OASC | DATA

Refractive Outcomes: Keep Your Eye on the Ball — Before and After the Game

When looking to improve patient satisfaction, remember, that which can’t be measured, can’t be improved upon.

By Joseph F. Jalkiewicz, Contributing Editor

According to the Centers for Disease Control and Prevention, an estimated 3 million Americans undergo cataract surgery each year, with success rates approaching 98%. Meanwhile, another 700,000 Americans undergo refractive corneal procedures such as LASIK or PRK, hoping to eliminate the need for eyeglasses or contact lenses, with 85% to 92% of them emerging with 20/40 vision or better.

With refractive surgery success rates highly dependent on surgeon skill and experience, it raises an important question: Are you doing everything you can to ensure your patients are among the most satisfied? Excellent outcomes in refractive cornea and cataract surgery depend nearly as much on what you do outside the operating room as what you do in it.

“Preoperative data quality is the most important factor to ensure patient safety and achieve reliable outcomes,” says Jessica Ciralsky, MD, Assistant Professor of Ophthalmology, Weill Cornell, New York, NY. “Choosing the proper candidate, optimizing the patient’s ocular surface, acquiring accurate and reproducible testing and selecting the treatments according to postoperative, data-derived nomograms are all important to achieve patient satisfaction.”

Preoperative Patient Assessment

Thorough assessment and preparation are vital to successful outcomes, says R. Bruce Wallace, MD, founder and medical director of Wallace Eye Surgery in Alexandria, La.

As part of their patient assessments, especially with respect to confirming a patient’s candidacy for refractive surgery, Dr. Wallace says corneal and cataract surgeons should look for out-of-range measurement findings, such as very steep K readings, very long (>25) or very short (<22) axial lengths and irregular astigmatism.

“A large percentage of our patients have these issues, which can account for lower-than-expected conversion to premium IOLs,” he says, adding that patients should also be questioned and examined for conditions such as rheumatoid arthritis and thyroid disease that could lead to future optic nerve or macular disease.

Once a patient’s candidacy for surgery is confirmed, he should then be examined for ocular disease that could affect surgical outcomes.

“Accurate and stable preoperative testing and data collection are essential for good refractive outcomes,” says Dr. Ciralsky, noting that ocular surface disease is extremely common and can significantly degrade the results of refractive surgery. A healthy ocular surface with a good tear film improves the accuracy of corneal curvature readings and wavefront maps and avoids measurement artifact, she says, noting that a healthy ocular surface also helps to improve postoperative comfort and visual recovery.

Common conditions that should be addressed before any refractive corneal or cataract procedure include blepharitis, meibomian gland dysfunction (MGD), aqueous deficiency, lid comorbidities and conjunctival chalasis.

“I would estimate at least 35% of the patients seeking refractive surgery in our practice have dry eye, meibomian gland dysfunction or ocular allergy that requires treatment prior to refractive surgery,” says Edward Lai, MD, Assistant Professor of Ophthalmology, Weill Cornell, New York, NY.

“The LASIK population has a very high number of dry eye sufferers because they’ve been in contact lenses previously, at least in the most common scenario, and they no longer want to wear contact lenses because of the hassle, irritation, and comfort limitations inherent with daily use,” agrees Thomas Harvey, MD, a refractive eye surgeon and partner with Chippewa Valley Eye Clinic in Eau Claire, Wisc. “One often-forgotten reason is that mucin- producing cells on the surface of the eye can be lost with disease-related and surgically induced inflammation, so tear film dynamics are abnormal. Mucins are needed to help anchor the tear film to underlying corneal epithelium,” Dr. Harvey added.

A New Era in Testing

Evaluating patients is vitally important, yet some conditions can be challenging to detect and accurately measure. Fortunately, preoperative tests have advanced greatly in recent years, and refractive eye surgeons have more numerous and effective preoperative tests at their disposal than perhaps at any other time in ophthalmic history. These include macular OCT, tear osmolarity, and questionnaires, such as the ocular surface disease index; and wavefront aberrometry and corneal topography. Others include MMP-9 detection, OCT quantification of the tear meniscus, lipid layer interferometry, and noncontact topography-based tear breakup time (TBUT).

“When it comes to refractive cataract surgery and LASIK, we’ve been witnessing one of the most important series of improvements in preoperative analysis and postoperative results compared to any therapeutic care in all of medicine,” says Dr. Wallace. With respect to cataract surgery, in particular, he cited laser interferometry and better computerized IOL formulae as “major drivers” of dramatic diagnostic improvement.

“Newer preoperative tools such as aberrometry and better astigmatic analysis will likely improve our ability to help cataract and corneal refractive patients. We’re also enjoying more sophisticated intraoperative technology, allowing not only better predictability of excellent outcomes, but faster visual recovery,” he says.

“The advent of wavefront analysis enables the evaluation of higher-order aberrations. This allows for better customization of treatment,” says Dr. Lai. “Newer corneal imaging machines use advanced technologies such as slit-scanning photography to provide data on the posterior surface of the cornea which older placido disk-based systems couldn’t. This newer imaging has helped us better predict signs of ectasia,” he adds.

Indeed, thanks to advances like these, gone — or at least nearly gone — are the days of checking items such as pupil size and corneal bed thickness post-flap creation. With improved tomography, says Dr. Lai, refractive eye surgeons can more confidently identify irregular astigmatism, corneal warpage and signs of ectasia.

“Improved tomography allows us to rule out patients at risk for ectasia and proceed with LASIK procedures with less worry,” she says.

While new tests and technologies have largely replaced older ones such as applanation biometry and manual keratometry, some older tests continue to retain their seat at the diagnostic table.

“The basic slit-lamp examination is still our standard of care and should include evaluation of tear breakup time, meibomian glands, vital dye staining and Schirmer testing,” says Dr. Ciralsky.

“Undoubtedly, I place the most emphasis on TBUT and Schirmer without anesthesia,” agrees Dr. Harvey. “Preoperatively, some of these lower-cost methods that are considered ‘old school’ by many people are still critical in determining candidacy. Vital stains like fluorescein and lissamine green still have a very important role in determining a patient’s appropriateness for surgery.”

Preoperative Treatment is Key to Good Outcomes

Once thorough testing and assessment are completed, getting the patient’s eyes into as healthy a condition as possible before surgery is vital to a successful outcome. In patients with diagnosed allergy and/or dry eye, the goal is to improve the ocular surface and, in turn, increase ocular comfort and visual acuity by decreasing inflammation, stabilizing the tear film and increasing aqueous production, all of which promote epithelial healing.

“Patients require a healthy ocular surface for reproducible testing. I think this is well recognized and most surgeons aggressively treat ocular surface issues preoperatively,” says Dr. Ciralsky. “In patients with dry eyes, I tend to begin treatment more aggressively with cyclosporine 0.05%, dosed twice per day, in conjunction with a course of a topical steroid at least 1 month prior to the planned surgery. Punctal occlusion is another option and should be considered.”

Meanwhile, patients with blepharitis and MGD, which can cause an inadequate tear film lipid layer, with resulting tear instability, can also be treated by oral supplementation with Omega-3 fish oils and flaxseed oils to help restore normal meibomian gland health, says Dr. Wallace. Oral doxycycline and/or topical azithromycin can be useful in appropriate patients. Patients with ocular allergy should be treated with a topical antihistamine or mast cell stabilizer, with or without a short course of steroids.

“It’s important to note that many of these treatments should continue well into the postoperative period for patient comfort and best results,” says Dr. Ciralsky.

Postoperative Assessments for Ongoing Improvement

In regard to the postoperative period, refractive eye surgeons should take care to track the results of every procedure.

“It’s very important to analyze postoperative data to improve your results,” says Dr. Lai. “I usually wait at least 3 months after LASIK and 6 months after PRK surgery to evaluate final refractive outcomes. It’s important that preoperative and postoperative measurements be taken in the same conditions. I check autorefraction, manual refraction, corneal topography and wavefront refraction. I use this data to develop a personal nomogram that I use for continued adjustments and improvements.”

In addition, with today’s new technology and improved accuracy, Dr. Lai says, “I find it worthwhile to make very fine adjustments in treatment plans (even less than 0.25 D) and I have more confidence to enhance smaller degrees of residual refractive error.”

Collecting and analyzing patient data on the patient-population level can also help surgeons and their practices improve over time, says Dr. Wallace.

“Postoperative refractive data collection has been a part of our practice for more than 20 years,” he says. “We dubbed this routine our Patient Satisfaction Program. We’ve always felt that if you don’t measure something, you can never improve on it.”

Indeed, in today’s era of value-based health care and high patient expectations, the importance of comprehensive pre- and postoperative patient testing and assessments to a refractive eye surgeon’s success can’t be understated.

“Across the board, all these procedures have seen major advances in predictable results, which have fostered higher patient expectation for improvement in uncorrected visual acuity,” observed Dr. Wallace. “When premium IOLs or LASIK come into play, the stakes are higher because patients are paying out of pocket. Patients are looking to be more independent from spectacles or contact lenses, and they expect us to deliver.” ■