for glare and halos, from entering the cornea.
Dry eye symptoms
Lubrication therapy is the most common form of treating dry eyes experienced after laser refractive surgery. Advise lubricating eye drops or ointments to alleviate dry eye symptoms and improve ocular surface comfort. It is important to have patients on a lubricating regimen immediately after surgery; this may help to prevent dry eye symptoms before they start.
However, in certain patients, other modalities like punctal plugs or prescription medications can also help to improve ocular surface disease. Treating underlying meibomian gland dysfunction (MGD) is also paramount to improving dry eyes.9
You can begin conservatively with warm compresses, lid hygiene, and meibomian gland expression to address mild evaporative dry eye. There are other modalities (e.g., Lipiflow, iLux, TearCare) that provide mechanical expression of the glands for more advanced MGD.10
Regression
It is important to understand why regression can happen after laser vision correction. Because corneal power is basically stable after the first 2 years of life and axial length generally keeps stable after 20 to 30 years old,11 the changes of refractive error may be mostly due to changes in lens power and anterior chamber depth (ACD).
All patients should experience a mild refractive drift over time due to the crystalline lens growing layers of protein. In other instances, it is important to monitor epithelial thickness maps to watch for epithelial remodeling that may occur during myopic LASIK surgery due to a volume of the central corneal stroma being removed.
It has been assumed that to compensate for the variations in stromal curvature, epithelial remodeling occurs to restore a smooth and uniform optical surface.12,13 We now understand that corneal epithelial thickness plays a key role in defining total corneal power, even though it is less so than the stroma, and can manifest as a refractive change after refractive surgery.14
Studies have found that a change in central epithelial thickness induced a myopic refractive shift in both low and high myopia.15 Scheduling regular follow-up appointments to monitor post-operative changes allows for signs of changes or regression to be caught earlier. Intervention strategy should be based around the cause and patient concerns.
Unrealistic expectations
Emphasize the importance of realistic expectations during pre-operative counseling and informed consent discussions. Provide educational materials and resources to help patients understand the range of potential outcomes and limitations of refractive surgery. This is especially true of patients who are presbyopic.
When the natural crystalline lens loses its ability to accommodate, many patients do not fully understand this concept, including how it limits their ability to focus at near. It is important to take time and explain the natural physiologic changes that occur so patients do not have any unwanted surprises after their surgery.
To learn more about how to set realistic expectations for refractive surgery patients during consultations, read Top Tips for Refractive Surgery Consultations!
In conclusion
Dealing with patients disappointed with their refractive surgery outcomes requires a compassionate and comprehensive approach. It is easy for a patient to lose trust in their surgeon when they do not achieve the results that they want.
By practicing empathetic communication, conducting thorough evaluations, and offering tailored treatment plans, ophthalmologists can effectively address patient concerns and work towards optimizing visual outcomes. Include the patients by collaborating with them and exploring the potential solutions that are available to common complaints.
By being clear and transparent about how you navigate these common challenges you have the ability to foster patient satisfaction and trust in the long term. Fortunately, most of these issues can be treated, and you can achieve patient satisfaction once again.
