Are you ready to perform laser-assisted in situ keratomileusis (LASIK)? Do you know where to start? Can you afford the liability of a bad outcome — and lawsuits — at this point in your career? Will you be sued?

LASIK surgery is like the little boy in the nursery rhyme: when it is good, it is very, very good, but when it is bad, it is awful. A good LASIK procedure delivers good, pain-free vision in a matter of minutes. In many eyes, the quality of vision actually improves over what the patient has experienced with contact lenses or glasses. But LASIK procedures gone bad can lead to decreased vision, scarring, corneal transplant and, yes, a lawsuit guaranteed to make you miserable.

Here we’ll look at ways to avoid bad outcomes by carefully planning the procedure — before you even offer it.

As you consider how LASIK will fit into your career plans, keep these facts in mind:

• LASIK is the fastest-growing segment of ophthalmology today, and outstrips cataract surgery in many practices that offer both procedures. This even includes many of the huge cataract centers around the country. If the impending FDA approvals for LASIK come through, you can count on another surge in LASIK volume.
• Although many weekend LASIK courses are available, hands-on LASIK courses are rare. Even today, few residencies teach and let residents perform LASIK.
• Most malpractice suits in refractive surgery center on some problem with the informed consent, and are commonly precipitated by something a staff member has said or done, not by the surgeon.
• The technology available for LASIK is exploding. LASIK can be performed in the United States today with at least six different keratomes and four different lasers. New technology has made LASIK easier, safer and better than ever.

Contrary to what you may have heard, any ophthalmic surgeon with good clinical and surgical skills can perform LASIK. This year, hundreds (maybe thousands) of ophthalmologists will perform their first LASIK procedures. Most will do fine, but some will experience regrettable complications — the learning curve can be steep. How can you avoid the pitfalls?

Louis Pasteur said, "Fortune favors the prepared mind," an observation that certainly applies to starting LASIK. How can you prepare? Beyond developing the surgical and clinical skills of a LASIK surgeon, you’ll have to train your staff and organize your clinic properly. Your staff members play a large role in the care and counseling of LASIK patients, and they have to be trained to do so. You’ll need to prepare your office administratively. When you do start, start slowly. Pick your patients carefully and have an experienced surgeon with you for your first cases.

This is a large undertaking. But a motivated surgeon can probably accomplish it all in about 3 months. Do make the effort. The time invested will pay off for years in the form of a stronger practice with fewer problems.

Here are some suggestions to smooth your transition into LASIK.

The new LASIK surgeon needs to acquire three different types of knowledge before starting out.

• Do your homework
. The first ones, obviously, are the surgical skills and theoretical background of the procedure. These include how to perform the procedure, how the keratomes and lasers operate, the theory behind refractive corrections, operating room management, the pros and cons of LASIK and the relative merits of LASIK compared to other forms of refractive correction.
You can learn some of this information in weekend courses, books and articles. Take as much time on courses and reading books as you need to feel very comfortable. Avoid the rhetoric of keratome and laser manufacturers that would discourage you from learning about other technologies. Most important, don’t limit yourself to one point of view. LASIK is changing so quickly that today’s best methods may be outdated tomorrow.
• Observe carefully
. Next, find surgeons who are willing to accept visitors and let you observe surgery. Don’t be shy about visiting other practices. Most surgeons enjoy the compliment of your presence. A tip for finding surgeons who welcome visitors is to ask the instructors at the courses. Course instructors usually accept visitors themselves or will know of others who do.
You’ll learn more about surgery by observing an experienced surgeon than you will in 100 courses.
While you’re at a surgeon’s practice, talk to his staff members. Watch them interview and examine patients. Ask for samples of the forms they use in the clinic and operating room. Be sure to pick up a LASIK informed consent form. If you improve these materials for your practice, send them the improved forms. They’ll appreciate the favor and may offer useful comments.
• Study the equipment
. Like a pilot, you need to learn more than how to operate your equipment. You must learn how it works, how it breaks and how to fix it when it does break. This applies especially to keratomes. Although they’re better than they used to be, these blades are still subject to failure at the worst possible moments. Once you’ve selected your equipment, learn all you can about using it. Don’t rely on technicians or sales personnel for your surgical outcomes; instead, become informed yourself.

Refractive surgery patients are different from your typical ophthalmic patient. They’re younger, more affluent, and they’re spending their own money for an elective procedure. They’re typically much more informed, or want to become informed, about their procedure. Complicating the situation, they may have heard stories that cause them to mistrust refractive procedures.

The interaction of your staff with your refractive patients plays a pivotal role in how they’ll perceive you as a surgeon. When asked, are your staff members excited to discuss LASIK? Or do they make comments such as, "You may want it, but no one is going to operate on my eye!" Can they appropriately answer basic questions about LASIK?

Retraining staff to incorporate a new procedure into your practice can be tricky. Some may never fully convert. The old aphorism, "One bad staff member can sink a refractive practice" rings true, and sometimes the only response is to eliminate that person from the ranks.

Some suggestions for training staff members:

• Consider having key members of your staff join you when you visit other practices. Let them model their approach after experienced refractive technicians.
• Make up a list of "common patient questions" and videotape the staff responding to them. Play back the videos and comment — constructively — on how they could improve their answers. Be sure everyone is providing the same information to patients.
• Review your preferences for examining patients. Are your refractionists consistent in their technique? Do they elicit the proper history for a refractive patient, including an occupational history, hobbies, sports, night driving, need for reading glasses and other information relating to visual function requirements?

The administrative preparation of a refractive practice is critical. Considerations range from marketing, procedure pricing, buying supplies and equipment, establishing contracts with laser centers or other practices, developing strong informed consent, rearranging the clinic and operating schedule, etc. Again, take your cue from established practices. Their experience can save you hours of frustration and a great deal of money.

There are many good models for incorporating LASIK into a general ophthalmology practice. You’ll find them presented in the administrative sections of every meeting of refractive surgeons. All the models have one thing in common: they recognize that the patient is also a consumer who has other choices. Successful refractive surgery practices don’t keep patients waiting. They schedule visits conveniently. They provide same-day initial evaluation and surgery packages. They have various financial options available to their patients, ranging from cash discounts for full payment to loan plans with local institutions.

How are you going to access a laser? Should you buy a keratome, or lease? Has your informed consent undergone legal review? Where will your patients come from? Will you a) advertise at first, or b) just find patients within your practice? (Correct answer: b!)

A good administrator can sort these issues out. Having these issues settled before you begin will help you avoid many frustrations and potential liabilities as you begin to offer LASIK in your practice.

You’ve been to all the courses, read all the books, visited all the practices, prepared your staff and clinic, and you have yet to do your first case. Intimidated? You should be. In most LASIK cases you’ll be operating on the healthy eyes of active people, correcting a problem that they’ve had for years and that will never cause them harm.

Get help. Have an experienced surgeon with you for your first cases. Pay that person, if necessary. Utilize his experience. Review the charts together, interview the patients together, and discuss each case in detail. Have them return for the day 1 postoperative exam. Maintain the relationship so you can call with questions that arise later. LASIK isn’t difficult, but it is exacting. A good proctor can help with keratome placement, flap management, centration of the ablation, patient fixation, laser calibration and with troubleshooting the many things that can go wrong.

Like any surgical procedure, LASIK isn’t a casual undertaking. At first, it will require as much effort as, say, your first cataract operation. Remember that ordeal? As with that first cataract operation, patient selection is critical. Just as you wouldn’t want to have had a 4+ nuclear sclerotic lens, you won’t want your first LASIK to be a 12D myope. Nor should the mayor’s wife be on your list of first patients, or any hyperope. Instead, your first patients should be low-spherical myopes who are congenial and have non-stressful jobs.

Staff members and their families are excellent candidates. Not only will they act as built-in testimonials later on, but they already trust you.

Current technologies avoid many of the problems that used to plague refractive surgeons. The new keratomes are a huge improvement over previous versions. Newer lasers deliver better, more accurate, smoother ablations. Experienced surgeons can help you with your early cases. Good, comprehensive courses are offered across the country. Local help is often available at your laser center.

Mark Twain once said, "The worst things in my life never happened to me." Your early LASIK experience should be exciting, not terrifying. Let the horror stories feature somebody else. Prepare well, take the time to train your staff, prepare administratively and ask for help.

LASIK has arrived as a mainstream procedure. If you follow Pasteur’s advice, you can add it to your practice without regrets.

It’s well recognized that the PRK algorithms that are supplied with most lasers need some adjustment for LASIK. It’s also well known that the factors that influence nomogram adjustment are surgeon-specific, and can’t be generally shared. Where do you start?

Variables that influence nomogram adjustments can be generalized under three headings: patient, laser and surgeon. Patient issues are the least understood, and at first, you can ignore most of them beyond refractive error and age. The laser issues include not only the laser brand, but the specific laser, software version, calibration, Hertz rate and the laser room environment. Assuming that you’ll share a laser at first and don’t intend to purchase your own, you can glean important information about the laser from other surgeons at your center.

The surgeon issues are perhaps the most important — and the most difficult for a new surgeon to define. The length of stromal bed exposure, the intensity of the operating lights through the procedure, fluid management, ablation techniques, etc., all can affect the ablation rate of corneal tissue. Unfortunately, until you’ve done about 100 eyes, your technique will be evolving and will defy standardization. So for now, you have to ignore this issue, also.

The best initial strategies are to borrow a nomogram from another surgeon at your site, or use an average nomogram for the laser (you can obtain one from other surgeons using the same laser brand). Starting on low myopes reduces the influence of nomogram adjustments; these are the best initial patients. After all, 15% of 3D is 0.45D, which may be tolerable, but 15% of 10D is 1.5D, which won’t be.

To develop your own nomogram, you’ll need to track your outcomes. Unless you do, you’ll always be shooting in the dark. If you start outcomes tracking with your first cases, you’ll have a grasp on your own nomogram adjustment very quickly. From there, it’s just a matter of refinement.

At least two commercial software programs are available to assist in outcomes analysis and facilitate nomogram development. A recently introduced program called The Refractive Consultant, developed in conjunction with Jack Holladay, M.D., of Houston, uses sophisticated regression algorithms to track outcomes and develop a "smart" nomogram that incorporates variables that are found to be statistically significant (contact: sales@refractiveconsultant.com). The ASSORT program, developed by Noel Alpins, M.D., of Melbourne, Australia, allows conventional statistical analyses, and includes the Alpins method of vector analysis (contact: info@assort.com).

Guy M. Kezirian, M.D., F.A.C.S., is an ophthalmologist based in Paradise Valley, Ariz. He is president of SurgiVision Consultants, Inc., and owns an interest in The Refractive Consultant, a nomogram-generating software product for use in LASIK and PRK.