Educating patients on refractive surgery options

Optometrists need to align yourself with a surgery center that you have vetted, trust, and whose refractive philosophy you understand to such a degree that it becomes your own. (Image credit: Adobe Stock/Vadim)

When talking with patients about their options for improving vision, optometrists should take the time to explain surgical procedures. Perhaps you think that your patient population isn’t interested in refractive surgery; nevertheless, I’m going to share some options that you might never consider unless you read this article. Have I piqued your interest? Don’t believe me? Read on and find out.

First, let’s discuss some important facts. You need to go a little Stuart Smalley: look yourself in the mirror and say, “I am good enough. I may be standing in the way of my patient’s surgery. I am capable.” Patients look to their optometrist as a trusted and respected source of information, and this confers great power upon us. The exam room should be a safe place to share good and bad news with them. Not reviewing potential surgical options is akin to telling a patient who asks about glasses that they aren’t a good candidate for spectacles because you only offer vision therapy. Education is king and dispensing it makes you valuable.

Secondly, letting patients know why they are not good candidates is more important than telling them they are candidates. There is no better way to establish credibility than by detailing the potential limitations of refractive surgery in a given patient. For example, a 45-year-old patient with 20/20 vision who has noticed some blurring up close would fall into a gray area. In that case, the best course is to monitor the lenses for any dysfunction or cataract changes, consider monovision contacts, and let the patient know that there are pharmacological options to help with myopia.

Lastly, laser-assisted stroma in situ keratomileusis (LASIK) is still king, and refractive surgery is still synonymous with LASIK. It should be the working assumption unless proven otherwise. Excellent candidates for LASIK achieve excellent results. You really know that you are old if you remember a time before the procedure was approved by the FDA (before 1999), and the advances that have been made since then in terms of flap customization only serve to enhance its life-changing results.

Nearly 10 years ago, the Patient-Reported Outcomes With LASIK (PROWL) study confirmed LASIK’s success. The PROWL studies—both civilian and military—dispelled a lot of the common misconceptions about the procedure, including that it caused dry eye and glare at night. These rumors seem to rear their ugly heads whenever there is a slow news year or some columnist likes to reminisce about the way things were in the old days. PROWL found that patients had lower postoperative levels of glare and dryness than before surgery. If these arrows slung at LASIK do anything, it is to remind us that we still must be diligent in finding excellent candidates and saying no when necessary.

You may be wondering who is and isn’t a great candidate for refractive surgery. And, frankly, there may be subtle patient characteristics that you don’t have the tools to assess. That is why you need to align yourself with a surgery center that you have vetted, trust, and whose refractive philosophy you understand to such a degree that it becomes your own. You may work with a surgeon who is great at lens replacement but doesn’t do LASIK or know a center that offers LASIK but not implantable contact lenses. You get the point: none of this is one-size-fits-all, and no single procedure will suit every patient.

LASIK

The FDA has approved LASIK for patients with up to approximately +6.00 diopters of hyperopia, –12 diopters of myopia, and 6.00 diopters of astigmatism. The procedure uses a blade or laser to create a flap, exposing the stroma for ablation with a laser.

Pros

1. The most obvious benefit of LASIK is improved vision. Although there is no guarantee that all patients will have perfect eyesight afterward, around 96% of those who undergo LASIK achieve 20/20 vision. Those who don’t still find their vision dramatically improved and their reliance on eyeglasses or contact lenses significantly reduced.
2. Although no procedure is entirely risk-free, laser vision correction is now safer than ever before.
3. The healing time from a procedure is typically
   24 to 36 hours, meaning minimal downtime.
4. LASIK entails very little discomfort relative to other corneal refractive procedures.
5. Enhancements are made under the same flap.

Cons

1. The potential for flap complications may be the single drawback to LASIK. Patients need to be cautious about flap dislocation, particularly during the first month post-op.
2. Because the procedure is irreversible, all patients require a thorough preoperative
   cornea evaluation.

Photorefractive keratotomy

The FDA has approved photorefractive keratotomy(PRK) in patients with up to approximately +6.00 diopters of hyperopia, –12 diopters of myopia, and 6.00 diopters of astigmatism. During the procedure, which requires topical anesthesia on the ocular surface, the central epithelium of the cornea is removed, an excimer laser is used to treat the exposed stomal corneal tissue, and a bandage contact lens is placed on the cornea.

Pros

1. Because no flap is created, those complications don’t apply.
2. Corneal tissue is spared, which makes PRK possible in thinner corneas.
3. Same outcomes as LASIK surgery.
4. Certain states allow the procedure to be performed by optometrists.

Cons

1. PRK is far more painful than most corneal refractive procedures.
2. Healing can take upwards of 6 weeks, with the potential for 24 to 72 hours of downtime immediately following the procedure.
3. Enhancements require the same procedure,
   and patients can expect the same discomfort and downtime.
4. The potential exists for over-healing and hazing of the cornea.

EVO intraocular collamer lens

The FDA has approved the EVO intraocular collamer lens in patients with −3.00 to −20.00 diopters of myopia and astigmatism of up to 4.00 diopters who have met endothelial cell density requirements for age and anterior chamber depth. These lenses are implanted through a 3.5 mm or smaller incision after instillation of an ophthalmic viscosurgical device (OVD) in the anterior chamber. The lens is placed in the ciliary sulcus. With the addition of the 360 μ diameter central port, an iridotomy is no longer needed.

Pros

1. Vision improves rapidly.
2. Offers superior results, with the lens close to the nodal point.
3. Can be removed if necessary.
4. Offers UV protection.
5. Because this is not a corneal refractive
   procedure, it may be an option for patients
   with corneal dystrophies, degenerations, or
   thinner-than-average corneas.

Cons

1. Invasive and expensive.
2. Limited refractive parameters (no current hyperopic options).
3. Anterior chamber depth and narrow angles that may be limiting.
4. The implantation is not visible to the surgeon
5. Potential for intraocular infection and inflammation.
6. Potential cataract formation.

Small intrastromal lenticular extraction

The FDA has approved small intrastromal lenticular extraction(SMILE) for the treatment of –1.00 to –10.00 diopters of myopia and –0.75 to –3.00 diopters of astigmatism. During a SMILE procedure, the VisuMax excimer laser (Carl Zeiss Meditec) is used to create a small incision followed by a small disc-shaped lenticule of corneal tissue, which is removed through the incision to reshape the cornea.

Pros

1. Speed of recovery
2. Small incision with little to no
   flap-associated complications
3. Preservation of corneal nerves

Cons

1. No custom-laser options, thus potential for high-order aberrations
2. Loss of suction during the procedure
3. Difficult lenticular dissection and extraction
4. No enhancement capabilities
5. Limited refractive error options with no hyperopia treatment

Refractive lens exchange/clear lens extraction (RLE/CLE)

The use of an intraocular lens is considered off-label, and the FDA offers no parameters. The procedure is performed by anesthetizing the eye, making 2 incisions, and instilling an OVD. The anterior capsule of the lens is removed, exposing the natural crystalline lens (corneal incisions, arcuate incision to correct astigmatism, and capsulotomy can be made with a femtosecond laser). The lens is then broken into small pieces and liquified with a phacoemulsification device. The IOL is placed in the existing capsule.

Pros

1. Successful, safe, and commonly performed.
2. New lens options.
3. Applicable to all vision ranges.
4. Quick visual recovery, with little to no downtime.
5. Removable and replaceable lens.

Cons

1. Invasive surgical procedure.
2. Potential for glare and halos.
3. Irreversible permanent removal of natural crystalline lens.
4. Immediate presbyopic induction.
5. Potential for intraocular infection
   and inflammation.

Conclusion

One of the greatest advances in refractive surgery was the small laser diameter that made possible accurate and detailed changes to the cornea; single-handedly making pupil size and aberrations inconsequential for LASIK candidacy.

Furthermore, we can look forward to new and evolving surgical options: adjustable IOL options, lenticular insertion, small aperture phakic IOLs, and much more. However, today we have great choices to meet almost every refractive error and to stabilize unhealthy corneas that patients deserve to hear about. To help them manage refractive errors with, or without, spectacles and contacts, we must be well-versed in all things refractive.