REFRACTIVE Î4 EWAP MARCH 2022 amount of time looking at screens. He said physicians should look for lagophthalmos and counsel these patients about the potential for greater dry eye and the need for postop artificial tears. If a patient were to have higher order aberrations, which Dr. Clinch identifies with the WaveLight Topolyâer 6ario Diagnostic Device (Alcon), he has performed Contoura (Alcon) treatments on post-LASIK patients to reduce aberrations. The physician needs to explain to the patient that treating higher order aberrations can have variable outcomes. He usually advises against treating higher order aberrations if the patient’s procedure was done a long time ago and they’re functioning reasonably well. Dr. Nikpoor noted that she will set the appropriate expectation by telling patients it may take two or three treatments to achieve the final result. “Time tends to heal a lot of the aberrations in both that the cornea will respond and the brain tends to neutraliâe some of the aberrations,” Dr. Clinch said. Dr. aktorovich shared the reasons she finds for unhappy post-LASIK patients. There are patients whose outcomes don’t align with their expectations. A good example of this is when a patient with mixed astigmatism also has significant accommodation, she said. “We can operate on M,x, but their vision will worsen over the years as they lose their accommodation. "r we can operate on C,x and they will be nearsighted initially. In this case, they may need to do vision therapy,” Dr. aktorovich said. Dr. Clinch said he’s a big proponent of mild monovision in the pre-presbyopic, myopic patient. rom the standpoint of expectations, he said hyperopic patients need to be counseled preop that their convalescent period might be longer and they might experience nighttime visual disturbances for a longer period of time compared to their myopic peers. Highly myopic andÉor myopic astigmats also could have a longer convalescent period, and they should be told they might need a touch-up. "ther unhappy patients, Dr. aktorovich said, are those who feel like the surgeon doesn’t have time for them or is dismissive or defensive. There are also patients who may need help understanding what’s normal during the healing process, she added. “If they don’t understand, it could be upsetting. If they do, they are reassured. If there is a plan of action to maintain a good healing process, that’s even better. Some symptoms are a normal part of the postoperative healing. With modern screening, techniµues, and technologies, they are unlikely to persist. Be supportive, systematic, caring,” she said. Dr. Nikpoor agreed and shared a particularly challenging case. She had a patient with severe neuropathic pain after P,K and saw her freµuently for several months. “I reiterated at every visit that her pain was real and that I was committed to helping her get through this. She joined a acebook support group and thanked me for taking her pain seriously. She shared that many members of the group were frustrated by their experience with their surgeons who dismissed them,” she said. What do you do? If you do find an unhappy postLASIK patient in your chair, Dr. Nikpoor said she starts with a data collecting phase where she’s trying to figure out what they’re happy and unhappy about with their vision. “I repeat back what I hear to make sure I’m understanding them correctly. Then I’ll go through the possible solutions for each thing they’re unhappy about,” she said. “At the end of that conversation I’ll ask, ¼If you did this again, would you make the same decision¶’ A lot of times they say, ¼"h, yes.’ I try to leave it on that positive note. They’ll usually say that in spite of the negatives, it has made their life better. I also want to know for my own sake that they would have chosen the same procedure.” The unhappy patient is the one whose calls you should be returning right away, Dr. aktorovich said. After listening to them, she says, “I can totally understand what you’re saying” and “I am committed to helping you.” "nce you’ve identified what’s causing their discontent, spend time explaining what’s going on so they understand. Dr. aktorovich said she doesn’t dumb down her explanations; she finds patients understand and appreciate when she takes the time to explain what’s going on in technical terms. If a patient’s vision is blurry, do a refraction and demo even the smallest prescription in a trial frame. Dr. aktorovich said this will reassure the patient, even if they don’t decide to do a touchup procedure. Dr. aktorovich advised involving a significant other in
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