Retaining the Presbyopic
Steps you can take in your practice.
BY DEEPAK GUPTA, O.D., F.A.A.O., Stamford, Conn.
More and more optometrists comanage refractive surgery with ophthalmologists. In some offices, coman-
agement represents a significant portion of income. The most common refractive procedure, laser assisted in-situ keratomileusis (LASIK), often has excellent results. But the vision problem LASIK doesn't currently correct is presbyopia.
Since many people undergoing LASIK are older than 40 and have presbyopia, they require careful management to ensure that you retain them as patients. This month, I'll discuss how to do it.
Steps to take
Follow these steps with this patient group:
Make patients feel welcome.
Everyone in your practice, from the receptionist to the optometric assistants, must take an active role in proper patient management. Even though many patients know that LASIK doesn't solve the problem of presbyopia, you and your staff must remain optimistic that the patient still may undergo LASIK as long as he realizes up front that he will need to take steps to manage up-close vision after the procedure.
The minute a patient enters your practice, the staff should make him a part of the health care delivery system by listening to him. This will help address his specific needs -- if you find out he's on the computer 6 hours daily, you address computer vision syndrome -- and will also make him feel that you're interested in him as a person rather than a source of income. It also helps the patient feel connected to you, so he'll return to your practice.
Explain the need for regular eye exams. Many refractive surgery patients feel that they no longer need to see you after the post-op period because they'll have "perfect" vision. You must set them straight from the first discussion about LASIK.
Teach them that regular eye exams are even more important after LASIK because you need to monitor for possible changes in the cornea. Although LASIK results may be good short term, you don't know what may happen long term.
I also tell the patient how a regular eye exam allows me to monitor overall eye health. I can see the eye's internal structures, which can help me detect early warning signs of cataracts, glaucoma, macular degeneration, cataracts and even high blood pressure and diabetes.
Some doctors have patients sign "contracts" agreeing to a yearly eye exam after refractive surgery. Although not legally binding, these contracts emphasize how important you feel routine examinations are. Some refractive surgery companies give a patient free enhancements if he has a yearly eye exam, while others offer a discount on the enhancement. Both are excellent ways to increase patient retention and compliance.
Address computer vision problems. Many presbyopic patients will have problems with computer work after LASIK; therefore, I routinely prescribe computer glasses with anti-reflective (AR) coating to reduce glare for these patients.
I've found it helpful to address this issue before surgery and then at the 1-day post-op visit. Although some doctors wait a couple of months for the refraction to stabilize, I feel that this discussion should take place early. If you satisfy a patient earlier, she's more likely to be happy with your office and return for continued care. And if you initiate a dialogue early in the process, the patient will be ready for glasses when the time comes.
Help myopes who can't read without glasses post-operatively. This sounds complicated but is easy to do. Before referring the patient for surgery, I fit him with a planned-replacement soft lens that only corrects distance vision. This lets the patient simulate the way vision will be after surgery.
Since the surgery can be imprecise, I over-minus the patient by 0.25D to ensure he's fully aware of the limitations of his near vision. I like to fit patients without significant astigmatism in a lens like the PureVision or the CIBA Night and Day lens and let them wear it as extended-wear for 1 week, after which I see them again. This provides post-op vision simulation 24 hours a day. The patient will either come back after a week and cancel the surgery or will have a reasonable idea of what to expect after the procedure.
Although you might think that it's a bad practice (in terms of revenue) to cancel surgery, having an unhappy patient is far worse. You'll get the short-term revenue but lose a long-term patient and a referral source.
Sometimes, if a patient is truly motivated for the surgery but didn't like the distance-only contact lenses, I fit him with monovision lenses and apply the same principles to see if that's an option.
Stock over-the-counter (OTC) reading glasses. Because many post-LASIK patients will have easily correctable reading add needs, we stock ready-made OTC reading glasses. Although they're not a major source of revenue for our dispensary, they help our practice in several ways:
- When we give our post-LASIK patients a free pair at the 1-week post-op visit or the 1-day visit, they can go home and enjoy comfortable reading vision without stopping anywhere else.
- Because we stock the readers, that patient will know he or she can come and purchase more at any time. We make a small profit on them but would make zero profit on readers purchased elsewhere.
- Stocking OTC readers forces patients to visit our optical shop, which helps boost future sales and referrals.
Try enhanced monovision for patients who don't want glasses. I prescribe a bifocal contact lens in one eye for patients who still don't wish to wear glasses or contacts after the surgery. I've found the Acuvue Bifocal, the CIBA Vision Focus Progressive, and Sunsoft Additions are excellent choices. Remember that some patients will require a little time to get accustomed to the idea of wearing contact lenses because getting out of them may have been part of the initial motivation to have the surgery.
You can usually fit soft lenses about 4 to 6 weeks after surgery. That's the time it takes for the corneal thickness to stabilize and the sensation to return to pre-surgery levels. If you're thinking about fitting a bifocal rigid gas-permeable lens, wait 3 months after surgery to allow the cornea sufficient healing time to withstand rigid lens movement.
Relieve dry eye symptoms. Dryness is a frequent complication of refractive surgery and a common complaint of contact lens patients. Depending on severity, you can prescribe artificial tears or install punctal plugs. I prescribe moderately thick lubricating drops and see the patient 1 week after the contact lens fit. If the drops don't work, I usually bypass the thicker solutions and bedtime ointments and go straight for punctal occlusion.
Improve your recall system for these patients. I've set up a three-tier recall system.
1. We send the patient a postcard 2 months ahead of time, reminding him of the need for an eye exam.
2. We follow this postcard with a second one 2 weeks before the annual exam date and then a phone call a week after it.
3. If the patient still fails to make an appointment, we send a letter reminding him of the need for regular eye examinations.
Worth the effort
Retaining presbyopic post-LASIK surgery patients requires time and effort, but it's energy well spent. These patients have trusted you enough to allow you to do the pre-op and post-op for the surgery. As long as you show them the value and importance of your services, they'll keep coming to you for periodic eye examinations. You'll get the short-term revenue of the co-management fees, but you'll also retain the long-term revenue of the regular eye examinations.
Dr. Gupta practices full-scope optometry at Stamford Ophthalmology in Stamford, Conn. You can reach him at
Optometric Management, Issue: February 2002