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Up Front | Nov 2010

EDITOR’S PAGE: The Many Layers of Patient Selection

There are perhaps as many layers to the process of patient selection as there are to an onion. Peeling back the first layer may reveal the patient’s personality and his or her expectations, but multiple layers must be peeled before the surgeon can safely recommend the proper treatment. Patient history, preoperative exams, assessment of visual needs, contraindicated procedures, and patient counseling are other layers that must be considered.

But there is more than one way to slice an onion. This issue, which is dedicated to patient selection, examines how surgeons approach this crucial part of the surgical process. There is no standard approach to patient selection, and what works for one surgeon may not work for the next. However, one common theme exists in every successful strategy, and that is to learn as much as possible about your patient and establish a clear and realistic set of expectations before surgery.

Peeling back the first layer and uncovering the patient’s personality should be followed by construction of a well-considered preoperative course. Our cover series starts with Jérôme C. Vryghem, MD, of Brussels, Belgium, and Rudy M.M.A. Nuijts, MD, PhD, of Maastricht, Netherlands, who offer their five pearls for the perfect preoperative examination. Both surgeons emphasize the necessity for preoperative testing, including macular function, ocular biometry, and anterior chamber imaging.

Setting patient expectations is also an important layer of patient selection. Guy Sallet, MD, FEBOphth, and K. Robberecht, MD, FEBOphth, both of Aalst, Belgium, share two case studies, one of which yielded high patient satisfaction after phakic IOL implantation and one of which did not. Drs. Sallet and Robberecht recommend establishing a good patient-doctor relationship to make patient satisfaction after surgery more likely. Oliver Findl, MD, MBA, and Sophie Tatzreiter, MD, both of Vienna, Austria, also demonstrate the importance of patient selection and preoperative counseling through two case studies. Several take-home messages are echoed in their examples of bilateral cataract and age-related macular degeneration, the strongest of which is that psychological factors and patient expectations affect postoperative patient satisfaction. For this reason, Drs. Findl and Tatzreiter advocate early detection of the warning signs associated with difficult patients.

Lastly, this cover series offers various articles on deciding which surgical technique is best for your patient. This layer of patient selection is not as concrete as other parts of the preoperative process. Francesc Duch, MD, of Barcelona, Spain, provides his insight on selecting patients for lamellar versus surface approaches to refractive surgery.

Approximately 30% to 40% of his laser cases are done using surface ablation, but Dr. Duch recognizes that this technique is complementary to lamellar approaches. Göran Helgason, MD, of Göteborg, Sweden, provides a table of the refractive surgery guidelines implemented at his practice, Capio Medocular. The guidelines not only help surgeons to choose among LASIK, phakic IOLs, and clear lens extraction, but it also facilitates patient workflow. Dr. Helgason notes that each surgical center should establish its own set of guidelines to be successful.

In the last two articles in this cover series, Damien B. Lake, MB, ChB, FRCOphth, and Saj Khan, MB BS, FRSCEd(Ophth), both of the United Kingdom, impart their wisdom of premium IOL selection. Dr. Lake lists his key steps in the assessment process, including identifying expectations and demands. He emphasizes the need to use phrasing that pushes the patient to understand that some compromises are inevitable with today’s premium lenses.

Dr. Khan’s approach, the family rule, calls for him to ask one simple question before he proceeds with premium IOL selection: “If this were my family, is this what I would recommend or do?” He stresses that each surgeon must be comfortable with the technology that he or she offers, and in return patients’ confidence will be reinforced.

I’m no expert on peeling onions, which is pretty evident to my husband, who watches me cry every time I cook with them, but I have learned a few tricks to minimize the tears. Hopefully this cover series will provide you with a few pearls for patient selection to minimize any tears that may be shed—by you or your patients—during the surgical course.