In my hands
Quicker ‘wow’ factor, fewer re-treatments with the laser of choice

Front surface power map of an eye with prior hyperopic LASIK Source: Warren Hill, M.D.

Being a successful corneal refractive surgeon today means you have to pay attention to the patient experience and make it as easy, comfortable, rewarding, and memorable as possible. When it comes to LASIK surgery, this includes delivering great vision with minimal re-treatments. Although as surgeons we realize residual refractive error can be easily corrected with subsequent treatments, to the patient it means you didn’t do your best, “something went wrong” or “it didn’t work.”
People are already nervous about the surgery—going blind has been ranked as the second-highest thing people fear, with cancer the first and death the third; one could conclude many people are more scared of losing their vision than they are of death! I’ve heard stories of patients who are 20/25 telling the referring physician the surgery wasn’t a success. I’ve heard of prayer groups set up for patients who have residual astigmatism after refractive surgery. So from the patient’s perspective, a re-treatment can feel like a failure. I’ve used numerous laser systems since the initial Food and Drug Administration approval in the late 1990s, and my current laser of choice is the Allegretto (Alcon, Fort Worth, Texas) for three main reasons: The ‘wow’ factor is much more immediate than with other lasers I’ve used. The re-treatment rate in my hands is significantly lower. And the platform provides four options to customize the treatment for patients. Before using the this laser, I had a re-treatment rate of about 10%. With the Allegretto, this has fallen to around 4%—and my patients range anywhere from +5 D to –12 D, with up to 6 D of cylinder.
As surgeons, we have to address the fears patients have—whether they’ve vocalized their concerns or not. We have to make sure the patients have all the information they need to make good decisions about their health and lifestyle. Even though we’re in a serious recession, my percentage of cases from referrals has increased. I think one reason is because my re-treatment rates have decreased. If a referring OD sends you five cases and another surgeon five cases, and you have one re-treatment and the other surgeon has none, the OD will often draw the conclusion that the other surgeon is better. That can lose you referring doctors. Even the smallest reduction in re-treatments can lead to significantly more referrals. I have not changed my surgical techniques or strategies at all, so I do believe that much of the increased referral rates are because using the Allegretto results in much better surgical outcomes with a single procedure.
The ‘wow’ factor

Giving the patients what they want and are hoping for is the best way to grow your refractive practice. As I said before, patients are anxious about the surgery. On the day of their procedure, they’ve finally gotten to an emotional place where they tell themselves they can do this and that it’s okay. Sitting up immediately post-op and realizing they are “not blind” and can see, followed by a deep sigh of relief is one of the signature moments of the entire process of vision correction—and the sooner you can make it happen, the happier the patient is. As soon as the surgery is complete, I tell and demonstrate to patients that their vision is already starting to get better. They tend to focus on that, and to show them how much better their vision is I have myopes read a clock across the room and hyperopes read their watch. The ‘wow’ factor is generally quite immediate after surgery with the Allegretto. I have found that if they’re excited about their outcomes in that immediate time period, they’ll tell everyone they know.
One of the reasons I began using this laser was because I have found that it can treat hyperopes up to +5 D very well with rapid improvement in uncorrected distance vision. With other laser systems, I generally found a very different post-op course with significant myopia after hyperopic LASIK, but I have not found that with the Allegretto. I’m comfortable treating hyperopic refractions, as long as the post-op Ks will be below about 49. I get great results on my hyperopic patients with this laser. Moderate hyperopes are by far my happiest patients, especially those over 40.
Everyone wants the “whole enchilada” after they have LASIK surgery—it’s hard for patients over 40 to comprehend that they might have better distance vision, but they’ll need to use reading glasses. Mild myopes can still read without glasses before undergoing LASIK; the mildly myopic presbyope who undergoes LASIK is going to have both their reading and intermediate vision worsened and only their distance vision improved. So they get one out of the three things they’d like without glasses. But the hyperopes get three out of three (distance, intermediate and near) improved. As with all procedures, not everyone is a good candidate for hyperopic LASIK. If they’re unresponsive to dry eye treatments or have uncontrolled surface disease like blepharitis, I will try to optimize the ocular surface preoperatively with oral omega-3 fatty acids from fish oil capsules, oral doxycycline, and/or prescribe hot compresses to open up and improve meibomian gland function. If I can’t do so, I generally reject these patients for LASIK, especially hyperopic LASIK.

Lasers instead of lenses

One other thing I’m really enjoying about the Allegretto is performing PresbyLASIK, a technique I learned from Michael Gordon in San Diego, and pioneered by Roberto Pinelli, M.D., in Italy. This procedure is becoming more popular as an off-label procedure throughout the U.S. There are several options available today for the presbyopic patient. Premium IOLs are great, but without a cataract, I’m generally reluctant to perform cataract surgery. Monovision is an option, but if they don’t like monovision with contact lenses, they’re usually not going to like monovision LASIK surgery. Many people still think if you have LASIK, you’ll never need glasses, which can lead to patient dissatisfaction even after you explain presbyopia very clearly. With PresbyLASIK on the Allegretto, I’ve been able to provide spectacle-free vision for the vast majority of my presbyopic patients. One key to keeping patient satisfaction levels high in this group of patients is to make sure you’ve conveyed that this is not “typical LASIK” and they will not be jumping up and down with joy immediately after. I tell them their vision will take about 6 months before they get their final results. This doesn’t mean they can’t function during that time, just that they will often have to rely on reading glasses some of the time. I have numerous presbyopic patients over 50 years old with uncorrected vision of J1, 20/20. One other important point regarding choice of laser system for treating presbyopic patients is that wavefront-guided enhancement is often difficult to perform on eyes with premium IOLs because of imaging difficulties associated with these lenses. Wavefront-optimized treatments, however, are based on corneal curvatures and work very well on our presbyopic patients who have had premium cataract surgery Over the years I have come to appreciate that not all eyes can receive the same treatment approach. I highly value that the Allegretto platform gives me multiple treatment path options: wavefront-optimized, wavefront-guided, PresbyLASIK (which is off label), and I anticipate being able to use Topography-Guided once it receives FDA approval.
Re-treatments years later

Patients who had laser surgery years ago and now need a re-treatment are often experiencing lenticular aging issues. As long as the BCVA is not compromised, I think re-treatments with the Allegretto are easy to perform and offer another “wow” for patients. They’re immediately impressed with the incredibly rapid return of great vision after the Allegretto. I personally think it has to do with the ablation shape of the laser. To keep patients at ease and make their surgical experience less stressful, we have only a glass divider between the reception area and the surgical suite. The Allegretto has a very small physical footprint, so it looks much less intimidating than many other systems. Finally, when you have lower re-treatment rates, you have more time to spend on new patients. This reduces the need for the surgeon to explain to the patient why they’ve just spent thousands of dollars and need more surgery to say nothing of having to perform these enhancement procedures the associated risks (epithelial ingrowthwith flap lifts, for example) and the resulting expenses.
These are all are good things to avoid, and fewer re-treatments equal a happier patient, a happier staff, and therefore a happier surgeon. For all these reasons and its advanced technology capabilities, the Allegretto is now my laser of choice- for myopes, for hyperopes, for presbyopes, and for any necessary re-treatments.

Editors’ note: Dr. Rubinfeld has no direct financial interests related to his comments.

CONTACT:

Rubinfeld: (301) 654-5290; rubinkr1@aol.com