Baby Boomers are aging, and they have high expectations for their vision. They want to see everything and are more willing to pay for it. As premium surgeries continue to increase and expectations continue to be set high, we need to be sure we are ready to answer their questions and develop relationships with surgeons who are highly skilled at delivering what the patients’ expect.

To that end, there are certain things that those in refractive and/or co-management situations that do to keep our day moving smoothly. I have recently had a few days that were not so smooth when patients were upset after they had surgery.

We use informed consent and extensive preoperative discussion, modern preoperative measurements, and advanced surgical techniques to ensure happy outcomes. Despite all this, surgical complications occur and we have to manage these patients. In most cases, these complications are mild and non-vision threatening. Thankfully, the most common reason to be upset is residual refractive error which the patient perceives as blurry vision. Patients may quickly become frustrated, angry or depressed when complications occur. Managing these patients while maintaining healthy patient and co-management relationships can be challenging.

I also feel that complications from elective procedures are harder for patients to handle emotionally than complications from medically necessary procedures. Complications are bad enough when you had no choice but to undergo a surgery. If a patient did not have to have a surgical procedure, but rather chose to have it, and then suffered complications, it can send the patient into a tailspin. I spent seven years of my life helping patients who had elective vision correction, suffered a complication, and regretted the decision to have the procedure to some degree. Flap tears, lost flaps, dense stromal scarring, ectasia, and retinal detachments after paying $3000 or more for surgery does not make a patient happy. For some, the idea that they did this to themselves is overwhelming, and more than they can bear. I had enough patients use the word suicide that we had protocols in place when patients mentioned it or appeared to need emergent help.

Surgical complications affect those with mental health issues more so than those with a healthy mental status. Hassidim, et al, evaluated surgical complications in patients with psychiatric disorders.

Considering emergent surgical procedures (appendectomy and laparoscopic cholecystectomy), psychiatric patients demonstrated a longer hospitalization duration, with increased rate and severity of postoperative complications. Any mental health disorders will become more problematic with complications. Surgeons tend to under-recognize psychological disorders until they interfere with evaluation and treatment. While it is not our job to manage mental health disorders, we should be mindful of mental health issues in our patient population. Early referral to their current mental health provider if complications are noted in a patient taking mood altering medications or antipsychotics is beneficial.

When faced with an unhappy patient, I typically address their main complaint verbally and work to diagnose the etiology as soon as possible. I try to reassure them that we have a plan “that in my experience, has worked well.” I describe my clinical plan based upon demonstrated diagnostic imaging and assure them that I am supporting them during this period of healing. Then I repeat my acknowledgment of their chief complaint and promote positivity until their next visit when I do it all again. I focus on clinical findings, and moving forward rather than rehashing “what went wrong”. I answer questions truthfully, but do not offer more information than required if it is likely to be inflammatory.

Here are a few rules we have in place in our practice:

1. Document preoperatively so you can refer back to it (sometimes by holding it up to their face to see it).

2. Treat ocular surface disease before measurements are taken for surgery. Continue the treatment for at least 6 weeks after the procedure. Any surgical procedure will exacerbate ocular surface disease, and patients will incorrectly assume the problem is solely due to the procedure. Taking external photos prior to surgery is helpful in this regard.

3. If the cornea is a problem, show the patient their topography before the procedure. For example, we demonstrate keratoconus or irregular astigmatism with printed maps prior to surgery.

4. Never tell a happy patient they have a reason to be unhappy about their acuity. When I enter the room, I ask how they are doing. If they are satisfied with their vision, I do not refract. I look at the autorefraction my technician supplied, and verify the refractive error is what I expected based upon the biometry printout.

5. Monovision patients should be checked binocularly. This saves you 10 minutes of explaining why the distance is blurry in the near eye. Can they do what they want to do without glasses or contacts? Excellent. I reference the autorefraction here as well.

6. We do not tell patients S/P refractive surgery that they can’t see because they have had surgery. This typically applies to RK patients, but could apply to a LASIK patient with a mishap or ectasia. The conversation goes much smoother if you address the problem causing the vision loss. For example, a patient with ectasia suffers from irregular astigmatism or problem with the shape of the cornea. RK patients have a problem with irregular astigmatism and glare from scarring.

7. Never tell a patient they have glaucoma, dry eye, a retinal detachment, or ectasia because they had refractive surgery. Stay in the present and move forward with treatment.

8. For patients S/P refractive surgery needing cataract removal, IOL measurement may be tricky. I do mention our use of advanced technology to determine the appropriate power of the IOL, and our plan to do our best to determine the correct power given that their cornea is not a natural shape. I do not dwell on it, but I do mention this and document in the chart that it was discussed.

Our technicians are familiar with our rules and mirror them. A supportive team with advanced diagnostics is reassuring to the patient and makes my day go much more smoothly.

¹Ayal Hassidim, Sharon Bratman Morag, Moshe Giladi, Yael Dagan, eRoie Tzadok, Petachia Reissman, Amir Dagan.  Perioperative complications of emergent and elective procedures in psychiatric patients.  Journal of Surgical Research.  Volume 220, December 2017, Pages 293-299.

²James L. Levenson, MD.  Psychiatric Issues in Surgical Patients Part I: General Issues Primary Psychiatry.  May 1, 2007; 2007;14(5):35-39.