Be Your Patients’ Trusted Source for Answers About Refractive Surgery

Refractive surgery is something many patients consider but often seek initial information on from a surgeon rather than their optometrist. And when those patients proceed with surgery, they are not likely to return to their optometrists for postoperative care or their future ocular health needs.

To change this, I started initiating conversations about refractive surgery and was surprised at how quickly patients responded, saying they’d always wondered whether surgery would work for them and wanted to learn more about their options.

If you’re like me, you try to be the main source of education for your patients about all vision-correction options. Because I’ve chosen to have LASIK myself, I especially enjoy sharing my story and educating patients on the facts about their candidacy for surgery without placing any pressure on them.

Following is a brief overview of the topics I discuss with patients and the sorts of things I say.

CORNEAL LASER SURGERY

Talking to patients about surface or lamellar laser surgeries such as PRK or LASIK is fairly straightforward. I explain that lasers are used to reshape the cornea and reduce the patient’s need for glasses or contact lenses.

Most people who have heard of LASIK don’t realize that the improvement in vision it offers
isn’t permanent. It’s helpful to point out that, as our bodies age, the near vision changes, and we eventually need reading glasses to see fine print. I explain that most people notice vision changes around age 40, regardless of whether they’ve had refractive surgery—it’s simply how the eye ages. I like to note that when this time comes a slight prescription for eyeglasses or contact lenses can improve their vision, or another surgical option can be considered if appropriate.

Patients should be made aware that corneal refractive surgery doesn’t speed up or slow down
the aging process. Many patients have friends or family members who have had LASIK or PRK and are familiar with the procedure, expectations, and recovery, so they may not have many questions other than whom you trust to perform the surgery.

LENS SURGERY

Phakic IOL

Some patients may have been told that they weren’t good candidates for LASIK or PRK because their corneas are too thin. This is the case for many highly myopic patients. I typically tell patients that with recent advances in implant technology, we can now offer myopic and astigmatic correction with the Visian ICL (STAAR Surgical). I explain that this technology adds an implant rather than subtracts from their natural cornea tissue. I also explain that, because it’s a more involved surgery, the cost is higher and the risk profile is slightly different, but it may be a safer option for this patient’s eyes compared to LASIK.

(Another phakic IOL, the Artisan [Ophtec USA], is FDA-approved and available in the United States, but because it is a rigid PMMA lens that requires a large incision, it is not used as often as the foldable small-incision Visian ICL.)

The same presbyopic changes that we discussed regarding LASIK and PRK would be expected with a phakic IOL. Your patients may have quite a few questions about phakic IOLs because this intraocular procedure isn’t as common as the corneal laser procedures. I’d suggest offering them a follow-up visit with you to discuss it further, or a referral to your trusted surgeon for an evaluation. (To determine whether your patient is a good candidate for an ICL, see ICL Guidelines.)

To prevent pupillary block and reduce the risk of angle-closure glaucoma, the phakic IOL patient will have a laser peripheral iridotomy performed before the implantation procedure or an iridectomy performed at the time of the lens placement. The ICL is placed in the ciliary sulcus, just behind the iris and anterior to the natural lens. The ideal vault is between 250 µm and 750 µm, or approximately 100% of corneal thickness.¹ Although pupillary block and angle closure are rare, they can happen if the ICL is incorrectly sized. An ICL that is too large can cause excessive vault that crowds the angle, and a lens that is too small can have a shallow vault, causing anterior subcapsular opacities and early onset cataract.

Refractive Lens Exchange

For patients 40 years and older who want to improve their full range of focus, a refractive lens exchange (RLE) may be a better option than LASIK or PRK, after which they would still need glasses for near vision. I like to explain to patients that some of the benefits of a lens-based procedure, such as RLE, are permanent vision improvement, elimination of future cataract development, and correction of hyperopia, myopia, and/or astigmatism.

With more IOL options to choose from now than ever before, your patients can gain a wider range of focus that is permanent with RLE. Most patients reduce their dependence on glasses or contact lenses for most of what they do. I briefly discuss the cost/investment by letting patients know that there are different types of lens implants available that can improve their vision. The more the lens helps them see, the bigger the investment will be.

SEIZE THE OPPORTUNITY

As with all surgeries, risks and benefits must be carefully considered before proceeding. We are our patient’s primary eye educators, and as such we have a unique opportunity to help them learn about surgical options and support them through preoperative and postoperative care.

Rather than shy away from surgical conversations with patients, we should embrace them. We can be objective and trusted sources for information on all things related to our patient’s vision needs and support them through a lifetime of good ocular health. Patients want to hear your recommendations regarding their eyes.