Role of the treating surgeon in the consent process for elective refractive surgery

Steven C Schallhorn,1–3 Stephen J Hannan,3 David Teenan,3 Julie M Schallhorn1 1Department of Ophthalmology, University of California, San Francisco, San Francisco, 2Roski Eye Institute, University of Southern California, Los Angeles, CA, USA; 3Optical Express, Glasgow, UK Purpose: To compare patient’s perception of consent quality, clinical and quality-of-life outcomes after laser vision correction (LVC) and refractive lens exchange (RLE) between patients who met their treating surgeon prior to the day of surgery (PDOS) or on the day of surgery (DOS). Design: Retrospective, comparative case series. Setting: Optical Express, Glasgow, UK. Methods: Patients treated between October 2015 and June 2016 (3972 LVC and 979 RLE patients) who attended 1-day and 1-month postoperative aftercare and answered a questionnaire were included in this study. All patients had a thorough preoperative discussion with an optometrist, watched a video consent, and were provided with written information. Patients then had a verbal discussion with their treating surgeon either PDOS or on the DOS, according to patient preference. Preoperative and 1-month postoperative visual acuity, refraction, preoperative, 1-day and 1-month postoperative questionnaire were compared between DOS and PDOS patients. Multivariate regression model was developed to find factors associated with patient’s perception of consent quality. Results: Preoperatively, 8.0% of LVC and 17.1% of RLE patients elected to meet their surgeon ahead of the surgery day. In the LVC group, 97.5% of DOS and 97.2% of PDOS patients indicated they were properly consented for surgery (P=0.77). In the RLE group, 97.0% of DOS and 97.0% of PDOS patients stated their consent process for surgery was adequate (P=0.98). There was no statistically significant difference between DOS and PDOS patients in most of the postoperative clinical or questionnaire outcomes. Factors predictive of patient’s satisfaction with consent quality were postoperative satisfaction with vision (46.7% of explained variance), difficulties with night driving, close-up vision or outdoor/sports activities (25.4%), visual phenomena (12.2%), dry eyes (7.5%), and patient’s satisfaction with surgeon’s care (8.2%). Conclusion: Perception of quality of consent was comparable between patients that elected to meet the surgeon PDOS, and those who did not. Keywords: consent process, refractive surgery, laser vision correction, refractive lens exchange, quality of life outcome

Angle Kappa is Not Correlated with Patient-Reported Outcomes After Multifocal Lens Implantation

Xi Liu,1,2 Stephen J Hannan,3 Steven C Schallhorn,4,5 Julie M Schallhorn5,6 1Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Military Medical University), Chongqing, People’s Republic of China; 2Key Laboratory of Visual Damage and Regeneration & Restoration in Chongqing, Chongqing, People’s Republic of China; 3Optical Express, Glasgow, UK; 4Carl Zeiss Meditec, Dublin, CA, USA; 5Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA; 6Francis I. Proctor Foundation, University of California United States, San Francisco, CA, USACorrespondence: Julie M Schallhorn, Francis I. Proctor Foundation, University of California, 490 Illinois St, San Francisco, CA, USA, Tel +1 415-514-1922, Email [email protected]: To examine the effect of preoperative angle kappa on patient-reported outcomes after multifocal lens placement during cataract surgery and determine if it is an effective measure for preoperative patients screening for multifocal lens placement.Setting: Private refractive surgery clinics.Design: Retrospective cohort study.Methods: All patients undergoing bilateral cataract or refractive lens exchange surgery with a target of emmetropia between 2013 and 2017 at Optical Express (Glasgow, UK) with multifocal lens placement for whom preoperative angle kappa measurement and a postoperative month 1 patient-reported outcomes measures were available were included.Results: A total of 1368 patients were identified. Median preoperative angle kappa was 0.41mm with an interquartile range of 0.30mm to 0.53mm. Preoperative angle kappa did not have a significant association with patient-reported satisfaction with vision (correlation coefficient 0.15, 95% confidence interval − 0.081 to 0.39, P = 0.20) nor with patient-reported photic phenomena (P > 0.09 for all comparisons). A receiver-operator characteristic analysis did not yield a viable cutoff predictive of patient-reported satisfaction.Conclusion: Angle kappa was not predictive of patient-reported satisfaction in this study. This study did not find evidence that it should be used as a screening test for patients considering multifocal intraocular lens placement.Keywords: angle kappa, multifocal intraocular lens, refractive lens exchang

Monovision LASIK in emmetropic presbyopic patients

Michelle Y Peng,1 Stephen Hannan,2 David Teenan,2 Steven J Schallhorn,1,3 Julie M Schallhorn1,4 1Department of Ophthalmology, University of California, San Francisco, CA, USA; 2Optical Express, Glasgow, UK; 3Carl Zeiss Meditec, CA, USA; 4F.I. Proctor Foundation, University of California, San Francisco, CA, USA Background: To evaluate the efficacy and patient satisfaction of laser in situ keratomileusis (LASIK) monovision correction in presbyopic emmetropic patients.Methods: A retrospective review of 294 patients who underwent LASIK for monovision was conducted. All patients had preoperative uncorrected distance visual acuity in each eye of 20/25 or better in both eyes and underwent primary LASIK treatment in one eye with a near target; 82 patients underwent surgery in the distant eye for hypermetropia. Patients completed a patient-reported-outcome questionnaire at their one-month postoperative visit. Analysis was performed on a per patient basis with a logistic regression model.Results: Patients achieved a postoperative mean spherical equivalent of -0.05 diopters (D) in the distant eye and -1.92 D in the near eye. Prior to surgery, 64.7% (n=178) of patients reported they were satisfied or very satisfied with their vision; postoperatively, this increased to 85.4% (n=251). The greatest predictor of dissatisfaction after surgery was severe patient-reported visual phenomena (glare, halos, starbursts, ghosting) (odds ratio 1.18, P=0.001).Conclusions: LASIK monovision for presbyopic patients with low refractive error and good preoperative uncorrected distance visual acuity is both safe and effective with high patient satisfaction. Patients who were dissatisfied in the postoperative period tended to be those with postoperative visual symptoms. Keywords: monovision, LASIK, presbyopia, refractive surger

Informed consent in refractive surgery: in-person vs telemedicine approach

Steven C Schallhorn,1–3 Stephen J Hannan,2 David Teenan,2 Martina Pelouskova,2 Julie M Schallhorn1,4 1Department of Ophthalmology, University of California, San Francisco, CA, USA; 2Optical Express, Glasgow, UK; 3Carl Zeiss Meditec, Dublin, CA, USA; 4F.I. Proctor Foundation, University of California, San Francisco, CA, USA Purpose: The aim of this study was to compare the quality of consent process in refractive surgery between patients who had a preoperative consent discussion with the surgeon using a telemedicine approach and those who had a face-to-face discussion.Methods: Patients treated between January and December 2017 (8,184 laser vision correction [LVC] and 3,754 refractive lens exchange [RLE] patients) that attended day 1 and 1-month postoperative visit were retrospectively reviewed. Preoperative consent preparation included a consultation with an optometrist, observation of an educational video, and written information. Patients then selected either a face-to-face appointment with their surgeon (in-clinic group) or a telemedicine appointment (remote group) for their consent discussion, according to their preference. Patient experience questionnaire and clinical data were included in a multivariate model to explore factors associated with consent quality.Results: Prior to surgery, 80.1% of LVC and 47.9% of RLE patients selected remote consent. Of all LVC patients, 97.5% of in-clinic and 98.3% of remote patients responded that they were adequately consented for surgery (P=0.04). Similar percentages in the RLE group were 97.6% for in-clinic and 97.9% for remote patients (P=0.47). In a multivariate model, the major predictor of patient’s satisfaction with the consent process was postoperative satisfaction with visual acuity, responsible for 80.4% of variance explained by the model. Other significant contributors were postoperative visual phenomena and dry eyes, difficulty with night driving, close-up and distance vision, postoperative uncorrected distance visual acuity, change in corrected distance visual acuity, and satisfaction with the surgeon’s approach. The type of consent (remote or in-clinic) had no impact on patient’s perception of consent quality in the regression model.Conclusion: The majority of patients opted for telemedicine-assisted consent. Those who chose it were equally satisfied as those who had a face-to-face meeting with their surgeon. Dissatisfaction with surgical outcome was the major factor affecting patient’s perception of consent quality, regardless of the method of their consent. Keywords: informed consent, telemedicine, refractive surgery, LASIK, photorefractive keratectomy, refractive lens exchange&nbsp

Outcomes of excimer laser enhancements in pseudophakic patients with multifocal intraocular lens

Steven C Schallhorn,1–3 Jan A Venter,2 David Teenan,2 Julie M Schallhorn,3 Keith A Hettinger,2 Stephen J Hannan,2 Martina Pelouskova2 1Department of Ophthalmology, University of California, San Francisco, CA, USA; 2Optical Express, Glasgow, UK; 3Department of Ophthalmology, University of Southern California, Los Angeles, CA, USA Purpose: The aim of this study was to assess visual and refractive outcomes of laser vision correction (LVC) to correct residual refraction after multifocal intraocular lens (IOL) implantation. Patients and methods: In this retrospective study, 782 eyes that underwent LVC to correct unintended ametropia after multifocal IOL implantation were evaluated. Of all multifocal lenses implanted during primary procedure, 98.7% were refractive and 1.3% had a diffractive design. All eyes were treated with VISX STAR S4 IR excimer laser using a convectional ablation profile. Refractive outcomes, visual acuities, patient satisfaction, and quality of life were evaluated at the last available visit. Results: The mean time between enhancement and last visit was 6.3±4.4 months. Manifest spherical equivalent changed from -0.02±0.83 D (-3.38 D to +2.25 D) pre-enhancement to 0.00±0.34 D (-1.38 D to +1.25 D) post-enhancement. At the last follow-up, the percentage of eyes within 0.50 D and 1.00 D of emmetropia was 90.4% and 99.5%, respectively. Of all eyes, 74.9% achieved monocular uncorrected distance visual acuity 20/20 or better. The mean corrected distance visual acuity remained the same before (-0.04±0.06 logMAR [logarithm of the minimum angle of resolution]) and after LVC procedure (-0.04±0.07 logMAR; P=0.70). There was a slight improvement in visual phenomena (starburst, halo, glare, ghosting/double vision) following the enhancement. No sight-threatening complications related to LVC occurred in this study. Conclusion: LVC in pseudophakic patients with multifocal IOL was safe, effective, and predictable in a large cohort of patients. Keywords: excimer laser enhancements, pseudophakic patients, multifocal IO

Comparison of the 1st Generation and 3rd Generation Wavefront-Guided LASIK for the Treatment of Myopia and Myopic Astigmatism

Stephen J Hannan,1 David Teenan,1 Jan A Venter,1 Keith A Hettinger,1 Colin W Berry,1 Noelle C Hannan,1 Huba J Kiss,1 Dasi Raju,1 Julie M Schallhorn2,3 1Optical Express, Glasgow, United Kingdom; 2University of California, San Francisco, Department of Ophthalmology, San Francisco, CA, USA; 3F.I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USACorrespondence: Stephen J Hannan, Clinical Services Department, Optical Express, 200 St Vincent St, Glasgow, G2 5SG, United Kingdom, Tel +44 7740592389, Email [email protected]: To compare refractive, visual, and patient-reported outcomes associated with a 1st generation wavefront-guided (WFG) treatment with those associated with a 3rd generation WFG treatment.Patients and Methods: This retrospective study included patients who underwent femtosecond laser-assisted in situ keratomileusis (LASIK) for myopia/myopic astigmatism. Two random stratified samples of patients who underwent either 1stgeneration (WaveScan, Johnson & Johnson Vision, Santa Ana, CA) or 3rd generation (iDesign 2.0, Johnson & Johnson Vision, Santa Ana, CA) treatment matched on preoperative refraction were compared (4290 eyes of 2145 patients in each group). One-month postoperative visual, refractive, and patient-reported outcomes were analyzed. Refractive and monocular visual acuity analyses were performed using one random eye of each patient.Results: The percentage of eyes achieving 20/20 or better uncorrected vision was 91.3% (1958/2145) in the 1st generation group and 95.9% (2056/2145) in the 3rd generation group (p< 0.01). Binocularly, the percentage of patients with 20/20 or better UDVA was 97.0% (2080/2145) and 99.2% (2127/2145) in the 1st and 3rd generation groups, respectively (p< 0.01). The mean postoperative MSE was − 0.01 ± 0.33 D in the 1st generation group and +0.19 ± 0.33 D in the 3rd generation group (p< 0.01). Postoperative refractive astigmatism had a mean value of − 0.20 ± 0.26 D and − 0.18 ± 0.24 D in the 1st and 3rd generation groups, respectively (p< 0.01). The mean correction index of refractive astigmatism was 1.09 ± 0.53 in the 1st generation group and 1.02 ± 0.38 in the 3rd generation group, p< 0.01. The overall percentage of patients satisfied with vision was 92.8% (1991/2145 patients) in the 1st generation group and 97.3% (2087/2145 patients) in the 3rd generation group (p< 0.01).Conclusion: For the majority of postoperative variables, there were significant differences between 1st and 3rd generation treatments. The 3rd generation treatments had better visual acuity outcomes and higher patient satisfaction.Keywords: wavefront-guided LASIK, myopia, aberrometer, refractive outcomes, patient-reported outcome