The thought of refractive surgery has most likely crossed the mind of every glasses or contact lens wearer at least once.
Being able to confidently discuss the various refractive surgical procedures, comprehending their respective risks and benefits, and mastering the essential principles of post-operative care offers a powerful means to nurture deeper connections and trust with your patients.
The importance of refractive surgery co-management
The landscape of refractive surgery is continually evolving, marked by constant advancements in procedures, techniques, and diagnostic tools. These advancements result in safer, more accurate, and highly individualized treatment plans for patients.1
Despite the increased safety and accuracy of current refractive surgeries, pre-operative and post-operative co-management remain integral to a seamless and rewarding experience for both practitioners and patients alike.
Table 1 outlines three key principles of co-management.
| Pre-operative Exam and Discussion | Proficiency in Pre- and Post-operative Care | Collaboration with Surgical Team |
|---|---|---|
| Detailed discussion of expectations | Extensive knowledge of each surgery type | Full transparency between surgeon and co-managing doctor |
| Review of medical history | Effectively address patient concerns and offer support during recovery process | Consistent patient communication from both doctors |
| Thorough eye exam and pre-operative measurements | Adeptly identify and manage or refer associated complication | Establishing clear surgical and co-management protocol |
| Explanation of surgical process |
Table 1: Courtesy of Garrett Pennell, OD.
Pre-operative counseling and education
The foundation of patient satisfaction after refractive surgery is based upon establishing realistic goals and expectations.
The co-managing doctor and surgeon play a vital role in discussing these expectations, benefits, and potential risks of the procedure the patient will be undergoing.
Setting expectations for visual outcomes with patients
While current refractive surgery technology can significantly improve a patient’s vision, patients must understand that perfection may not be achieved, and outcomes can vary from person to person.2 It is crucial to engage presbyopic and pre-presbyopic patients in a thoughtful discussion about the potential requirement for reading glasses after refractive surgery.
Although many patients may initially struggle to comprehend the possibility of requiring eyewear post-surgery, it is imperative to address this topic before the procedure. The option of monovision can be explored through contact lenses if the patient expresses a desire to reduce their reliance on glasses, yet it remains essential to emphasize the possibility of needing glasses for specific tasks and activities.2
Discussing healing and visual recovery timelines with patients
Healing times following refractive surgery can vary based upon the procedure, as well as the type and magnitude of refractive error. Patients with myopia tend to experience a relatively quick visual recovery, while patients with hyperopia and/or high amounts of astigmatism may take several weeks or even months to stabilize and achieve sharp vision.3
Proactively engaging in a comprehensive pre-surgical conversation with patients regarding anticipated healing and visual recovery timelines can serve to alleviate concerns, especially for those experiencing extended healing periods.4
Pre-operative assessments
Initiating a pre-operative assessment for refractive surgery necessitates a detailed review of the patient and family medical history. Some medications and pre-existing medical conditions, such as Sjögren’s syndrome, keratoconus, or corneal ectasia, may contraindicate refractive surgery. Other medical conditions may make one procedure more suitable than the rest.4
A thorough eye examination is another very important step in determining a patient’s candidacy for refractive surgery. The key elements of this examination include assessment of the patient’s eye health, measurement of refractive error and visual acuity, and identifying any eye conditions that would discourage refractive surgery. This portion of the pre-operative assessment requires normal equipment available in any eyecare office.5
Pre-operative testing and diagnostics
The constantly evolving diagnostic tools used by eyecare providers have revolutionized refractive surgery, allowing surgeons to develop a completely customized treatment plan for each patient.
Technologies such as corneal tomography with global pachymetry, wavefront analysis, and optical coherence tomography capture various measurements and images to generate a digital model of the anterior segment.
These measurements and images provide precise details about the corneal shape, thickness, and curvature to identify any irregularities, asymmetries, and potential risks for developing a corneal ectatic disease.1
Once a patient has been deemed a good candidate for a specific refractive surgery, the surgeon reviews the patient’s expectations and goals, as well as the associated risks and benefits.
Available refractive surgery procedures
Currently, there are several available refractive procedures, each with pros and cons, making proper patient selection key to success. We will address four of the most common.
Laser-assisted in situ keratomileusis (LASIK)
LASIK is the procedure preferred by most surgeons and patients due to the potential for rapid visual recovery, high patient satisfaction rate, and low incidence of complications.
Nevertheless, it's important to acknowledge that the creation of a corneal flap, unique to LASIK, introduces a distinct set of potential complications and imposes certain limitations on the range of correctable refractive errors.6
Photorefractive keratectomy (PRK)
Photorefractive keratectomy is a great refractive surgery alternative that preserves more corneal tissue, making it a preferred option for patients with thinner or irregular corneas. PRK also eliminates the risks associated with creating a corneal flap.
Nonetheless, it's important to note that PRK comes with certain trade-offs, including an extended and occasionally less comfortable recovery period, as well as a slightly higher potential for the development of corneal haze.7
Small incision lenticule extraction (SMILE)
Small incision lenticule extraction represents the latest innovation in the realm of refractive surgery, offering patients a swift recovery similar to LASIK while mitigating the risk of post-operative dry eye.
The SMILE procedure uses a femtosecond laser to create a lens-shaped piece of tissue within the cornea, which is then extracted through a small incision to correct myopia and astigmatism. SMILE is associated with the disadvantages of increased surgical complexity, inability to treat hyperopia, and limited long-term data compared to other refractive surgeries.8
Implantable collamer lens (ICL)
The implantable collamer lens (ICL) is a refractive surgery alternative for patients with thinner corneas or higher myopic refractive error that are not candidates for corneal-based procedures.
The ICL procedure is currently approved by the FDA for a minimum myopic spherical equivalent refractive error of 3 diopters and an anterior chamber depth minimum of 3 millimeters. ICLs can also correct up to 4 diopters of astigmatism. It is important to note that this procedure is not currently available for hyperopic correction.9
Comparing refractive surgery procedures
Table 2 outlines the differences between refractive surgery procedures.
| LASIK | PRK | SMILE | ICL | |
|---|---|---|---|---|
| Quick Recovery | X | X | X | |
| Minimal Discomfort | X | X | X | |
| Thin Corneas/High Refractive Errors | X | X | X | |
| Hyperopic Correction | X | X | ||
| 2 to 3 Days of Discomfort | X | |||
| Slow Visual Recovery | X | |||
| Risk of Flap Complications | X | |||
| Less Long-Term Data | X | |||
| Higher Surgical Risk | X |
Table 2: Courtesy of Garrett Pennell, OD.
Potential post-operative complications from refractive surgery
Dry eye
Dry eye is one of the most common complications experienced after refractive surgery.10 It is important to integrate a thorough dry eye assessment into the pre-operative screening examination.
Diagnostic tools such as tear break-up time (TBUT), Schirmer score, corneal fluorescein staining, tear osmolarity, meibomian gland secretion score, and the Ocular Surface Disease Index (OSDI) questionnaire can help uncover the cause and severity of dry eye. Determining and addressing the underlying cause of dry eye prior to surgery can significantly enhance the likelihood of a successful surgical outcome.
The key to successful management of dry eye before and after refractive surgery includes copious preservative-free artificial tears, lubricating ointments at night, punctal plugs, and sometimes ocular corticosteroids or prescription dry eye medications.
Patients will commonly report related symptoms such as ocular discomfort, foreign body sensation, blurred vision, or fluctuating vision. Most patients experiencing dry eye after refractive surgery will return to their pre-surgical baseline TBUT and Schirmer scores within 6 to 12 months.10
Glare and halos
The utilization of wavefront analysis technology has marked a notable reduction in the frequency and severity of glare and halos post-refractive surgery. As a part of pre-surgical education, it is crucial to address the common occurrence of glare and halos in the initial post-operative period, assuring patients that they typically subside within a few months following the procedure.
However, should these visual disturbances persist beyond this expected timeframe, it becomes imperative to pinpoint and address their underlying causes through diligent evaluation and potential treatment. The most common causes of glare and halos after refractive surgery are residual refractive error, higher-order aberrations, dry eye, and corneal irregularities.11
Infection and inflammation
Proper sterile surgical techniques have significantly reduced the incidence of the potentially serious complications of post-operative infections and inflammation. Additionally, the post-operative use of antibiotic and anti-inflammatory eye drops has played a crucial role in this reduction.
While the likelihood of encountering post-surgical infections or inflammation is exceedingly rare, it is of high importance to promptly identify and refer patients experiencing these complications back to their surgeon due to the sight-threatening nature of such issues.
Managing complications following LASIK
Diffuse lamellar keratitis (DLK) is a distinct form of post-operative inflammation associated with LASIK, requiring early detection and management to prevent visual complications.12 Due to the corneal flap created during the LASIK procedure, patients have the additional risks of flap dislocation, folds/striae, or epithelial ingrowth/flap debris.
Flap dislocation and macrostriae are surgical complications that require prompt referral back to the surgeon for a flap refloat and repositioning. The management of microstriae and epithelial ingrowth/flap debris is dependent upon the patient’s symptoms, as well as the size, location, and stability of the cells or debris.13
Managing complications following PRK
The regrowth of the corneal epithelium after PRK is a gradual process, often causing moderate discomfort lasting 2 to 4 days despite the utilization of bandage contact lenses after surgery.
While most patients experience complete epithelial healing by the third or fourth day, a small percentage may have a residual epithelial defect, easily managed by extending the use of a bandage contact lens for a few additional days.
PRK patients may also face an increased risk of recurrent corneal erosions, which is also typically addressed with bandage contact lenses and antibiotics.7
Current rates of refractive surgery patient satisfaction
With the current technology in refractive surgery, the patient satisfaction rate is at an all-time high. Clinical data has shown that LASIK has a patient satisfaction rate of 96%. Even with such a high satisfaction rate, a small percentage of patients will have a post-surgical outcome of being undercorrected or overcorrected.14
Effective co-management involves educating the patient about the amount of residual refractive error post-surgery, exploring the options for resolution, and monitoring their refraction for stability after surgery. An in-depth conversation about the risk versus benefit analysis of an enhancement surgery can offer invaluable clarity and context for the patient.
While the decision to pursue an enhancement surgery rests with the surgeon and patient, the collaborative partnership between the surgeon and co-managing doctor plays a pivotal role in determining the best course of action, ensuring the patient is both well-informed and optimized for success.2
Post-operative counseling
Post-operative counseling builds upon the framework of the pre-operative consultation and examination. The most important responsibilities of the co-managing doctor are ensuring medication compliance during the surgical recovery period, monitoring and treating any post-surgical complications, and ensuring patient satisfaction by addressing patient concerns.
All patients are prescribed a specific regimen of eye drops to manage post-operative inflammation and minimize the risk of post-operative infection. Communicating between the surgeon and co-managing doctor ensures a clear understanding of the regimen prescribed to each patient.
With this information in hand, the co-managing doctor can provide detailed guidance to the patient, reinforcing the significance of medication compliance for a smooth and successful recovery.6
Supporting patients during the recovery period
While the post-surgical recovery period is a time of happiness for most patients, other patients may encounter challenges or unexpected outcomes that require thorough attention and personalized care. Some patients will express concern over common issues that are normal and often temporary, such as dry eye, intermittent blurry vision, or even asymmetric vision between each eye.
Reassurance and emotional support during the sometimes challenging or prolonged recovery period can significantly alleviate anxiety, bolster patient confidence, and contribute to a more positive refractive surgery experience.15 As a patient surpasses the critical immediate post-operative period, the co-managing doctor will continue to play a pivotal role in their ongoing care throughout the long-term follow-up phase.
The focus of long-term, follow-up exams shifts towards monitoring the stability of the refractive correction achieved through surgery, visual acuity, and ocular health to ensure that the patient's improved vision remains consistent over time. It's also an opportunity to address any emerging visual needs or concerns that may arise, whether due to natural aging or other factors.16
Conclusion
The successful co-management of refractive surgery hinges on several key principles that ultimately shape the patient's experience and outcomes.
A thorough refractive surgery examination and in-depth discussion with patients about the surgery and expected outcomes pave the foundation for patient satisfaction. This process not only allows the surgical plan to be tailored to the patient but also establishes realistic expectations.
Proficiency in pre-operative and post-operative care in all forms of refractive surgery is equally important. Co-managing doctors should possess the confidence to address potential concerns of refractive surgery patients and adeptly manage any complications.
Collaboration and open communication between the surgeon and co-managing doctor is crucial to providing seamless continuity in patient care and optimizing patient outcomes.
This harmonious cooperation between the surgical team and co-managing team can also cultivate invaluable professional relationships within the eyecare industry. Successful co-management of refractive surgery is rewarding for all parties involved.
Mastering all the aforementioned elements will significantly elevate your success rate in refractive surgery co-management, leading to satisfied eyecare teams and pleased patients.
