This article is about refractive surgery. Yes, you read that correctly—now, don’t stop reading. For some, the thought of reading “another refractive surgery article” is paramount to eating Brussels sprouts. However, refractive surgery is a treatment modality that is viable, relevant and timely. So, keep reading.

Today’s economy demands a more streamlined and efficient optometric practice. Moreover, it demands the eye care professional to be attuned to the changes in patients’ wants and needs. The strengths needed today are very similar to those our 16th president drew upon when he used his sagacity to hold a dream together.

Abraham Lincoln’s first inauguration, in 1861, came at a time when the country was on the brink of dissolution. The fledgling government that Lincoln attempted to hold together was rife with dissension and had lost sight of the big picture—a United States. Lincoln’s political acumen was derived from his compassion and understanding of the people. Decisions were predicated on the will of the people, and not until he believed that his actions would be accepted by the people did he act. Lincoln was able to put his personal feelings aside and embrace the more important issue: what is best for the country. This led him to build a cabinet of savvy, political-minded men who, at times, were also his rivals.

Similarly, we as optometrists have found our profession in the same political and public misrepresentation for a long while. Much like Lincoln’s adept ability to understand what his constituents could accept, optometry can foster change and engender a sense of confidence in our patients. Now is the time that we as eye doctors should assert our opinions and provide refractive and medical knowledge for our patients’ benefit.

The Importance of Education
But first, your staff, your patients, and most importantly, you must be well educated on the topic! Lincoln was a voracious reader and spent hours educating himself, preparing for his role. The country was at war, so Lincoln read countless books on the art of war.

For optometrists, knowing the technology that is available or forthcoming is imperative to establishing doctor-patient confidence. Too often have I seen excellent refractive candidates who were told by their doctors that they were not candidates! What results from this situation? A lack of credibility for the optometrist and his office. Find and take advantage of reputable resources to make sure that you are aware of the latest and developing refractive surgery findings. For example, the Optometric Council on Refractive Technology (OCRT), the literature, lectures and conferences, industry discussion, and networking with local surgeons are all strong sources of information.

In your office, display brochures and reading material for patients’ reference; this also reflects your commitment to refractive surgical options. How many placards of contact lenses do you have on your counters? Look around at all the posters of glasses in your practice. Where are the refractive surgery posters? If you have a newsletter, use it as a venue to present current refractive treatment options, patient testimonials and your involvement in the procedure.

Even asking if your patient is interested in lessening their dependence on contact lenses or glasses will make a huge impact. Ask: “Have you thought about refractive surgery? Are you thinking at all about LASIK or surgery to get out of your glasses or contacts?” This acts as a compass, guiding your patient to you as a source of knowledge about refractive surgery. Then, depending on their answer, you can take steps accordingly.

However, to truly craft a refractive practice, you have to embrace the technology. Think about your choices in lenses or contacts. Do you often recommend options that you believe are ineffective? No! Our treatment options are based on clinical experiences that have positive effects on our patients. It is hard to argue that refractive surgical options are not safe or efficacious overall. As a part of the educational process, visit your refractive surgeon’s facility. Learn about the process and procedure, view the surgical center, and understand what your patient will experience. Lincoln visited the front lines on many different occasions. How can you lead men to battle if you have never viewed it firsthand?

Lincoln was able to rely on generals to carry out his plans. In your situation, the ophthalmologist is your general. As the commander-in-chief of your patients, you need to work with your surgeon to devise the best plan. Lincoln worked with (and removed) many generals, until he found success with Grant and Sherman. Find a surgeon who aligns with your professional standards, ethic and doctrine.

Educating your staff is easy! Many companies offer educational materials about their products, or they will send a representative to the practice to discuss it. Bring your staff to a conference or hand out “homework,” and you’ll give them the tools they need to man your front line. Now that you have educated yourself and your staff, your patients ought to be aware that you embrace refractive surgery when appropriate. This is the time to adhere to a medical model.

Refractive Surgery Technology Advances Refractive lens surgery is not limited to those patients who require presbyopia correction. Toric IOLs are expanding and creating opportunities for topographically challenged patients as well as highly astigmatic patients. And, the use of toric IOLs and limbal relaxation incisions now can be more precise with the introduction of the ORange (WaveTec Vision). This intraocular wavefront analyzer provides real-time evaluation of sphere, cylinder and axis. As small and compact as the ORange is, its large dynamic range (-5.00D to +20.00D) exceeds that of office-based wavefront aberrometry systems. Conventional wavefront technologies, such as Shack-Hartmann, are capable of measuring refractive power in a limited dynamic range, typically from -10.00D to +8.00D. The ORange uses Talbot-Moiré interferometry, which has a wider range of effective measurement than Shack-Hartmann and maintains a high resolution throughout its range. As a result, the aberrometer can accurately measure aphakic eyes intraoperatively, which aids in more accurate IOL power calculations, particularly in eyes that have undergone previous refractive surgery. Current applications of the ORange include measuring LRIs, guiding their placement and ensuring the accurate positioning of toric IOLs. By the end of this year, the addition of a hyperopic lens to the aberrometer will enable surgeons to perform on-the-table IOL calculations in an aphakic eye.

Medical Preparation
This is a paradigm shift for most of our practices. Typically, we look at the eye as a refractive organ that provides vision. Yet, without a clear refractive surface, efforts to improve the eye’s vision are thwarted by the inflammatory process. Exactly as a practice is only as strong as the weakest employee, the eye’s refractive ability is only as good as the refractive surface. Fortunately, the most common side effect of refractive surgery, dry eye, can be vanquished with pretreatment and education.

Ocular surface inflammation can confound the best result, and must be treated appropriately. So, a thorough evaluation of the lid margin, tear volume, corneal surface, conjunctiva and retina is critical.

Before the patient undergoes refractive surgery, pretreatment of the ocular surface is not only pragmatic, but also economically sustainable. The evidence of any lid disease, even asymptotic, warrants treatment. New FDA-approved technologies, such as the TearLab (Ocusense), may alleviate some of the diagnostic quagmire. With a sample taken from one tear, the TearLab can provide instantaneous osmolarity results and information about your patient’s ocular surface environment. Also, the use of lissamine green, sodium fluorescein, and phenol red thread tests should become more commonplace. (For more on how to manage patient’s dry eye, see “How to Establish a Dry Eye Center.")

However, listening to patients is still the most crucial part of your examination and diagnosis. The Lincoln White House had no gate or guards; constituents could venture onto the grounds and see the president daily. Lincoln listened to the country.

Likewise, listening to your patients can actually help you form and initiate a management plan. The use of lid hygiene scrubs and warm compresses should become more standard practice. Tears may provide some relief, but the palliative nature of these drops leaves your patients in a vicious cycle. The inflammatory nature of dry eye and lid disease was understood almost two decades ago. As medical eye care providers, we need to treat with the most potent and effective regimens to decrease inflammation.

Tears alone are not always sufficient. In a poll of the members of the Optometric Council on Refractive Technology, for 80% of refractive surgery-minded doctors, the next line of treatment after tears was the use of cyclosporine.¹ Cyclosporine has proven to increase tears and reduce inflammation that will affect visual quality. This has been proven in contact lens patients as well as refractive surgical patients.² For individuals who will benefit—patients with demonstrable pre-existing levels of dryness—the use of cyclosporine may help. But, for those with less dryness, the drop may not provide as much of a perceived benefit. Much like the use of a prophylactic antibiotic, cyclosporine can enhance the tear quality to provide better outcomes.

Likewise, treating the lid margin before any refractive surgery procedure is beneficial. It has long been established that tetracycline derivatives help improve posterior blepharitis.³

 But, recent studies have shown that the use of topical azithromycin has the same clinical benefit without the systemic side-effects.⁴

Also, you need to follow your patients before you can refer them for surgery. These medical follow-ups are an important part of the doctor-patient relationship that results in the best refractive outcomes. We have many tools in our armamentarium (punctal plugs, neutraceuticals, topical treatments, etc), and it would be shameful to start a regimen without follow-up. How would you know if your treatment is working or not?

IOL Success Strategies Preoperative: • Discuss patients’ desires. • Evaluate topography for abnormalities. • Discuss astigmatism management (≥ 0.75D). • Treat ocular surface conditions, such as dry eye and blepharitis. • Avoid hypercritical patients. Postoperative: • Evaluate for any ocular surface conditions and residual refractive error. • Treat any cystoid macular edema. • Monitor capsular opacification. • Rely on judicious positive affirmation.

Successful Surgery
Economists believe that 2010 will see a spike in refractive surgical procedures. Right now, patients have not lost interest; they are just holding off. LASIK is still the most popular corneal refractive surgical procedure. The use of femtosecond technology to create flaps has surpassed the microkeratome in both safety and usefulness. Last year, Abbott Medical Optics released the fifth-generation Intra-Lase laser. The iFS Advanced Femtosecond Laser is capable of creating a corneal flap in less than 10 seconds, and it also creates an inverted bevel-inside cut angle for a safer and stronger flap, as well as elliptical or custom flaps. Such capabilities, combined with the advances in wavefront-guided LASIK, furthers the consistency and limited side effects of the procedure.

Interestingly, patients over the age of 55 are the least likely to report laser vision-correction surgery side effects, slightly beating out patients age 40 and younger, according to a recent Consumer Reports survey of 793 adults who underwent one of these procedures in the past eight years.⁵ Further, the survey showed that patients between the ages of 40 and 54 are at the greatest risk of postoperative side effects. These findings deviated from previous survey data, which also revealed—not surprisingly—the younger the patient, the greater the likelihood of positive outcomes.⁵ Laser vision correction surgery patients younger than the age of 40 were the most likely to report improvements in their effectiveness at work as well as in sports and leisure activities.⁵ Consumer Reports editors theorize that doctors may be doing a better job of eliminating inappropriate candidates. We also have adopted refractive options that relate to our patient.

The advent of the Visian ICL (STAAR Surgical) as a viable refractive procedure safely expands our refractive surgery candidates’ options. This phakic posterior chamber lens is inserted through a 2.5mm self-sealing corneal incision. The lens can be fitted for a patient with a prescription as low as -3.00D; however, its most visible benefit is seen in those patients who are outside the safe parameters of LASIK—e.g., those with corneas that are too thin, topographies that are questionable or that demonstrate irregularities or exceptionally high myopic refractive errors. Although we can use a bioptic approach and combine technologies to treat astigmatic myopes, the anticipated FDA approval of the toric version of the Visian will ultimately benefit our patients.

Innovation and the adoption of new ideas are other exceptional qualities that helped Lincoln as president. Optometrists need to be quick to embrace new technology, because we are most often the only eye doctors that patients see. Shedding our “myopic” view of the profession will help us to advance.

Take, for example, the use of Intacs (Addition Technology) for the correction of keratoconus. Designed for low myopic correction without removing tissue from the central cornea, these cylindrical PMMA segments have now been inserted successfully into keratoconic (and ectatic) eyes. As reported by Marlane Brown, O.D., at the 2009 OCRT symposium, of 25 eyes with KCN or ectasia treated with Intacs and CK at Minnesota Eye Consultants, 80% currently tolerate spectacles or contact lenses with an average of 16-month follow-up.

Another promising refractive process involves strengthening the stroma. Clinical trials are studying the infusion of riboflavin 0.1% into the corneal stroma with a UV-X light source to create a corneal cross-link. The use of corneal collagen cross-linking (C-3R) then creates a more stable cornea in KCN, ectactic and post-RK patients. C-3R may be a procedure that optometrists can and should embrace since the non-invasive nature will most likely fall into our purview.

Presbyopic Correction
I’ve always believed that the “holy grail” of refractive correction is treating the presbyopic patient. More presbyopic refractive options are becoming available to our patients. Clinical studies are attempting to measure the effectiveness of corneal inlays, develop nomograms to create presbyopic correction on the corneal surface, and use a femtosecond laser to treat within the cornea.

The Femtec laser (Bausch & Lomb) for IntraCor, works within the stroma to correct emmetropic patients’ presbyopia within 1.00D to 1.50D. A series of small concentric cuts in the stroma create a central steepening with smooth transition zones, resulting in an increased depth of field and providing both distance and close vision in the eye.⁶ This same phenomenon has been seen in hyperopic LASIK patients who have an inducement of negative spherical aberration and see well at near.⁶

This is the rationale for a new technique, progressive multifocal LASIK (PML). PML, developed by Roberto Pinelli, M.D., requires either the Technolas (Bausch & Lomb) or WaveLight Allegretto laser (Alcon). As an off-label use of these lasers, PML may provide another surgical option for our near-vision challenged patients. Data from the Gordon & Weiss Vision Institute, as presented by David Geffen, O.D., at the 2009 OCRT symposium, show that, with 214 patients reporting after three months, 86% had better than 20/20 uncorrected distance visual acuity, and 95% of the patients saw better than J3.

Lincoln realized the end of the war was only attainable if he could rally the populace behind him. He greeted all whom he met with respect and a firm belief that all men were created equal. This respectful and dignified attitude led many to see Lincoln as honest, dedicated and nurturing—all qualities that patients expects to find in their doctor. We try to speak with conviction when we are confident in our motives. When we talk to refractive surgery candidates about the current state of intraocular technology, we should impress upon patients the advantageous situation in which they find themselves.

In my experience, the average age at which a patient undergoes cataract surgery is 62 years. The need for the procedure is borne from the desire to improve visual quality; however, it is also an opportunity to discuss refractive surgical outcomes. Let’s face it—glasses (especially reading glasses) are the harbinger of old age. Modern cataract surgery has to be considered and treated as a refractive procedure.

The three lenses approved by the FDA for presbyopic correction continue to evolve. The Crystalens AO (Bausch & Lomb) features an aspheric front surface with a robust 5.0mm optic zone diameter. This accommodating lens induces negative spherical aberration and shortens the near focal point. The single focus of this lens, combined with the aspheric surface, reduces the risk of glare and haloes. Patients can expect a near focal improvement with exceptional distance vision as the lens arches forward to achieve the refractive change.

Two diffractive lenses have also been upgraded in this past year. The near focal point of the ReStor 4.0 (Alcon), 3.20D, compromised patients’ intermediate abilities. So, the newer ReStor 3.0 includes a spectacle plane add of 2.50D within the same 3.6mm apodized diffractive area.

Also, the Tecnis Multifocal IOL (AMO) features an anterior aspheric surface as well as a full diffractive posterior surface. The advantage of a full diffractive surface vs. partial is the pupil independence that the Tecnis allows. Pay attention to the size of your patients’ pupils when considering surgical options.

Not all lenses are perfect for any individual, and patients need to be educated about the potential complications. Yet, studies have shown that as many as 94% of patients with pseudophakic presbyopic lenses would choose to have a presbyopia-correcting lens implanted again.⁷ Moreover, rates of spectacle autonomy are as high as 90% after such a procedure.⁷

After the Operation
Postoperatively, pay close attention to the small details such as inflammatory dry eye and early capsular opacification. Measure your patients’ success relatively—not objectively. The phrase “20/happy” applies with all refractive surgery patients, but it carries even more weight with our presbyopic patients.

As Lincoln was addressing the country from the lawn of the White House on the day of his second inauguration, his sincere compassion for his constituents shone through all of his actions. However, his ability to speak the language of the people was his greatest gift—a treasure that we optometrists carry with us every time we walk into an exam lane.

Refractive surgery is relevant and beneficial for our patients. Lincoln was relentless in his desire to better our great nation, and optometrists need to prepare ourselves in the same manner. Although more than 145 years separate us from Abraham Lincoln’s presidency, his ability to simply know what the public wanted and look to the future are virtues that will help prepare us for the exam lane.

Dr. Bloomenstein is the director of optometric services at Schwartz Laser Eye Center in Scottsdale, Ariz., and he is the current president of the OCRT. He is also am adjunct assistant professor at the Southern California College of Optometry.

1. Optometric Council on Refractive Technology. Available at: www.ocrt.org (Accessed December 2009).
2. Hom MM. Use of cyclosporine 0.05% ophthalmic emulsion for contact lens-intolerant patients. Eye Contact Lens. 2006 March;32(2): 109-11.
3. Ta CN, Shine WE, McCulley JP, et al. Effects of minocycline on the ocular flora of patients with acne rosacea or seborrheic blepharitis. Cornea. 2003 Aug;22(6):545-8.
4. Akhyani M, Ehsani AH, Ghiasi M, Jafari AK. Comparison of efficacy of azithromycin vs. doxycycline in the treatment of rosacea: a randomized open clinical trial. Int J Dermatol. 2008;47(3):284-288.
5. Consumer Reports. Health Blog: Considering LASIK? Watch for Our Upcoming Report. Available at: http://blogs.consumerreports.org/health/2009/07/lasik-eye-surgery-lasik-survey-getting-the-best-price-for-lasik-survey.html (Accessed December 2009).
6. Ruiz LA, Cepeda L, Fuentes V. Intrastromal correction of presbyopia with a femtosecond laser system. J Refract Surg. 2009;25:847-54.
7. Abbott Medical Optics. TECNIS Multifocal Foldable Acrylic Intraocular Lens package insert.