REFRACTIVE EWAP MARCH 2022 Îx conversations with the patient, if the patient agrees, and she gives her cell phone number to all patients. Ensuring happy patients Dr. Nikpoor said her practice has a lot of capital equipment for preop testing that she finds helpful in assessing and optimiâing the ocular surface. Her practice doesn’t reµuire a contact lens holiday before screening, but if at screening there are signs of an abnormality, scans are repeated at their preop appointment. Dr. Nikpoor said they put patients on loteprednol Î days before their preop appointment because it cleans up the ocular surface for good refractions and topography. If there is any question about epithelial conditions, she’ll get an epithelial map. If the topography is suspicious for subclinical keratoconus, she’ll do P,K. Dr. Nikpoor advised ICLs for patients who are higher myopes, in cases where the stromal bed would be pushed to less than Î00 microns, and where there would be more than 40% tissue altered with a cornea-based procedure. Preoperatively, Dr. aktorovich looks for things like slight inferior steepening on the topography that could be a sign of either forme fruste keratoconus or epithelial basement membrane dystrophy (EMBD). She performs epithelial thickness mapping with widefield "CT to help differentiate between the two conditions. She steers patients with forme fruste keratoconus toward a lens-based procedure and patients with EBMD toward P,K. Dr. aktorovich said she’s not afraid of steering patients away from surgery altogether. These patients often have good vision with contact lenses or glasses, and they expect great vision without these aids after. She tells these patients preoperatively about the healing process and what that could entail as well as the rare complications that could happen. Dr. aktorovich said to not rush the preop process, tailor it to the patient’s specific prescriptions and ocular findings, and consider having them come in for several visits. EWAP Reference 1. Eydelman M, et al. Symptoms and satisfaction of patients in the Patient- ,eported "utcomes With Laser In Situ Keratomileusis (P,"WL) studies. JAMA Ophthalmol. 201Ç;1Îx\1Ζ22. Editors’ note: Dr. Clinch is in practice with Eye Doctors of Washington, Washington, D.C., and has interests with Alcon. Dr. Faktorovich is in practice at Pacific Vision Institute, San Francisco, California, and declared no relevant financial interests. Dr. Nikpoor is in practice at Aloha Laser Vision, Honolulu, Hawaii, and declared no relevant financial interests. Tae-im Kim, MD Professor, Department of "phthalmology, 9onsei 1niversity x0 9onsei-ro, Seodaemun-gu, Seoul, South Korea taeimkimJgmail.com ASIA-PACIFIC PERSPECTIVES L ASIK has genuinely improved the µuality of life. Waking up one morning to see the clock with clear eyesight would be a lifechanging event. But there’s one thing that we must never forget\ most of our patients have probably lived with fair corrected vision just wearing glasses or contact lenses. Any well-fitted lens would have allowed for great vision, even subduing minor surface irregularities and astigmatism. ,efractive surgery has made immense progress to the point where there ispas some would argueplimited room for further improvement. However, refractive surgery carries the potential to bring about unexpected results. There is always the risk of complications as the cornea has one of the most intricate neural networks in the human body. In this respect, great precautions must be taken before recommending refractive surgery to patients with fair corrected vision, as per Dr. aktorovich’s comment. 1nsatisfactory outcomes such as residual refractive errors or dry eye are clear problems easily identifiable and treatable. However, “discomfort” that patients complain aboutpthe symptoms that can neither be clearly described nor specifiedpis the situation that most baffles us. irst, it is necessary to discern whether the patient’s discomfort is a form of visual µuality or neuropathic pain. In the former case, residual refractive errors and ocular surface integrity must be accurately evaluated. Since irregularities and unstable tear film are major causes of visual µuality impairment, proper management is imperative. ,estoration of thick, healthy tear layer is also extremely important in reducing discomfort and improving optical integrity after surgery. In the latter case, problems become ambiguous and treatment becomes more difficult. This is when we must actively listen to the patients’ complaints, empathiâe with their pain, and try various methods to show that we’re trying to help solve the problem. All surgeries should be done after extensive preoperative assessment and refractive calculations; the surgeon must fully explain the risks and limitations of the operation and take time to optimiâe the ocular surface preoperatively to prevent the “unhappy patient.” Patients around the age of forty carry high risk, as satisfaction rates significantly deteriorate with presbyopia progression. Since adjustment to monovision varies by patient, trying contact lenses in advance may help predict one’s tolerance to monovision. Surgeons must keep in mind that for patients who are intolerant of a fully-corrected dominant eye and undercorrected non-dominant eye with contact lens simulation, monovision may not be a suitable option. ditors½ note\ Dr. im declared no relevant financial interests.
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