EyeWorld Asia-Pacific September 2012 Issue

September 2012 12 EWAP FEAturE AT A GLANCE • In eliciting the problem from unhappy patients, some practitioners attempt to drill down on a single problem • Many patients return years after surgery with complaints of recurrent refractive error, which may be related to problems of aging such as presbyopia or cataracts • For some patients where surgery isn’t an option, a neurological approach or even use of specialty contact lenses may be the answer for the interim When patients strike an unhappy pose by Maxine Lipner Senior EyeWorld Contributing Editor How to change the refractive picture I t’s the kind of thing that even the best practitioners occasionally face—the unhappy refractive surgery patient straggling through the door. Managing these cases requires special care that can begin at the outset and a dedication that may stretch for years. Here’s how you can strive to satisfy patients in even the most difficult cases. For Richard L. Lindstrom, MD, adjunct professor emeritus, University of Minnesota, Minneapolis, Minn., USA, managing the potentially unhappy patient begins even before any surgery takes place. “Those patients who are normal risk patients, I simply tell them about the most common problems and then the worst problems,” he said. He makes them aware of potential problems as benign as the need for another treatment and as significant as a sight-threatening infection or post- LASIK ectasia. Views from Asia-Pacific John S. M. CHANG, MD Director, Guy Hugh Chan Refractive Surgery Centre Hong Kong Sanatorium and Hospital 8/F Li Shu Pui Block, Phase II 2 Village Road, Happy Valley, Hong Kong Tel. no. +852-2835-8885 Fax no. +852-2835-8887 johnchang@hksh.com T he best way to avoid having an unhappy patient is prevention; preoperatively, careful screening and detailed discussion. The first question I ask is why they want refractive surgery and what they expect from the surgery. Managing expectation is the most important. Under promise and over deliver. After detailed consent first by showing the patient a video, I then personally address the most serious complications and also the most frequently occurring problems. Using the femtosecond laser will significantly decrease the incidence of complication. When facing the unhappy patient, make sure you are clear what the problem is. Spend some time and listen to the patient’s problem/s. When patients are angry and hostile, very often they are scared they will go blind or the problem will get worse. A little reassurance will go a long way. I agree with Dr. Stonecipher: solve the problems one by one, start with the one that bothers them most; if you cannot solve that one then solve the next one, as long as you show you care and are trying your best to solve their problems they will feel better and stick with you. After all, they trusted you and let you operate on their eyes in the first place! One of the things I find very useful is the hard contact lens; once placed over the patient’s eye, it will correct many problems, e.g., uneven bed, decentration, small optical zone, small cap, irregular astigmatism. This shows the patient that they have not lost their vision permanently, that with the correct treatment they can potentially regain their vision. As Dr. Lindstrom says, “Even if we can’t fix you now we can fix it later with newer technology.” Studies have shown that 80% of law suits are due to misunderstanding and miscommunication between the doctor and the patient. It is very important to give them reassurance and tell them you will not abandon them.Editors’ note: Dr. Hwang and Prof. Joo have no financial interests related to their comments. Editors’ note: Dr. Chang has no financial interests related to his comments. Artist’s conception of a visual aberration Source: Elizabeth A. Davis, MD For the high-risk patient, he hones in on the specific finding that makes this particular case more complex. For significant dry eye patients, for example, he makes it clear that something like LASIK may worsen the condition. “We need to make them aware that they have a dry eye and that while in the majority of patients LASIK doesn’t permanently make dry eye worse, in a small number it does,” Dr. Lindstrom said. Likewise for those with possible risk factors for post-LASIK ectasia, Dr. Lindstrom will go the extra mile and often switch the patients from LASIK to surface ablation and even obtain special informed consent. “In the future I think what we’ll do with many of these patients is collagen crosslinking with simultaneous PRK, or perhaps LASIK or sequential PRK once the crosslinking has healed,” he said. Karl G. Stonecipher, MD, medical director, TLC Laser Eye Centers, Greensboro and Raleigh, NC, USA, takes a similar initial tact. “We always have a conversation before surgery that surgery is not perfect,” he said. While his average risk for an enhancement is between