Eyeworld Supplements

by Jason P. Brinton, MD Incrementally improving patient outcomes 9 "It will now take an extra 33 happy patients to overcome one unhappy patient." Jason P. Brinton, MD W hen laser vision correction was first performed 25 years ago, patients and surgeons alike were thrilled to be able to reduce high levels of myopia to much more manageable lower levels, complete with thinner spectacles. With time, advances in excimer lasers have brought more sophisticated ablation profiles, reduced ablation depths, optimized or customized ablation shapes and blend zones, iris registration, dynamic eye trackers, and intraoperative correction for both dynamic and static cyclotorsion. Femtosecond lasers improved flap quality, and we were now consistently providing patients with 20/20 vision. But is 20/20—as measured on an eye chart—good enough today? The simple answer is, "Not anymore." More importantly, how we measure refractive success is as important as how we achieve it for our patients. A 2013 ASCRS Clinical Trends survey found almost 20% of respondents don't have a standardized method for determining if their patients are successful. We need better metrics. The visual performance angle Years ago the decision to get LASIK was to end spectacle or contact lens use. Today people want postop vision to be better than their best corrected visual acuity (BCVA). At Durrie Vision, we use a variety of laser and femtosecond platforms and prospectively evaluate patients scheduled to undergo bilateral LASIK to develop new outcome metrics. Achieving 20/20 with the tools we have available, however, doesn't ac- count for issues that may adversely impact the perception of good vision—contrast sensitivity, night driving issues or higher order aberra- tions, or fluctuating vision early on. We concentrated on the speed of visual recovery (how fast could patients return to normal activity, etc.) and subjective evaluations. By month 1, 100% of the eyes were 20/20, and 92% were 20/16. Subjectively, 77% felt comfort- able sending a text message immedi- ately after surgery, and 100% felt comfortable driving after 4 hours. Our internal analyses found that levels of patient-reported dry eye were significantly lower than what patients reported preoperatively (dry eye was not induced in patients without a history of dry eye). Halos, glare, and night vision problems were also significantly better than preop levels for wavefront-guided and wavefront-optimized treat- ments. For us, the key subjective question is how likely the patient is to refer a family member or friend. Refractive practices survive and prosper on word-of-mouth referrals. Our marketing research found that practices used to be able to over- come one unhappy patient by having 9 happy ones. These days, social media has drastically altered those numbers—it will now take an extra 33 happy patients to overcome one unhappy patient. We simply cannot afford to have unhappy patients. Preoperative evaluations A decade ago, 90–95% of our patients were happy. These days, we believe those numbers need to be closer to 100%. To do this, we employ compre- hensive testing on all new patients. In addition to the standard battery of preoperative tests (manifest re- fraction, ocular dominance testing, etc.), we measure endothelial cell counts via spectral microscopy, Figure 1. Measuring laser vision correction outcomes Source: 2013 ASCRS Clinical Survey Figure 2. Month 1 binocular uncorrected distance vision across laser platforms Source: Durrie Vision continued on page 15 Refractive cataract surgery

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