LASIK
Are You Certifiable?
This new ophthalmologist shares her experiences getting certified to perform LASIK.
By Amanda Cook, M.D.

We are practicing in an era of opportunities that previous generations of ophthalmologists could barely have imagined. Take laser refractive surgery. A significant number of patients who are wearing spectacles and contact lenses are good candidates for LASIK, LASEK and the various iterations of refractive surgery. Unthinkable before 1996. Of course, surgeons who'd completed their training before the excimer laser was FDA-approved for LASIK had to go "back to school" to keep in step with this burgeoning technology.

Today, LASIK courses are increasingly making their way into residency programs. I was fortunate to take part in such a course during my third year of residency at the University of Pittsburgh Medical Center, under the guidance of Deepinder K. Dhaliwal, M.D., and Francis S. Mah, M.D. We used the VISX Star laser there, and the course in which I participated was sponsored by VISX, which provides the instruction and certification program.

In this article, I'll give you an overview of the program I completed — both the highlights and the challenges.

My certification course in-volved 2 days of lectures; two wet labs; and successful completion of at least one supervised LASIK surgery. We were tested following each lecture, and I recall our instructors stressed that complication management and post-op care would be as important as performing the surgery itself.

In the wet labs, we practiced on pig eyes, learning how to use a microkeratome and the laser. We also learned how to calculate corneal thickness to identify appropriate candidates, and we became familiar with the algorithms that help determine exactly what the treatment will be. Cutting the flap is a critical component of the surgery, and I remember that learning to use the microkeratome was the most challenging aspect of the training.

Although we were required to complete just one supervised case, I performed four. All of my patients were moderate myopes with low astigmatism, and all of them were very happy with their results. Three achieved 20/20 uncorrected visual acuity (UCVA) and the fourth achieved 20/15 UCVA.

There were no major complications during these procedures, but they weren't all textbook either. During one surgery, the microkeratome stopped, but we were able to restart it without any problems. And during another procedure, the flap didn't lie down perfectly at first. After some maneuvering, the situation was remedied, with no adverse effect on the final outcome.

Find Your First Case

Patient selection is always important in LASIK cases, but particularly for your first few cases. Naturally, you want to choose an excellent surgical candidate, but you also should choose someone whose expectations are reasonable. Patients need to understand that reading glasses may still be part of the overall post-op picture.

Many of us operated on a friend or family member for our first case. This can be a difficult situation, as well. For instance, one of my first cases was a neighbor. I was concerned that he might take advantage of the relationship by calling with frequent concerns or complaints after the procedure. I was relieved that this was not the case.

Another challenge you may encounter is simply getting a patient to agree to be your first case. As you know, LASIK patients are paying out-of-pocket, and they're looking for the best that money can buy. They're not thrilled at the idea of residents essentially "practicing" on them.

The university provided some incentive by offering patients a discounted fee because they were also subjects of a study Dr. Dhaliwal was performing, comparing the LASIK outcomes of residents to the outcomes of attending physicians. Many of us who participated in this course performed our surgery or surgeries toward the end of our third year, which also helped patients overcome their reluctance. By then, I think they rationalized that we were that much closer to being bona fide physicians.

Practice Before You 'Go Live'

Choose your patients wisely and make sure you know what you're doing once they're under the laser. We had the opportunity to do numerous 'dry runs' under the laser before performing live surgery, and I would highly recommend that aspiring refractive surgeons not underestimate the importance of a run-through.

Another challenge was simply finding a mutually convenient preoperative screening appointment time for me, the patient and the attending physician. The pre-op screening — which includes refraction, corneal topography, pachymetry, etc. — is critical to your outcomes but can be time-consuming. So carving out an appropriate amount of time from a busy schedule can take some juggling.

Lasting Impression

The LASIK certification course was a high point of my surgical training, and the lessons learned during the process will accompany me throughout my career.

Since completing this certification process, each time I've performed LASIK, I hear Dr. Dhaliwal's words: "Down Click." This was her instruction on how to seat the microkeratome properly — now 2 years into private practice, those words still go through my head. QnMD

Dr. Cook practices in Indiana, Pa.