The July 2004 issue of the Journal of Cataract and Refractive Surgery contained a report on a survey of refractive surgeons conducted in 2003 by the Magill Research Center for Vision, which was presented in part at ASCRS in San Francisco last year. This is the third such survey and many of the results are well worth highlighting.
 

About the survey itself

Reference: J Cataract Refract Surg, Vol 30, Number 7, July 2004, “Special Report: Refractive Surgery Survey 2003”, Kerry D. Solomon MD, Luis E Fernandez de Castro, MD, Helga P. Sandoval, MD, Luanna R. Bartholomew, PhD, David T Vroman, MD

Who it covers: A questionnaire was mailed to 8920 ASCRS members worldwide. There was a 13.2% overall response rate (1174 questionnaires) ranging from 14.8% (Canada) to 6.6% (Asia).

What time period does it cover: The questionnaires were mailed to recipients in January 2003 and returned by March 2003. The responses refer to surgical practice in 2002.

What geographical areas are covered: Predominantly US practices (920 of 1174) with the balance from Europe, Asia, Latin America, Canada, Oceania and Africa.
 

About the surgeons

Subspecialties: I was frankly dismayed to read that only 14.4% of respondents were refractive surgery specialists. The majority (47.3%) were comprehensive ophthalmologists and the balance specialists in everything from cataract to glaucoma. While I recognise that many excellent surgeons may not have started with refractive surgery as a subspecialty, I consider it a poor reflection on the profession that in general it does not expect refractive surgeons to be specialists in their field. The majority of refractive surgery candidates/patients would simply take it for granted that their surgeon has specialised training of equivalent duration to that of a surgeon in any other specialised area of ophthalmology (after all, if they have to see a retinal specialist or send their child to a pediatric ophthalmologist, they can fairly expect those experts to have subspecialised in retina or pediatrics). Furthermore, surgeons of all descriptions and in many countries advertise themselves as refractive surgery specialists or (even more commonly) laser surgery or LASIK specialists, irrespective of their formal subspecialty training. How is a conscientious patient/consumer to navigate this maze and find out who really IS a specialist, short of hiring an investigator?

Have they had refractive surgery themselves: 3.4% (18 surgeons) reported having had refractive surgery in 2002. In total 17.5% of surgeons reported having had refractive surgery at some time in the past.
 

About co-management

59.2% of surgeons reported co-managing their 2002 refractive surgery cases, and of those, 72.1% followed AAO/ASCRS guidelines for comanagement. Interestingly, the article states that those who co-managed more than 25% of their patients were less likely to follow the guidelines.
 

What lasers are being used?

According to the survey, 56.4% used the VISX S2/S3 in 2002 while 15.1% used the Alcon Autonomous LADARVision. However, that would appear to reflect the heavy weighting of the survey to US respondents, because in Asia and Europe, the Bausch & Lomb Technolas was the clear leader and in Latin America, the Nidek.
 

How do they evaluate patients for LASIK?

93.8% performed corneal topography. I would have to say the 6.2% is a little worrisome when you think about the numbers of patients getting surgery.

88.1% measured pupil size in dim light. Of those, more and more are moving towards infrared pupillometry — about one-third more than the previous year. Enough said; anyone who visits the website knows how we feel about pupils and why.

23.2% performed pre-operative wavefront measurements.

Now for the bad news: Only 34.5% performed a tear-secretion test (Schirmer) before LASIK. This is beyond appalling — we all know dry eye patients are at increased risk of severe dry eye, but we don't bother to screen them? (And if you want to cheat, scroll down to the Complications section and see what the most frequently reported complication of LASIK is.) Explanations are in order, please!
 

Surgical planning and techniques

Pupil size: It was a little difficult to draw meaningful conclusions from the data because of the way the questions were apparently put to the surgeons (the data collected referred exclusively to the gap between ablation and pupil size, without reference to the absolute size of either, which we think may actually be an important part of the equation). However, from the results that are available, it appears that:

(a) Overall, a majority of surgeons don't want to make an ablation (that is, full optical zone, never mind the blend) that is more than 1mm smaller than the dim-light pupil — the actual number isn't given but this seems apparent from the graphs; and

(b) 29.1% want the ablation to be the same size [presumably they mean 'at least the same size'] as the dim-light pupil.

Not surprisingly, the relative reluctance or willingness to allow a gap between ablation and dim-light pupil appeared to be somewhat correlated to the laser used: that is, those using lasers where the maximum ablation size is small were willing to leave larger gaps than those using lasers capable of larger zones. I leave it to the reader to resolve the which-came-first-the-chicken-or…   (pupil size doesn't matter, therefore I can safely use a smaller zone laser, or my laser has a small zone, therefore pupil size doesn't matter?) Alright, I'll stop sniping now and concede that I am highly gratified to note that at least as of January 2003, surgeons on the whole appeared to think that pupil size does or might matter, because if they didn't, the majority would have said there is no cut off for the difference between the ablation zone and the dim-light pupil (depending on the laser, between 8% and 17% said they did not have a cutoff for pupil size in relation to the ablation).

Residual stromal thickness: Most (71.6%) leave a minimum of 250-274 microns. 15.5% use a higher minimum of between 275-299 and 10.6% use 300 as a guideline.
 

LASIK Retreatments

Enhancement rates were reported between 1% and 10%, which seems approximately consistent with clinical trial results.

The vast majority of surgeons lift flaps rather than recutting, though some recut if the enhancement is done more than 6 months post-operatively.
 

Complications

Most common complications of LASIK: Dry eye, glare, DLK, and epithelial ingrowth (in that order).

10% of respondents reported patients requiring corneal transplantation during 2002, and of those, the most common reason was reported to be ectasia (41.1%).

6.6% of respondents reported that they removed or amputated at least 1 corneal flap during 2002.

These are merely some highlights from the survey results. For further information and contact details, click here for the abstract.

Next week: We will return to the discussion of "Informed Consent Hot Spots."