It wasn't long ago that we had only two options for patients with astigmatism: eyeglasses and limbal relaxing incisions. But technological developments have added significantly to our armamentarium, including:

• laser-assisted in situ keratomileusis (LASIK)

• toric intraocular lenses

• improved contact lens technology

• combination procedures, including lensectomy and limbal relaxing incisions.

The growing complexity of astigmatism management requires us to rethink our decision-making trees. Our reward for making this effort is a satisfied and growing patient base, the cornerstone of a practice of any size.

Let's review some hypothetical scenarios you may experience and discuss possible options you can pursue to meet your goals.

1. The troubled bank teller

Patient:

Mary Jones, 59, employee of a busy bank.

History:

Mary's correction: OU +7 -2.5 x 90°, O.D. +6.0, -2.0 x 90°. Mary has a family history of cata-racts and glaucoma. She presents with an early onset of cataracts in both eyes. She wears progressive addition lenses but isn't satisfied with them, or with the bifocals she wore previously.

She's most frustrated by near work, especially while counting money under the pressure of long lines at the bank. She's still 6 years away from retirement and is seeking a solution to her problem. If she can't find a solution, she may have to quit, giving up maximum retirement benefits.

What the patient tells you:

Mary first learned of refractive surgery for astigmatism more than a year ago, when her daughter's friend underwent the procedure. Since then, she's been saving her money, including two, year-end tax refunds from the Internal Revenue Service, to pay for the procedure.

What you tell the patient:

Mary's astigmatism and myopia fall outside the appropriate range for excimer laser treatment. However, because of her cataracts, you might recommend cataract surgery with the Staar Toric intraocular lens (IOLs). Then you can address her frustration with near work. You may try to fit her in a pair of glasses that provide better vision, especially if the toric implants work out well for her. You may also suggest monovision to her and simulate the result with a trial frame preoperatively in the office.

2. The promising young golfer

Patient:

Thomas Wilson, 17, who has the potential to earn a college scholarship on the fairways.

History:

Thomas's correction: O.U. -4.75 -1.75 x 90°, O.D. -3.75 -2.00 x 90°. His mother brings Thomas to you in hopes that refractive surgery will eliminate his myopia and astigmatism. Thomas, a healthy, mature high school senior, tells you he's been unhappy with his contact lenses.

What the patient's mother tells you:

Mrs. Wilson says that she and her son have been discussing refractive surgery with an optometrist for 2 years. The O.D. has told them that Thomas's refraction would need to be stable for at least a year before he could qualify for the procedure.

Mrs. Wilson has noticed that her son's prescription hasn't changed in 18 months, prompting her to take advantage of a free consultation offered by your office. She says that Thomas's O.D. hasn't been enthusiastic about refractive surgery. She suspects that the doctor won't make a referral because he's afraid of losing a long-term contact lens patient.

You see on the paperwork compiled by your staff that Mrs. Wilson initially believed her major medical insurance plan would cover her son's refractive surgery. After having her apply for financing for the procedure, your staff has noted that she has a high-risk, asset-to-debt ratio. She'll probably qualify only for a monthly payment plan under one of the higher-interest payment options your office offers. How should you proceed?

What you tell the patient's mother:

Performing refractive surgery on a 17-year-old presents an unacceptable risk. Although his correction has been stable for more than a year, you still need to wait at least a year -- perhaps as many as 3 years -- before performing surgery on this patient.

You tell Thomas and his mother that he may ultimately benefit from refractive surgery because his refractive error is well within the approved range for myopia and astigmatism. But before you send the mother and son out the door with high hopes for the future, you need to address two issues:

Financial status:

Refer Mrs. Wilson to your patient coordinator to ensure that she fully understands the financial responsibility involved in paying for an elective procedure, as well as specific things she can do to improve her credit rating or save funds while waiting for the time when her son can undergo treatment.

Visual status:

You could refer Thomas back to his O.D., who may be able to achieve an improved contact lens fit, given recent advances in soft and rigid gas permeable toric lens technology. You could then offer to co-manage with his O.D. at the appropriate time.

How you proceed may depend on your relationship with the patient's O.D. and other O.D.s in the community. (You may not want to alienate them by being perceived as an ophthalmologist who "steals" patients.) Ultimately, you need to decide what's in the patient's best interest -- and also yield to the patient's preference.

3. The corporate achiever with dry eyes

Patient:

Jennifer Perkins, 32, an advertising account executive.

History:

Jennifer's correction: O.U. -5 -6.0 x 90°, O.D. -2.5 5.5 x 90°. She also has a recent history of dry eye symptoms.

What the patient tells you:

Jennifer hates glasses and doesn't want to bother with contact lenses, after 19 years of wearing them. In the past, she's accepted compromised acuity in return for freedom from glasses. But now she's battling dry eye symptoms that at times make her contact lens intolerant, especially after long hours of work. You note that 9 months ago she was successfully treated for blepharitis, which is still a problem for her from time to time. Her most recent tear break up time measured at less than 10 seconds.

"If at all possible, I want to have the laser procedure, even if it's not going to make my eyes perfect," she says. (Financial qualification isn't an issue for Jennifer.)

What you tell the patient:

First, you'll need to initiate a proper dry eye management protocol, reflecting the latest treatments and approaches. At this stage, her dry eyes clearly disqualify her as a candidate for refractive surgery.

You recommend an aggressive dry eye treatment regimen, including increased hydration, progressive use of drops and, if necessary, punctal occlusion. At her next visit in 1 month, you can determine if dry eye management has helped her become an acceptable candidate for surgery.

At that point, you tell her, you can re-view her options. Up to 9D of cylinder of astigmatism can now be corrected by the excimer laser. But you'll need to consider corneal thickness, to ensure that you maintain a residual central thickness of at least 250 microns. And, you'll need to decide whether you can meet Jennifer's expectations while treating her at the upper limit of the approved range. Fastidious at work and unhappy with previous vision correction efforts, she won't be easily pleased.

One alternative might be a two-stage surgical approach, in which you correct her astigmatism in two steps to increase the chance of achieving a maximal outcome. Careful pre-op counseling would be necessary for her to understand that enhancement surgery is likely. This factor, combined with her hard-to-please attitude, makes her a marginal candidate who may better be served by avoiding surgery.

Another possibility is to see if she's willing to wait until 2002, when the new phakic intraocular lenses (IOLs) should be approved and available as a correction option.

4. The almost perfect candidate

Patient:

Albert Schwartz, 29, Internet entrepreneur.

History:

His correction: OU, -2.00 1.50 x 90°, O.D. -3.50 1.75 x 90°. His history is otherwise unremarkable.

What the patient tells you:

Albert says he regularly converses by e-mail with clients and partners around the world. Recently, while complaining that he's always losing or breaking his glasses, he learned from a distant colleague that laser surgery is now available for people with astigmatism. There's only one problem: His mesopic pupil dilation is
8.0 mm in diameter.

What you tell the patient:

Because of his age, health and minimal correction needs, Albert is a perfect candidate for LASIK -- and would most likely achieve an excellent outcome. However, his surgical results will be compromised because his pupil diameter is greater than 6.5 mm. You explain this reality to him and offer him the possibility of the following two options:

• accepting the likelihood of night vision rings and halos post-operatively

• waiting for the availability of the toric implantable contact lens.

Or, perhaps, he would do just as well to simply to keep his glasses on throughout the day, instead of risking loss or breakage by constantly taking them off and putting them back on while he works.

The whole package

As you can see, today's options for astigmatism have turned management of these patients into a creative challenge. But if you handle them wisely, the results will be well worth the effort. We hope these examples will help guide you through these new decision-making trees.

Dr. Wright has been in private practice for 17 years, specializing in cataract and refractive surgery. He's used the excimer laser since 1989 and has performed more than 12,000 LASIK procedures. He has no proprietary interest in Staar Surgical.