The Power of Positive Thinking on Refractive Surgery Expectations
Thanks to improved tools and techniques, patients can expect excellent visual outcomes. Let them know that.
BY Robert Murphy, CONTRIBUTING EDITOR
When LASIK first gained widespread acceptance in the mid-1990s, surgeons used to proclaim the importance of minimizing patient expectations. The mantra was to “under-promise” and “over-deliver.” Patients were to know upfront that LASIK didn’t guarantee they could discard their glasses, which would still be needed in certain circumstances. A key selling point was the ability to see your alarm clock during the night without glasses. It wasn’t long before some management consultant or imaginative surgeon coined the term “20/happy” — that is, never mind the actual postoperative visual acuity; the ultimate goal was to leave the patient content with whatever vision they ultimately achieved.
Patient satisfaction remains a paramount goal. But these days when refractive surgeons routinely deliver 20/20 postoperative vision even with moderate to higher myopes, and frequently do better than that — in the 20/16 and 20/12 range — maybe it’s time to rethink how doctors frame and manage patient expectations. No longer must most patients be content with a 20/happy outcome that falls short of their visual needs or desires. At some $1,500 to $2,000 per eye, it’s likely that patients want more than to see the alarm clock unaided at 3:00am. They want unaided functional vision throughout the day — and, with isolated exceptions, they can get it.
Better tools and techniques have also led to improved outcomes following cataract surgery. (See the sidebar: “Improved Outcomes From Cataract Surgery.”) A greater number of variables make visual outcomes following cataract surgery harder to predict. Yet thanks to femtosecond laser capsulorhexes, more effective lens positioning and IOLs with optics surpassing those of previous generations, patients can expect reasonably good postoperative vision, if perhaps with the aid of a modest spectacle correction.
Refractive surgery patient expectations have risen even as the surgical capability to meet them has kept pace. A 2009 worldwide meta-analysis by Kerry Solomon, MD, and colleagues looking at 2,198 post-LASIK outcomes up through 2008 found that 95.4 percent of patients were satisfied with their visual outcome.1 This analysis predates subsequent advances in surgical skills and technology seen in the last few years.
As long as word-of-mouth referrals remain the chief avenue leading patients to your door, a refractive surgery candidate whose friend or family member achieved 20/20 or better arrives wondering: Why can’t this surgeon do the same for me? If so, what sense is there in pretending that your outcomes are less successful than they really are? If you have a strong track record, convey it to the patient. Flaunt your success. Hard-and-fast numbers sometime speak louder than words. Also mention that in rare cases requiring enhancements, those who don’t achieve optimal vision the first time around often have an excellent chance of doing so with a touch-up.
| How to Achieve Excellent Refractive Surgical Outcomes |
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| If reputation is a keystone of any successful refractive surgery practice, perhaps no one has worked more assiduously to build his over the past three decades than Overland Park, Kan., surgeon Daniel S. Durrie, MD. Even his radio ads are tailored with this in mind, targeted not just to prospective patients but also to former patients with the aim of promoting referrals, which account for 85 percent of his refractive surgery volume. Dr. Durrie’s practice model is not for everyone. For one thing, his private-pay patient population is limited almost exclusively to those seeking refractive surgery. His stipulation that each patient must receive a 20-minute consultation with the surgeon automatically limits his daily schedule to three patients per hour. An extensive battery of preoperative testing delves into multiple variables idiosyncratic to each particular patient, and in turn guides his selection of procedures and the specific means to perform them. A variety of multiple femtosecond and excimer lasers at the practice as well as numerous software options allow for a broad menu of surgical approaches. Even if you’re not ready to abandon general ophthalmology to specialize exclusively in refractive surgery, there’s no denying that Dr. Durrie has carved out a highly successful niche in Eastern Kansas. Here’s a look at what he does best. Preoperative Evaluation The first step in creating a practice along Dr. Durrie’s model is to arrange your schedule so that you can spend 20 minutes faceto-face preoperatively with each patient. Along with this comes extensive presurgical testing which includes: manifest and cycloplegic refraction, corneal pachymetry, corneal topography, wavefront aberrometry, lens-density measurements, photos of the lids and lashes, photos of the lenses, OCT and retinal evaluation. Results are fed electronically into the exam room and conveyed in a manner patients can understand. “Since we’re in the private-pay area, we’re not limited on what tests we can do on somebody,” Dr. Durrie says. “We do enough tests and evaluations so that we know — at the end of our exam and after we have met with them — what the best procedure is for them. We do not charge an additional fee to the patients for the extra tests; rather, it is a cost of business to make sure we are choosing the right procedure for our patient.” When consulting the patient on what to expect, Dr. Durrie looks at the long-term picture. “I tell patients all the time, ‘Today, we’re going to evaluate your lifetime vision plan. We’re going to look at your vision for a lifetime, not just the next five or 10 years.’” Following the pretesting and consultation, sometimes patients who came in for LASIK are better candidates — owing to their refractive error and other variables — for phakic IOLs or a refractive lens exchange. Selecting Methods and Means The preoperative testing provides invaluable guidance not only in choosing the procedure best suited to the patient’s needs and desires, but also the most appropriate instrumentation, software and (when indicated) IOL to make it happen. Think of it as two main decision trees with multiple limbs and branches. “We do all this evaluation and then analyze the data that tells us: Is this a patient who should have their lens replaced?” Dr. Durrie says. “Is it somebody who’s better for a phakic IOL than a corneal procedure? If it is a corneal procedure, should it be a surface ablation or a LASIK procedure?” Then it’s a matter of the most suitable instrumentation, decisions that likewise stem from the pretesting data. “The evaluation tells me which of the excimer lasers would be better for them,” says Dr. Durrie, who owns several. “And we have multiple femtosecond lasers, so it tells us which femto would be better.” Dr. Durrie carries this philosophy all the way down to software: should it be wavefront-optimized, wavefront-guided or topography- guided software? There’s no one definitive answer for all patients. “It’s a combination of taking the time to meet with the patient and understand their goals and objectives,” says Dr. Durrie, “and then all of the objective tests as well as a subjective understanding, which help me go through that decision tree.” A critical juncture comes when deciding between an intraocular or corneal procedure. “If it’s an intraocular procedure, is it a phakic IOL or a refractive lens exchange?” Dr. Durrie says. “And then if it’s a refractive lens exchange, we start looking at this patient’s needs. That will guide us in selecting among blended monovision, a multifocal lens or an accommodative lens.” A decision to opt for a corneal procedure prompts its own set of surgical choices. First, choosing between surface ablation and a flap procedure. “If it’s a surface ablation, then we need to decide which technique to use for epithelial removal,” Dr. Durrie says. Next comes the choice of excimer laser and then the software to use. “If it’s a lamellar procedure, I have to decide which femtosecond laser we should use to make the flap, and then which excimer laser we’re going to use to make the correction, and what software we’re going to use.” Postoperative Measures Dr. Durrie is ready and willing to perform enhancements to get the patient to his or her optimal unaided visual acuity. He also makes a point to have patients return to his office for all postoperative follow-up visits. “We don’t send them back to somebody else,” Dr. Durrie says. “We see our own patients postop. Part of our delivery on expectations is this philosophy: if we take you on as a project, we’re going to be there for you long term.” |
Many patients have already done their homework — and consulted trusted colleagues who have undergone refractive or cataract surgery — before stepping into your office. They already have a good idea of what they can expect. Rather than under-promise and over-deliver, maybe it’s time simply to promise and deliver.
Expectations, Outcomes, Satisfaction
Mick Jagger’s famous refrain, “You can’t always get what you want,” may apply to love and its discontents, but sounds increasingly outdated when it comes to refractive surgery. In recent years, a mutually reinforced dynamic has emerged between patient expectations and surgeons’ ability to deliver superior outcomes. Plot them on a Cartesian plane and you could say patient satisfaction marks the point where expectations and outcomes intersect. And that point seems to be rising with each passing year.
| Refractive Surgery and Cataract Surgery Become One |
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| Even as refractive surgeons are achieving unprecedented visual outcomes, advances in cataract surgery likewise have made it possible for many patients to enjoy better postsurgical vision with fewer complications. While a greater number of variables make it difficult to predict with accuracy and convey to patients their likely visual outcomes, cataract surgeons can paint a rosier picture than those drawn in the past. Technology Leads the Way Technological advances have paved the way to better outcomes. “The improvements in cataract surgery have probably been greater than the improvements in LASIK,” says Fairfield, Conn., cataract and refractive surgeon Eric Donnenfeld, MD, of Ophthalmic Consultants of Long Island, as well as a clinical professor of ophthalmology at New York University School of Medicine and a trustee at Dartmouth Medical School. “And the accuracy has improved markedly.” These surgical advances span a wide range, from better preoperative testing and ocular surface care to improved intraocular lenses to the femtosecond laser for accurate capsulorhexes, and effective pre- and postoperative medications. “We have improved biometry with the IOLMaster and the Lenstar so that IOL predictions have improved as well,” Dr. Donnenfeld says. “We can provide better care of the ocular surface to make sure the tear film can provide optimal vision.” He puts patients on Restasis two weeks preoperatively and three months following surgery. Presurgical wavefront aberrometry allows for correction of spherical aberrations, with other correctable aberrations likely on the horizon. Intraoperative instrumentation likewise has made major strides. “The femtosecond laser has improved the accuracy of the capsulorhexis and the accuracy of the incisions,” Dr. Donnenfeld says. “LRIs are more reproducible, and cylinder correction is more accurate.” Intraoperative wavefront aberrometry allows surgeons to titrate the patient’s refractive accuracy and pick the most suitable lens during surgery. And then there are the lenses themselves. “Lenses have become aspheric, which improves the quality of vision, and we have toric and multifocal lenses that we didn’t have before,” Dr. Donnenfeld says. Effective lens/capsule biomechanics has advanced as well. “That will turn into better predictability in terms of lens positioning, and therefore better predictability of refractive outcome,” says Perry Binder, MD, a clinical professor of Ophthalmology at the Gavin Herbert Eye Institute at the University of California, Irvine. Postoperative use of NSAIDs and the potent corticosteroid Durezol (difluprednate, Alcon Laboratories) have reduced the severity of cystoid macular edema, allowing for a more rapid visual recovery. “There is less corneal edema and less retinal edema because of the strength of the steroid, which is four to six times more potent than Pred Forte,” Dr. Donnenfeld says. Patient Expectations How do these advances translate to patient education and visual expectations? Cataract surgeons don’t have the luxury of promising 20/20 or better the way refractive surgeons often can. But they can cite the many advances that in numerous cases yield better outcomes than those of the past. San Diego private practice surgeon Steve Schallhorn, MD, presents his main options to presbyopic patients in this manner: “There are two different options for intraocular lenses,” says Dr. Schallhorn, who also serves as medical director for the UK-based international laser vision correction company Optical Express. “One method allows us to give you either good distance or near vision in each eye. Another approach uses special lenses that can give you both distance and near vision in each eye, but require some adaptation to give you the best results. And there’s a premium price that must be added for that lens, which is not covered by Medicare.” Lake Villa, Ill., surgeon Mitchell Jackson, MD, offers patients a three-tier selection of outcomes, choosing his lenses and setting his fees accordingly. “We do a lifestyle lens option,” says Dr. Jackson, who is also a clinical associate at the University of Chicago School of Medicine. “We don’t sell the lens implant, we sell the outcome.” The first is the standard option. “We tell patients that if they qualify for the standard one, which Medicare pays for, we set the expectations on that for glasses for all distances of vision postoperatively,” Dr. Jackson says. Option two is what he calls driving vision. “They’re legal to drive, but that expectation is only 20/40 or better. And we set the expectation that they’ll have to wear glasses for near vision 100 percent.” Finally, there is the presbyopic option. “It kind of implies that they’re going to be free of glasses 100 percent of the time, but we tell them that about 80 percent of the time they’re going to be free of glasses and may have to wear readers in low light or reading small print like on pill bottles.” Clearing a Higher Bar A host of variables make it tricky to achieve outstanding visual outcomes following cataract surgery. Yet recent developments in preoperative and intraoperative instrumentation, IOLs and medications are already yielding improved outcomes, with even better ones expected to come. “I think there’s going to be a higher bar for cataract surgery than that of refractive surgery, secondary to concomitant disease in the aging eye, but progress is being made, says Colton, Calif., refractive and cataract surgeon Christopher Blanton, MD, president and CEO of Inland Eye Institute. “And I think there’s an optimistic future that cataract surgeons will some day be able to bring their patients to the same level.” Refractive cataract surgery, now mostly considered an alternative approach, continues its ascent to the forefront. |
“You have two opposing issues that have been going on in the last 10 years,” says San Diego private practice surgeon Steve Schallhorn, MD, who also serves as medical director of the UK-based international laser vision correction provider Optical Express. “One is that patient expectations have been rising. In turn, the success of surgery rises with the expectations. And expectations certainly play a role in patient satisfaction. On the other side, countering the rising expectations, we’re doing a better job with surgery,” he says, citing improvements in femto flap creation, wavefront-guided ablation profiles and refined nomograms. “So we’re doing a better job, but we need to do a better job to meet rising expectations. It’s an endless cycle.”
You’re not likely to find a more enthusiastic advocate of promoting optimistic patient expectations than Overland Park, Kan., surgeon Daniel Durrie, MD. Of course, it helps that he ranks among the nation’s leading refractive surgeons not only in experience and surgical skill but overall patient management in his busy private pay-only practice. An extensive battery of preoperative tests and a 20-minute patient-surgeon consultation establish criteria not only for which procedure is best for a particular patient, but also which instruments, refractive IOLs in appropriate instances, and software are best suited for each case.
Also noteworthy: some 85 percent of his patients arrive by referral from a previous patient usually delighted with his or her visual outcome. Naturally, the new patient seeks a similarly happy outcome. Specifically, he or she wants a lifetime of excellent near and distance vision without glasses and contact lenses. To get there, Dr. Durrie offers a menu of surgical options that includes PRK, LASIK, phakic IOLs and refractive lens exchange.
Dr. Durrie’s confidence, based among other factors on an excellent track record, creates an ideal atmosphere for an honest and in most cases positive discussion on what the patient can expect. “I have very high expectations before we take on a patient who is a good refractive surgery candidate,” Dr. Durrie says. “And I don’t mind telling patients that I expect them to see 20/15 if they have the potential, because I think that’s what they’re going to get. Many surgeons like to under-promise and over-deliver. I would rather be able to say, ‘This is what I expect, and I expect to be there.’ I have confidence in what we do.” (See sidebar, “How to Achieve Excellent Refractive Surgical Outcomes.”)
| Disclosures and Contact Information |
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| Dr. Binder is a medical monitor for AMO, and the medical director of Acufocus. He can be reached at garrett23@aol.com. Dr. Schallhorn is the medical director for Optical Express, a multinational laser vision correction provider based in the UK. He can be reached at scschallhorn@yahoo.com. Dr. Jackson serves on the speakers bureaus of AMO, Allergan, Ista Pharmaceuticals, Bausch & Lomb and Alcon Laboratories. He can be reached at mjlaserdoc@msn.com. Dr. Blanton is a medical monitor for AMO, and a consultant for the company's IntraLase excimer laser platforms. He can be reached at blanton007@aol.com. Dr. Durrie has had consulting, travel, research and/or lecturing relationships with the following refractive surgery companies in the past year: AMO, AcuFocus, Alcon, LenSx, NexisVision, Wavetec, Ziemer. He can be reached at hmcwhirt@durrievision.com. Dr. Donnenfeld is a consultant for Allergan, Alcon Laboratories, AMO, Bausch & Lomb and Wavetec. He can be reached at eddoph@aol.com. |
Naturally, not every patient will achieve 20/15. Following the preoperative evaluation, some are ruled out as poor refractive surgery candidates. Others may arrive with a tricky refractive error that precludes the sunniest optimism. This is one reason why Dr. Durrie is reluctant to cite outcome statistics even as his office shelves groan under the weight of highly favorable studies.
“I don’t like to quote statistics because it generalizes too much,” Dr. Durrie says. “For example, if somebody comes in and they’re +3.00 -4.00 x 90, which means they’re hyperopic with a bunch of astigmatism in both eyes, and their best corrected vision is 20/30, that patient doesn’t apply to anything that was in our clinical trials where most patients are 20/15 the next day. So what you want to do with their expectations is match them to their eyes.”
Just How Good Are Outcomes?
Refractive surgery outcomes are better than ever, thanks to numerous improvements in technology and technique. Not least among these are femtosecond laser-made flaps that are customized and predictable, as well as wavefront aberrometry, which sets the scene for more accurate ablations than those of a decade ago. Advances in software have added considerably to improved postsurgical vision.
Wavefront-guided corneal refractive procedures have made a huge impact on visual outcomes. “A lot of us went from having about 85 percent of patients 20/20 postoperatively to up to 98 percent 20/20,” says Colton, Calif., surgeon Christopher Blanton, MD, who also serves as president and CEO of Inland Eye Institute with offices in Southern California and Ontario. “And it made it very easy to convert people to get the wavefront-guided procedure, because they saw the obvious benefits in doing that. I don’t have any problem with people being conservative in their expectations, because it’s hard to get hurt under those circumstances.”
Lake Villa, Ill., surgeon Mitchell Jackson, MD, ascribes his excellent post-LASIK visual outcomes in part to the use of the femtosecond laser for his flaps, as well as updated software for his excimer laser and a dynamic eye tracker. “According to our data, we are currently at 20/20 or better without enhancements after the primary procedure 98 percent of the time, with an enhancement rate of 1.2 percent,” says Dr. Jackson, who is also a clinical associate at the University of Chicago School of Medicine. “We’re at 100 percent 20/30 or better. In terms of lines of vision, we have zero percent in terms of lost best corrected visual acuity, with about 70 percent gaining one line and about 30 percent remaining the same” as their preoperative best corrected vision.
From Enhancement to Enchantment
Many surgeons report enhancement rates as low as 1-2 percent. This compares favorably with the 15-20 percent rates prevalent with first-generation laser vision correction. But don’t underestimate the value of assuring patients preoperatively that you will readily perform enhancements to bring them to their best possible unaided vision. Patients like to know that this option is available, and that their postoperative vision does not depend solely on a single procedure — especially when told that the enhancement is covered by the initial fee.
“We look at it as built into our process,” says Dr. Durrie, who estimates his enhancement rate at one percent following LASIK for low to moderate myopes, and perhaps 15 percent for trickier cases such as those involving presbyopia. “So we don’t hold back on enhancements, and we don’t charge for enhancements.”
When dealing with presbyopes, for example, Dr. Durrie advises the patient, “‘We’re going to try to give you near and distance vision. That’s more difficult to do, and it may take us more time. We may need to do a touch-up.’” He says they appreciate the candor. “In fact, our enhancement patients are pleased that we’re willing to put in the time to try to make them better. Many of my referrals come from the fact that we’re willing to do that.”
Start Spreading the News
It’s not just lofty patient expectations that are driving improvements in refractive surgery. External factors such as impending Medicare cuts, increasing competition and decreasing secondary insurance reimbursements are putting pressure on many ophthalmic surgeons to expand their refractive surgery volume. One way to do that is to create a reputation for delivering excellent postoperative visual outcomes. Word gets around.
“There’s a lot of pressure to convert a greater percentage of patients” for refractive surgery, says Perry Binder, MD, a clinical professor of ophthalmology of at the Gavin Herbert Eye Institute at the University of California, Irvine. “Reputation is one weapon. Good marketing helps. But the one-on-one conversation with the doctor is what’s going to do it.” Those who seize this opportunity to convey with confidence an optimistic yet accurate portrayal of expectations for postoperative visual outcomes will serve the needs of both their patients and their practice. OM
Reference
1. Solomon KD, Fernández de Castro LE, Sandoval HP, Biber JM, et al. LASIK world lliterature review: quality of life and patient satisfaction. Ophthalmology 2009;116(4):691-701.
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