The preoperative patient evaluation is perhaps the most critical component in achieving successful outcomes after refractive surgery. It is during this encounter that the surgeon develops an impression as to whether the patient is a good candidate for refractive surgery. Perhaps the most important goal of this evaluation, however, is to identify who should not have refractive surgery.
The evaluation actually begins before the physician sees the patient. Technicians or refractive surgical coordinators who interact with a patient may get a sense of the patient’s goals and expectations for refractive surgery. If the patient is particularly quarrelsome about the time or date of the appointment or argues about cost, the surgeon should be informed. Such a patient may not be a good candidate for surgery.
Important parts of the preoperative refractive surgery evaluation include an assessment of the patient’s expectations; the social, medical, and ocular history; manifest and cycloplegic refractions; a complete ophthalmic evaluation, including slit-lamp and fundus examinations; and ancillary testing (Table 2-1). If the patient is a good candidate for surgery, the surgeon should discuss the benefits, risks, and alternatives with the patient as part of the informed consent process. (See “Discussion of Findings and Informed Consent” later in this chapter.)
Because accurate test results are crucial to the success of refractive surgery, the refractive surgeon must closely supervise office staff members who are performing the various tests (eg, corneal topography or pachymetry) during the preoperative evaluation. Likewise, the surgeon should make sure the instruments used in the evaluation are properly calibrated, as miscalibrated instruments can result in faulty data and poor surgical results.
One of the most important aspects of the entire evaluation is assessing the patient’s expectations. Inappropriate patient expectations are probably the leading cause of patient dissatisfaction after refractive surgery. The results may be exactly what the surgeon expected, but if those expectations were not conveyed adequately to the patient before surgery, the patient may be disappointed.
The surgeon should explore expectations relating to both the refractive result (eg, uncorrected visual acuity [UCVA; also called uncorrected distance visual acuity, UDVA]) and the emotional result (eg, improved self-esteem). Patients need to understand that they should not expect refractive surgery to improve their best-corrected visual acuity (BCVA; also called corrected distance visual acuity, CDVA). In addition, they need to realize that refractive surgery will not alter the course of eventual presbyopia, nor will it prevent potential future ocular problems such as cataract, glaucoma, or retinal detachment. If the patient has clearly unrealistic goals, such as a guarantee of 20/20 uncorrected visual acuity or perfect uncorrected reading and distance vision, even though he or she has presbyopia, the patient may need to be told that refractive surgery cannot currently fulfill his or her needs. The refractive surgeon should exclude such patients.
Table 2-1 Important Parts of the Preoperative Refractive Surgery Evaluation
Excerpted from BCSC 2020-2021 series: Section 13 - Refractive Surgery. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.