The Basics: A New Direction for Some ISRS Symposia?

By Linda Roach

After an ISRS-sponsored symposium on the fundamentals of refractive surgery for residents drew an overflow crowd at the American Academy of Ophthalmology’s Annual Meeting in Chicago in early November, the symposium’s organizers have explored continuing their “back to basics” learning opportunities for next year’s Annual Meeting in New Orleans.

With all 275 seats occupied and dozens of other people standing, late arrivals at the “Introduction to Refractive Surgery for Residents” symposium were turned away at the door for safety reasons, said ISRS President Amar Agarwal, MBBS, MS, FRCS, FRCOphth (Lon.), of Chennai, India.

Dr. Agarwal and other ISRS leaders had suspected that a “how-to” session based on the accumulated knowledge of top refractive surgery experts would be popular. But the magnitude of the response was a surprise, said Ronald R. Krueger, MD, ISRS president-elect and a co-organizer of the symposium.

A Thirst for Fundamentals

“People obviously want to hear presentations that are comprehensive and easy to understand, so the information doesn’t go over their heads. They want core information,” said Dr. Krueger, medical director of refractive surgery at Cleveland Clinic's Cole Eye Institute.

Perhaps some in the audience also were drawn there by the reputations and expertise – even star power – of the panel that Dr. Krueger and co-chair Dr. J. Bradley Randleman, ISRS Executive Committee member and editor of the Journal of Refractive Surgery, assembled for a two-hour whirlwind journey through the fundamentals of refractive surgery. The symposium included:

Dr. Krueger on "Basic LASIK Patient Evaluation"
Dr. Randleman on “Topographic Evaluation”
Dr. Sonia H. Yoo, professor at the University of Miami’s Bascom Palmer Eye Institute, on "Step-by-Step PRK and LASIK Surgery”
Dr. Marguerite B. McDonald, ISRS Executive Committee member on "PRK-vs.-LASIK Decision Tree"
Dr. Agarwal on "Intraoperative Complications and Management"
Dr. David R. Hardten, ISRS Executive Committee memberon "Postoperative Complications and Management”

Despite the symposium’s name, only about 40 percent of the audience appeared to be current ophthalmic residents, Dr. Krueger said. Based on audience questionnaires, 40 percent were practicing ophthalmologists who wanted to learn how to perform LASIK, and 20 percent were experienced LASIK surgeons.

“You might ask why an ophthalmologist already in practice or even an experienced LASIK surgeon would want to attend. At specialty meetings like the AAO and ISRS, they are always hearing about the cutting-edge things that are new or off in the future. But in a session like this one, they get the core information they need,” Dr. Krueger said.

Such a symposium might be a refractive surgery refresher for some veteran ophthalmologists, and for others it might inform decisions about expanding into LASIK and PRK, Dr. Krueger said.

A Warm Welcome for the Step-By-Step Approach

Dr. Yoo, who guided her listeners through the PRK and LASIK procedures, step by step, said, “As I was preparing, I was a little worried that my talk would be too simple.” But afterward she concluded that the audience was grateful for this level of detail.

Nothing is decided yet, but Drs. Krueger and Agarwal are hopeful about the possibility of repeating “Introduction to Refractive Surgery for Residents” in New Orleans next year.

“Now that we see this tremendous response, we have to consider how to address the need for basic information this reflects,” he said. “You have to have a balance of both basics and surgical techniques."

Five Tips For Happier LASIK Patients

Interested in improving satisfaction in your LASIK patients? The senior instructor at the “Step-by-Step Primer to Starting LASIK in 2012” course at the Academy’s Annual Meeting in Chicago recommended some tweaks in surgical routines that may put bigger smiles on your patients’ faces. (Course #338, 9 a.m., Monday, Nov. 12)

Here are some of the tips offered by Dan Z. Reinstein, MD, MA(Cantab), FRCSC, FRCOphth, a refractive surgeon who practices in London, Paris and New York City.

1. Crosscheck yourself to avoid mistakes.
No matter how proud you are of your preop routines, mistakes can happen. So double- and triple-check everything before beginning surgery. Do you have the right patient? The correct eye? Do the numbers from the original exam match the patient on the table? Is the axis of astigmatism set correctly? Better to check and re-check than to find yourself apologizing to the patient later for an avoidable mistake.

2. Talk, talk, talk. All the time.
It is important for the surgeon to talk continuously – with silences of no more than 1 or 2 seconds – throughout the procedure. This not only relieves the patient’s anxiety but also prevents the patient from talking. “If they talk, this distracts the patient from doing what I want them to do during the procedure,” Dr. Reinstein said. So avoid gaps in your monologue.

3. Describe what the patient is about to feel, not what you are about to do.
You want to build the patient’s confidence and trust in you, and to lower anxiety. So describe what each step is going to feel like, right before it happens.

4. Say the same things the same way every time.
Develop a good “script” for yourself, and follow it during every LASIK case. “If your patter isn’t the same every time, you’ll stutter and stumble on your words, and the patient will lose confidence in you and get anxious,” he said.

5. Avoid surprising the patient.
This is important because a patient who experiences unexpected discomfort, or who hears a scary sound, might lose trust in you or – worse – startle at a critical time during the procedure, Dr. Reinstein said.

For example:

Before beginning to cut a flap with a mechanical microkeratome, acclimate the patient to the sound by buzzing the device in the air for a few seconds.
Take a few extra seconds to open the lid speculum slowly and gently while placing it. The patient will feel excessive discomfort if you open it quickly, he said.

What Does It Take To Be Great?

"To be a great LASIK surgeon you need to be someone who enjoys and takes pleasure in the perfection of repetition,” Dr. Reinstein said. “Like a concert pianist or an airline pilot, you take pleasure in executing the perfect performance over and over again. But you're ready for any situation which requires an alteration of your process."

Dr. Agarwal is a consultant for Abbott Medical Optics, Bausch + Lomb Surgical and STAAR Surgical. He receives royalties from Slack and Thieme Medical Publishers, and is an equity owner in Dr. Agarwal's Pharma.

Dr. Krueger is a consultant for Alcon, Clarity Medical and Presbia. He has received lecture fees from Alcon, and holds equity in Calhoun Vision and LensAR.

Dr. Yoo is a consultant for Alcon, Bausch + Lomb Surgical, Optimedica and Transcend, and she has received lecture fees from Alcon and SLACK, Inc. She has received grant support from Allergan, Carl Zeiss Meditec and Genentech.

Dr. Reinstein is a consultant to Arcscan and Carl Zeiss Meditec. He receives royalties from Arcscan.