Comanagement of refractive surgeries: What are you waiting for?

Comanagement leads to better, more cohesive patient care. In the end, when we work together, we all win. (Adobe Stock/lordn)

Comanagement of patients between disciplines is important, especially for eye care providers and surgeons. Although not new, this concept is one whose importance we continuously discuss as the scope of practice continues to expand in many states. The number of graduating ophthalmologists and the number of ophthalmology residency positions have been stagnant since 2012, whereas the number of patients requiring ocular surgeries has only grown.¹ The need for surgical comanagement continues to increase, but many optometrists have not made the leap. We will discuss the benefits of comanaging surgical patients with ophthalmologists as well as some of the most common complications and how to address them in patients who undergo refractive and cataract surgery.

Comanagement for the win

Sharing the responsibility of postsurgical care is beneficial for both patients and doctors. The option to have postoperative care with the optometrist may be preferential to the patient because of office location or workflow, decreasing time required for follow-ups. Patients may also feel more comfortable seeing their optometrist because they have a previous relationship. For the surgeon, this helps decrease chair time, allowing them to spend more time performing surgeries. It gives us, as optometrists, the opportunity to retain our patients and set the stage for continued care while increasing office revenue.

You know your patient best. More than likely, you have had more chair time with that individual than the surgeon has. As such, we can better convey information to the surgeon regarding personality, visual demands with work or hobbies, and ocular health history. When referring patients for evaluation, send this patient information along with prior office notes to help aid the surgeon’s discussions and decisions regarding options for the patient.

It is important to establish a good communicative relationship with your comanaging surgeon. This allows for open and continued dialogue about patient outcomes and possible complications. Have discussions with the surgeon about their preferred protocols; this existing rapport will benefit the patient and decrease chair time. For some of the more severe and concerning complications, the patient may need to see the surgeon immediately. Having their cell phone number and the office manager’s or surgical coordinator’s direct contact information is important to streamline this process.

Common complications associated with corneal refractive surgery

Whether we are discussing the corneal refractive surgery small incision lenticule extraction (SMILE), photorefractive keratectomy (PRK), or laser-assisted in situ keratomileusis (LASIK), the most common—or concerning—complications are very similar. At the 1-day postoperative appointment, there are few concerns for complications, given none occurred intraoperatively. On day 1, it is important to examine for any flap complications with LASIK and ensure proper placement of bandage contact lens with PRK. During the slit lamp examination, look at flap position, using retroillumination to help identify any macrostriae or malposition of the flap. Microstriae, small oil droplets under the flap, and the occasional sterile filament from surgery are common.² Microstriae are not typically visually significant and should be noted; treatment will depend on the surgeon. Oil from the skin under the flap will slowly dissipate but should be well documented and watched closely. Any foreign body or filament under the flap can lead to an inflammatory response by the body, and the surgeon should be alerted.² Sometimes the flap is lifted and foreign bodies or filaments are removed. Other times, if there is no inflammation, they are left in place, documented, and monitored.² Because macrostriae are more visually significant, their presence should be conveyed to the surgeon immediately and will likely require a flap lift and reposition to resolve.³

In PRK, the epithelium should heal in 4 to 7 days and the bandage contact lens can be removed.² At this point, central corneal haze, punctate epithelial erosions, and a healing line are expected and should slowly improve as the cornea continues to heal over the coming weeks.^2,4 If at any point after the 1-week appointment the vision decreases and the haze worsens, it may mean steroid administration should be increased and extended from the surgeon’s normal regimen.² Changes in healing outside those already expected, such as persistent epithelial defect or corneal haze or worsening of either, should be conveyed to the surgeon.

Flap melt, epithelial ingrowth, or concerns for microbial keratitis or diffuse lamellar keratitis warrant an immediate phone call and office visit with the surgeon for patients who undergo SMILE, PRK, and LASIK.^3-5 This doesn’t mean that we as optometrists can’t diagnose or manage these complications; however, notifying the surgeon is the most conservative approach, helping ensure the best prognosis for the patient and legal coverage for us.

Dry eye is considered one of the most common complications related to corneal-based refractive surgery.^3-5 It is important to address any ocular surface disease prior to referral for refractive surgery evaluation for 2 reasons: (1) to improve preoperative measurements to ensure better postoperative outcomes and (2) to minimize risk and worsening of postoperative ocular surface disease. Remind the patient to adhere to use of—at a minimum—preservative-free artificial tears every 1 to 2 hours after surgery for the first month.

Common complications associated with intraocular refractive surgery

Complications associated with intraocular refractive surgeries, refractive lens exchange (RLE), and implantable collamer lens (ICL) are also similar. In fact, complications from RLE are the same as those from traditional cataract surgery because they are the same procedure. Immediately after surgery at the 1-day postoperative appointment, the biggest concern is IOP. In either surgery, low IOP may indicate poor wound closure.^6-8 In the slit lamp examination, ensure the anterior chamber is well formed and perform a Seidel test.^6,8 If the patient has a positive finding from the Seidel test and there is active fluid leakage, administer a pressure patch for the patient and alert the surgeon of the complication.^6,8 Typically, a pressure patch for 24 hours will resolve this, but the patient may need a suture depending on the incision site appearance.^6,8

High IOP at the 1-day postoperative examination in RLE is most commonly related to retained viscoelastic used during surgery.^6,7 This will dissipate over 48 to 72 hours, and IOP level should return to normal.^6,7 Manage the increase in IOP by using IOP-lowering topical medications such as brimonidine or timolol.^6,7 Prostaglandins are usually avoided because they can increase inflammation. Burping the wound to release some fluid may also be performed; however, it only decreases the IOP for approximately 1 hour, and topical medications will still be needed. A severely high IOP at any time may also benefit from short-term use of oral acetazolamide.

High IOP at the 1-day postoperative examination in the case of an ICL may indicate either retained viscoelastic or, in the presence of corneal edema and iris bombe, a pupillary block/angle closure.⁷ A laser peripheral iridotomy is performed prior to surgery for these patients to decrease the risk of pupillary block/angle closure, but it can still happen and is considered an ocular emergency.⁷

If IOP is elevated at follow-up 3 to 4 weeks later, this is an indicator that the patient is a steroid responder.^6-8 Steroid response, although it can occur earlier, usually doesn’t happen until after 3 to 4 weeks of using the topical ophthalmic steroid. At this time, topical steroid can be tapered if inflammation is no longer present. If the patient has persistent inflammation, steroids may need to be continued or increased and a topical IOP-lowering medication introduced.^6-8 In a patient with persistent inflammation at 1 month, be suspicious for retained lens fragment in the angle and vigilantly perform gonioscopy.^6-8 Alert the surgeon in either case. Depending on the surgeons preference and the underlying cause, they may elect to do a subconjunctival injection of steroid to help resolve.

Endophthalmitis, although rare, is a serious complication where hours can make the difference in managing the condition. Most commonly, patients with endophthalmitis will present at approximately 3 to 7 days after surgery with sudden marked vision decrease, pain, and light sensitivity.6,8 Patients should be notified at their 1-day follow up that if they experience sudden decrease in vision or increase in pain, they should call either the optometrist or surgeon’s office immediately, because at that point their condition should only improve. If a patient presents in your office and you suspect endophthalmitis, call the surgeon immediately and be prepared to refer to a retina specialist for a tap and injection (culture and treatment).

Risk for cystoid macular edema (CME) after surgery, also known as Irvine-Gass syndrome, is at its highest 4 to 6 weeks after RLE surgery.^6,8 This is, in part, why both steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are continued for a long period—to decrease risk of development. If at 1-month postoperative appointment the patient’s best corrected visual acuity has decreased or is not 20/20, obtain an optical coherence tomography image of the macula to rule out CME. If CME is found, restart or increase the topical steroid and NSAID, notifying the surgeon of the findings. Depending on CME persistence and severity, the patient may need to return to the surgeon or see a retina specialist.

Finally, regardless of surgery, when do we send patients back to the surgeon regarding residual refractive error? The most important thing to ask your patient is, “Are you happy with your vision, and can you function?” If the answer is “yes,” then they are 20/happy, and an enhancement is not needed. If the answer is “no,” they are far from where their refractive goal was, or there is a complication such as a rotated lens, it is time to refer them back to the surgeon to discuss options.

Comanagement leads to better, more cohesive patient care. In the end, when we work together, we all win.

References

1. Ophthalmology residency match summary report 2021. Association of University Professors of Ophthalmology. Accessed January 28, 2023. https://059987482848-shared-prod.s3.amazonaws.com/Specialties/OPHTH-R/2021+Ophthalmology+Residency+Match+Summary+Report.pdf

2. Lighthizer N. The Ophthalmic Laser Handbook. Lippincott Williams & Wilkins; 2021.

3. Tsai PS, McLeod SD. Treatment of macrostriae and epithelial ingrowth following laser in situ keratomileusis with interrupted sutures. Arch Ophthalmol. 2003;121(12):1800-1801. doi:10.1001/archopht.121.12.1800

4. Murueta-Goyena A, Cañadas P. Visual outcomes and management after corneal refractive surgery: a review. J Optom. 2018;11(2):121-129. doi:10.1016/j.optom.2017.09.002

5. Asif MI, Bafna RK, Mehta JS, et al. Complications of small incision lenticule extraction. Indian J Ophthalmol. 2020;68(12):2711-2722. doi:10.4103/ijo.IJO_3258_20

6. Chan E, Mahroo OAR, Spalton DJ. Complications of cataract surgery. Clin Exp Optom. 2010;93(6):379-389. doi:10.1111/j.1444-0938.2010.00516.x

7. Zhang H, Gong R, Zhang X, Deng Y. Analysis of perioperative problems related to intraocular implantable collamer lens (ICL) implantation. Int Ophthalmol. 2022;42(11):3625-3641. doi:10.1007/s10792-022-02355-w

8. Liu C, Bardan AS, eds. Cataract Surgery: Pearls and Techniques. Springer International Publishing; 2021:227-240.