Misc: The LASIK/PRK switcheroo

I stick pretty much exclusively to dry eye in the blog, but occasionally if something else related to eyecare is on my mind I'll digress....

One of the discussion forums I'm involved with (lasermyeye.org/forums) deals exclusively with refractive surgery. It used to mostly be home to lasik complications patients but it's evolved a lot and these days, with the interesting shift back to surface ablation that we've been seeing, it's mostly dominated by patients who are experiencing unexpected bumps in healing after PRK. While some end up with long-term issues, I'd say the majority of visitors to D'Eyealogues were simply poorly informed about what to expect during healing from PRK, or are experiencing an unusually long and bumpy recovery, or both.

These patients are often scared to death when they find they can't work or drive three weeks post-op and don't understand why their doctor seems unconcerned. Or they are concerned at how dramatic the ups and downs of their vision seem in the weeks and months after surgery - often wondering, is there still hope my vision will get better or is this it for me? Often all they need is to read the stories of fellow patients and with a little hand-holding, a little coaching about being patient, they come to understand that what they are experiencing is (relatively) normal and that in all probability they will be just fine. At the same time, though, when I come across patients who are in real emotional distress and have clearly not had any heads up at all about the possibility that PRK healing might interfere this much with life, I encourage them to make their feelings known to their surgeon and clinic, for the benefit of future patients.

Coming to the point now....

I am amazed that we continue to periodically get reports of patients being scheduled for LASIK surgery and then, on the day of surgery, being switched to PRK at the last minute after the surgeon decides their corneas are too thin for LASIK or spots some topographical abnormality.

Guys/gals, is this within the standard of care for refractive surgery? If so, in my opinion, it should not be.

There is, of course, considerable variety in how these situations are handled, ranging from moderately rational-sounding to absolutely appalling. In the best cases I've come across, the patient is given a new informed consent form, shown a video, and given some time to ask questions, as well as a choice about whether to go ahead with surgery that day or re-schedule. In other cases... well, there are the ones who have signed their forms and taken their valium and then are told they're going to have PRK instead. There are even some who were NOT told, or at any rate did not understand - and left the clinic after the surgery UNSURE of what kind of surgery they had just undergone. (I kid you not.) Most worrying to me of all are one or two switcheroo cases where the change was made but the file was not updated and so the patient was given post-operative instructions for LASIK although they had had PRK. We had a case like that where the patient did not know anything was amiss until they described their postop medication regimen to us in the forum. Even then, the patient had to go over the head of a stubborn, misinformed clinic staff member in order to get it straightened out. All while re-epithelializing. Beautiful, just beautiful.

This stuff is very worrying to me. It's bad enough how many people we hear from who were scheduled for PRK and were given, er, "optimistic" descriptions of what re-epithelialization and subsequent vision fluctuation would/could be like. But when a surgical plan is changed that drastically on the very day of surgery, the patient does not have the opportunity to do their own research at their leisure about how surface ablation differs from LASIK and what it will mean for them in the short and long term.

My question to surgeons: Given the risk of the patient not fully understanding the implications of doing surface ablation rather than LASIK, how can you justify switching surgeries on the day of the scheduled surgery? Why not re-schedule the surgery, allowing the patient time to educate him/herself and review their options?

The only reasons I can think of to proceed as scheduled are exclusively for the benefit of the clinic and surgeon. After all, if the patient is sent away to think about it, they might...

1) Decide not to have surgery at all.
2) Decide to postpone it indefinitely.
3) Start questioning the competence of a doctor who didn't figure out until the day of surgery that LASIK was not the best option.
4) Go get surgery someplace else.

In my opinion, the ethical case is cut and dried. Surgeons have an obligation to put the best interests of the patient first. Period.

If you've been too busy patting yourself on the back for noticing the patient's increased risk before firing up the microkeratome or the intralase to think about this aspect of the "patient's best interests", please step back a moment to see things from the patient's point of view.

You may think you can justify a same-day switch on the basis that you told the patient all about PRK and s/he seemed to understand and confidently voiced agreement to go ahead. But put yourself in the position of the patient. They've been planning this for quite awhile, and steeling themselves for a surgery to a really important part of their body. They showed up, they swiped their credit card, they filled out the forms, they're all prepared - and they feel all the pressure of messing up other people's day if they bow out. There is simply no way a patient can be expected to make a thoroughly objective decision on their own under those circumstances.

Or you might justify a same-day change on the basis that if you send the patient away, worse will happen. Maybe the lasik mill down the street will take them on and, given their thin corneas, they'll end up with ectasia. (And golly aren't you great for identifying their risk factor and admitting it rather than going ahead!) True, some patients are foolish enough to "shop around" for someone to do LASIK even when told it's not safe for them. I'm still not inclined to let you off the hook. You're just rationalizing. Two wrongs don't make a right.

Patients undergoing elective vision correction surgery deserve the opportunity to thoroughly understand the surgery they are getting. Please don't take this away from them by switching surgical plans at the last moment. At the end of the day, it's very little different than taking walk-in patients for same-day surgery.

The honourable, ethical thing to do when you determine that LASIK is inappropriate on the day of surgery is to refuse to perform surgery on that patient that day. Send them away with lots of information to review, schedule a surgery for another day if you want, but give them time.

Sensible patients will truly value you for it.