EyeWorld Asia-Pacific September 2015 Issue

42 EWAP REFRACTIVE September 2015 How to achieve the best refractive outcomes by Lauren Lipuma EyeWorld Staff Writer AT A GLANCE • Settling for 20/20 falls short of what can be achieved with modern technology and what most patients expect. • Good patient selection, understanding the patient’s goals and expectations, and acquiring an accurate preop refraction are critical to achieving good outcomes. • Spend extra time with unhappy patients—they become the best referrals. • Don’t forget about PRK—it is an excellent choice as a primary procedure and for refractive enhancements. Experts share strategies for hitting a refractive target and how to deal with less than optimal results P ostoperative visual acuity is arguably the biggest driver of the success of a refractive practice. 20/20 UCVA has traditionally been the benchmark of success for refractive surgery outcomes, but over the past several years, surgeons have started to question whether 20/20 is the best they can do. What do today’s LASIK patients want and expect from elective refractive surgery? Is 20/20 an appropriate target—or is it just an arbitrary number? Here, three experienced refractive surgeons weigh in on what targets surgeons should aim for in a modern refractive practice, how best to hit those targets, and how to deal with less than optimal results. What target should surgeons aim for? Although some patients are happy with 20/20 vision postop, this doesn’t mean it should be the ultimate goal—or a benchmark of success. “With the current state of knowledge about the capabilities of the human eye, to settle for 20/20 as an outcome would be to fall short for both our patients and for ourselves,” said Christopher Blanton, MD , medical director, Inland Eye Institute, Colton, Calif. Humans have the potential to see close to 20/8 vision, based on the size of retinal photoreceptors, and Dr. Blanton thinks a refractive surgeon’s job is to bring patients as close to that visual limit as possible with the available technology. “We set our goal at 20/15 and we chose this because we know that 92% of our patients are capable of seeing this vision with their best correction,” he said. “Fewer patients can see to the 20/12.5 and 20/10 level, although in the future I would not rule these out as new goals.” Rather than select a certain visual acuity as the target, Charles “Chaz” Reilly, MD , Rashid, Rice, Flynn & Reilly Eye Associates, San Antonio, and Daniel S. Durrie, MD , clinical professor of ophthalmology, University of Kansas, Overland Park, aim to give their patients better vision than they had before surgery with glasses or contacts. “My own goal is to try to provide ‘super vision’ to my patients,” Dr. Reilly said. “I fully expect for my myopic patients that their uncorrected vision post laser vision correction be better than their best corrected visual acuity preoperatively.” With the wavefront technology and increasingly accurate corneal topographers available today, surgeons should know what target they can hit with each patient. “These procedures have been around for 25 years now—there’s no reason to be guessing what the results are going to be. In well selected patients using modern diagnostics, improved vision performance should be the goal,” Dr. Durrie said. How do you achieve the best results? Three main factors contribute to whether the surgeon will hit a refractive target: good patient selection, understanding the patient’s goals and expectations, and acquiring an accurate preop refraction. According to Dr. Durrie, today’s refractive technology is capable of correcting astigmatism better than glasses or contacts, giving patients better vision than they had before surgery—but only if those patients are well selected. “We rarely see someone who is disappointed anymore, but we don’t do corneal surgery on everybody who comes in, especially if they have lens changes or if they have uncontrolled dry eye,” he said. “We want to treat those things and not have the procedure be blamed for their unhappy vision.” It is also important to understand the patients’ goals and manage their expectations—and not just in terms of visual acuity. “There are many aspects to vision that 20/20 does not capture: quality of vision and range of vision, to name two,” Dr. Reilly said. Some patients may prefer to sacrifice a small amount of distance vision to enhance depth of field, for example, so it is crucial that a surgeon takes the time to understand the patient’s visual needs both before and after surgery, he said.