When performing refractive surgery, it is important to realize that if we help patients see 20/20 uncorrected, but they feel like their image quality is reduced, we have not done our best job. Preservation of best corrected image quality (BCIQ) and optimizing uncorrected image quality are paramount.

We should approach refractive surgery in a comprehensive way and consider whether we’re going to counsel the patient on doing nothing and continuing with optical devices or recommend a surgery on their cornea or lens or add a phakic IOL to their optical system. PRK, LASIK or SMILE are all quality corneal refractive options, but we don’t want to push the limits of the cornea and reduce image quality.

Being well versed in the technologies of lens-based surgery, be it a pseudophakic or phakic lens, really helps us keep corneal laser vision correction in its sweet spot. In this article, I will provide a breakdown of what you need to know when adding refractive surgery to your practice.

EDUCATE YOURSELF FIRST

The first thing to do when adding refractive surgery to your center is educate yourself. It’s helpful to shadow other doctors and develop a relationship with someone who can be a mentor to you. A mentor can help with a confusing topography or an enhancement judgment call, for example. It is also great to have someone to bounce things off of.

You should also listen to how other doctors and their well-trained technicians talk to the patient. I like to call this “refractive surgery speak.” It is very helpful in setting up proper pre-experience expectations and optimizes the psychological aspect of the refractive surgery journey, which I will discuss below.

Also, it’s important to utilize the resources of our societies, and publications such as Ophthalmology Management. The ASCRS is a wonderful organization that helps make the process easier through its various publications, white papers, online resources and webinars — be sure to check out the ASCRS Young Eye Surgeons (YES) Webinar that was moderated by Dagny Zhu, MD, last month that takes a deeper dive into the topics discussed in this article and more (bit.ly/3miul17 ). Additionally, the ASCRS annual meeting provides a wealth of educational resources, including lectures, posters and skills transfer labs.

By educating yourself, you can then confidently educate your team, your referring doctors and your community.

REFRACTIVE CONSULTATIONS AND PATIENT HISTORY

Refractive surgery is very rewarding when you choose the right patients and perform a quality surgery. If recommending the wrong procedure or performing it on the wrong patient, it can be devastating to their life. Making time for refractive consultations helps you and your team get to know the patient and allows an opportunity to align their expectations with reality so that you can meet or exceed them if they choose to proceed with surgery.

Refractive surgery, like any surgery, is not perfect because of the variables of the human healing response. To set proper expectations, I tell my patients, “We can do great measurements and deliver a great surgery for you, but we cannot control every detail of your healing process and you may need an enhancement or fine-tuning surgery. So, you have to be patient with this process.”

Additionally, I also tell them “I am not here to rid the world of eyeglasses … I am here to help you choose the surgery that will help you do the majority of what you do without glasses. Yes, a lot of patients do achieve spectacle independence, but if you can go into this thinking that if you can do the majority of what you do comfortably without glasses but may have a thin prescription for occasional use — like nighttime driving or sitting in the back row of a dimly lit theatre — then you have proper expectations.”

One of the most important questions I want a patient to answer is, “How is your nighttime image quality?” If someone has a quality nighttime image with their optical devices, there is a high chance a well-performed refractive corneal, phakic IOL or refractive lens exchange surgery will result in a good quality image. If their low light image quality is reduced, we need to figure out why. This includes testing for dry eye since the air-tear interface is the most powerful lens in our optical system.

We also need to consider an early lens change. This may be difficult to see at the slit lamp but is aided by diagnostics. By ruling out other causes of reduced image quality, we start to suspect it as the vision reducing issue. In that case, we suggest doing nothing or considering lens replacement.

Having a good rapport with your team on patient selection is key. About 90% of the patient’s time in the office is spent with the staff, so they know the patient’s personality oftentimes better than you do. Tell your team to let you know if any of the patient’s comments or personality make them less of a quality candidate.

THE MANIFEST REFRACTION

The refraction, and doing it very well, is also important. Pushing plus to minimize the influence of accommodation is key. Having a good BCIQ (make sure the 20/20 line looks crisp) is crucial to a successful refractive surgery outcome.

Also, the cycloplegic refraction (we use 1% cyclopentolate) is important to make sure that we understand the refractive state of the eye when the lens is in its unaccommodated state. During a cycloplegic refraction, we aren’t using these numbers to dial into the laser — we’re looking at how accurate the manifest refraction is. If there’s a 0.5-D or greater difference in spherical equivalent, we will bring the patient back for a post-cycloplegic refraction and push plus with the knowledge of the cycloplegic refraction — ideally, we’re able to match the manifest refraction to for the ultimate accuracy in outcomes.

DIAGNOSTICS

One key test for refractive patients is corneal topography. This can help you ensure the patient doesn’t have corneal warpage from contact lens wear — or worse, early keratoconus that you do not want to operate on and make worse (alternatively, consider crosslinking to stop its progression).

If it takes a technician a while to line up a patient for topography, and the patient is staring and not blinking because they are concentrating and trying to be helpful, the tear film dries out. A dry eye or a technician not recognizing a long acquisition time can really throw off a patient’s measurement. To increase accuracy and standardize your diagnostics, teach your team to babysit the tear film. Have patients take a complete blink after they get aligned to freshen their tear film. Then, capture the image within the next 5 seconds. This is helpful for autokeratometry, wavefront analysis, A-scan measurements, epithelial mapping and more as well.

If the test still looks irregular, we treat the patient’s ocular surface disease and bring them back another day to repeat testing with a healthier tear film.

We do not use an artificial tear to perform a diagnostic test out of concern of lessening the accuracy of our measurements.

Your corneal diagnostics, in combination with tear film diagnostics like osmolarity and meibography, can also help you understand if the patient has dry eye. The first thing I do if I see an irregular topography is have it repeated with a fresh blink. If there is a repeatable irregularity, I do a quality tear film analysis, image the epithelium or think about whether there’s a true anterior stromal irregularity that would lessen the patient’s candidacy for refractive surgery.

THE EXAMINATION AND CONSULTATION

The examination and consultation for refractive surgery are so important, as are the basics of understanding that the eye is healthy from front to back. In addition to getting to know the patient’s eyes, it is a great time to get to know them as a person as you assess for concerning personality characteristics, such as being a perfectionist. Getting to know your patient helps you combine their visual expectations and your knowledge of the various refractive surgery options, along with their eye and refractive status so that you can make the best recommendation.

One of the most important moments in the consultation is the recommendation. By getting to know the patient and their hobbies, occupation and visual goals, you can use your knowledge and help them understand what you would do if it were your eyes or the eyes of someone that you love.

LEARNING THE NUANCES

I perform all mainstream refractive surgeries, including PRK, LASIK, SMILE, phakic IOL surgery and lens replacement surgery. PRK is a wonderful procedure for many reasons, including no flap for occupational reasons such as military or police where trauma is a worry. LASIK is still the most common procedure we do and minimizes the haze risk.

SMILE use has grown so much over the past decade because it combines what we love about PRK (no flap) with what we love about LASIK (fast vision return and no haze risk). Phakic IOLs in patients with the proper anterior chamber depth and cell count are one of the most rewarding procedures a doctor can deliver. Lens exchange with an advanced implant in presbyopes — especially when nighttime image is starting to reduce — is such a beautiful way to deliver a permanent, lifelong correction and visual joy at distance, intermediate and near. You want to learn the nuances of these procedures to make the best recommendation.

Also, it is important to know your comfort level with these surgeries and look for opportunities to increase your level of confidence. I am comfortable with corneal refractive up to -8 D of myopia and +4.0 of hyperopia and will consider higher in the right situation. Corneal refractive surgery, for example, in a -6.0 D 21-year-old with a cornea less than 500 um thick — where the residual stromal bed after a LASIK procedure is going to be less than 300 um — is where many surgeons start to get nervous and lean toward a phakic IOL or simply continuing with contact lenses if they are going well.

Nuances and surgeon preferences that represent the art of refractive surgery are so helpful to learn about from other experienced doctors.

INFORMED CONSENT

Educating the patient about the various options is important. For instance, a -5.00 D non-presbyopic myope with a quality BCIQ can be a candidate for PRK, LASIK, SMILE or a phakic IOL. The patient needs to understand the pluses and minuses of each option, besides the list of risks with refractive surgery. We know that if performed properly, laser vision correction is one of the most successful surgeries known to man, but it is important that patients understand the risks.

SURGERY PREPARATION

As far as surgery time, I like to emphasize the patient prep happening close to the time that I’m either in the room or just about ready to be in the room. Since we use betadine in our prep after a topical anesthetic, we need to understand that as soon as the numbing drop is in, it can start to affect corneal hydration since the patient’s blink rate is reduced (teach your team to make sure the patient’s eyes are closed until you are there). It can also affect epithelial adherence if we wait too long to perform their procedure.

Having a consistent choreography of patient prep and then the physician being there for the laser vision correction is very important.

VERBAL ANESTHESIA

We talk the patient through every step of the procedure. For instance, with SMILE or LASIK, I always tell them they are going to feel pressure and their vision is going to dim out and to understand that it doesn’t last very long and it’s very tolerable. I explain that the best thing to do when their vision dims out is not to worry and not to move. This includes not moving their fingers, toes, feet, hands or, most importantly, not letting their head drift because patients who understand they shouldn’t be moving may not realize they’re slowly drifting away.

I also tell them, “We don’t want your chin to drift up or down, and I will be reminding you during the laser.” I also explain to them that “there will be a short period of time where I ask you to not talk,” and this is while I’m pushing the foot pedal and delivering the laser energy, because talking creates movement.

I do this in a calm, consistent voice of verbal anesthesia and it is so helpful in laser vision correction. You will find that it also calms you as the surgeon.

THE SURGERY: ADDITIONAL PEARLS

Coach John Wooden of the UCLA Bruins used to say, “Be quick, but don’t hurry.” I apply this saying to efficiency in surgery as well, because I don’t want the cornea to dry out and create under corrections. I also do not like to moisten the cornea if possible because it can swell quickly and irregularly and potentially affect outcomes.

If for some reason you have removed the epithelium or lifted a flap and there is a delay, you sometimes need to use good judgment and moisten the stroma, but this does not help your accuracy.

To efficiently deliver the surgery, have everything ready with regards to laser data review, entry and arming prior to removing the epithelium or lifting a flap. I like to create a “taco” when I lift the flap so that it minimizes flap dehydration. If there are very many tissue bridges after a femtosecond laser flap or SMILE procedure, using a 0.12 forceps to stabilize at the limbus while dissecting with a spatula can greatly facilitate your surgery.

When you shadow other surgeons, either in person or on video, look for ways to increase your surgical efficiency by watching their technique in their surgical procedures.

THE BUSINESS OF REFRACTIVE SURGERY

When surgeons have learned all of the above and have created a true refractive offering in their practice, they can have the confidence that marketing and attracting patients will be a wonderful experience and result in growth for their practice.

Whether you choose to dedicate your career to refractive surgery like I have or just as a service line in your practice, you will find it as rewarding as I do. Following the guidelines presented in this article will provide you with a great start to a successful refractive surgery practice journey. OM

Vance Thompson, MD, is a comprehensive refractive surgeon in Sioux Falls, S.D., and the founder of Vance Thompson Vision. He participated in the FDA-monitored trials for PRK, LASIK, SMILE, multiple phakic IOLs and multiple presbyopia-correcting IOLs. Disclosures: Dr. Thompson does research and consulting for Alcon, Bausch + Lomb, BVI, Johnson & Johnson, Rayner, STAAR Surgical and Zeiss.