LASIK: The Gold Standard Refractive Procedure

In this debut episode, James Loden, MD; Sondra Black, OD; Gary Wörtz, MD; and William Wiley, MD, explain why they believe LASIK remains the gold standard of refractive surgery. Listen as expert physicians share insight into the improvements of this technology since the late 1990s, and how to educate your referral network so optometrists can properly inform patients about the procedure.

This podcast is an editorially independent program supported with funding by Johnson & Johnson Vision.

Editor’s Note: At the time of the podcast recordings, Sondra Black, OD, was an Independent Consultant. Dr. Black is now Head of Professional Development and Education for the Commercial Division of Johnson & Johnson Vision.

LASIK: The Gold Standard Refractive Procedure

Host: This is an editorially-independent program supported with funding by Johnson and Johnson Vision.

Welcome to this podcast series on success with LASIK surgery. My name is Ranna Jaraha, and I will be asking several physicians about their experience with the technology. In this first installment, we’ll be discussing why LASIK is still considered the #1 refractive procedure. We have with us today an accomplished group of eyecare providers, starting with Dr. James Loden, of Loden Vision in Nashville, Tennessee.

Dr. Loden: Hello, thank you for inviting me today.

Host: Next we have Dr. Sondra Black, an optometrist and industry consultant from Toronto, Canada.

Dr. Black: Hello, Ranna.

Host: We also have with us Dr. Gary Wortz of Commonwealth Eye Surgery in Lexington, Kentucky. Welcome Gary.

Dr. Wortz: Thank you so much for having me.

Host: Finally, we also have Dr. Bill Wiley of Cleveland Eye Clinic in Brecksville, Ohio. Welcome Dr. Wiley.

Dr. Wiley: Happy to be here.

Host: Thank you all for joining us today. So we’re here to talk about LASIK vision correction, the role it plays in each of your practices, and how we can learn from your clinical experiences. Let’s start with Dr. Wortz, can you share where we are today with refractive technology?

Dr. Wortz: Sure. Sometimes I tell patients that the newest thing about LASIK is that it's old. And I don't mean that in a bad way. I mean that actually in a good way. Since the 90's, we’ve only made very incremental improvements in the foundational technology of excimer laser ablation of the cornea. If you think about the transformative changes that have happened in technology in general between the 1990's and today, it's pretty amazing that there really hasn't been anything that has come close to making LASIK obsolete. There may be other surgical options that are starting to approximate the safety and efficacy of LASIK, but I don't really see anything coming down the pike that is going to make LASIK obsolete.

And we can talk about nuances in the technique of individual surgeons, that one surgeon may prefer to use a different type of laser or other preferences. But really no matter how you perform LASIK, it’s the application of a computer driven algorithm to digitally reshape the cornea. The role of the physician is sort of limited in terms of setting the machine up, creating the flap, and then registering the eye, but LASIK really is the first procedure of the 21st century, and it just so happens to have been born ahead of its time in the 90's.

Host: Over the years, there seem to have been significant improvements in LASIK outcomes - how do you explain that if the technology hasn’t significantly changed? Dr. Black?

Dr. Black: Well LASIK technology has only changed fairly incrementally over the last decade or so. We’ve learned so much that now we can really push the outcomes into the range of ‘consistently outstanding.’ The femtosecond flap and wavefront guided lasers and eye tracking systems have virtually eliminated surgical complications. In addition to that, we have such good diagnostic equipment that now we’re effectively stopping any bad candidates before they have surgery. We used to do just topography, but now we also do tomography and we look at the posterior float. We are looking for and treating dry eye disease and preventing problems before they happen. With all of the technology we have both diagnostically and surgically, the odds of a patient not getting 20/20 vision or having any type of problem are just extremely slim.

Host: Dr. Loden, what are your thoughts?

Dr. Loden: When I started performing LASIK in 1997, 20/30 or 20/40 uncorrected vision was considered a reasonable outcome – not great, but reasonable. We now aim for 20/20 on all of our patients, even 20/15 without any residual astigmatism. With the advanced laser vision technology of today, we’re pushing 99% of our patients across the finish line to 20/20 and happy. The quality of the procedure, the fast visual recovery, the great one-day post-op satisfaction, are all the reasons that LASIK, in my mind, is so successful and my go-to procedure.

Host: One thing that I am hearing is that part of the reason we’re seeing improved outcomes is because we are being more particular with patient selection for LASIK. Tell me, who is the ideal candidate for LASIK?

Dr. Loden: I agree you should be highly selective with your LASIK candidates, don’t try to push the limits. Don’t perform surgery on very high hyperopes, be cautious with very high astigmatism and very high myopia. We have to face the current reality that a dissatisfied patient can take to social media and tell a whole lot of people. With this in mind, I amreally cautious of patients that are 20/25 or 20/30 best corrected vision prior to surgery. They just don’t seem to understand why they are not 20/20 after LASIK and, in my experience, will be the patients most likely to blog about their unhappiness. I try to keep to patients that are 20/20 and 20/15 best corrected vision prior to surgery.

Host: Dr. Wiley, what do you think?

Dr. Wiley: Yeah I agree, you know, LASIK currently is the gold standard, it is very versatile. It’s what patients know and understand, and other refractive procedures are add-ons. To be a refractive surgeon today, you have to be comfortable with all of the surgical options. But LASIK is the number one procedure for refractive surgery and I think everything else sort of builds on that and is synergistic with it.

The versatility of LASIK is one of its strong points. I can use it to treat a wide range of prescriptions in addition to treating astigmatism. Such that you know, while there are other procedures out there that can treat higher prescriptions, a lot of them aren’t currently approved in the US for treating astigmatism, thus limiting their scope. Many patients, quite frankly, come in with some amount of astigmatism and it’s important to treat that to achieve the expectation of crisp 20/20 vision.

While PRK can also functionally treat astigmatism, it’s not a practice builder. Patients are seeing well on the chart, sometimes even better than LASIK, but the road to get there was much more challenging and in our current culture, a longer healing period is harder sell. People want great vision and they want it quickly, and LASIK is the best tool we have right now to deliver that across the broadest patient range.

Host: Let’s focus in on some data that supports LASIK’s position as the gold standard. A 3-year longitudinal study was published by Price and colleagues that of all the available vision correction options, LASIK produces the highest levels of satisfaction, and actually has a better long-term safety profile than glasses or contact lenses. This study joins a number of studies from 2008 onward that all show patient satisfaction rates of 95% or higher. How does this satisfaction rate translate to your practices?

Dr. Wortz: A 95% satisfaction rate is actually quite astounding, basically unheard of in medicine or life in general. And we truly have that with LASIK. The biggest regret that many patients have is that they didn’t get the procedure earlier so they can benefit longer. Our patients’ experience is so positive overall, that I think in our minds we round that up to 100%. Then, any time a patient is even slightly annoyed or having any kind of difficulty that we need to coach them through, as surgeons we kind of feel that we’ve failed. An unhappy patient is so abnormal that psychologically it can create kind of a barrier for us, so it’s important to remember that very few things in life will bring a patient as much satisfaction as a LASIK procedure, and we should be proud to help them with that.

Host: Dr. Loden and Dr. Black, what have your experiences been?

Dr. Loden: I actually think 95% satisfaction is low compared to what I see in my practice. When we look at the studies that are out there, basically every one of them says 95% satisfaction, but one of the things that's interesting about those studies, is that most did not allow enhancements. When you look at post-enhancement satisfaction, you're really going to get up to close to 99% satisfaction, which is what our in-house statistics show. I would say that 99% satisfaction rate is within the theoretical range of what we can perform right now.

Black: And patients find the procedure simple and virtualy pain-free. They go home, take a nap, and when they wake up they can see without their glasses or contacts. The vast majority of patients are able to legally drive on day one and are already 20/20. It’s this amazing wow factor that makes patients excited enough to tell their friends. It really is a life- changer for them.

Host: While these outcomes are excellent, I’m wondering if we may have the problem that Dr. Wortz mentioned, but with the patients. Do they hear 99% or 95% satisfaction rate and automatically round up to 100%, and then maybe become disappointed should anything be less than perfect?

Wortz: When we first started doing LASIK, there was about a 40% chance that the patient would need an enhancement. So we told patients that up front and they would have surgery, get an enhancement 2-3 month later, and think you were wonderful. Now, an enhancement has gone from a probability to a signal of failure, which really shouldn’t be the case. So I tell patients, "This procedure is probably the most well tolerated and most well loved procedure in all of medicine. And I have every confidence in the world that you are going to be happy. But we have to remember we are operating on living tissue, and living tissue in the body always wants to go back to where it started from. We are going to make a change, and that change is perfect based on the day of surgery. If your cornea regresses, however, it's not a sign that the laser didn't work. It's that your body is healing and trying to go back to its native state. If that occurs, we can go back and we can re correct it. Not a big deal."

Black: I also don’t think we have to promise the moon. All you have to tell the patient is that at the end of the day, they are going to drastically reduce their dependence on glasses and they’e going to be comfortable. Patients don’t come in asking if surgery is 100% guaranteed, and if they do, we just explain that all patients heal differently and some may need an enhancement. We always address everything that can happen, and all the patients receive an extensive informed consent form. It also helps to start patients on their day-one post op by having them read the 20/40 or 20/50 line and then exclaiming “wow, this is amazing - you can legally drive already!” and then feed on that excitement as you go down the chart. So much depends on how you portray things and the emotions you give off. It’s also worth mentioning the safety factor. Patients think that if they can buy contact lenses online, they can’t do much harm. But there are studies that show that the rate of infection is actually higher with contact lenses than with LASIK surgery.

Loden: What we want to achieve is a super, super happy patient. If you look at Dr. Steve Schallhorn’s data from the past, a patient that is 20/15 is three times more likely to refer a friend or family member than a patient who is 20/20. That’s a big difference. Fortunately, we can hit that 20/15 quite frequently, and that is why our LASIK business continues to grow. Ecstatic patients share with their friends and family, and those friends want LASIK too.

Wortz: LASIK is a procedure that was made for the era of social media. Patients who attain great results just can't help but share the good news with their friends and family, typically through social media platforms. And that’s the best kind of advertisement, because it is unsolicited, and from a trusted source. At the end of the day, it is the excellent results that are really responsible for generating many more LASIK patients.

Host: This is all excellent information. I want to turn the conversation a bit now. All of our LASIK patients have been seeing optometrists for years to address their vision correction needs. Do we need to be extending our education of the current standing on LASIK outcomes to our referral network as well?

Black: Definitely. When we first got LASIK in the late 1990’s, we were excited, and we were talking to everyone about it, especially our referral network. Now I think we assume that everyone is educated about both the procedure and the technology, but that isn’t necessarily true. There is a whole younger generation of ODs that don’t even think about bringing it up in their private practices, which is where the majority of patients are. I think we really need to be out there, showing our referral network where we are today with LASIK, the diagnostic advances as well as surgical improvements, and encouraging them to discuss it with their patients. The majority of our referral network has no idea where the technology is at these days.

Wortz: Yes, one of the first things we try to do in terms of marketing is build advocacy within our referral market. It’s important to keep the story alive with our network, and I encourage colleagues to host office-based educational events, which have proven to be quite effective in my practice.

Host: Thank you to Drs. Wiley, Black, Loden and Wortz for sharing your current outcomes with LASIK surgery. We’ve learned that small refinements to the technology and pre-operative diagnostics have resulted in extraordinarily high rates of patient satisfaction, even close to 99% in some of your offices. The result of excellent outcomes is a natural increase in LASIK patients.

This concludes our first installment in a special podcast series on LASIK. This is an editorially-independent program supported with funding by Johnson and Johnson Vision. Stay tuned for additional episodes on how to communicate with your patients about the technology and how to market it effectively.