EyeWorld Asia-Pacific September 2014 Issue

September 2014 16 EWAP FEAturE Counseling patients about refractive enhancement by Ellen Stodola EyeWorld Staff Writer Depending on the patient, a surgeon may want to discuss refractive enhancement preop W hen handling keratorefractive enhancement in pseudophakic patients, it may be necessary for a surgeon to discuss a patient’s options and counsel him or her about the necessity of refractive enhancement preoperatively. There are a number of factors to consider in this conversation, including what type of lens the patient is receiving, cost issues, and the possibility for patient dissatisfaction after the surgery. Richard Tipperman, MD , Wills Eye Hospital, Philadelphia, Pa., U.S.; William Trattler, MD , Center for Excellence in Eye Care, Miami, Fla., U.S.; and Kevin Waltz, MD , Eye Surgeons of Indiana, Indianapolis, Ind., U.S., weighed in on this topic. Do you discuss this preop with all patients? Dr. Tipperman said that he discusses the possibility of enhancements with patients who express a strong desire for a specific refractive outcome. “I do not routinely discuss this, but it is likely a good idea,” he said. He knows some surgeons who have patients sign waivers indicating that they understand that results can vary on a patient- to-patient basis and may not be exactly as a patient desires. “Fortunately, if patients wish to have their post-refractive outcome adjusted, this can usually be done with laser vision correction, but there are additional costs for this,” he said. Dr. Tipperman added that for multifocal IOL patients, particularly ones with significant astigmatism, it might be necessary to have a discussion before surgery. “I explain that they will need to cover just the facility fee costs,” he said. “We price our toric and multifocal patients so that it includes touchups,” Dr. Trattler said, “so this is not usually a preoperative conversation.” “Our day-to-day goal is be on target, so if the subject is broached with patients, it’s a simple point that if the outcome ends up over or undercorrected, it can be finetuned postoperatively.” Dr. Waltz discusses these possible refractive enhancements with certain patients, adding that it becomes more apparent depending on the patient if this is going to be a good option. For AT A GLANCE • Not all patients will end up needing keratorefractive enhancement, but it is important to have a plan in place that patients know about beforehand to avoid last minute surprises. • Patients who need counselling include those with previous laser vision correction, monovision patients, and those receiving multifocal, accommodating, or toric lenses. • Many surgeons include some of the price in premium procedures and may have the patient pay a facility fee or wrap it into the total cost. example, someone with cataracts who is 20/60 and does not care if they wear glasses is not a patient who is going to want refractive enhancement postoperatively. He will discuss this with patients who are getting a toric lens because they are obviously paying extra to get a refractive outcome, so there needs to be an enhancement strategy in place for them. Dr. Waltz added that these patients cannot be surprised with the enhancement strategy after the fact. This strategy also applies to patients getting multifocal or accommodating lenses. Patients need to be aware that there is a possibility of a second procedure, approximately what that would be, and whether it’s going to be covered or not, he said, adding that he believes these patients should be covered and the doctor should put enough money into the initial fee to take care of what is needed. It is necessary going in to know the cost to do the enhancement and what your rate of enhancement is, he said. Dr. Waltz said that there are other groups of patients with whom he will discuss refractive enhancement preoperatively. These include patients who are getting monovision and patients who have had prior laser vision correction surgery. Currently, he ends up having this conversation with about 60% of his patients. “You want to have a number of strategies available to cost effectively and clinically effectively do the enhancement,” Dr. Waltz said. “You want to have a menu of options lined up and ready to go before you even do the first surgery.” Extra costs The idea of extra costs associated with premium and enhancement procedures are often daunting to patients, but there are a number of ways physicians can deal with this. Dr. Trattler said that for his patients getting a presbyopic lens, the Crystalens (Bausch +