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Sujal Shah
Consultant Ophthalmic Surgeon, Bhatia Hospital, Lilavati Hospital, Mumbai.

The battle to correct refractive errors has been waged since the time of the early Greeks who reportedly used glass balls filled with water for magnification. The first spectacles were made in 1286. Ever since the invention of spectacles, man has sought different means to minimize dependence on them. In the 1850ís spring loaded mallets were used to flatten the cornea to correct myopia. This was followed by various methods that involved making incisions over the cornea to alter its shape and hence the refractive error.

Though several attempts have been made for the surgical correction of refractive errors throughout ophthalmic history, the use of surgery has been devoted almost exclusively to the restoration of visual function or to treat disease. Over the last decade, the emphasis has been more and more on the surgical correction of ametropia with an explosive cascade of methods and devices devoted to this purpose, the latest and the most advanced of which is LASIK (Laser In-situ Keratomileusis). LASIK in its conventional form and wavefront-guided technology is a major paradigm shift for ophthalmology, with the emphasis shifting from treatment of diseases that threaten sight to treatments for the enhancement of natural vision.

Imagine waking up and seeing clearly without having to reach for your glasses or contact-lenses. Laser vision correction (LASIK) is making this dream a reality for millions of people worldwide. Since the first LASIK procedure by Pallikaris in 1989, millions of patients worldwide have undergone LASIK. No other advance in the history of medicine has experienced such a rapid increase in public interest or public and professional acceptance. Market estimates say that approximately 1% of the US population has now undergone LASIK.

Laser In-situ keratomileusis (LASIK) is a laser technique that reduces considerably (for higher order myopia) or removes completely the need for external eyewear such as glasses or contact lenses. This technique is an optimum combination of two different techniques called Automated Lamellar Keratoplasty (ALK) and Photorefractive Keratectomy (PRK). ALK has been performed since 1949 whereas PRK has been performed since 1985.

LASIK is an elective procedure that people undergo by choice to correct their refractive error because they prefer to reduce their dependence on external eyewear such as glasses and contact lenses and improve their unaided natural vision. It is more often a preference than a necessity. Therefore, subjective patient satisfaction should be an important parameter for assessing the success of LASIK. There are numerous articles that address the results of LASIK in a clinical perspective. Such articles have dispelled the fears of many by establishing beyond doubt that LASIK is a safe, effective, predictable and stable procedure with an overall low risk of complications. However, in the mass of scientific data such as graphs and tables the patientís subjective feelings have been lost. There is a paucity of literature that addresses patient satisfaction after LASIK.

Satisfaction after LASIK is a reflection of the actual clinical outcome and its deviation from the patientís expectations. Experience that closely matches what a patient expects makes for a happy patient. LASIK because of its elective nature should be approached with extreme caution and must be held to the highest standard of care. Ac cordingly, the selection, evaluation, counseling and management of patients should be conducted assiduously. It is important to realise that LASIK is a professional service and not a consumer commodity that the media and market pressures may make it seem. As with any professional service, outcomes and hence, satisfaction rates will vary across different centres. A cavalier approach to LASIK is absolutely unacceptable and will be reflected in clinical outcomes and patient satisfaction.

To understand patient satisfaction after LASIK it is important to understand the advantages of LASIK and how it overcomes some to the lifestyle disadvantages of spectacles and contact lenses.

Spectacles are cosmetically unappealing, the weight of the glasses bothers some people and can cause changes over the skin of the nose, they optically minify the image in myopias, making distant objects appear smaller. There is a degree of distortion when looking through the periphery of the glasses, the field of vision is reduced, eye strain may be experienced from poor fits, and on leaving a cold room moisture can fog the glasses and blur vision for a few minutes. Glasses are unacceptable for certain vocations such as the Army, Navy, Air Force, airhostesses and professional sports. Glasses can alter the quality of life, such as an inability to see across the room or the street without glasses, inability to react in an emergency, prone to trauma and breaking of the lens in emergencies, fogging during cooking and inconvenience when playing with small children. Outdoor activities such as swimming, water sports and rafting are curbed.

Contact lenses require repeated motivation with fastidious attention to hygiene during insertion and removal failing which vision-threatening infections may result. A back-up pair of glasses is always required. Contact lenses can cause dryness and irritation with prolonged wear. Recurrent allergies may develop in the lids and they can get lost in the eye. Protective glasses are required when going into windy, dusty climates. With prolonged wear they can affect the health of the cornea and there is a recurring cost involved for changing the lenses and solutions. In addition to this, most of the lifestyle limitations due to spectacles remain.

LASIK overcomes all these disadvantages and in addition to this, magnifies objects, improves the field of view, and improves ones natural vision to a point that almost all activities can be pursued without requiring either glasses or contact lenses. Wavefront-guided procedures have been developed not only to enhance visual acuity but also to improve on contrast sensitivity especially in dim light conditions.

Some of the more common reasons why people undergo LASIK are:

1. Contact lens intolerance

2. Cosmetic

3. Social (marriage)

4. Tired of wearing glasses

5. Lifestyle activities that are inhibited due to glass or lens wear

6. Occupational (Pilots, navy, defence, modelling, air-hostess)

Success after LASIK depends on the clinical outcome and how happy the patient is with the outcome of surgery. Care is required during the preoperative assessment, counseling and postoperative period to obtain the highest satisfaction from your patients.

Preoperative examination

This includes a complete eye assessment and certain tests in addition to determine a patientís suitability for LASIK. The assessment helps the surgeon to understand the patientís visual requirements both, vocational and avocational and to develop a customized treatment plan, anticipate any special concerns during the treatment and to assess the patientís psyche and his expectations from treatment, the refractive error must be patiently and accurately checked, the eye needs to be assessed as a whole and any pre-existing eye diseases must be ruled out. A brief systemic history is also required especially for conditions that could affect healing.

Patient counseling

This is a very significant part of the preoperative work-up. Every effort must be made to educate and appropriately counsel patients regarding results and possible complications of LASIK and what is a reasonable expectation in his/her case, to ensure an intelligent decision is made. Refractive surgery should be bought rather than sold. Patients have high expectations from modern medicine that are often unrealistic and encouraged by media coverage. The physician should be careful not to take advantage of such a mindset. Patient and physician must work together to determine what is best for the patient. The objective of the counseling by the treating refractive surgeon should be to understand and evaluate the patientís requirements and determine whether these are realistic. Further, the patient should be explained clearly what to expect from the treatment, including commonly asked questions such as:

1. Is it painful?

2. Are there restrictions on activity?

3. When can I return to work?

4. When will my vision improve?

5. If my result is not satisfactory, can I resume wearing my contact lenses?

6. If my correction is not right, can I be retreated?

The decision to perform surgery is an important one. All the patientís questions and concerns must be addressed to their satisfaction and patients should be encouraged to clear any doubts that they may have. To ensure the most satisfied patients, it is imperative that the surgeon identifies those patients who might be disappointed with merely "good" results ("not so sharp" 20/20 or better) or minor aberrations in vision. While only a minority of patients undergoes refractive surgery for occupational reasons, these patients must clearly understand the employerís requirements because specific visual results may not be attainable. Concern should be demonstrated for those patients who ask obsessively detailed questions, ask the same questions repeatedly, or demand unreasonable assurances.

The following are results from a patient satisfaction study conducted by the author on a series of 300 consecutive patients undergoing LASIK for one or both eyes.

Are you happy with the outcome of your treatment?

Did the outcome meet with your expectations?

Do you feel that the reasons for which you had the treatment were fulfilled?

How many of your activities can you manage without requiring glasses?

How often do you feel that you still need glasses to see clearly?

Would you recommend the treatment to a friend or a close relative?

What are the reasons for dissatisfaction?


Refractive surgery has been developing for over a hundred years. Surely those prescient 19th century clinicians and investigators could not have anticipated the rate and direction of growth in refractive surgery over the past decade. Thus our ability to predict the future is inextricably constrained by our present fund of knowledge. As new technology is developed, there is often a high level of enthusiasm that sometimes clouds objective scientific examination. Spectacular results fan the lay press that seeks such revolutionary technology. Caught up in the hype, there is a temptation for clinicians to "get on the bandwagon" without adequate training and experience. Unfortunately this pattern has been repeated many times.

Ophthalmology is embarking on a new course, one treating inherently non-vision-threatening problems rather than vision-threatening diseases. While the endpoint is similar ó useful vision ó the ultimate goal is assuring useful vision to each individual patient. It behooves us as clinicians to defend against the triviality of LASIK as a medical procedure, to ensure that treatment is performed only after the requisite experience is acquired and that the highest standard of care is adhered with results that are gratifying for both the clinician and patient alike. Only then will the Hippocratic oath be well served!

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