Careful patient evaluation is essential in order to determine whether a patient is a candidate for LASIK surgery. The criteria used to determine candidacy are divided into two parts, psychosocial and anatomical. Each will be considered individually.
A good candidate for LASIK surgery should be capable of understanding the risks of the procedure and that risk-free surgery does not exist. The patient must be willing and able to follow instructions before, during, and after surgery. A patient who resists listening to a discussion of the risks may be a poor candidate for surgery. If the patient is unable to understand the surgeon due to a language barrier or disability, adequate preoperative counseling and intraoperative instructions will be more difficult to achieve. The patient must be available for postoperative follow-up. Beware of the patient with a challenging schedule who may not understand the care that is required after surgery.
Managing patient expectations is one of the greatest challenges a LASIK surgeon faces. This begins during the preoperative consultation. The patients should be told what level of visual acuity is reasonable to expect, with a subsequent enhancement procedure if needed. This can be expressed, as an expected range of visual acuity a particular patient would be likely to achieve. It is helpful to mention the surgeon's rate of enhancement for patients of a similar age with similar refractive error. A patient who expects perfection after surgery is destined to be unhappy postoperatively. Do not confuse visual acuity with visual function. A patient with 20/20 Snellen acuity may be unhappy due to loss of near vision, ghosting, decreased contrast sensitivity, glare, or other problems that affect the quality of vision. Personal characteristics of the best LASIK patients include an easygoing nature, a positive outlook, a well-adjusted personality, a patient comfortable using less than a full refractive error correction, and a willingness to wear glasses for reading or night driving. Intense individuals, patients with a grim outlook, highly emotional or vitriolic patients, or highly critical patients may not be well suited for LASIK surgery.
The patient's psychosocial candidacy for the procedure should be assessed while the history is taken as well as during the examination. Input from well-trained technicians or an office personnel is valuable information that should not be dismissed. However, it should not be considered a substitute for the surgeon's personal evaluation.
In general, the most reproducible results are obtained when LASIK is performed on a healthy patient with healthy eyes. There is less risk when the orbital and lid anatomy allow adequate exposure for the microkeratome or a femtosecond laser ring. The refractive error should preferably be well within the approved limits for the specific excimer laser being used. Patients with severe dry eye, absent corneal sensation, or inadequate eyelid closure are poor candidates for surgery. If a mechanical microkeratome is to be used and the corneal contour is abnormally steep or flat, the surgeon and the patient should be aware of the increased respective risks of buttonhole and free cap. The risk of buttonhole or free cap related to abnormal contour is of less concern when the flap is created with a femtosecond laser. LASIK may be a poor choice if the corneal diameter is unusually small. Finally, the corneal thickness is a major factor in determining the amount of refractive error that can safely be treated.
A standardized laser refractive surgery form, designed for recording the history and examination, can assist the surgeon in documenting pertinent information in an orderly manner. Using such a form can reduce the chance of inadvertent oversight in the evaluation. There is an advantage to using a form in which the results of multiple postoperative visits can be easily tracked. As practices transition to electronic medical records, templates should be modified to incorporate elements required for LASIK evaluation. While risks can be quickly recorded in a dot phrase, it is worthwhile to addend the statement to document the discussion of particular risks that are relevant to the specific patient.
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