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Many practicing optometrists struggle with a question similar to this: “Should I refer my patient for refractive surgery and get a one-time fee for collaborative care, or should I continue to provide glasses and contact lenses with a yearly eye exam instead?”
As an optometrist who works in a refractive surgery referral center, I can tell you this: Patients are having refractive surgery with you or without you. If you want to stay in the loop and continue to be a part of their lifetime care, consider at least starting a conversation with potentially interested patients about refractive surgery. When you refer patients to a reputable laser vision clinic, you can be sure they are having the procedure done safely, and you can be involved in the pre- and postoperative care.
Our practice requires that patients have a comprehensive eye examination every year to keep what we call their “lifetime warranty.” Patients can choose any practice for their routine eye exam (in fact, our office does not provide routine eye care). This is where you are an important role for patients: they need exams every year, it may as well be at your office.
Refractive surgery patients are typically very happy postoperatively, and their routine eye exams are a snap. If you were not involved in their surgical care or in any discussions before their surgery, patients may feel bad or guilty about coming back to you and may instead find a new doctor. I know that this happens. At our refractive surgery center, we strongly encourage patients to return to their optometrists for all of their pre- and postoperative care. However, you must remember that it is up to the patient to choose who performs his or her postoperative care, depending on who he or she is most comfortable with. At times, the patient may choose to stay with the surgery center for postoperative care.
FINANCIAL BENEFITS OF COLLABORATIVE CARE
We pay approximately $500 per eye for collaborative care. We collect the full surgical fee on surgery day, then we send the optometrist a check for their services. This is usually within a week or two after surgery. The fee includes a preoperative dilated examination with cycloplegic refraction and four postoperative appointments for LASIK patients. This is not bad revenue for five appointments, four of which are typically 10 minutes long. PRK patients require a few additional visits. Our practice typically does follow-up on day 3, day 5, and then every 2 weeks until the patient’s vision is clear, then 3-month and 6-month visits. PRK patients typically have six or seven postoperative appointments.
If patients return to their optometrists for yearly eye exams, a good revenue stream can come from this patient population. Research by the Vision Council in 2013 found that 96% of refractive surgery patients wear plano sunglasses, and 20% wear over-the-counter reading glasses.1 These same patients were 50% more likely than the general population to purchase high-end plano sunglasses. And do not forget about the presbyopes. They still need readers, and some patients will choose progressive lenses—yet again more practice revenue.
Presbyopic patients may also consider monovision with a disposable contact lens. I call this “mono on demand” because the patient can have monovision when he or she wants it. For example, it might be handy at a social event or an important meeting where the wearer wants to see faces in the distance and name tags or a computer at near. Once the event is over, the user can just throw the daily disposable contact lens away and enjoy good distance vision on the drive home. Patients love this option.
The Vision Council also found that the demographics of refractive surgery patients are younger, more female than male, and from a higher-income household than the general population. In addition to new patients, there are many who had refractive surgery several years ago who now need a low-power correction for driving. There is also the monovision patient who desires a prescription pair of glasses for driving and outdoor activities. And each of these patients has family members who are also potential patients. The possibilities are endless.
Most refractive surgery centers have up-to-date equipment such as aberrometers, topographers, pachymeters, and other corneal imaging instruments. You do not need to invest in this equipment yourself. Your patient can be seen at the surgery center for a preliminary screening, and all the appropriate preoperative testing will be completed there. You will receive a report from the surgery center with the results, and their consultants will let you know whether your patient is a good candidate for surgery.
In fact, many will do an initial consultation at no charge and let your patient know all the latest surgical options. All you have to do is perform the comprehensive dilated examination with cycloplegic refraction, prescribe the appropriate medications, and do the postoperative follow-up appointments. You already do routine eye exams and follow-up appointments now. How is this different?
You also do not need to spend time billing an insurance company for your services. You can either bill the patient directly for your services or have the patient sign a fee agreement that reviews your fees for perioperative care.
WHAT DO YOU HAVE TO LOSE?
What do you have to lose when you don’t mention refractive surgery to your patients? You lose the opportunity to provide these services, in the near term and the long term:
- preoperative glasses for contact lens wearers without a backup pair
- collaborative care fee
- monovision contact lens trial
- yearly routine exams
- high-end plano sunglasses
- driving or distance glasses
- high-end readers or progressive lenses
- continuation of care with these patients and their referrals of friends and family
Refractive surgery patients receive their pre- and postoperative care somewhere, and they purchase the items mentioned above from somebody. It may as well be your practice. Do not miss the opportunity to be involved in integrated surgery care due to a misguided and “myopic” perspective on potential lost revenue for yearly contacts and glasses.
TRENDS IN REFRACTIVE SURGERY
A survey among US members of the International Society of Refractive Surgery in 2014 identified a number of interesting trends.2
The femtosecond laser was the most commonly used means of LASIK flap creation among survey respondents (71%). Among the respondents, 52% reported using the IntraLase FS (Abbott Medical Optics), 8% the Femto LDV (Ziemer Ophthalmic Systems), 5% the Victus (Bausch + Lomb), and 11% reported using another femtosecond laser. A Moria microkeratome (model name not specified) was used by 10% of respondents (Figure 1).
Among excimer lasers, half of respondents (50%) reported using the Star S4 (Abbott Medical Optics; formerly Visx). The WaveLight (Alcon) was a close second, named by 44% of respondents, and Bausch + Lomb (model name not specified) was named by 6% (Figure 2).
Preferred flap thickness was 100 µm for 68% of responding surgeons and 120 to 130 µm for 30%. Only 1% of respondents reported using flap thicknesses of 150 to 160 µm thickness (Figure 3).
Minimum residual stromal bed thickness required for LASIK was mixed among the surgeons responding; 34% reported preferring 250 µm (US Food and Drug Administration minimum), 23% preferred 275 µm, and 36% preferred 300 µm. Our practice falls into the more conservative group at 300 µm (Figure 4).
Survey respondents reported a 22% increase in total volume of laser vision correction from 2012 to 2013. Total laser vision correction volume in 2014 among survey respondents was 549,000 cases, including 428,000 LASIK procedures and 121,000 surface ablation procedures. PRK has represented 22% of overall laser vision correction volume for the past 4 years, according to the survey authors (Figure 5).
COLLABORATIVE CARE GUIDELINES
Once you decide to get involved in integrated refractive surgery care, there are some basic guidelines to follow. First, find a reputable refractive surgery center with up-to-date laser technologies that include wavefront diagnostic capability and femtosecond laser. Second, select your surgeon carefully. You want someone who is conservative, skilled, and compassionate to patients in the operating room.
Following are some basic calculations to help you determine whether your patient is a candidate for refractive surgery.
Assess Corneal Thickness
It is vital to determine whether a prospective refractive surgery patient’s cornea is sufficiently thick to permit laser ablation. Some basic calculations are helpful to rule patients in or out:
Determine the dioptric power of the cornea in the highest power meridian, and multiply this number by 15 for custom ablation and 12 for conventional ablation. The result is the depth of tissue, in microns, that must be ablated to correct the error. For example, a patient with a refraction of -6.00 D -1.00 D × 180 will require 7.00 D of correction. Calculate 7 × 15 = 105. For a custom treatment, 105 µm of tissue must be ablated. Another example: A hyperopic patient with a refraction of +2.25 D -1.25 D × 180 will require 2.25 D of correction. Calculate 2.25 × 15 = 33.75. The custom treatment will require a 33.75-µm ablation.
The next step is to determine the residual stromal bed thickness, and whether it will be sufficient to allow LASIK. You need to know your refractive surgery center’s preference for flap thickness and for minimum residual stromal bed thickness. Our preferred flap thickness is 110 µm with flap creation using the IntraLase FS femtosecond laser, and our preferred minimum stromal bed thickness is 300 µm. Continuing with the example of the myopic patient, say his corneal thickness is 550 µm. Is this patient a candidate for LASIK? Do a quick calculation: 550 (total corneal thickness) – 105 (ablation depth) – 110 (laser flap thickness) = a 335-µm residual stromal bed. This is adequate corneal thickness to allow LASIK.
Consider Corneal Curvature
This factor is often overlooked by referring doctors. The guideline we use for steepest postoperative corneal curvature is 47.00 D keratometry (K) in hyperopic treatments and 36.00 D K in myopic treaments. Steepening treatment is usually a one-to-one increase in curvature. For example, in a +2.25 D hyperope, the K will be steepened by 2.25 D. Myopic flattening is usually 75%; that is, a -10.00 D myopic eye will receive 7.50 D K of flattening.
A +2.25 D hyperopic patient with a starting K of 46.25 D will require an additional 2.25 D K of steepening, which will leave him or her at 48.50 D K. According to our guideline, this patient is not a refractive surgery candidate because the resulting corneal curvature will be steeper than our maximum of 47.00 D K. If the -10.00 D myopic patient has a starting K of 42.00 D, the calculations would be 42.00 D K -7.50 D K = 34.50 D K. This patient also would not qualify for LASIK or PRK because her postoperative Ks would be outside of our parameter guidelines—too flat for our minimum of 36.00 D K.
Either of these patients could be considered for refractive IOL exchange or clear lens exchange for an IOL rather than corneal ablation. The myopic patient could also consider the Visian ICL (STAAR Surgical) as long as her astigmatism is minimal.
Address Dry Eye Issues
A healthy ocular surface is an important criterion to consider prior to surgery. Dry eye disease (DED) is one of the most common refractive surgery side effects we treat in the Mile High City. Preoperative Schirmer test scores should be at least 10 mm preferably. Zone-Quick (manufactured by Yokota, various distributors) should be at 20 mm or greater. The corneal surface must be free of punctate staining. If the patient does not meet these minimum criteria, dry eye treatment should be initiated.
DED syndrome is a medical, billable diagnosis, and you can bill for these appointments through the patient’s insurance prior to surgery. I strongly advise you do this preoperatively, rather than managing the disease postoperatively. Patients may feel that DED management should be part of their included postoperative care and may not be willing to pay the copayments and insurance-billable visits if you wait to manage the dryness after surgery. On the other hand, they are often highly motivated preoperatively to have the surgery and therefore more willing to do the DED management beforehand and pay for the appropriate care.
Prolonged DED can affect surgical outcomes, and patients may not be satisfied with their results if they experience discomfort. Patients may need an enhancement in the future due to poor initial healing secondary to DED.
Consider Pupil Size
Pupil size is less of a concern now, with the availability of customized wavefront technology. However, I still take time to discuss the risks of halo and glare with patients who have pupils larger than 7 mm. In my own clinical experience, patients will notice increased halo and glare for the first 2 to 3 months postoperatively, and then it dramatically decreases over time. Patients who undergo wavefront customized ablations rarely complain of halo and glare beyond 6 months postoperatively.
Pay Attention to Topography
A symmetric corneal topography is, in my opinion, the most important criterion in considering refractive surgery for a patient. If the topography is slightly asymmetric, then we discuss PRK. If any irregular pattern or irregular astigmatism is seen, we decline to perform surgery.
Topography interpretation requires practice and a good topographer. A good refractive surgery center will have an up-to-date topography device and the clinical expertise to determine whether a patient is a suitable candidate for LASIK or PRK, or whether no surgery should be recommended. The referring doctor will receive the report from the surgery center with appropriate surgical recommendations for the prospective patient.
Each surgeon has personal preferences for what he or she feels is acceptable. Once you work with a surgery center, you get a good understanding of each surgeon’s preferences and what he or she is looking for on the topography. Subtle topographic clues guide the clinical decision making. At times, this can feel more like an art than a science. It gets easier; the more patients you manage, the better you become at interpreting corneal topography.
PROFESSIONAL BENEFITS OF COLLABORATIVE REFRACTIVE SURGERY CARE
If current market trends increase, more patients will be seeking refractive surgery. If you talk about refractive surgery options with your patients, you are more likely to be involved in the process when they decide to go for surgery. This has the potential to be a strong revenue generator that you may have been overlooking.
For example, if you collaborate in the care of one patient each week who undergoes laser vision correction in both eyes, your fees would amount to $1,000/week. Over 52 weeks of the year, that is $52,000 for one patient a week. And that does not include all the other opportunities such as providing sunglasses, readers, monovision contact lenses, and so on.
Do not underestimate the benefits of integrated care for refractive surgery. There is great satisfaction when your patient arrives for the day-1 follow-up and gives you a high five or a big hug because he or she can see for the first time without contacts and glasses. The celebration is very rewarding, especially if you have been seeing this patient and perhaps his or her family members for many years. And with the collaborative care model, you go through the entire process together.
Once patients experience their “hassle-free vision” after refractive surgery, they will send their family and friends to you for the same procedure. This leads to more patients and helps to build your practice. Even better, you did not have to spend advertising dollars to garner the referrals.
The best part, though, is sharing the excitement of 20/20 uncorrected vision with your patient. It can be a life-changing experience for the patient. Aside from any financial rewards, do not miss out on the emotional reward of sharing this special moment together. n
1. Vision correction needs of refractive surgery patients. International Vision Expo and Conference Las Vegas website. http://www.visionexpowest.com/Press/Vision-Voice-Newsletter/Vision-Correction-Needs-of-Refractive-Surgery-Patients/. Accessed April 21, 2015.
2. Duffey RJ, Leaming D. US Trends in Refractive Surgery: 2014 ISRS Survey. Paper presented at: Refractive Subspecialty Day; October 17, 2014; Chicago., IL.
Vandi Rimer, OD
• Diplomate, American Board of Optometry, and residency director, ocular disease and ocular surgery comanagement, Omni Eye Specialists at Spivack Vision Center, Centennial, Colorado
• firstname.lastname@example.org; (303) 740-5475
• Financial disclosure: none acknowledged