The annual refractive surgery volume is in the millions globally.1 A recent Market Scope report suggested that the number was expected to grow at a compound annual rate of 9.6% from 2020 to 2025, with surgical yearly volume increasing from 3.6 million to 5.8 million procedures.2
This represents an estimated generation of $10.3 billion in total patient fees globally in 2025—up from $6.5 billion in 2019—for a compound growth rate of 9.5%.3 As surgical options continue to expand and improve, nearly every type of refractive error can be addressed, including presbyopia.
Overview of refractive surgery procedures
A successful refractive surgery service can be a practice builder for a multispecialty ophthalmology practice: satisfied refractive surgery patients are often the best advertisement a practice can have. Satisfied patients can help grow a practice through word of mouth and positive reviews, especially online.
It is crucial for surgeons to be mindful and respectful of patients’ needs and concerns. Patients should not feel pressured or compelled into an elective procedure, especially given the high expectations and financial investment. Therefore, surgeons must balance their desire to grow their practice with their willingness to serve their patients’ best interests.
The refractive surgery consult is more critical than ever to set and meet expectations of the growing demand for spectacle independence. We present our top tips for getting the most out of a refractive surgery consultation for patients and surgeons.
Table 1: List of current refractive procedures that surgeons can provide patients with varying visual needs and goals.
Top tips for a successful refractive surgery consultation
1. Make a positive first impression.
First impressions are important. Staff who answer the phone should have high energy and in-depth knowledge of what is available at their center and the consultation process.
- Be friendly and helpful in answering questions, while knowing their limitations in providing medical advice
- Offer the patient a no-cost, no-obligation screening visit, if your practice provides such
- Capable of giving the patient a good idea of what to expect during the consultation, including:
- Who they will meet and speak with
- What they should bring with them
- How long the consultation be
- Notification about dilation
- Any upfront costs (if applicable) associated with the visit
2. Make sure the patient is properly prepped.
Preparing the patient for consultation involves advising them not to wear contact lenses at least 1 week before having measurements taken. While surgeons’ preferences may vary, soft contact lenses should be discontinued 3 to 10 days before the initial visit, and hard contact lenses even longer (2 to 3 weeks, with some surgeons preferring an additional 1 week for every decade of rigid contact lens wear).
Explain the importance of this policy, as many will not want to stop wearing contact lenses for this amount of time—they are seeking spectacle independence, after all.
Ensure that staff explains to the patient that prior to surgery, an extensive history and examination will take place, along with specialized measurements and eye tests, to ensure they are a good candidate and determine what procedure would be best for them. Prepare them for a visit that can take up to 2 hours (or more).
Many patients may call or arrive expecting LASIK as the only refractive surgery option, partly due to its popularity and mainstream marketing. Patients should be informed that several options for refractive surgery are potentially available for them and that a customized, personalized recommendation will be made during their consultation.
3. Obtain an accurate and comprehensive history.
While seemingly unglamorous, obtaining an accurate and thorough history is vital. It is essential to understand why they are seeking further correction at this time.
Some important questions to ask during refractive surgery consultations include:
- Any previous eye surgery or laser procedures? If so, when it was, what was done, the pre-operative refractive details, and any complications should all be explored.
- A commonly forgotten eye surgery for young adult patients seeking refractive surgery is strabismus surgery.
- What are their current struggles/limitations with their vision, and why are they considering refractive surgery? What are their expectations?
- Contact lens wearer? If so, what type, how often, and when was the last time they wore them?
- Does the patient sleep in their contact lenses? Do they shower in their contact lenses? Do they swim or have exposure to water in the eye while wearing contact lenses? Be sure to note the financial burden associated with the patient’s specific contact lens.
- Stability of their refraction over time? Do they have old glasses’ prescriptions or frames they can bring? Are there any old prescription records?
- Occupation and lifestyle? Do they work in an environment conducive to dry eye syndrome? Are they at any risk for trauma to the eye due to lifestyle or recreational needs?
- General ocular history, particularly previous eye injuries or dry eye issues? Be sure to ask about corneal problems, such as recurrent erosions, allergic eye disease, corneal ulcers, and traumatic injuries.
- General medical history, including diabetes, autoimmune disease (e.g., rheumatoid arthritis, lupus, and systemic immunosuppression).
- Make sure to ask about systemic medications, especially a history of isotretinoin, amiodarone, and Imitrex (sumatriptan). These medications can delay healing post-operatively.
- For female patients, be sure to ask if they are pregnant, trying to conceive, or nursing; it is best to avoid elective refractive surgery during these times.
4. Perform a thorough slit-lamp exam.
A thorough anterior and posterior segment exam is imperative to rule out any disease/anomalies that might affect candidacy, as well as assess for signs of previous refractive surgery.
Dry eye assessment should be performed so that any ocular surface disease can be addressed before proceeding with surgery and also to ensure the accuracy of topographic measurements and refractions. Dry eye disease is among the most common complications in many refractive surgeries and is, therefore, essential to manage upfront.4
Consider pupil size in photopic, mesopic, and scotopic conditions, as patients with larger pupils may be more prone to night vision complaints; however, these issues are decreasing with modern techniques of larger ablation zones (≥6.0mm).5
5. Complete ancillary testing and anterior segment imaging.
Objective and subjective refraction guide decisions on what procedure might be best. A cycloplegic refraction is vital, especially in younger patients.
Remember that young myopic patients can (and love to!) accommodate significantly during manifest refraction, causing an unwanted “more-minus” refraction. Using this refraction may lead to over-correction, making a previously myopic patient now hyperopic after laser vision correction—also making them very unhappy.6
By performing a cycloplegic refraction, surgeons can determine the true refractive error of the eye(s). The cycloplegic refraction may guide the surgeon to treat closer to the cycloplegic refraction (in older patients) or slightly in between the manifest and cycloplegic refractions (in younger patients).6
Corneal wavefront topography
Corneal wavefront topography and/or tomography should be performed to assess the shape, curvature, and identify any irregularities of the cornea. Capturing this information can lead to customized treatment strategies depending on the refractive procedure and laser machine.
Any irregularities should prompt repeat imaging, especially if ocular surface disease is present.
Corneal pachymetry
Corneal pachymetry with both optical and ultrasonic measurement should be performed to determine if corneal thickness is appropriate for laser ablative procedures. The minimum corneal thickness pre-operatively may vary depending on refractive status and type of procedure; however, it is crucial to consider a residual stromal bed (RSB) thickness of >250µm to avoid postoperative corneal ectasia.7
Most surgeons prefer to leave >300μm RSB. In recent years, the percentage thickness altered (PTA)—defined as (flap thickness + ablation depth) / pre-operative central corneal thickness—has gained popularity as a supplementary metric to the calculated RSB values.8 A PTA of ≥40% has been shown to be significantly associated with the development of corneal ectasia, a devastating complication after LASIK.9
Biometry
Other procedure-specific measurements, such as biometry if considering RLE, to determine the appropriate intraocular lens (IOL) power. Ultrasound biomicroscopy (UBM) and specular microscopy are important if considering phakic IOL for endothelial cell count and anterior chamber depth/sulcus for lens sizing. Some surgeons also assess corneal biomechanics with specialized devices.
6. Administer comprehensive patient education.
Patient education is arguably the most essential part of the consultation. Do not delegate this to ancillary or non-medical staff. You should use brochures and videos, but personal, conversational time is necessary. Patients are not only paying for your surgical skills but also for your “brain time” to help guide them to making the best decision for themselves, including if that means no surgery. Manage expectations, under-promise and over-deliver.10
Compare and contrast the various procedure options, ensuring an adequate understanding of the risks and benefits of each, and make a recommendation based on expertise on what would be best suited for them.
Clearly lay out what to expect before the surgery, on the day of the surgery, post-operatively, and at home.10 Patients must understand the healing process is as necessary as the actual surgery. Compliance with eye drops and surgeon’s instructions is essential to ensure good outcomes. Be sure to tell patients they may need additional time off work for procedures with potentially longer recoveries (e.g., PRK).
It is also important to give realistic recovery expectations. This is especially important if the prospective patient has family members or a significant other who had refractive surgery with excellent outcomes. Explain to the patient that their surgical journey should not be compared to others’ results.10
Handout materials and patient education videos can be valuable, especially in the waiting room or before the visit. You may want to use stock handouts/videos, but many patients find a customized handout or video for your practice can provide a more personalized touch.
The decision to have refractive surgery can be overwhelming; a patient may not be able to decide what they want to do in their one pre-surgical visit. That leads to another point: it’s acceptable for the patient to go home, think about things, and return in a few weeks.
Make sure patients don’t feel obligated to make a decision quickly; after all, this is an elective procedure and not a vision-threatening one. Leaving with information helps the patient continue to educate themselves after the consultation. If they are to book a procedure, handouts with the pre-op, day of, and post-op instructions are helpful to ensure preparedness and reassurance.
7. Be knowledgeable of insurance/payment considerations.
Nearly all health insurance plans do not cover elective refractive surgery procedures because they are considered elective or cosmetic. However, if there is a medical necessity for a refractive procedure, such as vision problems due to certain conditions/diseases (e.g., keratoconus), then insurance may provide coverage for specific procedures (e.g., INTACS or cross-linking).
Depending on the plan's rules and regulations, Patients can use funds from flexible spending accounts (FSA) and health savings accounts (HSA) to pay for refractive surgery costs. A patient seen “early” in the calendar year may wish to save up money in FSA/HSA accounts for refractive surgery later in the calendar year. This has the added benefit of allowing additional time for recovery during the holidays—though this may make you very busy before the holidays if you are trying to take time off.
It is helpful if an individual is on staff to discuss finances, scheduling, and other logistics separately from the refractive surgeon. This conversation can happen at the tail end of the visit.
Conclusion
Demand, expectations, and options for refractive surgery continue to rise. An effective refractive surgery consultation is crucial to patient and physician satisfaction.
Surgeons must have extensive knowledge of the available surgical options and select suitable patients given their refractive error, age, ocular/medical health, previous refractive surgery, lifestyle factors, ocular measurements, and visual goals.
Even more important is understanding there is a balance between educating the patients about refractive surgery versus over-selling the procedures.
Thorough examination and testing are recommended to ensure candidacy. Having an experienced team to support the consultation from the initial phone call to discussing insurance/payment details is an asset that cannot be overlooked.
Finally, spending time on patient education to ensure a realistic understanding of the procedures offered should help ensure a positive refractive surgical experience for all.
