Overcoming the learning curve for laser-assisted in situ keratomileusis (LASIK) doesn’t guarantee you success in refractive surgery. A once linear continuum of advances in refractive technology has branched into a diversity of procedures that are readily available or visible on the horizon.
To position your practice for long-term growth, you’ll soon need to go beyond LASIK to master and manage Intacs intracorneal rings (ICRs), laser thermal keratoplasty (LTK), phakic implantable contact lenses (ICLs) and pseudophakic refractive intraocular lenses. And, of course, some of your patients will still opt for the two earlier procedures – radial keratotomy (RK) and photorefractive keratectomy (PRK).
In our practice, an FDA study site for some procedures, we offer nearly all of today’s refractive surgery options, including procedures that are still in clinical trials. Our hope in writing this article is to describe how you also can successfully incorporate these new options into your practice, and at the same time maintain quality of care – without creating confusion and generating unnecessary expense.
Developing a template
We have carefully structured all aspects of our refractive surgery practice, from marketing to staff education. As a result, we’ve developed a template for planning the refractive surgery practice of the future. (What may come as a surprise is that the practice of the future in our clinic still incorporates cataract and other reimbursement-based procedures.)
We tried to go into this new mode of practice with realistic expectations. The transition from a primarily cataract and laser surgery practice to a center for refractive surgery can be bumpy. The biggest change is adapting to the younger patient base that refractive surgery attracts. These patients want appointments late on weekdays and all day on Saturdays. Even though we’ve been open on Saturdays and until late one night a week for several years, we needed to make scheduling adjustments to staff for refractive surgery evaluations. This required us to set up new shifts, having some employees come in later and stay later.
We’ve also found that these younger patients want fast exams, so we’ve worked to streamline their appointments as much as possible. Consider the approximate breakdown, by percentage, of procedures we work into our routine:
- RK : Less than 1%.
- PRK: Less than 1%.
- LASIK : 90%.
- ICLs : Undetermined. Percentage restricted by limited number of slots approved for nationwide FDA trials. After FDA approval, we expect to eventually implant ICLs for 90% of high myopes (more than -7.0D).
- Toric intraocular lenses (IOLs): 20% of all IOLs implanted. We expect this percentage to increase when the approved diopter range increases.
- Multifocal IOLs : 1% to 2% of all IOLs implanted. Patient selection is important; these implants aren’t for everyone.
- LTK : Percentage restricted by limited number of slots approved for nationwide FDA trials. After FDA approval, we expect 75% of hyperopic refractive surgery candidates and 90% of low hyperopes and presbyopes to eventually fit into this category.
- ICRs (Intacs): Approximately 50% of myopes in the approved range (-1.0D to -3.0D) who have no astigmatism. (ICRs are also being designed for hyperopes.)
How everything fits in
Contrary to what you might think, the addition of these refractive options hasn’t required additional space and very little change in our staffing and scheduling. Consider:
- LASIK . Our surgeons like to perform LASIK procedures on specific days. We accommodate working patients by offering days later in the week, so they’ll have the weekend to recover. Many patients take Friday off so that they’ll have 3 days away from work. Patients who travel to us seem to find it easier to take off Thursday, allowing them to be seen 1 day after surgery and still get home for the weekend.
- Multifocal and toric IOLs . We fold these procedures into our routine cataract surgery schedule, 4 days a week.
- ICRs (Intacs). Our surgeons also like to schedule Intacs patients for days when they’re operating. Use of a good microscope and ideal operating conditions make this procedure more attractive to our physicians.
- ICLs . We also implant ICLs, still under investigation, in our surgical suite. Again, we include these patients as part of a normal surgical day for the doctor.
- LTK . As a study center for LTK, our practice uses Sunrise’s holmium laser for correction of hyperopia. This laser is a desk-top-size apparatus that fits nicely in any of our exam rooms. The doctor can treat patients any time he’s seeing patients in the clinic, without taking away time from his normal schedule.
It starts with the surgeon
Making room in your practice for this much diversity requires a dedicated physician who believes in offering different choices for a variety of patients. Our staff uses this dedication as a model for their participation and their desire to learn all the options available, helping steer patients into the right direction.
Our clinical director, Carol Fiola, R.N., has coordinated the logistics of absorbing these different procedures – while keeping the outlay of our investment dollars to a minimum and keeping patient convenience to a maximum.
We save on staff costs and maximize revenue by staggering staff hours and delegating refractive care to technicians and O.D.s, while the surgeon is in surgery. We also strive to keep all surgical time slots filled.
Staffing and office space
Mrs. Fiola has organized a small refractive team for each procedure we offer. These are staff members who are interested in offering something new to our patients.
Without hiring additional staff, you can use the skills and knowledge of current staff members to make these procedures go smoothly. A little training is all that’s needed.
The team members become problem-solvers, specialists in the services they offer. Of course, they all need to look to one key person to provide patient counseling, consent forms and scheduling for refractive surgery procedures. This person, the anchor of our team, has made it possible for us convert one area of our practice into a central refractive consultation space.
Ancillary phone operators screen patient calls by asking key questions relating to their vision and ocular history. We also educate them on the types of procedures available and the necessary exams required before determining patient candidacy.
We provide the phone operators with information packets, which they can mail to patients to educate them on the available options. However, our operators also try to schedule consultations for callers.
Getting patients in the door is important because they can easily become confused by the blanket marketing of laser vision correction.
Once in the office, earmarked as a possible refractive surgery candidates, they are routed to the right team, after we’ve assessed their vision.
How we handle referrals
We schedule appointments with our refractive coordinator for the patients who are referred to us from an outside doctor. Again, the coordinator is a key person in helping these patients understand their vision and which procedure or vision correction option (including contact lenses and spectacles) would be best for them.
The refractive coordinator needs to know the parameters for the available procedures and the requirements for procedures that are still undergoing FDA clinical trials.
Our goal is to steer the patient to the procedure that will benefit him or her the most. By offering these different options, you can generate a variety of word-of-mouth referrals – patients who want specific procedures you’ve performed on their friends and family members. This perpetuates individualized streams of incoming surgical candidates.
Maximizing the O.D.’s role
Referring optometrists play a major role in helping to grow a diverse refractive surgery practice. But keep in mind that you may encounter initial resistance among O.D.s. Many of them feel that you’re working to put them out of business, especially when you’re increasing the number of surgical options that can take their patients out of their glasses and contact lenses.
Our office is sensitive to this issue. Before beginning a public marketing drive, we invite all optometrists, opticians and other ocular specialists in our area to our practice for educational seminars. These events give them a chance to speak to the surgeons, one on one, about how these procedures will affect their practices. Doing this helps them get comfortable with the concept of multiple refractive surgery options – and also helps them confidently discuss different options with their patients.
Optometrists need to feel a part of the opportunity to take these patients out of glasses and to improve their lifestyles. O.D.s need to see this involvement as a potential source of growth in their offices. They’ll see increased volume from more patients investigating refractive surgery – as opposed to a decline in volume associated with fewer returning patients.
The key to continuing referrals is to keep close contact with the doctors in person and via letter, newsletter and phone. Brief updates remind them who we are and the type of cutting edge care we provide. Some of our seminars consist of live refractive surgery procedures. Doctors and referring specialists observe the entire process so they can be more adept at explaining procedures to their prospective patients.
These outside vision specialists are instrumental in gathering social information about each patient. Therefore, they need to be well-versed in all of the available options. Keep in mind that patients may qualify for several procedures. You’ll need the inside information that the patient has shared with his primary vision specialist to help the patient make the best choice.
Optometrists can also get involved in the new procedures you offer – even ones still under study. Getting them involved increases the services they can personally offer their patients and singles them out as advanced practitioners.
Marketing refractive diversity
Mary Briggs, our director of public relations, uses consistent messages when advertising to the public. Her goal is to explain our advanced technology in all areas of eye care, including products and customer service.
Every time we offer a new technology, we find that the percentage of patient appointments jumps dramatically. Many people are drawn initially to a particular procedure. But advertising new technology of any kind also brings in more routine patients and cataract patients. The public seems to interpret specialization in one procedure as special expertise in all of the services we offer.
"Offering options to patients, having the latest technology – these are the vital components of what has made us successful so far and will continue to do so," Mary tells us. "Scoffing at new ideas, dismissing promising technology, avoiding equipment upgrades because they are too expensive – these are the things that doom a practice to mediocrity. "
We ask patients who visit for routine exams several questions relating to their vision. On the exam form, we include a question about refractive surgery, below where we ask about glasses and contact lens. With this approach, you may find a patient who has a strong interest in refractive surgery information – even if he hasn’t come to the office with that in mind. The staff can then use this as an opportunity to capture additional patients for refractive procedures.
About those younger patients
As we mentioned, incorporating refractive patients into a cataract practice involves more than just opening the doors for growth. You need to blend your high percentage of geriatric patients with the young and middle-aged population that seeks refractive surgery. Staff must adapt to the new demands of this age group, including their insistence on appointments at convenient hours.
Mrs. Fiola, our clinical director, stresses customer service to the clinic staff and sets up a customized selection process for each patient.
"The diverse backgrounds of our patients justifies our need to offer every option," she explained to us. "Our doctors are able to satisfy patients and help them realize their expectations."
For example, if reversibility is a concern, we steer patients toward ICLs or Intacs. Many of our patients are in their 40s, just beginning to experience presbyopia. Providing them with trial contact lenses for monovision gives them time to get comfortable with that option before we perform a procedure that creates a monovision effect.
Currently, our Baby Boomer refractive surgery patients generally can afford surgical correction. They are long-time wearers of contact lens or glasses, and they appreciate the freedom refractive surgery provides.
Creating a new trend
Many ophthalmologists are turning away from cataract procedures and moving full force into refractive surgery. Our goal is to build on both ends.
We want to be involved in the refractive surgery explosion. But we also want to remain well rounded, offering the best of all types of care. We see cataracts, macular degeneration, glaucoma and other conditions as opportunities to provide excellent patient care.
Happy refractive patients don’t go away just because you’ve corrected their vision. They remain patients and send more patients. When they inevitably develop other conditions, we want to give all of them the best treatment available. There will always be more and better ways of doing things. Why shouldn’t we be doing all of them?
How To Get Involved In New Procedures
New technology for refractive procedures is in constant motion. As a physician, you need to look at each procedure closely and early. Determine which would benefit your patients the most. Choose a variety of procedures to ensure options are available to patients.
If you’re interested in study protocol procedures, invite the companies into your practice. They need to have as much confidence in you as you do in their products.
Proper and accurate follow-up and record-keeping are paramount when you’re involved in FDA studies. Delegate one or two staff members to be contacts for patients and the companies. Patient satisfaction and staff involvement depends on your comfort level with a procedure.
Allow the study protocol to fold into your existing practice without disrupting your entire pattern. Running a well-organized clinic and appointing a designated staff will endear you to new companies looking for assistance and help with patient accountability.
Indications For Today’s Options
- LASIK
*FDA studies for the LTK procedure also dictate a variety of other inclusion and exclusion criteria.
Individualizing Surgical Options
Here are hypothetical examples of how to expand choices for your patients.
- Scott Truax, 25, responding to an ad on Intacs, makes an appointment for a free evaluation. He is -4.50D in the right eye and -4.00D in the left, with 1.75D of astigmatism OU. He has no trouble wearing contacts but doesn’t want to bother with them. Our first step is to educate him on the Intac procedure and the range of correction it will accommodate. The patient must have a thorough explanation of the procedure he desires before you lead him on the path to the procedure that’s best for him. Many patients want procedures that don’t meet their needs. The education you offer lets them get involved in their care. Using this approach, we steer Mr. Truax toward LASIK, because Intacs are only for patients with a correction of -1.0D to -3.0D and no astigmatism.
- Mrs. Moon schedules a LASIK evaluation. An active 65-year-old, she’d like to undergo the procedure so she can golf without her glasses. Upon examination, she is found to be slightly myopic, with about 2.0D of astigmatism in both eyes. She also has signs of significant cataract formation in both eyes. After we discuss LASIK and alternative options, she opts to have her cataracts removed and toric IOLs implanted to correct her astigmatism. Many elderly patients like Mrs. Moon want "that laser surgery." These patients are typically in their mid 60s and experiencing trouble with their glasses. Patients in this age group, with signs of cataracts, must be told that LASIK won’t benefit them for long because their cataracts will get worse. In addition, calculating intraocular lens (IOL) powers after refractive procedures is still in early stages of perfection.
- Beth Fox has been wearing glasses since she was 3. Now 33, she has come in after hearing our radio ad about LASIK. At this point, she can only wear contacts a few hours a day. Ms. Fox has already seen an ophthalmologist who’s turned her away because she isn’t a candidate for LASIK. Because the surgeon didn’t tell her why, she comes to us with hope that we’ll perform the procedure for her. We find that Ms. Fox is +7.0D in her right eye and +7.5D in her left. She also has .25D of astigmatism, OU.
Currently, we can treat hyperopes up to +6.0 with no astigmatism correction. After we explain the LASIK procedure, Mrs. Fox watches a video and learns why she doesn’t qualify for the procedure. Fortunately, she’s a good candidate for the ICL, as a study patient. Because implantation of ICLs is an investigational procedure, we review several unique issues. Mrs. Fox will need to consent to an extensive preoperative evaluation and numerous postoperative follow-ups. She will also need to undergo preoperative laser iridotomies, at least 1 week before ICL implantation. As a hyperope, recognizing that ICLs are the best choice, she undergoes the procedure and later tells us that she’s extremely happy with her vision.
Educating patients and helping them make their own decisions supports a better environment for a good refractive surgery outcome. Patients feel they have choices and are in control of their choices. Being able to offer many options keeps you from trying to squeeze all refractive patients into one type of procedure, empowering you to produce more favorable outcomes and happier patients.
–David C. Brown, M.D., F.A.C.S., and Gina Stancel, HCRM, CST
Dr. Brown is founder and medical director of Eye Centers of Florida, Fort Myers, Fla., a progressive ophthalmology practice serving a 13-county region in southwest Florida. Gina Stancel is surgicare administrator at Eye Centers of Florida.
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