50,000 LASIK cases convince surgeon of procedure's value
By Stefanie Petrou-Binder MD
AFTER performing 50,000 refractive surgeries over the past ten years now, Canadian ophthalmic surgeon, Marc Mullie MD is a convincing advocate for LASIK.
"The magic of LASIK is that the results are extremely predictable. It is, without a doubt, our ‘gold standard'," he told a session at the Congress of German Ophthalmic Surgeons (DOC).
Dr Mullie discussed three sets of interacting factors that he feels determine a successful refractive outcome and which the refractive surgeon must optimise: surgical, patient, and surgery-related factors.
"Titratability is an extremely powerful and useful surgical tool for enhancements. Since LASIK is an elective procedure, patient expectations are very high, and we must have a technique that is titratable. This aspect is one of the huge advantages of LASIK and one that stands out, especially within the context of LASEK. PRK or LASEK retreatment for under- or over-corrections or regression is very unpredictable, because of the unpredictability of the corneal epithelial response," he explained.
Dr Mullie urged refractive surgeons to always try and maintain a smooth corneal surface. He explained that the cornea is a perfect optical organ and that it behoves surgeons to keep it that way, particularly in the central optical zone. "The corneal contours need to be smooth, without irregularities. Irregular astigmatism can develop from a bad cut, and poor ablations make the patient very unhappy. Re-treatment is extremely difficult," he said.
Dr Mullie explained that sharp treatment edges usually result in glare and halos, especially at night when the pupil dilates and catches the edge. Regression sets in when the epithelium tries to fill in the defect. Smoothing the cornea with some form of PTK is usually the only solution. "We want a well-centred, smooth ablation in the central optical zone. We want to avoid inducing irregular astigmatism, sharp treatment edges in the optical zone, decentration, and scarring. In a bad case, one or more of these elements will unfortunately be found together."
Decentration is one of the worst complications as it often combines elements of both irregular astigmatism and sharp corneal edges. Even with refinements and trackers, decentration is not uncommon, he asserted.
"The reason for this is that no tracker system so far can properly detect ‘eye-roll'. The fixation lights on most lasers are rather poor. Re-treatment of decentration is fraught with difficulty so we have to aim at prevention. Don't put all of your faith in trackers, instead monitor the patient fixation constantly," Dr Mullie advised. Corneal scarring creates visual distortions. This entails long-term management of the problem. Dr Mullie admitted that many of these complications do not resolve:
"I am still following patients with corneal scars from PRK 10 years later." Patient factors relate primarily to the fact that LASIK is an elective surgery. A good rapport, building trust, giving realistic expectations to the patient, and nurturing hope when complications arise are all very important. The surgeon needs to build a relationship with his patient. Dr Mullie suggested that refractive surgeons meet their patients a day or so before surgery and not just ten minutes beforehand. This allows the good, old-fashioned doctor-patient relationship to establish itself.
The patient needs to trust his doctor. In fact, most patients come for refractive surgery only after hearing that someone they know had it, benefited from it, and liked their surgeon. A positive experience and low complications attract people, Dr Mullie said. He commented that the surgeon should probably not be wearing glasses if he wants to promote patient trust. He should have refractive surgery himself, as well as his staff. Preparing the patient for the possible surgical and functional outcomes is essential. Before having surgery, the patient should first exclude contact lenses as a possible solution to wearing glasses. This will give him additional conviction for having surgery. The surgeon should warn the patient that he might require glasses at night.
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Dr Mullie stressed that the surgeon learn to deal with the different ‘visual personalities' of his patients. Is the patient the type that identifies his looks with glasses, or is he perhaps a visual perfectionist? In his assessment, the ideal patient for refractive surgery is a positive, happy, risk-taking, freedom-seeking type, who won't feel upset with a residual myopia of 0.5D. The better the patient is prepared for possible eventualities, the less chance there is of a lawsuit against the surgeon. If a complication ensues, the surgeon must assure his patient that new technologies will be able to solve his problem, if it cannot be solved now. The surgeon must face up to problems. He cannot stick his face in the sand and expect them to go away, Dr Mullie warned.
Dr Mullie believes that the surgeon's attitude, once called ‘bedside manner', can make all the difference in the way a patient feels. The surgeon should be caring, smiling, conscientious and humble. "Because refractive surgery is an elective procedure that your patient has ‘bought', he is effectively a client and a customer, which means that he is always right- very different from the rest of medicine where we deal with diseases," he pointed out.
"Surgeons in general are creatures of comfort. We don't like to change until we are forced to. It takes insight sometimes to realise that you must change techniques even though they may be contrary to common sense." He said that by keeping an open mind, the surgeon with the right attitude, and reasonable judgement and skills, who desires the greater good of his patient, will invariably get a good result. "I wasted about a year resisting LASIK, and wasted a lot of time doing PRK. ‘Cerebral sclerosis' can set in. For progress to continue, we all have to keep an open mind. As refractive surgeons, we must be aware that refractive surgery is an imperfect science and that there is still potential for inflicting damage on patients if we are not careful in our craft. Take no unnecessary chances and have the courage to change, for advancement."
Dr Mullie performed his first PRK with a broad-beam 5.0 mm excimer laser in 1992. Between 1992 and 1995, he performed several thousand PRKs. LASIK became his standard procedure in 1995.
Marc Mullie MD
Clinic Medicale Rene Laennec,
Montreal , Quebec , Canada
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