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Inside Eyetube.net | Jun 2012

Decrease Your Enhancement Rate

Five pearls for nailing the refraction on the first try.

Although a number of factors affect patients’ satisfaction, their reactions after refractive surgery, whether the procedure was successful or not, are as unique as their personalities. Generally speaking, however, patient satisfaction largely depends on the success of the first treatment, as the need for an additional procedure to correct even the slightest residual refractive error is considered a failure by the patient of the procedure and the surgeon. Striving for a low enhancement rate is part of the goal, but counseling patients undergoing enhancements is even more important. Below I review five pearls that I have found helpful for decreasing my enhancement rate for laser refractive surgery.


No. 1: Determine possible reasons for the unexpected result. Today, laser corneal surgery is extremely accurate. In the hands of experienced surgeons, the retreatment rate is below 1%. When the desired result is not achieved, however, it is imperative to determine possible reasons for this unexpected result. Was there an abnormal corneal healing response or an unexpected biomechanical issue? Was the patient following your instructions concerning postoperative care? Was the initial surgery uneventful, or did you experience difficulties? Was the laser calibrated properly? Were there other unexpected outcomes on the same operative day? Was the patient agitated and uncooperative?

Answering these and other questions can help prevent similar errors in the future. We must remember that it is always easier to achieve a good outcome with the initial surgery than with a retreatment.

No. 2: Make time preoperatively to optimize tear film quality and characteristics of the cornea. Taking optimal care of the tear film before refractive surgery will greatly enhance a patient’s visual quality after surgery. I always recommend lubricating eye drops (ie, preservative-free hyaluronic acid artificial tears) used at regular intervals throughout the day for at least 2 weeks prior to surgery and 3 months following surgery. Nutritional therapy also plays an important role in pretreatment for dry eye syndrome. I advise patients to take high-dose capsules containing omega-3 and omega-6 fatty acids on a daily basis starting 1 month before surgery to help maintain the tear film’s normal lipid composition. In severe cases of dry eye, punctal plugs can be placed before surgery is performed.

Because dry eye syndrome is an inflammatory condition, reducing inflammation after surgery is necessary to minimize symptoms. Prescribing cyclosporine is extremely useful for reducing dry eyes in patients with marked preoperative hyperosmolarity or tear film abnormality.

No. 3: Know the associated complications for retreatment procedures and intervene accordingly. Typically only minimal corneal reshaping is necessary during an enhancement, meaning the laser procedure takes just a few seconds. Unfortunately, complications can still result, and patients should be made aware of the nuances associated with any enhancement procedure. For instance, retreatments after LASIK induce more epithelial ingrowth than the initial procedure. Therefore, I always place a bandage contact lens in these cases to minimize ingrowth of epithelium under the corneal flap. In cases of retreatment after PRK, I discuss with the patient the use of mitomycin C to reduce corneal haze.

No. 4: Reassuring the patient may require more chair time. Need for a second procedure is accompanied by a crisis of confidence in the doctor-patient relationship. Reassure the patient and the family that retreatments are normal and that nothing went wrong during the first treatment. Let the patient and his or her family ask questions, and patiently reply to all of them extensively. Be confident when communicating with the patient and insist that a good outcome is possible. Let the patient share his or her anxiety with you and try to take it away as much as possible.

No. 5: Consider other enhancement options. In addition to laser surgery enhancements such as LASIK and PRK, do not forget there are other options. In cases with corneal abnormalities, thin corneas, and dry eyes, for instance, a phakic IOL can be the best solution. In patients older than 55 years, refractive lens exchange can be an option for enhancement.


We all have our own lists of pearls to boost surgical results. Sharing even the smallest pearl with others helps to further our enhancement outcomes and increase patient satisfaction. Hopefully you can find a new pearl on this list.

Erik L. Mertens, MD, FEBOphth, is Medical Director of Medipolis, Antwerp, Belgium. Dr. Mertens is a Co-Chief Medical Editor of CRST Europe. He states that he has no financial interest in the material presented in this article. Dr. Mertens may be reached at tel: +32 3 828 29 49; e-mail: e.mertens@medipolis.be.