Patient satisfaction with refractive error correction important, says Dr. Waring

Refractive error is the leading cause of visual impairment in the world, and it is importantthat clinicians assess patient satisfaction/quality of life involving any effort to address refractive error,said George O. Waring III, MD, in his lecture after receiving the Mildred Weisenfeld Award for Excellence inOphthalmology.

Refractive error affects 30% to 70% of the population, or 153 million people, according to the World HealthOrganization, he said, adding that, in comparison, 124 million people have low vision and 37 million areblind.

Glasses, contacts, and IOLs are the most common prosthetic devices used to address refractive errors, said Dr.Waring, clinical professor of ophthalmology, Emory University, Atlanta. Cataract surgery is the top operation inhumans in the Western world in terms of volume, he added.

The Prospective Evaluation of Radial Keratotomy study, of which he was co-chairman with Peter J. McDonnell, MD, had a psychometric component, Dr.Waring said, even though the funding source provided no resources to evaluate quality of life. This componenthad three indices: satisfaction, fluctuation in vision, and glare.

"At the time [1981 to 1995], this was the first attempt to get a scientific questionnaire to evaluate thesepatients," he said.

Now, several efforts have been or are being undertaken to assess patient satisfaction with LASIK, Dr. Waringsaid. The Quality of Life Impact of Refractive Correction, or QIRC, questionnaire as well as the Vision Qualityof Life Index have found that patients who undergo refractive surgery are more satisfied with their quality oflife than are those who wear contact lenses or glasses, he said.

Also, he said, Kerry D. Solomon, MD, recently released a meta-analysis of the literature on quality of life and patient satisfaction after LASIK. He reviewed 2,915 abstracts and 1,581 articles and found 308 well-designed studies, 19 of which were well-designed in regards to patient satisfaction and quality of life. Those 19 articles involved 2,199 patients in 13 countries. Ninety-five percent of them (range, 87% to 100%) were satisfied with LASIK, and 5% (range, 0% to 13%) were unsatisfied, regardless of the date of surgery or whether LASIK was performed inside or outside of the United States.

Dr. Solomon reported three main reasons for patient dissatisfaction: dry eye, glare and halos at night, and residual refractive errors. The "dry eye" after LASIK is not dry eye at all but is corneal neuropathy that will improve in 2 to 5 years after surgery, Dr. Waring said. "It's a slow recovery for this," he said, adding that no way to completely address corneal neuropathy exists right now. "It's a part of LASIK," Dr. Waring said.

Regarding night vision and halos, he said, "Here we can do something: we can optimize the ablation profile," making an aspheric transition zone to result in a postoperative prolate cornea with less spherical aberration.

Residual refractive errors can be addressed via re-treatments (enhancements) performed subsequent to the original LASIK procedure, Dr. Waring said.

Patients need to be counseled preoperatively that LASIK re-treatments are an acceptable part of the operation "until human biological variability disappears," he said.

In addition to counseling patients about what they can expect from the procedure, Dr. Waring said, patient satisfaction with LASIK also could be increased through better nomograms; better registration of eye and laser; centration of the pupil, line of sight, and visual axis; improved quality-of-life questionnaires to help clinicians determine areas of concern.

Also, the joint task force recently formed by the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology, the FDA, and the National Eye Institute "will try to learn more about why patients are dissatisfied with LASIK and how clinicians can address it," Dr. Waring said.