What is the best way to handle unhappy, angry or emotional post-op refractive surgery patients? I thought I knew a lot about this topic – until I saw a presentation by John Potter, vice president of Clinical Affairs for TLC Vision. He described how, and why, patients may react after an unexpected visual loss. I recently spoke with John and asked him to share his unique approach to dealing with unhappy patients. I hope you will find this as useful and interesting as I did. – Marguerite McDonald, MD, FACS

CLINICAL UPDATES
- MMC can inhibit haze formation after PRK for residual myopia following RK
- Early steroid-induced increase in IOP after LASIK can cause corneal edema and a sudden decrease in vision
- Central lamellar flap necrosis can occur with femtosecond laser created flaps
- Slight advantage for optic shift IOL compared to conventional IOL
- Aspherical IOL results in better optical quality compared to spherical IOL
- Early DSAEK results: promising, but not yet a replacement for penetrating keratoplasty

ISRS/AAO INFORMATION
- Save money and avoid long lines; register early for the 2007 ISRS/AAO annual regional meeting in Beijing
- Make your travel and hotel arrangements to Beijing today
- 2006 ISRS/AAO membership dues are payable now
- ISRS/AAO to participate in the MEACO Congress in Dubai
- Help us tell the story of ISRS/AAO, send us your photos

INDUSTRY NEWS
- Icon LASIK opens its first clinic in China

CALENDAR
- Upcoming meetings

CLINICAL UPDATES

MMC can inhibit haze formation after PRK for residual myopia following RK
This prospective study of 14 patients (22 eyes) with under-correction or regression following RK finds that a single intra-operative application of MMC 0.02 percent for two minutes resulted in improved uncorrected visual acuity and residual refractive error in all eyes with minimal haze formation and loss of BSCVA 12 months after treatment. Also, 85.5 percent of eyes had a refractive outcome within 0.50 D. Journal of Refractive Surgery, March 2007

Early steroid-induced increase in IOP after LASIK can cause corneal edema and a sudden decrease in vision
This retrospective review of 15 patients (29 eyes) who experienced a decrease in UCVA within the first three weeks after surgery finds that rapid diagnosis and treatment can control IOP and recover the visual loss. These patients presented with flap edema but without signs of interface fluid or inflammatory response. Patients with low myopia who experience an early postoperative decrease in vision require urgent examination to exclude steroid-induced IOP spike. The authors also recommend close follow-up in patients with a family history of glaucoma or glaucoma suspects. Journal of Refractive Surgery, March 2007

Central lamellar flap necrosis can occur with femtosecond laser created flaps
A retrospective chart review identified severe central flap inflammation and necrosis in nine eyes of eight patients, two of which underwent flap creation with a femtosecond laser. This condition appears to differ from diffuse lamellar keratitis because the location of stromal inflammation is in the flap anterior stroma, not in the flap interface. The condition can lead to some visual loss. It usually causes a temporary hyperopic shift, which regresses in most patients. Treatment with corticosteroids appeared to have little effect on outcomes. Journal Refractive Surgery, March 2007

Slight advantage for optic shift IOL compared to conventional IOL
This prospective, non-randomized study gave patients implanted with the1CU a minor statistical advantage in reading vision. Both groups achieved BCVA of one for distance at one month postop, which was maintained at 12 months follow-up. Of the patients implanted with the 1CU, 2.7 percent achieved a final near visual acuity of Nieden 1 to 3 with distance BCVA. No control patients achieved such near vision. The accommodative effect of the 1CU differed from patient to patient and was not predictable. Journal of Refractive Surgery , February 2007

Aspherical IOL results in better optical quality compared to spherical IOL
An evaluation of optical aberrations in eyes having uneventful cataract surgery finds the aspherical IOL yielded better ocular aberration and optical quality. Induced coma was somewhat higher in the aspherical group, but overall results were unaffected. Physiologic IOL decentration after correct in-the-bag implantation did not negate the advantages of asphericity. A separate study finds improved mesopic contrast sensitivity with the aspherical IOL, which led to patient reports of improved vision quality. Journal of Cataract & Refractive Surgery, February 2007

Early DSAEK results: promising, but not yet a replacement for penetrating keratoplasty
This prospective series of 26 patients (26 eyes) finds that 20/20 vision is possible with this technique, but most patients achieved 20/30 to 20/40 vision. Nearly one third of the donor lenticules needed to be either repositioned or replaced. Still, the authors conclude that Descemet’s stripping and automated endothelial keratoplasty (DSAEK) offers significant advantages over standard penetrating keratoplasty for patients with Fuchs’ dystrophy and pseudophakic bullous keratopathy. Ophthalmology, February 2007

Back to Top

ISRS/AAO INFORMATION

Advance registration ends April 11. Early registration allows you to take advantage of reduced fees and avoid the long lines of onsite registration. Apply online or by downloading the application and returning it to ISRS/AAO. Fax: +1-415-561-8583 or mail: 655 Beach Street, San Francisco, CA 94109 USA.

Make your travel and hotel arrangements to Beijing today
ISRS/AAO has posted resources on its Web site to help you plan a successful trip to Beijing, from travel and housing information to a letter of invitation and program schedule.

2006 ISRS/AAO membership dues are payable now
If you have already paid your dues, thank you. If not, you can do so online.

ISRS/AAO to participate in the MEACO COngress in Dubai
ISRS/AAO will sponsor a refractive surgery session, featuring world renowned leaders presenting the latest techniques and developments in refractive surgery, during the Middle East African Council of Ophthalmology Congress, March 29 to April 1. “So New It May Not Be True!!” is scheduled for Saturday, March 31, 10:45 a.m. to 12:25 p.m. Be sure to also stop by the ISRS/AAO booth (#313) to visit with ISRS/AAO staff, renew your membership and review products. The Academy also has a booth (# 317) and organized other activities for the Congress, including a symposium on the contemporary management of common vitreoretinal disorders.

Help us tell the story of ISRS/AAO, send us your photos
To honor ISRS’ 20th anniversary Jorge Alio, MD, has arranged to have published a history of our organization, from its formation and growth to its current status as the world’s largest and strongest eye care organization dedicated solely to refractive surgery. If you have photos that would help tell our story, please forward them to Annamarie Hastings at ahastings@aao.org. The book will be presented during the ISRS/AAO Gala Dinner & Dance during the Academy’s 2007 Annual Meeting in New Orleans. Photos need to be at least 300 dpi and no smaller than 4 X 4 inches. If you have many images or very large images, you may post them on our FTP site at ftp://ftp.aao.org (Username: isrsaao Password: isrsaao). To import your images, create a new folder labeled with your full name, and then drag and drop the images from your computer into the folder on the FTP site. Lastly, please e-mail ahastings@aao.org to let us know of your contribution. If you need assistance, call Annamarie at +1-415-447-0398.

Back to Top

INDUSTRY NEWS

Back to Top

Back to Top

FEATURE

The Best Way to Handle Unhappy, Angry or Emotional Refractive Surgery Patients

Marguerite B. McDonald, MD in an interview with John Potter, Vice President of Clinical Affairs for TLC Vision

I thought I knew a lot about this topic – until I saw a presentation by John Potter. I recently spoke with John and asked him to share his unique approach to dealing with unhappy patients. I hope you will find it as useful and interesting as I did.

Do you only work with refractive surgery patients?
Yes, patients who are referred to me by our surgeons. Typically, these patients have experienced considerable postoperative eye or vision problems.

The challenging cases, then.
Yes. Refractive surgeons often report that they are bewildered by strong patient reactions when things don’t go as well as the surgeon and patient expected. Early on, I made a number of mistakes because while I understand surgical complications can happen I was unprepared for patient responses to unexpected outcomes. Once I accepted that complications are not necessarily the same thing as unexpected results I radically changed my approach.

You are saying that it’s not necessarily the severity that upsets refractive surgery patients, but the unexpected outcome?
Exactly. The emotion does not stem from the scope of problem, but because expectations were not met. Of course, this does not mean that the surgical outcome itself was bad. This may be the very first time in the patient’s life that they lost vision, or had an unexpected outcome from any surgery.

Can you share an example?
Let’s say your patient wanted monovision, but both eyes were corrected for distance. This patient can become as emotional and distraught as the patient with an incomplete or free flap.

That’s a terrific example. Why do you think there is such a disparity in the way these patients react?
First, it is impossible to judge how significant someone else’s visual loss is. It’s also important to remember that for the patient it is not about the degree of loss, but the loss itself. This is often where the communication breaks down. The surgeon says “but your outcome is good” and the patient is focused on the fact that it is still not what they expected.

What is it that drives the refractive surgery patient’s distress?
Grief. These patients are grieving for a loss that they have experienced, which is a normal human response. Understanding grief, and what to expect, requires knowledge and sensitivity that may not come naturally; especially for refractive surgery where complications are rare. Surgeons are often unprepared for an emotionally distraught patient.

Once you changed your approach, what happened?
Well, I saw dramatic results. We rarely have legal actions filed against our surgeons and/or our company, and we help a lot of patients for whom the surgeon-patient relationship has been damaged or lost. It is very uncommon for a patient or a surgeon to be dissatisfied with the manner in which we resolve patient disputes.

Can you describe the grief process?
Sure. I have identified nine stages:

1. Shock. Patients may enter a state of shock, and appear to be numb or even accepting of their circumstances. It is important to recognize this. Things may appear to be fine, and that all is well, but it will become evident that this is not the case once the patient moves to the next stage – usually in a matter of days or weeks.

2. Emotion. This phase is very predictable. Your patient may express anger and frustration and, because surgeons are not used to having patients yell at them, they may react by withdrawing. It is important to stay close to your patient, even with a brief phone call to communicate your concern and describe what your intentions are.

3. Depression. Anxiety, anger and grief can result in a situational depressive state for patients. It is not uncommon for patients to share thoughts of ending their own lives. While I am not aware of any patient who has ever acted on these thoughts, this expression can help you understand where the patient is in the grief process.

4. Physical symptoms. I have heard patients say, “My eyes are so bad that I cannot work at all” or “my vision is so bad, I cannot even drive at night.” Complaints of back pain, and other symptoms unrelated to eyes or vision are not uncommon. If you discover that the patient is still working full-time or driving at night, you may think the patient is not being upfront with you, and that is frustrating. It is best to say that you understand their difficulties with work or driving activities, and not challenge statements that seem contradictory – it will push the patient backward and even cause withdrawal, which damages all the progress you have made.

5. Anxiety. At this stage, it is common to hear “I will go anywhere, and do anything to fix my problem. This is intolerable. I want you to fix this now.” It may be tempting to appease the patient by performing additional surgery, but the results almost never fulfill expectations. It is also likely to further strain your relationship - possibly to the breaking point.

6. Guilt. The patient may ask you if having refractive surgery was a mistake. This is difficult – especially when faced with unexpected results. Also, considering that you spent time with your patient to carefully explain the options, benefits and risks of surgery, you may not honestly believe that surgery was a mistake.

7. Anger and Resentment. Anger and resentment may be expressed over what patients feel their surgeon has, or has not, done. It may even become the patient’s mission to remind you of their suffering. Some patients may express their emotions on Web sites, explaining their feelings about their unexpected refractive surgery results. While this can be an especially challenging time, it is important to stay close to the patient because at this point the patient needs his or her surgeon more than ever.

8. Resistance to returning to normal. It can be trying when patients resist your attempts to schedule a treatment or arrange for additional surgery. However, while it may seem odd, the harder you push the more resistance you will encounter. Back off and give the patient space. Encourage him or her to wait until they feel the time is right. Stay in touch over the next months. Do not push and remain committed to respecting the patient’s decision when they are ready.

9. Hope returns. Your patient will begin to look ahead, not dwell on the past, and be ready to make a decision about how they would like to proceed. The patient may end up with better vision, and refractive surgery will improve the patient’s quality of life, rather than serve as a major focus. When this happens it is a remarkable experience. I’ve heard patients apologize for previous behavior, and countless patients – who were previously unhappy - have even offered to make themselves available to other patients with similar problems.

Are there a few general principles that surgeons can keep in mind, as the patient moves from stage to stage?
In all stages of grief always honestly communicate your concern. Again, when a patient is angry, or even yelling, being less than candid is natural. The last thing you wish to do is exacerbate the patient’s anger. The goal here is to maintain your patient’s trust and preserve the surgeon-patient relationship.

Throughout this entire process it is important to clearly explain your intentions. Perhaps more importantly, do not say that you understand what your patient is going through emotionally; most patients will tell you that you do not know and in most cases this is true.

Share what you do know with your patient, and explain how this experience will help you address future situations.

As refractive surgery patients go through the stages of grief it is important to stay in close contact. Be honest. If you do not have all the answers, offer to do what it takes to find the information and communicate your concern in regular phone calls. By doing these things you will help preserve your relationship, which can lead to happier outcomes for everyone.

Back to Top