Counseling the High-Risk Refractive Surgery Patient

Refractive surgery has taken off in India in the past few years, and the coming years are bound to be exciting. In the early days of refractive surgery, the number of surgeons in India performing these procedures was limited, primarily because of cost concerns. In the past 10 years, however, we have witnessed phenomenal growth in the number of patients seeking refractive surgery in our country—both within big metropolitan cities and smaller rural centers—and in the number of surgeons who perform any type of refractive surgery.

Increased awareness of the available treatment options coupled with the increasing prevalence of myopia among the younger population has led to the mushrooming of refractive surgery centers and ophthalmologists offering refractive surgery as part of their service. This article describes our approach to counseling patients for refractive surgery, including those who may be at high risk for complications.

THE SOCIAL ASPECT

Counseling patients for refractive surgery in India is probably not too different from counseling those patients from other countries, at least from an ophthalmic point of view. From a social point of view, however, it can be vastly different. The average age of patients undergoing refractive surgery at our center is 24.3 years, which is almost a decade younger than patients in the United States, for example.

Common reasons for undergoing refractive surgery in India range from social to cosmetic needs. One popular cosmetic cause for seeking refractive correction is an upcoming special occasion, such as a wedding. We see this most frequently among women.

The most likely individuals who desire refractive correction in India are job seekers, followed by non-Indian residents who are traveling from America or Europe during their annual holidays and international patients, primarily from Middle Eastern countries.

CANDIDACY AND COMPLICATIONS

Counseling patients about their suitability for refractive surgery is not too challenging, as most of them are aware of their options and have consulted elsewhere before they visit our center. We believe this is a great advantage of being in a tertiary care hospital.

There is always the occasional unsure patient who wants you to make the treatment decision. When confronted with this situation, our reply is always succinct: “We are here only to establish if you are suitable to safely undergo refractive surgery; the decision to undergo treatment is entirely yours.”

The variety of patients seen at LV Prasad Eye Institute requires us to have a range of counseling approaches. Most patients have tight timelines to undergo surgery, often due to upcoming job interviews, weddings, or travel. Generally, patients are well informed thanks to the wealth of knowledge available on the Internet, and their questions tend to be specific and centered chiefly around complications.

PATIENT EXPECTATIONS

Although patients are keen on achieving emmetropia after surgery, we advise all those undergoing laser refractive surgery that they should expect a refractive correction within a narrow range of ±0.50 D but that, in all likelihood, they will be spectacle free. We also tell them that the higher the refractive error, the higher the chances of a residual error and, consequently, the need for retreatments.

Apart from discussing the usual possibilities of flap-related complications and early postoperative issues, we place emphasis on explaining ocular dryness and the need to use artificial drops postoperatively. We also inform patients about the likelihood for postoperative glare and halos, which is especially common in patients with large pupils. This tends to be less of a problem in our patients than in those from other regions, as the majority have brown irises and smaller pupils. If a patient is keen on understanding the procedure, we show him or her animations of various surgeries.

SURGICAL OFFERINGS

At our center, we offer both microkeratome and femtosecond LASIK and ReLEx smile (Carl Zeiss Meditec). When asked if the latter two procedures are better, we explain that the final visual acuity will probably be the same with all the procedures but that the safety profile with femtosecond lasers is better.

For patients with suspicious topography or low corneal pachymetry, making LASIK surgery untenable, we suggest PRK as long as their topographic pattern is not suggestive of keratoconus. To facilitate the acceptability of surface ablation, we price this treatment lower than conventional LASIK. Another special category is patients who desire phakic IOL implantation. In our center, we limit the use of phakic IOLs to patients who are not suitable for laser ablative surgery and for those with refractive errors more than 8.00 D of myopia.

CONCLUSION

Counseling patients for refractive surgery in our setup in India does not differ too much from other practices. However, we do place an emphasis on being slightly conservative, and if we are unsure about a patient’s suitability for surgery we prefer to wait and reassess after 6 months.

Pravin K. Vaddavalli, MD, is Head of the Refractive and Cataract Surgery Service and a Consultant of the Cornea Service at LV Prasad Eye Institute in Hyderabad, India. Dr. Vaddavalli states that he has no financial interests in the products or companies mentioned. He may be reached at e-mail: pravin@lvpei.org.