Eyeworld Supplements

15 would implant a toric IOL, and just less than 10% would prescribe glasses or contact lenses. Interestingly, the average postoperative rotational error that was considered acceptable before it started to affect visual quality and acuity was 7.2 degrees, and 33% of respondents felt that 10 degrees or more of postoperative rotational error was acceptable. Additionally, 46.3% of respon- dents said that they aim for the lowest amount of residual astigma- tism, even if they had to flip the axis, and 53.7% said they never flip the axis and that they aim for the lower residual astigmatism in the same axis. According to the survey results, the most common device (used by more than 35% of respondents) to determine the power of astigmatism was the IOLMaster (Carl Zeiss Meditec, Jena, Germany). When making a decision on the axis, however, topography was the preferred method. If a patient has residual astigmatism, the first step in treatment is to determine the cause. Common causes of residual astigmatism include inaccurate preoperative measurements, inaccurate axis marking, ocular surface disease, surgically induced cylinder, IOL tilt, and IOL rotation. Treatment options include glasses or contact lenses, AK/LRI, laser vision correction, and reposi- tioning the IOL. For example, let's say a patient is 1 month after having a T9 implanted and has residual astigmatism of 1.75 D at 150 with uncorrected visual acuity of 20/60, so the patient is not too happy, and the IOL is currently aligned at 100 degrees. In cases like this, the surgeon can use the astigmatism fix calculator (www.astigmatismfix.com, developed by John Berdahl, MD, and David Hardten, MD). After plugging in the requested informa- tion, the surgeon will be told that rotating the lens to a particular axis will reduce astigmatism, and it will give him or her a predicted refrac- tion that should be achieved by ro- tating the lens to the recommended axis. In this example, the predicted refraction was –0.29 + 0.32 x150. So rotating the lens would be a good option in this patient as long as too much time has not elapsed since surgery and the patient is agreeable to a second surgical procedure. Next, the current and the ideal axes are marked, viscoelastic is injected underneath the capsule, the lens is freed up and rotated, and the residual viscoelastic is aspirated. The bottom line is that preven- tion is always the best treatment, so it is important to be precise in your continued from page 8 preoperative measurements, mark- ing and placement of the lens, and in removing residual viscoelastic from behind the lens and around the lens so it doesn't rotate postoperatively. At the end of the procedure, it is important to reinflate the eye to a good pressure and to make sure the incisions are sealed to avoid wound leakage and then shallowing of the chamber, which could lead to rotation of the lens. All of these things will lead to a good outcome and hopefully will not result in residual astigmatism. The good news is that if you do encounter residual astigmatism, the astigmatism fix calculator can help you find the best approach for treating and resolving it. Dr. Davis is managing partner of Minnesota Eye Consultants, and adjunct clinical assistant professor at the University of Minnesota. She can be contacted at eadavis@mneye.com. continued from page 9 and use both the Pentacam (Oculus, Wetzlar, Germany) and the HD Analyzer (Visiometrics, Barcelona, Spain). We perform optic nerve optical coherence tomography (OCT), wide field photos, and macular OCT. We take LOCS III photos and perform anterior segment OCT. These tests are repeated on patients' biennial exams. Endothelial cell photographs have been helpful for illustrating to patients the effects of contact lens overwear and setting appropriate expectations for patients with compromised endothelial cells. Con- firming these diagnoses in advance helps manage patient expectations. One additional benefit is that all these people will eventually need to have lens surgery. By collecting baseline data on 100% of them, we improve the chances that we will choose the correct IOL when the patient has refractive lens exchange or cataract surgery. Final thoughts None of what we do makes a difference if the patient is unhappy. Today, "20/happy" means different things to different people, depend- ing on their lifestyle. Our mantra remains: Patients must have at least the same vision postoperatively as their preop BCVA. Then we do the best we can to meet or exceed those expectations. We have moved our discussion away from talking about 20/20 out- comes to discussing the likelihood of a patient seeing 20/16 or 20/12.5, always explaining that the majority of our patients see 1 to 2 lines better than 20/20 after surgery. We also use online surveys to gauge patient feedback. We've and word of mouth are the only ways to successfully and continually grow a business. Direct marketing is often too expensive for very little return: Practices must spend about $400 per patient to break even. The latter two will only grow a business if the visual outcomes are exceptional. At TLC, we have our staff trained to test beyond 20/20. It's not enough to just provide an extra line. We have to give patients the best chance to see as well as they can. In a study we did in 2012 (n=94 patients), using the iFS femtosecond laser and CustomVue wavefront- driven ablations (Abbott Medical Optics, Santa Ana, Calif.), bilateral uncorrected distance vision at 3 months post-LASIK was exemplary— 95.7% of our patients had 20/16, and more than half had 20/12.5. These are the results Millennials will boast about to their entire social media "family." Millennials are going to immediately post to Yelp, Twitter, or Facebook about their surgery. Rein- forcing the successful outcomes with these patients will help grow your word-of-mouth referrals quickly. ODs are still a significant source of patient referral. When they choose your center, they're relying on your results to be exemplary— after all, it's likely the patient will still see the OD for most primary eyecare needs. Involve the OD com- munity by sharing your results and the capabilities of your technologies. ODs will be more confident in choosing your center if they know you're tracking results and continu- ally seeking to improve those results as well. continued from page 10 found we're much more likely to proactively address any issues that may arise than be relegated to reactively trying to "fix" an issue. In the first 3 months we used these surveys, we increased the percentage of patients who were "very likely" to recommend our center from 90.2% to 96.6%. Dr. Brinton is a partner at Durrie Vision in Overland Park, Kan., and an assistant professor of clinical ophthalmology at the University of Kansas. He can be contacted at jpbrinton@gmail.com. References 1. Kadlec D. Turns out Millennials are scary smart with their money. Time. Available at: time.com/64137/millennials-money. Accessed 16 April 2014. 2. Roose K. Are you a 'Yummy'? New York Magazine. Available at: nymag.com/daily/ intelligencer/2014/03/are-you-a-yummy.html. Accessed 16 April 2014. Dr. Probst is chief laser surgeon and senior medical advisor, TLC The Laser Eye Centers (locations in Chicago; Madison, Wisc.; and Tampa, Fla.). He can be contacted at leprobst@gmail.com. Corneal refractive surgery

• Cover