EyeWorld Asia-Pacific September 2012 Issue

September 2012 13 EWAP FEAturE Michael LAWLESS, MD Medical Director, Vision Eye Institute 4/270 Victoria Ave., Chatswood, NSW Australia Tel. no. +61-2-94249999 Fax no. +61-2-94103000 Michael.Lawless@vgaustralia.com D rs. Lindstrom and Stonecipher have brought their considerable experience to bear to help us deal with unhappy patients. If it is any consolation, at least you know when unhappy patients are actually unhappy. You also get a good idea of when patients are happy. There is a separate group that I think we as physicians tend to ignore, and that is the patients who are actually unhappy, but you never know. They either go somewhere else or they just don’t tell you if they haven’t achieved what they thought they would from surgery. Surgeons who pay attention to this group have busier and more fulfilling practices because they identify this group and act for them. It seems to me that this is all about communication and connecting with patients and Drs. Lindstrom and Stonecipher make these points. Communication is not about doing tests, although these are essential in obtaining the right information for you to make a clinical decision. It is the time spent talking to a patient one on one, preferably with a relative or friend, without distractions, without looking at charts or computer screens. Make the human connection. Reference is also made in the article to informed consent and we should always remember that informed consent is a process, not a single document. It is a process which involves information exchange between staff, surgeon and patient. It is also worth remembering that late unhappy patients, those who for example had LASIK in their late thirties and are now in their early fifties, are great patients to have in your practice. They have previously been motivated to achieve spectacle independence and that mindset tends to stay. With a discussion they can readily understand that their lens has changed in its ability to accommodate, its ability to deal with higher order aberrations and the decline in its clarity with age, and as cataract surgery becomes safer and intraocular lens options more appropriate, there is an opportunity to help these patients for a second time in their lives. Where help is not available Dr. Lindstrom gets it exactly right by saying “do not give up on the patient.” Even when treatment is not available for their particular problem, it may be so in a year, or two, or five, and the real possibility of technology improvement and a solution for an individual’s problem should always be discussed and the patient never abandoned. Dr. Stonecipher’s “tree snapshot” is also a very helpful four-point approach to dealing with these patients, ranging from a simple enhancement all the way to refractive cataract surgery and gives a good summary of how these patients should be approached. Remember these are patients who trusted you the first time and are willing to trust you a second time, and it is a compliment, not a burden, that they have returned. Editors’ note: Dr. Lawless is a consultant for Alcon/LenSx (Fort Worth, Texas, USA/ Hünenberg, Switzerland). Sri GANESH, MD Chairman and Managing Director Nethradhama Hospital Pvt. Ltd. No. 256/14, Kanakapura Main Road, 7th Block, Jayanagar, Bangalore–560082, India Tel. no. +080-26088000 Fax no. +080-26633770 chairman@nethradhama.org T he golden dictum in refractive surgery is “under promise and over deliver.” By toning down expectations and explaining the risks and benefits and also letting patients know that the goal of refractive surgery is to reduce dependence on glasses and contact lenses for day-to-day activities that improve lifestyle and not to give “eagle vision”, you can reduce the number of unhappy patients. Dealing with an unhappy refractive patient is often complex and needs a multipronged approach, as many of these patients may have co-existing problems like residual refractive error, higher order aberrations that degrade quality of vision (even when the patient has 6/6 vision), dry eye, extraocular muscle imbalance, etc. Most busy practitioners tend to dismiss unhappy refractive surgery patients and avoid them, especially if they have 6/6 vision, but keep in mind that you could lose 20 potential patients with one unhappy patient. A thorough preoperative evaluation and proper patient selection andmore importantly selection of the refractive procedure ideal for a particular candidate (LASIK, surface ablation, phakic IOL, CLE, etc.) will make a big difference in the patient being happy or unhappy after the procedure. Many patients seek refractive surgery as they have problems with their contact lens or glasses, e.g., early keratoconus patients not improving in their vision or having problems in quality of night vision, dry eye patients having intolerance to contact lens, etc. When an unhappy patient comes in early after corneal refractive surgery, he may have worsening of dry eye and also reduced contrast. These need symptomatic treatment and some hand-holding for a few months to allow them to settle down on their own. Residual refractive errors have to be enhanced if there is adequate residual corneal tissue, when they stabilize. Patients with complaints of reduced night vision, glare and haloes have to be investigated in depth for decent rations, residual error and higher order aberrations and treated with wavefront enhancements. Some patients have perfect refractive results, but complain of vague symptoms of asthenopia. These patients have to be evaluated with a detailed orthoptic workup and many a time there is some muscle imbalance or fusion problem, which can be treated with orthoptic exercises. A patient may come in some years later, unhappy with his vision. This could be due to worsening of dry eye symptoms, progression of refractive error, newer problems like presbyopia or the dreaded complication of ectasia. Some of the moderate to high myopes develop early nuclear sclerosis and this could lead to changes in refraction and degradation of quality of vision. For late enhancements, I prefer doing a surface ablation for low powers or a phakic IOL implantation for higher errors as re-lifting old flaps have a higher incidence of epithelial ingrowths and ectasia (especially if the flap is thick). Ectasia can be managed with corneal crosslinking, intrastromal rings, toric ICLs or a combination of these. The unhappy refractive surgery patient can sometimes be an enigma, and a second opinion from an experienced colleague and timely treatment can help put the smile back. Editors’ note: Dr. Ganesh is a consultant for Abbott Medical Optics (AMO, Santa Ana, Calif., USA), Schwind Eye Tech (Kleinostheim, Germany), and Hoya (Tokyo, Japan). 0.8 and 1.27%, he makes it clear that for some people, such as high myopes, this risk is significantly higher. “I say, ‘Overall the risk of [patients] coming back for a touchup is about 1%, but you’re pretty nearsighted so we’re probably going to be looking at a number like 7-8%,’” he said. “The same thing goes for astigmatism.” Through the early lens If a patient does return unhappy, Dr. Stonecipher does his best to emulate John Potter, OD, vice president, TLC Vision Corporation, who is the go- to person for any problematic TLC cases. “What John says is that patients who don’t get the outcome they want, whether it is continued on page 14