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THE clinical practice of refractive surgery continues to evolve rapidly. Yesterday's wonder tool is replaced by the next big thing, whether it is a better laser, a safer microkeratome or a faster software package.

In the ever-changing current of ideas, the surgeon is constantly challenged to keep up with the latest developments and incorporate them in practice to optimise surgical performance for better outcomes and happier patients.

The key to optimising performance is the nomogram. For the uninitiated, the Oxford English dictionary defines a nomogram as "a diagram representing a relationship between three or more variables in the form of a number of straight or curved scales, so arranged that the value of one variable corresponding to given values of the others can be read off by means of one or more straight lines drawn to intersect the scales at the appropriate values."

For a good nomogram, you need data based on a history of past outcomes. Outcomes research is considered the foundation of evidence-based medicine, which itself is considered the ideal guide to optimal clinical practice.
A busy refractive surgeon may have neither the time nor the inclination to perform outcome studies. Partly for this reason, these sorts of studies are often considered to be part of the academic realm of endeavour.

The number-crunching tools necessary for conducting this sort of analysis have really never been farther away than the nearest personal computer. The typical database program has almost everything you ever needed to keep track of cases and to compare outcomes based on a virtually unlimited amount of variables.

But learning database programming is rarely at the top of anyone's list of what to do with his or her free time.
Why is there no easy-to-use, out-of-the box database solution custom designed for the needs of refractive surgeons?

A couple years ago, Perry Binder MD, asked that same question. Dr Binder, director of the Gordon/Binder Vision Institute, a high-volume refractive practice based in La Jolla, California, wanted a program that would help him to keep track of his refractive surgery outcomes. His solution was to write a new programme himself.

"I had searched for a software programme that would help me keep track of LASIK results over time and just didn't find anything like what I wanted," he recalls.

"So, in my off-hours, I developed a prototype of a specialised database programme built on the FileMaker Pro programme. I then worked with a really great programmer to get this product up to the professional level of quality I had envisioned."

The result was a programme called Outcomes Analysis Software, a comprehensive software tool that is simple to learn and implement.

The programme walks you through the initial set-up as you create the database that will form the basis of subsequent nomogram development and outcome review. It can be installed on machines running Windows 95-2000, Windows XP™ or Macintosh OS. It can also integrate with FileMaker Pro running on Palm OS.

The programme, now in version 3.9, allows you to track the results of up to 38 surgeons and 60,000 patients. Data can be imported from standard data programmes, including Excel and Access. Surgical results can be analysed so that the factors affecting outcomes can be identified and modified if necessary. Nomograms for individual surgeons are generated on an ongoing basis.

The programme was designed with the needs of the clinician in mind. Practice friendly features include the ability to generate patient information and consent forms as well as patient satisfaction questionnaires. You can also create customisable summary referral letters and operative notes.

Once you get comfortable with the database, you can modify and edit it yourself to best suit your needs. New techniques and instruments can be added as they come along.

Just to be on the safe side, the programme performs numerous safety tests, making sure that postoperative corneal power will be greater than 37 D and the residual corneal thickness will be greater than 250 microns.

Once the database is up and running, data mining is simple. For example, you can easily ask the programme to find all eyes operated on by two different surgeons for myopia, between 1 D and 4D, with a follow-up of two months to one year, done with Visx laser and a Chiron microkeratome.

Hit the FIND button and the information is at your fingertips. You can choose to view the results as graphics or text.

"This is one of the advantages of outcomes analysis, to look and see exactly what you get," Dr Binder says. "It has become a very important tool in our practice. Data from all our patients are entered into the system."

Dr Binder has used the programme in his daily practice to accumulate data on more than 3,000 eyes. In particular, he has used this data set to conduct clinical research on the effects of various microkeratomes and lasers on factors such as achieved versus predicted flap thickness and visual outcomes.

The programme now also stores photographs and topographic maps. With built-in graphing features, it is also a good tool for preparing journal articles and conference presentation, he notes.

You can find out more about the programme at http://refractiveoutcomes.com/. A free trial version is available at the web site.

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