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Patient Counselling

Namrata Sharma, Rakesh Ahuja, Rasik B Vajpayee

The discussions between the patients and the surgeon before the actual surgical procedure represent the most important aspect of a pre-op refractive surgical evaluation. All other aspects such as the testing of the eye and the ocular examination are objective. The patient counseling is a subjective entity and the details on the patient personality and the expectations can be easily overlooked if the proper attention is not given.

Informed Consent

The informed consent before LASIK surgery is mandatory as it minimizes the liability risk. Informed consent is the process by which the patient becomes aware about the procedure’s risks, benefits, complications and alternatives so that he or she can make an informed decision whether to have the procedure.1–5

Informed consent does not release the doctor from the responsibility to ensure that the patient undertakes an informed decision, whether the surgeon personally undertakes the education process or delegates it in part to an assistant or media material (e.g. educational procedures, videotapes, websites etc).

Communication with the patient or building of a treatment alliance with the patient is a must and this begins preoperatively and continues throughout the postoperative period of patient care.

Informed consent should include appraising the patient of both the surgical and the non-surgical refractive options; the risks, benefits, side effects and expected outcome of the procedure; and a discussion of enhancement procedures. It is critical to ensure that the patient’s expectations are realistic. The patient who meets medical and surgical criteria for keratorefractive procedure but who has unrealistic expectations is not a good candidate for LASIK surgery.

That the risks, benefits, complications were discussed in detail with the patient and that the patient understands and accepts these options should be documented in the medical records of the patient.

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Timing of Consent Signing

The patient should receive a copy of the informed consent document well in advance of the planned surgery and should be encouraged to take it home to read and formulate any further questions. Signing the consent document on the day of the surgery is acceptable if the patient has been given the document for review ahead of time. A part of this document may be objectively made in the form of true/false questions, which serve to further educate the patient about this elective procedure.

Presbyopia

The patient should be made aware that the refractive surgery usually does not eliminate the need for additional reading correction, once the patient has entered the presbyopic age group. Further, for the patients nearing the presbyopic age group, the choice of monovision should be discussed. This may also be demonstrated (in the appropriate age group) with either a trial spectacle correction or more effectively with temporary contact lens.

Patient Expectation

It is crucial for the surgeon to evaluate and assess the patient’s expectations of LASIK surgery and to make sure that they are realistic. The patient needs to be aware that the goal of any keratorefractive procedure is to make them less dependent on glasses or contact lenses. This may be demonstrated to them by having them look thorough a phoropter or trial frame with a refraction that enables them to see 20/ 40 or 20/30 line clearly, but shows slightly defocused 20/25 and 20/20 lines. The patient is then allowed to compare this refraction with his or her current or best corrected visual acuity.

Further, it should be explained that although many patients achieve better postoperative vision, their uncorrected postoperative visual acuity may not be as sharp/crisp as their preoperative best corrected visual acuity due to decreased contrast sensitivity. The patient should also be made aware of what to expect after surgery (Table 3.1).

Complications

The patient should be well informed about the complications. The surgeon should emphasize that a specific refractive outcome is purely a statistic and not guaranteed for any one patient.4 A poor outcome for a specific patient is 100 percent for that patient.

The use of the microkeratome in the LASIK procedure adds the additional risks which may occur due to its stoppage/malfunction. The same holds true for the laser machine, which may stop or malfunction in between. Risk of infection, overcorrection, undercorrection, regression, loss of best-corrected visual acuity, haze and dry eye should also be explained.

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Table 3.1: What to expect after surgery

The following problems can occur in the postoperative period:

Upto 3 days

Mild pain and discomfort

Teaaring or watery eyes

Upto 1 week

Sensitivity to light

Hazy or blurred vision

Upto 4 weeeks

Dry eyes

Glare, difficulty driving at night

Upto 6 months

Fluctuations in vision

Side Effects

The common side effects of LASIK procedure include mild postoperative discomfort or pain, glare and the star-burst or halo symptoms.

Need for Further Surgery

The concept of the enhancement procedure in 5 to 10 percent of cases and the need for further surgery should also be discussed with every patient.

Alternate Options and Future Technology

The patient should be informed about the other surgical refractive modalities such as photorefractive keratectomy, intracorneal intrastromal corneal ring and phakic intraocular lenses as well as other non-surgical therapeutic options, including glasses and contact lenses. The patient must also be appraised of the newer technologies which may become available in the near future.4

CONCLUSION

Informed consent is a continuous process and building of mutual trust and rapport with the patient and not merely the signing of a form. A key goal of the informed consent process is to let the patient know that specific outcomes cannot be guaranteed. Careful documentation of all patient interactions is a must. The surgeon bears the ultimate responsibility of the patient.

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REFERENCES

1.Abbott RL. Informed consent in refractive surgery. Curr Opin Ophthalmol. 1998; 9(4):29–34.

2.Seller T. Ethical concerns. J Cataract Refract Surg. 1999; 25(2):156. No abstract available.

3.Ellis JH, Abbott RL, Brick DC, Weber P. Liability issues associated with PRK and the excimer laser. Surv Ophthalmol. 1997; 42(3):279–82.

4.Abbott RL. Informed consent. American Academy of Ophthalmology. Refractive Surgery 2000: Shaping the new Millenium. Pg. 15.

5.Abbott RL, Weber. Risk management issues in refractive corneal surgery. Ophthalmol Clin North Am. 1997; 10:473–83.

Appendix

(Model Consent Form)

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