LASIK has become the most popular surgical procedure for the correction of refractive errors. This popularity is due to the high success rate, minimal discomfort and fast visual recovery that the surgery affords. Unfortunately, at the same time that both the number of procedures and success rates have risen, so have patient expectations.

It is extremely important that you set appropriate expectations, tailoring them specifically to the patient based on his refractive error, age, unique eye conditions, occupation, hobbies and activities. This article explains how to align patient expectations with what you can deliver.

Be Honest
Some surgeons may be hesitant to have a frank discussion with a patient regarding risks, uncertainties and potential poor outcomes. Pride, concern about losing the patient’s confidence, and fear of discouraging the patient from surgery may all influence you to downplay potential negative aspects of LASIK. Preparing the patient appropriately will make the postoperative management much easier, however. Additionally, you will actually gain the

Dr. Elizabeth Davis and her technician confirm that the patient’s treatment has been correctly entered into the laser.

All photos Marnie Jorgensen

respect of the patient by being so open and honest. You will appear as more of a patient advocate than a salesperson. The patient expects you to be experienced and knowledgeable, not perfect. Furthermore, by clearly explaining realistic outcomes, the patient will feel that you have experience with similar cases.

Cues from the Staff
The staff in a LASIK practice is invaluable in helping to counsel the patient and/or notify you of any unrealistic expectations or concerns that the patient may have. Staff members often spend the most time with the patient—scheduling appointments, reviewing instructions and answering questions. A patient may feel more comfortable speaking with knowledgeable employees than with you. He may seek confirmation that what he has been told is true. Or he may inquire about a staff member’s own experience with LASIK. It is during these interactions that the patient may express his concerns and/or reveal his understanding of the procedure and its outcomes. A successful surgeon will not only listen to this feedback from the staff, he will encourage it. Such insight can be invaluable.

Don’t Make Promises
It is foolish and misleading to make promises or guarantees of any particular result. You can still appear optimistic and enthusiastic about LASIK without being unrealistic. Discussions about “20/20” vision are probably best replaced with discussions about “functional” vision—that is, vision that enables the patient to function without glasses or with a reduced dependence on them. Telling a patient he has a 95-percent chance of being 20/20 after LASIK makes an outcome of 20/25 seem like a failure or mishap.

According to Refractive Error
You should explain to the patient that for higher refractive errors (either sphere or cylinder), the outcomes are less predictable. With a single treatment, the patient is less likely to achieve a particular uncorrected visual acuity than a patient with a lower refractive error. Additionally, the visual recovery period

Getting good exposure. Explain to your patient the sensation the speculum will cause.

will be longer for patients with higher corrections. Fluctuations in vision from day to day and within a day will be greater. The chance that the patient will desire an enhancement is also increased. However, a patient with a higher refractive error will need to wait longer before stability is achieved and, hence, before an enhancement can be performed. Emphasize that he should not compare his visual recovery and outcome to another person’s without understanding these important differences.

Hyperopes need to understand that farsightedness is more difficult to correct than nearsightedness. Because there is a greater tendency for regression, prepare the hyperope for an initial period of intended overcorrection. Although the patient’s near vision will be much improved in the early postoperative period, his distance acuity may take several weeks or even months to reach its potential. Inform this patient that he may even need a pair of myopic distance glasses during this time period.

Age, Occupation and Activities
Although there is no upper age limit for LASIK, certain things should be emphasized to different age groups. A presbyopic patient who does not desire monovision correction must be counseled about the continued need for reading glasses after LASIK. Some myopic patients may not realize this also applies to them because they have avoided reading glasses or bifocals by taking off their glasses to read. They are not aware that this ability will disappear after LASIK.
This can be particularly disturbing to patients who prefer to perform close-up tasks without glasses. Threading a needle, removing a splinter, applying make-up and shaving are just a few activities that may suddenly become more difficult to the presbyopic LASIK patient. A person who works at a desk all day long and is used to spending most of his working day without glasses may suddenly find himself totally dependent on reading glasses. On the other hand, all of this may ultimately still be acceptable to the patient—but only if he has been forewarned. Patients can adjust to change, but they do not like surprises.

Since the risk of anterior basement membrane dystrophy increases with age and since this condition may not always be evident on clinical exam, spend a little more time explaining the risk of epithelial defects to patients age 50 and older.

Additionally, tell your patient that it is always possible that small changes in his vision may occur in the future and additional surgery may be desired. Indicate that additional fees may be incurred at that time, particularly since new technology will likely be available.

Counsel for Conditions
A patient with specific eye conditions needs extra counseling. Asymmetric astigmatism, dry eye, large pupils, thinner corneas, stable autoimmune disorders, etc., may not necessarily disqualify a patient from having refractive surgery, but he needs to be informed of the increased risks. This discussion will educate him about findings he might not have been aware of, allow him to make an informed decision and prepare him for any adverse events postoperatively.

Dry eye or ocular surface conditions such as blepharitis are common in many patients. This patient will likely recover slower, have greater fluctuation in vision, and will definitely still have dry eye or ocular surface problems postoperatively. Advance attention to these problems in the form of education, artificial tears, consideration of punctal occlusion, lid hygiene or oral antibiotics may allow an easier recovery period and make for a happier patient.

Many patients have some degree of asymmetric astigmatism, and, in most, it is stable and asymptomatic. Wavefront mapping may be useful in identifying those with significant asymmetry that may benefit from correction of the asymmetric astigmatism. In general, if a patient is happy with his glasses correction (which does not correct for asymmetry), then he will likely be happy with refractive surgery. If he has significant asymmetry, then he may be a better candidate for a custom ablation, either with his original procedure or with an enhancement after the bulk of his refractive error is corrected.

It is still unclear how much role pupil size plays in patient satisfaction after refractive surgery. In general, though, patients with larger pupils have more nighttime visual aberrations than patients with smaller ones. This is true in glasses, contact lenses and with refractive surgery. Use of a larger optical zone may reduce some symptoms, but at the higher levels of correction, deeper ablations are required, and corneal thickness may be a limiting factor, especially for LASIK.
Understanding whether the patient is willing to potentially trade some visual aberrations for an improvement in uncorrected vision is often difficult. A patient may require a second visit to further discuss this issue, especially if his pupil size is quite large or his correction quite high.

Discuss Alternatives
Part of the consent process is discussing with the patient not only the risks and benefits, but the alternatives, as well. You should always remind the patient, particularly one at higher risk, that he has the option of continuing to wear glasses or contact lenses. In this way, you do not appear to be trying to “sell” LASIK or convincing the patient to do something against his best interests.

As new technologies such as phakic intraocular lenses, conductive keratoplasty

Obtaining proper suction. You or your staff should counsel the patient beforehand that his vision will go dark during this step.

and wavefront systems become approved, it is likely that not all surgeons will be performing all possible procedures. Nevertheless, it is important that you remain educated about all that is currently available. In certain instances, the best procedure for the patient may not be one that you are experienced in performing and, therefore, you should make a referral.

Written Material and Seminars
Obviously, all the information a patient needs to know about LASIK cannot be provided in a short discussion with him. Good written material is helpful in educating your patient. A consent form that is an educational tool is important in listing potential side effects or complications from the surgery.
Seminars are a useful way of disseminating information, because a patient may often have a question that others have not thought of asking. In the end, though, it is important to make sure all the patient’s questions have been answered by you and your staff. Also, don’t discourage the patient from looking at various Internet sites for further information.

Pearls for Setting Appropriate Expectations in LASIK

• Be honest. • Take cues from your staff. • Do not make promises or guarantees. • Set appropriate expectations according to refractive error, age, occupation and activities. • Notify the patient about the effect certain eye conditions will have. • Encourage and answer all patient questions about their surgery. • Always provide alternatives. • Refuse to operate on the unrealistic patient.

The Unrealistic Patient
What happens when, despite appropriate counseling, the patient still does not appear to have realistic expectations? Perhaps he indicates he would not be happy with anything less than 20/20 vision or anything less than what he has with his glasses or contact lenses. Or maybe he does not understand presbyopia. In these situations, you must either take additional time to educate him or inform him that he is not a good candidate for the surgery.
It is entirely acceptable for you to refuse to operate on a patient who does not demonstrate an appropriate level of understanding of LASIK, its risks and potential outcomes. 

Dr. Davis is a partner at Minnesota Eye Consultants and clinical assistant professor at the University of Minnesota. Dr. Hardten is a partner at Minnesota Eye Consultants and a clinical associate professor at the University of Minnesota.