6 Pearls for Improving Refractive Surgery Results

Neil J. Friedman, M.D.

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1. Communication:
Clear, effective patient communication begins with the selection process and patient education. The informed consent discussion is also critical; therefore, I do these steps myself to ensure that the patient has realistic expectations as well as understands the limitations and potential complications of the refractive procedure. Preoperatively, I review the various steps of the surgery so that there are no surprises. During the treatment, when I am actually performing these steps, I explain what I am doing (i.e., "this is the suction ring you may feel some pressure now and the blinking light will go out", etc.). Verbal anesthesia is also helpful as the laser is firing, even for short ablations. Ten seconds of silence can seem much longer to an anxious patient, so continuing to speak encouraging words will relax and distract the patient. This becomes increasingly important for longer treatment times. Clear communication with technicians and nurses is also essential, and any special steps for a particular case should be reviewed with the team ahead of time. Doing so will help ensure that everything goes smoothly during the procedure. Postoperatively, prompt discussion of any complication is also important: be honest, explain the problem and the treatment plan, see the patient as often as necessary, and don’t be afraid to suggest a referral to a colleague for a second opinion.

2. Data:
Accurate, stable, and reproducible preoperative measurements are essential for excellent refractive results because this data determines the laser treatment. Contact lens wearers must discontinue lens wear for an appropriate length of time prior to preop testing, refractions must be consistent, corneal topography must be regular, and pachymetry must be sufficient for the planned level of correction. Similarly, it is also important to analyze the postoperative data. By tracking results and creating a personal nomogram, surgeons can optimize their refractive outcomes.

3. Equipment:
All instruments including those for preop measurements as well as surgical lasers and microkeratomes need to be maintained and calibrated routinely. A designated person should be appointed for these tasks and a record kept in a logbook. The surgeon should double-check all measurements, scans, and the data input on the laser. The surgical team should consider performing a time-out prior to commencing treatment as is routinely done in operating rooms. Furthermore, equipment software and hardware should be upgraded with technologic advancements (i.e., wavefront capability, eye tracking, iris registration, faster repetition rates).

4. Ocular surface:
The most important refractive surface of the eye is the tear film, so it is imperative to identify and treat any ocular surface disorders. A poor tear film can affect visual acuity, refraction, and corneal topography data as well as postoperative healing, so we must optimize the ocular surface pre- and post-op. This involves treating dry eye and Meibomian gland dysfunction aggressively. Other conditions must also be detected such as anterior basement membrane dystrophy, which can affect corneal measurements and influence the type of procedure to be performed.

5. Patient positioning:
Proper alignment under the laser is required for a well-centered ablation. Mark the limbus with the patient upright for astigmatic correction since significant cyclotorsion may occur in the supine position. I prefer to do this at the slit lamp and routinely perform this step even though the excimer laser I use (Visx Star S4) has iris registration, because the IR feature cannot always be engaged during a treatment. In addition, make sure the patient’s head position is correct so that the iris plane is parallel to the floor. This cannot be determined by merely looking through the microscope oculars and centering the laser on the visual axis because of possible parallax errors. Therefore, the surgeon should look at the eye position from the side of the headrest and adjust the patient’s head position if necessary.

6. Prophylaxis:
Preventing complications is a priority for all surgeons.

• Infection: it is important to perform treatments in as sterile a fashion as possible. Steps to avoid contamination include: administering broad-spectrum topical antibiotic eye drops pre- and post-op, prepping/draping the eyelids and lashes, wearing surgical attire (i.e., cap, face mask, gloves, and scrubs), properly sterilizing surgical instruments, and using disposables. An aspirating lid speculum or specialized drain can also be helpful for keeping the surgical field free of tear film debris.
• Scarring: for surface ablation, mitomycin-C has been extremely valuable for reducing the risk of haze/scar formation after deeper ablations (greater than ~70 microns) and retreatments.
• DLK: this vision threatening condition can potentially be prevented by starting topical steroids early and frequently (every 1-2 hours). Since routinely beginning my LASIK patients on such a regimen immediately after the procedure until their postop day one exam, I have not seen any more cases of DLK.