Ophthalmology Business

OCT 2013

Ophthalmology Business is focused on business topics relevant to the entrepreneurial ophthalmologist. It offers editorial, opinion, and practical tips for physicians running an ophthalmic practice. It is a companion publication of EyeWorld.

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expectations choice—not just from the surgeon's standpoint, but the patient has to be an equal partner in the decision since it's an elective process." Preop patient expectations Of the three hypothetical examples first mentioned, Dr. Chu said one of the hardest dilemmas any refractive surgeon will face is when a patient has poor visual potential in one eye. "I've spent as much as 3–4 months talking a patient down from surgery and into contact lenses if there is little hope for a good prognosis otherwise," he said. "In that scenario, the dilemma for the surgeon becomes an issue of educating the patient that he is no longer a refractive patient, but a medical patient with a cataract and retinal detachment." It's with these patients that Dr. Chu spends the most time mapping out a surgical strategy that may include a combination of laser vision correction, implantable contact lenses, and/or IOLs. For Dr. Thompson, when preop testing shows a caution, he's more inclined to recommend PRK rather than LASIK. "We have a much better understanding of how to lessen haze, too, so for a number of reasons PRK is sometimes a more conservative approach," he said. "If there's borderline thickness, there's always the option of a phakic IOL, too." If he sees signs of severe eye rubbing, he'll also dissuade a patient from laser vision correction. "If they're really insistent on LASIK I tell them they'll have to prove they can stop rubbing their eyes first," he said. In his practice, once he explains presbyopia to patients and that patient age is as much a factor as refractive error, most are willing to have a monovision result or get reading glasses. "I have an eye model in the office and show them that while I can reshape the cornea to help them see better, I cannot provide a flexible lens (I call it the 'reading lens'), and the only way to achieve those outcomes is through refractive lens exchange or cataract surgery," he said. Until a patient is over the age of 50, Dr. Thompson recommends waiting for refractive lens exchange. Dr. Buznego repeats tests with anomalous findings. "If a patient is walking and talking and the test says his heart rate is 10 instead of 100, you doubt the test, not the exam," he said. Dr. Devgan cautions surgeons about taking on every case, too. "Sometimes plano is not the best refractive target for patients age 40 or older. Instead, leaving one eye slightly myopic may buy an extra five or 10 years of not needing readers," he said. "In other cases, such as low myopes of presbyopic age who routinely take off their glasses to read, the best recommendation for the patient may be no surgery at all." Never be afraid to turn away a patient unless you're thoroughly convinced surgery is going to help improve vision, he said. Postop patient expectations Sometimes managing patient expectations is just as difficult postoperatively. "How many times has a patient complained about an unacceptable outcome but if you push him off for a month or so, suddenly the patient says the vision is great?" Dr. Buznego asked. "Don't be afraid to say no to a patient. In the end, you're going to be the one who lives with the decision—and increased patient dissatisfaction—in the long term." For overly insistent patients, he recommends trying to counsel them by relating anecdotes of other patients in similar situations who had both poor outcomes and good outcomes. Dr. Thompson explains to patients that he "can do pristine measurements and deliver a pristine treatment with the world's most sophisticated technology. But I can't control every cell or your healing response," he said. Patients who are close to their ideal postop vision may never get there, he said. "If they're on the 5-yard line, we can sometimes get the touchdown, but other times we're going to get stopped on the 1-yard line," he said. That's when it's helpful to re-explain that LASIK (or PRK) "is not about eliminating spectacles, it's about eliminating dependency." OB Editors' note: Dr. Buznego has financial interests with Allergan (Irvine, Calif.) and Bausch + Lomb (Rochester, N.Y.). The other physicians have no financial interests related to this article. Contact information Buznego: cbuznego19@gmail.com Chu: yrchu@chuvision.com Devgan: devgan@gmail.com Thompson: vance.thompson@vancethompsonvision.com October 2013 • Ophthalmology Business 7

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