Refractive surgery has become a global phenomenon, most likely because of its outcomes: good visual function without dependence on spectacles and contact lenses. Refractive surgery, therefore, has become as much a consumer good in our age as it is a sensitive surgical procedure. In my opinion, it is common for patients to have great difficulty differentiating between the two.

It goes without saying that every patient seeks the best possible solution when he is considering refractive surgery. With now more than 15 years experience in refractive surgery in both the United States and Europe, I am still amazed to follow the technology and market developments in refractive surgery. Our patients do not have the same expertise that we have, and more times than not they are overwhelmed by the number of treatment options and refractive centers that are available to them. It is easy to become confused or make a poor decision when presented with too many choices.

As surgeons, we have a responsibility to guide each patient toward a solution that makes the most sense for his refractive needs. That starts with reminding the patient to ask questions, and lots of them. Herein, I describe how—if I were a patient—I would investigate and choose the appropriate refractive center to fulfill my needs. (When I am asked, this is usually the advice I give my patients.)

THE PROCEDURE
Which procedure is appropriate for the patient's problem? The first step is clearly defining his objectives.

• What are you hoping to accomplish?
• What is your everyday visual function?
• Do you use a computer?
• Do you read and/or work outside?
• Do you participate in everyday recreation sports?
• Is far, intermediate, near vision, or all of the above very important to you?

A patient should also be familiar with the risks and possible complications of each procedure and understand any potential limitations the procedure may place on his everyday life. I think this is the most important element in a patient's satisfaction. The patient needs to know what he can expect after the refractive surgery procedure. What gets better, and what gets worse? What is the same? The surgeon should apply answers in simple terms.

Both the medical establishment as a whole and the individual ophthalmic surgeon must be clear when talking to a patient about these key elements, regardless of his educational level, age, or socioeconomic status. It is far more difficult to spend time with a dissatisfied patient after the surgery than it is to take time with him before.

THE CENTER
First, and most important, remind the patient to ask what technology is used by the center and how often this technology is updated. For example, is the laser new or is it 10 years old? What was the last time it was serviced? Some of this information is quite sensitive commercially and legally, and therefore it is difficult for surgeons and staff to answer such questions for a patient who is more or less unfamiliar with specifics; however, a patient should not be afraid to ask questions. Below are questions that are sensitive indicators of the quality control for each refractive surgery center:

• How is the center applying quality control?
• What are the actual additional charges for the procedure, including follow-ups and retreatments?
• How is the preoperative work-up conducted?
• Does the physician who will work on my case look at this work-up?
• What elements are evaluated by the center's associates?
• What percentage of patients treated in the specific center require reoperation?

THE SURGEON
Unfortunately, we commonly see patients who reduce the ophthalmic surgeon to just the person who steps on the pedal during the procedure. This notion has surfaced mainly due to big corporations that have franchised the concept of refractive surgery in several countries.

The patient should understand the surgeon's position in the chain of command. It is the final surgeon-patient relationship that defines a surgical procedure (and refractive surgery is a surgical procedure); it is this relationship that is able to buffer some of the issues previously mentioned.

The surgeon's intuition, judgment, and experience enable him to anticipate some of his patients' expectations, which the patient may or may not verbalize in his interview. The surgeon will set the standards for the technology used and the quality control.

As I previously mentioned, refractive surgery may have evolved to, in some ways, a consumer good. In my opinion, however, it remains a significant surgical procedure because it both affords the patient generally good eye health and holds tremendous potential for complications. Patients interested in refractive surgery should remember to ask:

• What is the surgeon's educational background?
• Is the surgeon involved in research?
• Is some of the surgery performed as part of a research project?
• What is the academic status of this surgeon?
• What is his training background and his specific experience with the refractive surgery procedures involved in my operation? (For example, an ophthalmic surgeon may have tremendous experience in radial keratotomy and low experience in LASIK. If a surgeon has tremendous experience in LASIK and no experience in intraocular surgery, how can the patient adequately decide between LASIK and phakic IOLs?)
• Who deals with potential complications, if encountered?
• Are complications evaluated elsewhere?
• Does the surgeon evaluate any complications that arise and decide on the next course of action, or is this done by his staff?

CONCLUSION
Keeping all elements of the procedure clear and straightforward for each interested patient is an essential element in his decision-making process. By reducing misconceptions and misunderstandings that lead to low patient satisfaction—which is the bottom line for both industry and ophthalmic surgeons alike—we can help each patient choose a refractive center that will meet his needs. Hopefully, that center will be yours.

I think categorization of each one of these elements (ie, the procedure, the center, and the surgeon) automatically defines a center of excellence—they exist in every country in the world.

I have not even spoken of the procedure itself, and this is on purpose. It is usually broken promises that upset patients and not minor procedure mishaps.

In my opinion, technology is important; however, surgeon competence is important as well. It does not necessarily require thousands of cases to create the competent surgeon. Rather, it takes knowledge and desire to be familiar with all potential complications and their management. This aides in the early diagnosis and safer, more efficacious management.

A. John Kanellopoulos, MD, is a Clinical Associate Professor of Ophthalmology at NYU Medical School and Director of the Laservision.gr Institute in Athens, Greece. Dr. Kanellopoulos is a member of the CRST Europe Editorial Board and is Section Editor for the Refractive Complications cloumn. He states that he has no financial interest in the companies or products mentioned. Dr. Kanellopoulos may be reached at E-mail: laservision@internet.gr; Web site: www.brilliantvision.com.