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From MD to OD: Tips for Referring Refractive Patients

A surgeon suggests some advice for ODs based on his perspective.

As a cataract and refractive surgeon, I am happy to get patient referrals, even if the referred patients are marginal candidates, they come to me with no documentation, or they know little about the procedures involved. Caring for a refractive surgery patient should be a partnership between the surgeon and the optometrist. Doing the following three things before referring a patient for a surgical consult can help to make you a better referral partner.

CANDIDATES

First, figure out if the patient is a good candidate before you refer.

A patient was recently in my office for same-day examination and surgery. My office in Los Angeles often does same-day appointments because it allows the patient to minimize traffic woes, particularly when coming from far away. The patient took 2 days off work and was very excited about having LASIK. The patient’s driver also took the day off work.

I examined the patient’s eyes and saw that, even though she was only 42, she had a posterior subcapsular cataract in the right eye. I had to tell her that she was not a candidate for LASIK. You could feel her disappointment. Her unspoken question was, “Why didn’t my doctor tell me this?”

Before sending a patient for referral, the optometrist should perform topography to find out whether keratoconus is present. Dilate the eye to see if the patient has a cataract. Do the necessary preoperative evaluation to be sure the patient is a candidate.

SETTING GOALS

Second, recommend a refractive goal for each eye to the surgeon.

In young people, the refractive goal will be emmetropia; in older patients, monovision is often appropriate, or sometimes bilateral reading vision is preferred. My goal is for every patient to leave the consultation with a plan for correcting his or her vision. This requires knowing the patient’s refractive goal.

I recently saw a 50-year-old woman with approximately -4.00 D of myopia in each eye. She wore glasses more often than contacts because when she wore contacts she couldn’t read. She had never tried monovision with her contacts. We tested monovision in a trial frame in the office, and she quite liked it. Clearly she was a possible candidate for a monovision correction after LASIK. I referred her back to her primary eye care physician and asked the doctor to try monovision contacts for her.

Imagine how much smoother the referral would have gone if the patient already knew she tolerated monovision contacts before her arrival. We could have finished the examination, developed a surgical plan, and scheduled her for surgery promptly. Instead, she had another round of visits at the doctors’ offices.

You know your patient much better than I do. Let me benefit from your long experience by recommending a refractive goal for each patient and each eye.

WHAT FITS THE PATIENT

Third, talk to the patient about the procedures that he or she is a potential candidate for.

Talking about procedures other than LASIK is particularly valuable for patients who aren’t good candidates for LASIK. It is not uncommon that I see patients with -10.00 D of myopia referred to my office for a LASIK consultation. For such patients, I recommend a phakic IOL, such as the Visian ICL (STAAR Surgical). When I make this recommendation, I see these patients’ eyes drop and their faces tense up because they are unfamiliar with the procedure.

Everyone knows somebody who has had successful LASIK. Most people don’t know anyone who has a phakic IOL. Uncertainty creates fear, and fear makes it hard for patients to decide to move ahead. Increasing familiarity by properly educating a patient reduces fear.

Patients with high myopia should be educated on phakic IOLs. For high hyperopes (greater than +2.50 D), a discussion about refractive lens exchange is appropriate. When prompted by a discussion with their optometrist, patients will usually Google a procedure for further information before arriving at our office. By briefly educating their patients, optometrists tee them up for the surgeon, speed up the education process, and create a more informed patient.

There is one caveat to this advice: Do not actually make a recommendation. Leave that up to the surgeon. It is uncomfortable for me as a surgeon to recommend something different from what the optometrist has previously recommended. It undermines the patient’s trust in both of us.

CONSIDER THESE THREE SUGGESTIONS

By following the three simple suggestions above, you will make better referrals, make your patients happier and more tightly wedded to your practice by bonds of trust, and also make your surgeon partner happier.

author
Robert K. Maloney, MD, MA(Oxon)
  • Editorial Board Member, CollaborativeEYE
  • Founder, Maloney Vision Institute, Los Angeles, California
  • rm@maloneyvision.com
  • Financial disclosure: None
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