Ascertaining each patient’s reasons for pursuing refractive surgery is crucial to the ultimate success of the procedure.

Common Patient Characteristics

• young to middle aged
  
• well educated
  
• professional
  
• successful
  
• type A personality
  
• potential for loss of income if vision compromised

Occupational Needs and Restrictions

INHERENT RISK OF SPECTACLE WEAR In some employment situations, vision correction with eyeglasses may pose inherent safety or health risks.

INHERENT RISK OF CONTACT LENSES Some work environments are particularly hazardous to contact lens wearers. For example, firefighters frequently encounter smoke and a police officer could lose his or her contacts during a physical confrontation.

• toxic chemicals infiltrating contact-lens material or affecting the ocular surface
  
• direct or indirect exposure to biohazards and potential for ocular damage
  
• desiccation from arid work conditions
  
• airborne foreign particles that may be trapped under the lens

NEED FOR UNAIDED VISUAL ACUITY Many professions are restricted to individuals with certain levels of uncorrected visual acuity. Although several of the policies that regulate these professions are now being challenged, individuals must research predicted outcomes, inherent risks, and possible exclusions for employment.

• branches of the military
  
• commercial airline pilots
  
• certain civil protection agencies and groups (e.g., Navy SEALs, the FBI, state troopers, local police officers)
  
• jobs with restrictive environmental or safety conditions
  
• jobs with policies denying employment to individuals who have previously undergone refractive surgery (generally because of concern about unstable vision and degradation of visual acuity at night)

Recreational Needs

• restriction of athletic activities because of eyeglasses
  
  
  
  • loss of peripheral vision from frames
    
  • problems switching from near to far focus with bifocal eyeglasses
  
  
• problems with contact lenses
  
  
  
  • desiccation
    
  • intolerance of chlorine in swimming pools when wearing contact lenses
    
  • submersion and potential loss of contact lenses during water sports
    
  • loss of independence if eyeglasses or contact lenses are broken or lost

COSMETIC AND PERSONAL NEEDS Regardless of what we view as critical, some patients perceive wearing eyeglasses or contact lenses as threatening to their lifestyles and occasionally their lives or health.

SPECTACLE INTOLERANCE Some patients consider refractive surgery because they have problems wearing eyeglasses.

Equally as important as patients’ reasons for pursuing refractive surgery are their reasons for avoiding surgery. A successful surgical outcome mandates that these issues be investigated and addressed during the preoperative visit.

Patient Fears

Patient education about what to expect before, during, and after refractive surgery is essential to a successful outcome. Discussion of a patient’s fears should be part of the preoperative assessment.

FEAR OF THE UNKNOWN It is human nature to avoid conditions that we do not understand or have limited information about. Refractive surgery often falls into this category and may be avoided for the following reasons.

• minimal understanding or knowledge about advancements in techniques
  
• lack of widely publicized or circulated high surgical success rates and lack of understanding about complication rates
  
• uninformed coworkers or unhappy postoperative refractive patients used as sources of information

FEAR OF SURGERY The general population fears surgery for several reasons.

POSTOPERATIVE FEARS As with other surgeries, patients often fear what life will be like after the procedure. Typical fears include the following.

• intense pain
  
• partial or total vision loss
  
• significant loss of central or peripheral vision
  
• permanent blindness

Ignorance

Lack of consumer education is probably the most significant reason why some otherwise qualified individuals do not seek refractive surgery. Misperceptions about the following topics contribute to their unwillingness to undergo surgery.

REFRACTIVE ERROR AND LEVEL OF CORRECTION Patients generally believe that their prescription is relatively severe because they cannot see without glasses. In reality the prescription is usually quite moderate.

• public misperceptions about possible ranges of correction (patients often believe that their refractive error is so severe that it cannot be surgically corrected)
  
• days of radial keratotomy and limited range of myopic correction
  
• hyperopia (patients often lack awareness about options because correction is often not required until later in life)
  
• presbyopia (see hyperopia)

TECHNOLOGICAL ADVANCES Technology has progressed significantly since radial keratotomy (RK) was first introduced in the United States in the late 1970s. Correctional techniques used by surgeons today utilize the excimer laser, corneal ring segments, or intraocular lenses (IOLs).

• hyperopic laser in situ keratomileusis (LASIK)
  
• hyperopic astigmatic LASIK
  
• cross-cylinder LASIK (for high and mixed astigmatism)
  
• multifocal IOLs
  
• intracorneal rings

APPLICABILITY OF MONOVISION Monovision correction by refractive surgery is a desirable alternative for two main reasons:

• its wide range of correction
  
• its applicability to patients of many ages

Cost

Many individuals who may be motivated to proceed with refractive surgery find the financial cost to be a prohibiting factor. Prospective patients may not be able to accurately compare the long-term costs of spectacle or contact-lens wear with the cost of refractive surgery.

FINANCING OPTIONS As with any other large-cost item, a patient may pay for refractive surgery using one of many financing options.

• personal loans
  
• low-interest-rate credit cards
  
• employer assistance programs (i.e., the patient’s employer pays a portion of the cost or the company has negotiated a group discount with the provider)
  
• “flex-spending” accounts (with tax advantages in the United States)
  
• “cafeteria plans”
  
• insurance (possibly a future option for refractive surgery, but few examples currently exist)

Occupational Needs

• safety eyeglasses for protection
  
• perfect visual acuity (as for pilots)

Postoperative Patient Expectations

Even with a “perfect” refractive outcome, some patients may not be satisfied if surgery does not meet their expectations. Often, initial discussion about the patient’s motivation sheds light on the person’s expected postoperative outcome and determines the best method of patient education.

• counseling of type A personalities or patients who are acutely critical of their vision about possible visual adverse effects and sometimes even discouraging them from refractive surgery
  
• investigation of each patient’s expectations and criteria for “good vision”
  
• demonstrations with eyeglasses or contacts essential for a successful “subjective” surgical outcome
  
• documentation that the patient is actively seeking refractive surgery (may prove valuable in postoperative discussions with patients who have unrealistic visual expectations)

A patient’s ocular history helps to identify any potential postoperative problems that may arise and allows for adjustment, postponement, or cancellation of the procedure in question if necessary.

Previous Trauma

• identification of any trauma in the cornea or other component of the visual axis that may alter corneal wound healing or potential visual outcome
  
• determination of condition, location, duration, and method of treatment (if possible)

Previous Ocular Surgery

The identification and evaluation of a patient’s previous ocular surgery status is critical to the success of subsequent refractive surgery. Several situations must be considered.

• artificial alteration of the refractive index secondary to faulty assumptions or calculations based on the IOL, scleral buckle, or other retinal procedures
  
• increased risk of retinal complications after surgical intervention
  
• difficulty obtaining proper suction and resultant flap complications

Family History

A thorough family history may elucidate potential contraindications or concerns with refractive surgery and long-term visual prognosis. A positive history of any of the following warrants further careful ocular evaluation prior to surgical intervention.

• glaucoma
  
• past history of high intraocular pressure after topical steroid application
  
• corneal dystrophy or degeneration
  
• untreated retinal pathology (e.g., retinal holes, tears, or detachment)

Medical History

The preoperative systemic history should include questions related to several diseases and conditions, including pregnancy and lactation, that may affect a surgical candidate’s suitability for surgery.

OCULAR DISEASES Presurgical assessment of refractive surgery candidates may reveal a history of several ocular diseases that precludes surgery or poses increased risk of intraoperative or postoperative complications.

VASCULAR DISEASES Any vascular disease that compromises a person’s ocular performance or health is a contraindication for refractive surgery. Some are listed here.

• hypertension
  
• diabetes mellitus
  
• clotting or other blood disorders

COLLAGEN VASCULAR DISEASES The severity of collagen vascular disease determines whether it needs to be evaluated before refractive surgery. Most patients with collagen vascular disease have very mild symptoms and use very little medication. If a patient is rheumatoid-factor positive and has severe collagen vascular disease, refractive procedures are contraindicated. Examples of collagen vascular disease are listed here.

• systemic lupus erythematous
  
• rheumatoid arthritis
  
• scleroderma
  
• fibromyalgia

INFLAMMATORY DISORDERS Inflammatory disorders, such as those listed below, should be controlled and stable prior to refractive surgery.

• multiple sclerosis
  
• hyperthyroidism
  
• Crohn’s disease

INFECTIOUS DISEASES An active infectious disease is generally a contraindication for refractive surgery.

• viral
  
• bacterial
  
• fungal

Medications and Allergies

Certain drug therapies may be contraindicated or alter postoperative outcome in patients undergoing refractive surgery. Allergies must also be considered.

• isotretinoin (Accutane; Hoffmann-La Roche Inc., Nutley, NJ) [contraindicated in potential photorefractive keratectomy (PRK) patients because of increased risk of PRK haze]
  
• sumatriptin (increased risk for epithelial defects after refractive surgery)
  
• antimetabolites and antirheumatic drugs (prolong or retard wound healing after refractive surgery)
  
• topical or systemic allergies to metals, latex, or laser gases

Prior Corrective Lenses

The patient’s refractive history provides data that enables the surgeon to utilize the surgical correction that will provide the best vision over the patient’s lifetime.

• frequency of previous visual exams
  
• refractive stability over the last few years
  
• frequency of and reason for changes in spectacle or contact lens prescription
  
• acceptance and adaptability of various near-correction options
  
• problems wearing eyeglasses or contact lenses (e.g., discomfort and intolerance)
  
• frequency and duration of contact lens wear (typical schedule)
  
• contact lens type (e.g., rigid gas permeable, hydrogel, polymethyl methacrylate)
  
• acceptance of monovision or bifocal contact-lens correction

Fundamentals

• disclosure of risks and benefits to patient
  
• patient comprehension of the information provided
  
• voluntary submission by patient to surgery

Key Components

Special Considerations

• Review any new developments in complications or technology that apply to refractive surgery.
  
• Obtain U.S. Food and Drug Administration disclosure for any procedures that have not been approved.
  
• Obtain investigational device exception disclosure for device exceptions.
  
• Send the consent form to the patient at least 24 hours before the procedure to allow the patient to assimilate the information.
  
• Obtain consent for bilateral procedures.
  
• Reference the patient to optometric follow-up.
  
• Instruct patients to write out key concepts to demonstrate that they understand them (e.g., “I understand that there are no guarantees”).
  
• Disclose all fees, including comanagement fees.
  
• The doctor also needs to sign the consent and include notes about any unique aspects of the case.