Published in Refractive Surgery

Top 5 LASIK Pearls

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8 min read
Review clinical pearls for ophthalmologists new to LASIK eye surgery, such as how to improve the patient's experience during surgery.
Top 5 LASIK Pearls
Laser vision correction is an especially rewarding surgery to perform. It is an extremely gratifying experience to witness a patient of yours with significant refractive error wake up and see clearly without corrective glasses or lenses for the first time. The surgery is truly life-changing for patients!
Laser-assisted in situ keratomileusis (LASIK) has become a leading laser vision correction procedure. The advent of new femtosecond and excimer lasers has allowed for even more precise and rapid LASIK surgeries over the last several years. In addition, advancements in wavefront-guided, wavefront-optimized, and topography-guided treatments provide patients with customized treatment profiles.
Here are my top five tips for becoming a successful new LASIK surgeon.

LASIK pearl 1: Know your patient and when to say “no”

Developing a rapport with your LASIK patient is invaluable. In my practice set-up, I perform my LASIK evaluations with the help of my technician staff. Other practices may have co-managing optometric colleagues who help perform the preoperative examinations for surgeons.

In either scenario, always take the time to get to your patient, whether it be during your initial evaluation or before surgery when you are meeting with them.

Be aware of how the patient responds to your description of the procedure, the discussion of risks and benefits, and the postoperative course. Get a sense of their anxiety level, their expectations, and their ability to connect with you.

Discussing LASIK with anxious, indecisive, and uncertain patients

I always take extra time with patients who are particularly anxious and address their concerns by providing them with the details they require to mitigate their anxiety. If I feel their level of anxiety may be a deterrent to performing surgery (i.e., very squeamish if I touch their eyes, jumpy during just the eye exam, etc.), I have them take time to think through whether surgery is the right option for them (not everyone is comfortable the concept of having surgery).
For indecisive patients, I aim to make a firm recommendation of the laser vision correction procedure I feel will be most successful for them. I encourage these patients to go home, think through their options, and return with additional questions for myself or my refractive coordinator. Lastly, I strive to paint a realistic picture of the intraoperative and postoperative course for patients with very high expectations.

In the rare event that I encounter a patient I do not connect with, I recommend they see another surgeon for an opinion, as I believe there should be inherent trust between the physician and the patient.

LASIK pearl 2: Do a thorough work-up before the LASIK procedure

I think the preoperative work-up for our LASIK candidates is by far the most challenging and nuanced part of the surgical journey. The actual LASIK surgery is largely straightforward and can be performed well by most ocular surgeons.
Be very thoughtful as you evaluate your diagnostic imaging (ie topography, tomography and epithelial thickness mapping) to ensure your patient is an excellent LASIK candidate.
Compare and contrast the patient’s current prescriptions in glasses and/or contacts and compare them to manifest and cycloplegic refractions in clinic.
If there are major deviations, ensure the patient has refractive stability and bring them back another day for repeat measurements to confirm. Take time to look through their medical history and medication list to find any medical comorbidities or medications that may render them poor LASIK candidates.
A thorough ocular exam is also key.
In your exam note, underscore pertinent negatives or positives of the eye exam (i.e., dry eye, corneal scarring, corneal guttae, lens opacities, and retinal pathology warranting a retinal consult before surgery). You want to identify any and/or all concerning features pre-operatively such that they are not found later and considered a postoperative complication.

LASIK pearl 3: Master verbal anesthesia

Laser vision correction is typically performed with a small dosage of an oral anxiolytic (I give all my patients 1mg of oral lorazepam 20 minutes before surgery). This works fine for the majority of patients. However, the addition of excellent verbal anesthesia can allow the surgery to go far smoother as well.
Before every procedure, I briefly prep my patients on what to expect so they know all these details before walking into the laser suite. I indicate which steps of the procedure may be more intense (i.e., eye pressure during the LASIK flap creation) and which steps I will need them to particularly focus on (i.e., focusing on the fixation light during the laser treatment). I warn them they may hear loud noises and smell things when the laser is firing and that this is normal.

I find it immensely helpful for patients to walk into the laser suite with an understanding of what they will be undergoing. During the surgery, I am constantly speaking and coaching my patient; I provide them with verbal cues as to where to look and when to hold still and am their cheerleader throughout.

They find comfort in knowing that I am present during the entire procedure and that they are doing a great job. I always ask my patients what music they want to listen to and play their preferred Spotify station when I can. My staff and I pride ourselves on keeping the entire experience patient-centric.

LASIK pearl 4: Be ready to face complications

As with any other surgery, complications can and will happen in your career. Be prepared to encounter them and know when to ask for help.
Steps for addressing and preventing LASIK complications:
  1. Know the next steps if there is a suction loss during the LASIK flap creation. I counsel all my patients that in the rare event this occurs, I may need to perform PRK as a staged procedure on a subsequent day.
  2. Understand how to manage diffuse lamellar keratitis (DLK), infectious keratitis, flap tears, flap striae, or refractive surprises.
Overall, complications in refractive surgery are very infrequent, but when they do occur, hold your patients close. See them more often in the event they are upset or worried about their vision and obtain opinions from more senior colleagues if the case is atypical. Make sure to monitor for refractive stability before performing an enhancement. Holding your patients’ hands throughout the process will assure them they are well taken care of.

LASIK pearl 5: Track your outcomes

I always believe we should perform high-quality surgery and further refine our techniques by tracking our outcomes. Be vigilant of all your preoperative measurements and ensure you are basing your treatments on the most accurate refractions.

Keep track of your patients’ refractive outcomes to understand how your patients are performing after LASIK.

If you find patients are healing with more residual myopia or hyperopia, re-evaluate the nomogram you are using to plan treatments. Several online calculators that I find help surgeons better plan their treatments (i.e., IBRA or SurgiVision Datalink) and permit input of postoperative data to track outcomes.

Key takeaways for LASIK procedures

As a newly minted refractive surgeon, be thoughtful in selecting your surgical patients, and know the ins and outs of your patients’ measurements, diagnostics, and personalities. Be their biggest cheerleader in the laser suite, and strive for excellence as you track your outcomes and refine your refractive results!
Nandini Venkateswaran, MD
About Nandini Venkateswaran, MD

Dr. Nandini Venkateswaran is a member of the Cornea and Refractive Surgery Service at the Massachusetts Eye and Ear Infirmary and an Instructor of Ophthalmology at Harvard Medical School. She is a fellowship-trained cataract, cornea and refractive surgeon. Dr. Venkateswaran earned her medical degree with a distinction in community health from the University of Rochester School of Medicine and Dentistry, where she was inducted into the Alpha Omega Alpha medical honor society. She completed her Ophthalmology residency at the Bascom Palmer Eye Institute/University of Miami, after which she completed a fellowship in cornea, external disease and refractive surgery at Duke University.

Dr. Venkateswaran truly enjoys employing her clinical and surgical expertise and research background to treat patients with a compassionate, customized and multidisciplinary approach. She specializes in complex cataract surgery, femtosecond laser assisted cataract surgery with intraoperative aberrometry, most advanced techniques in corneal transplantation (DMEK, DSAEK, DALK, PKP), laser refractive surgery (LASIK and PRK), corneal cross-linking, anterior segment reconstruction (including secondary IOL implantation and iris repair), dry eye disease and ocular surface lesions and tumors.

Dr. Venkateswaran is an active member of the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery and currently serves on several committees in these organizations. She has co-authored over 40 peer-reviewed publications and numerous book chapters early in her career. She has received several awards for her excellence in research and clinical care and has presented her scientific work at numerous national and international meetings.

Outside of work, Dr. Venkateswaran enjoys spending time with her friends and family, learning to cook, and riding her peloton bike.

Nandini Venkateswaran, MD
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