The Optometrist's Role In LASIK Comanagement
Do what's best for your patients while maintaining a mutually beneficial comanagement relationship. Here are tips from an O.D. at the other end of the referral.

The practice where I'm employed offers a unique perspective on how to build successful refractive surgery comanagement relationships. Ours is a secondary ophthalmic care center specializing in optometric referrals, with 14 optometrists and eight ophthalmologists on staff covering Arizona. With this statewide coverage, we have a large base of eyecare professionals who rely on our surgical centers to provide cataract, glaucoma, retinal and refractive services.

In this article, I'll discuss how new refractive choices have changed the role of referring doctors, empowering them to participate more actively in their patients' care. This discussion naturally begins with the patient-doctor relationship.

Understand patient goals

When talking with patients who are interested in refractive surgery, it's important to determine their goals before referring them to a surgical center. Your referral is the first and most important step in maintaining a relationship with your patient, even after he's undergone surgery.

It's important to determine patients' goals before referring them to a surgical center.

You'll find that some patients want to rid themselves completely of eyeglasses and contact lenses, while others would be content to decrease their dependence on these devices. You'll also encounter the occasional patient who thinks he should be able to see like he did when he was 18 years old. Asking the simple question, "What are you hoping to accomplish?" should guide you to the most effective refractive surgery that will help your patient meet his goals.

As the doctor on the receiving end of the referral, I find that patients who have discussed surgical aims with their primary eyecare professionals tend to have greater confidence in their doctors. More importantly, this discussion helps underscore your desire to do what's best for your patient and refer him to a center best suited to achieving that goal.

Refer appropriately

As the indications for refractive surgery expand, it's increasingly important that referring doctors keep up with surgical advancements and understand the parameters they cover, as well as the contraindications for each surgery.

For example, consider a 27-year-old pilot with a refraction of OD -6.75 -1.00 x 90 and OS -4.75 -1.00 x 88, who wants to reduce his dependence on eyeglasses. The patient requires excellent night vision, and he has 8.0-mm pupils in scotopic conditions with no ocular pathology. What would you recommend?

With the significant amount of myopia, large pupils and a desire for the best night vision, this patient is not a good candidate for conventional LASIK. A referral to a standard laser center would only waste your patient's time and create confusion. However, with the capability to treat an MRSE of -7.50D with a 10.5-mm treatment zone, while producing decreased spherical aberration (and, therefore, reduced night vision complaints), this patient is an excellent candidate for wavefront-guided treatment using the Alcon LADARVision System, which includes the LADARVision 4000 Excimer Laser and the LADARWave CustomCornea wavefront device. By referring this patient to a refractive center that performs CustomCornea, you provide the opportunity to improve his vision beyond that of current refractive treatments. The patient will return to your practice satisfied that you were able to refer him appropriately.

The large-pupil patient is a challenging referral. This example illustrates how thinking ahead results in a fruitful working relationship among you, the surgical center and the patient.

A more common case is the 20- to 40-year-old patient with mild to moderate myopic astigmatism. These patients have worn contact lenses and eyeglasses for most of their lives and want to see the world without lenses. Referring doctors often mistakenly assume that all these patients are viable candidates for LASIK.

How can you avoid this error? I recommend that you make a small investment in your practice to identify the roughly 15% of patients who are not great LASIK candidates and let them know right then and there in your office.

	A corneal topographer and a pachymeter are essential instruments for LASIK evaluations.

Have the right tools

Patients with asymmetric corneas or keratoconus clearly are not good LASIK candidates. A corneal topographer, therefore, is essential for your LASIK evaluations, not just to rule out inappropriate LASIK patients but to help you refer patients for the appropriate procedure.

You can buy a good topographer for about $10,000 to $20,000. Of course, this technology isn't limited to refractive applications; topographers have become a mainstay for fitting contact lenses and monitoring corneal pathology progression.

The second important piece of equipment you'll need for your refractive evaluations is an ultrasound corneal pachymeter. Why should you measure corneal thickness on your LASIK candidates? Although studies have raised the question of the exact thickness of a cornea that's prudent for LASIK surgery, most will agree that a minimum of 250 microns should be preserved on the stromal bed following surgery. The goal is to maintain the integrity of the cornea and avoid ectasia.

The Ocular Hypertension Treatment Study showed that corneal thickness may be a predictive factor in the development of glaucoma. Thus, pachymetry can be reimbursed for a one-time glaucoma screening per eye. More importantly, we know that a thicker cornea measures a false high pressure and a thinner cornea a false low. Since the Imbert-Fick law uses an average of 520 microns for the Goldmann IOP measurement, you can make a more accurate glaucoma diagnosis with pachymetry.

Knowing the corneal thickness, therefore, helps with IOP evaluation and is a launching pad for LASIK discussions. If a patient's candidacy is in question, you can simply call your LASIK center to find out the average flap thickness, the average microns/diopters for their laser and the residual bed they want to maintain. With this information, you can do some quick calculations to determine a patient's candidacy.

For example, a patient presented to the clinic for a custom LASIK treatment with a refraction of OD -4.00 -0.75 x 92 20/15. Ultrasound pachymetry measured OD 535 microns, and Colvard pupillometry was 6.00 mm. Therefore, if we wish to leave a 300-micron residual bed (this is the standard in my practice), we can use up to 235 microns of tissue for the surgery. A 160-micron plate will be used with the keratome. This leaves 75 microns, ample tissue available for treatment, with room for retreatment, if necessary.

Knowing the pre-op pachymetry reading and subtracting the residual bed and flap thickness helps prepare you and the patient before a referral.

Share your knowledge

Simply knowing a patient's goals and candidacy status isn't enough to make a referral. Now it's time to educate. This can be done, in part, with marketing materials in your waiting room, questionnaires on your intake forms and by having your staff discuss refractive options with your patients. However, patients benefit most from the doctor's continued education and knowledge of the state of the art.

For instance, over a year ago, when patients asked "What's new with LASIK?" we could only discuss the concept of wavefront technology and tell our patients "soon." In the last year, refractive surgery using wavefront technology (LADARVision CustomCornea) has become a reality. CustomCornea has the potential to:

• Provide better visual acuity than eyeglasses or contact lenses
• Minimize aberrations that lead to glare, halos and night vision problems
• Maintain or improve contrast sensitivity levels.

Patients want to know that the surgery you're recommending is safe and effective. Once you've established that they fit the profile for custom LASIK, you need to explain the advantages of this new surgical procedure.

Explain custom surgery

Your chair-side approach when discussing custom LASIK should convey that you understand the concepts, even as you simplify them to make the information more digestible for patients. I like to use the analogy of custom clothing. Patients understand the difference between a custom-tailored shirt and one bought off the rack. This analogy demonstrates that both conventional and custom LASIK correct refractive error, but that wavefront-guided CustomCornea LASIK involves custom measurements.

I avoid using words like "aberrations" that can confuse patients. Instead I describe these as small alterations or imperfections that aren't corrected by eyeglasses or contact lenses. Keeping the discussion to the basics solidifies your practice's commitment to recommending appropriate refractive care. In this way you align yourself and your patients with the state-of-the-art methods for correcting ammetropia.

Building for the future

Patients demand a high level of care from sophisticated healthcare professionals. To demonstrate your commitment to staying ahead of the curve, you should include custom LASIK in your discussions of refractive options, just as you do contact lenses and eyeglasses. Your patients will appreciate the fact that you're looking out for their best interests. 

Dr. Bloomenstein is the medical director of the refractive clinic at the Barnet Dulaney Perkins Eye Center. A fellow of the American Academy of Optometry, he lectures nationally and publishes extensively on anterior segment care and refractive issues.