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Article Date: 3/1/2014

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CLINICAL: specialty eye care
CLINICAL

  specialty eye care

Effectively Co-manage the Post-LASIK Patient

A look at our role in post-op patient satisfaction.

DAWN HOLSTED, O.D., OKLAHOMA CITY, OKLA.

Providing immediate care post-LASIK allows an increased level of interaction with your patients. This, in turn, helps you to demonstrate a high level of competency and involvement in the patient’s care. In addition, post-operative care can provide incremental revenue to the practice. And, frankly, I’ve found it to be a fun and personally rewarding challenge.

Here are the pearls to making co-management a success for you and your patient.

Secure co-management.

For the post-operative care to be performed by you, you must:

Secure the patient’s approval. Thus, when the patient expresses an interest in LASIK, educate them that post-operative care immediately following surgery can be provided in your office. Then, offer to coordinate the appointment with the surgeon or surgical facility.

Have the patient released to your care by the surgeon. The surgeon must sign a transfer of care agreement, acknowledging that the procedure and patient response to surgery went well, and that they are comfortable with the patient being managed by you, their primary care optometrist, from that date forward.

Provide a one-day post-op evaluation.

I learned early in my training that co-management is 90% reassurance and 10% clinical, a philosophy that has held true throughout my career in the post-surgical management of patients. If you’ve experienced a surgical procedure, you know the importance of hearing that healing is progressing, as it should.

The evaluation:

History. Start the exam on a positive note by congratulating the patient on having the procedure. Then, ask how it went, including any concerns or unexpected signs or symptoms they may experience. Also, document whether related medications were used as instructed.

Visual acuity. Start with the full Snellen chart open and 20/40 on the bottom row. Ask the patient to read the smallest line they can. If the patient is struggling, start with a large single row of letters, and let them read several lines.

Remember: If the patient has difficulty, you can check their vision with a pinhole to see whether the response is better, or you can double check with an autorefraction if you find residual refractive error manifest with swelling.

Learn About Co-managing

If you want to add post-LASIK exams to your clinic, start by learning more about the process.

I suggest following a surgeon on the day after LASIK surgery, to see them manage patients on the post-operative examination day one. Call your local co-managing surgeon office or referral center, introduce yourself and let them know you are interested in co-managing your surgical patients, and they will generally be happy to assist you from there.

During this visit, you can see multiple examinations and listen to the conversations between surgeons and patients.

Roughly 20/40 is expected day one post-LASIK. Therefore, if the patient exceeds this, be sure to share this with them.

Continue to reassure the patient, and congratulate them on achieving this visual acuity, as many of them haven’t read those lines sans refractive correction for years.

For those who struggle with this exercise, explain that visual fluctuation is normal due to the swelling from the surgery and healing. Also, educate patients that some patients may experience blurred vision at day one and clarity as they heal, while others may be clear at day one and blur a bit as they heal. This eases any concern patients may have when experiencing changes in vision.

Slit lamp. Examine the corneal surface for dryness, the flap’s position and smoothness, as well as any signs of infection or inflammation. If you discover slight debris, explain that this is normal and can be from meibomian gland secretions. Also, ensure no inflammatory reaction or diffuse lamellar keratitis is present. These conditions present in the first few days post-op.

After confirming normal findings, continue providing reassuring comments to the patient. For example, “The flaps look perfect, and you are starting off in excellent position.”

Manage potential complications.

While complications are rare, you must manage anything out of the ordinary and quickly report it to the surgeon. Continue communication and contact with the surgeon and their office. Doing so is imperative for you to facilitate ease of care to support or manage any post-operative findings that require immediate referral to the surgeon.

Post-LASIK side effects:

Poor vision. Though uncommon, if vision is 20/60 or worse at day one, this is generally due to corneal surface dryness or a wrinkled or displaced flap. Address the dry surface with medications, but immediately refer the patient to the surgeon for flap repositioning.

Diffuse inflammation. Discuss this with the surgeon, and decide whether the inflammation warrants lifting and irrigating under the flap or management by increasing the frequency of topical steroid drops. Also, as patients are often concerned about infection, explain, “This is not an infection. This is similar to an allergic reaction.”

Infection. If the patient presents at day one with conjunctivitis or mattering along the eyelids, alert the surgeon’s office. Be aware that you may see a mattered appearance of the eyelashes not consistent with infection, which is normal, as a result of use of the medications, primarily if steroid suspensions are used. Tell the patient not to remove it, so they do not inadvertently rub their upper eyelid, though you, the practitioner, may remove this.

Dry corneal surface. Occasionally, you will see superficial punctate keratitis early in the post-operative healing. When this occurs, utilize preservative-free artificial tears, and increase frequency of use. As this can cloud vision early, reassure the patient that it will resolve through time so they are not alarmed.

Epithelial defects. Occasionally, you will see an epithelial defect early post-operatively with LASIK. Typically, these resolve through time and increased use of preservative-free artificial tears. If the patient has a defect larger than 1mm or significant discomfort, apply a bandage contact lens for 24 hours.

Remind the patient to avoid rubbing or squeezing their eyes, to use their medications as directed and to contact you should they have an unexpected decrease in vision or an increase in symptoms.

A fulfilling experience

The vast majority of LASIK patients look excellent at day-one post-op and come to my office grinning from ear to ear. This is why the 10-minute evaluation with the patient is one of my favorite parts of my job, and I encourage you to try it. OM

Dr. Holsted is president and CEO of nJoy Vision, which specializes in co-management of refractive surgery, keratoconus treatment and laser cataract surgery. E-mail her at Dawn.Holsted@njoyvision.com, or send comments to optometricmanagement@gmail.com.



Optometric Management, Volume: 49 , Issue: March 2014, page(s): 35-37

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