Focus Co Management 2016

1. Pre-operative Screening
Parameters and
Retreatment
Considerations
Kirsten Beauchesne, OD
Focus Eye Centre

2. Biography
 Education: University of Ottawa and
Université de Montréal (1995-1999)
 Private practice: Vancouver, Ottawa
 Focus Eye Centre since 2007
 Refractive status: Hyperope
 Projected date for RLE: 2020+ 

3. Some wizards manage just fine with
glasses

4. Candidates for Refractive
Surgery by Age Group
 The Young Ones (18-24 years old)
 Stable 20s-30s (25-39 years old)
 Fed up Forties
 Freedom 50+ from glasses

5. Doctor, am I ok to have surgery
now? The Young Ones
18-24 year olds
 Proactive parents/grandparents seeking LVC
for older teens and 20s.
 Career seekers (athletes, law enforcement
etc).
 Young travelers

6. Special considerations for 18-24
year olds
 Minimum age: 18
 Refractive stability: less than one diopter change within
one year.
 Often myopes who require corneal flattening.
 post-op Ks not less than 35 (close to 1:1 ratio with Rx)
 Pachymetry to determine if PRK or SBK.
 15um per diopter. Minimum 325 um corneal bed.

7. Stable 20s-30s
25-39 year olds
 Sick of hassle of glasses and contacts.
 Busy lifestyle that can include young kids.
 Dry eyes, blepharitis, allergies, office
environment can start to reduce contact
lens wear time.

8. Special considerations for this
group:
 No surgery while pregnant or nursing.
 Presbyopia discussed.
 Monovision offered in select cases.
 Educate contact lens drop-outs about ocular
surface disease and meibomian gland
dysfunction. These issues are chronic
predispositions that are unrelated to LVC.
 Seasonal allergies can cause dry eye due to
inflammation and anti-histamine use.

9. Fed-up Forties
 Complex, high needs group
 Emmetropes seeking monovision
 Rise of the latent hyperopes -- I can see for
miles…I just need these cheaters for TV.
 Patients discouraged with multifocal glasses
or multiple pairs of glasses.

10. Special considerations for the 40s
 Focus Eye Centre proactive at offering
monovision.
 Maximum total hyperopic correction with
LVC is +3.00.
 Maximum Ks when steepening is 50D.
 Refractive lens exchange (RLE) now
available for non-LVC candidates (high Rxs)
 RLE discussed with all hyperopes.

11. Freedom 50+ (from glasses)
 Great candidates with realistic
expectations. Have often tried a multitude
of vision correcting options.
 Optometrists may overlook them as
candidates with high level of interest in
refractive surgery.
 Motivations based on travel, outdoor
activities and fitness goals.

12. Special considerations for 50+
 Educate (once again!) about ocular
surface disease and its chronic nature.
 Medications and health conditions may
contribute to dry eye.
 Future lens changes and RLE discussed.

13. Retreatment Considerations
Redirect negative language such as the following:
 My surgery didn’t work…something went wrong…I was
overcorrected…I was undercorrected…I looked at my
phone too soon (and that’s why my surgery was
disappointing).
 Retreatment should not be discussed too early such as
during the first 6 months.
 Focus on the positive
 Glass(es) half full attitude to be encouraged.

14. Language of consultation visits
1 week: I am checking your eyes’ recovery from
surgery. Expect vision to still be changing.
1 month: I am checking your progress so far. Tell me
about your adaptation process to monovision.
3 months: I am monitoring your progress at this point.
6 months: (If refractive outcome is not on target) Your
eyes are responding more slowly/responding in a less
predictable way/ did not stay reshaped as planned. I
will have FEC contact you to perform more detailed
tests.

15. Retreatment within 2 years
post-op
 Due to unpredictable healing the eyes did not
respond to the treatment plan.
 3% retreatment rate overall within the first year.
Higher with hyperopic (10%), high myopia and high
astigmatism due to greater reshaping of the cornea.
 Important to not retreat too early and to maintain
positive language.
 Minimum retreatment delay is 9 months (although
can be up to 2 years for stability).

16. Case study
Dr. Bob 61 years old (SBK July 10th, 2008)
 Interests: veterinarian, motorcycle, landscaping,
private pilot.
 Hates being dependent on glasses but aware that he
will require them for piloting airplane (as per
Transport Canada regulations), may need them for
driving at night or for certain near tasks.
 Pre-op ( 2008)
 OD UCVA 20/60 +1.25+0.50x006 45.37/45.62x068
 OS UCVA 20/50 +0.75+1.00x003 44.50/45.62x108

17. Case study
Dr. Bob 61 years old (SBK July 10th, 2008)
 2 weeks post-op: OD -0.25+0.50x090 OS -3.50+1.25x100
 January 23rd, 2009 ( 6 months post-op) OD pl OS -
3.00+0.75x090. Glasses prescribed for flying and bifocals for
computer/near. Successful outcome so far. Eyes still changing
slightly. Recheck at 12 months then again at 18 months.
 December 30th, 2009 (18 months post-op): OD pl+0.25x065 OS -
2.25+0.75x105
 November 9th, 2015 ( 7 years later) OD +1.00+0.25x100 20/20
OS -1.25+0.75x125 20/20
 Free of glasses most of the time but aware that he has age-
related changes. Glasses updated for distance and near. Monitor
for lens changes yearly. No retreatment recommended.

18. Retreatment beyond 2 years
post-op
 Refractive change due to young age or older age (lens
changes).
 Patients have the option of upgrading to new technology
if they are suitable candidates (additional fees apply).
 Lens yellowing, diminishing retinal sensitivity and ocular
surface disease create issues when retreating an older
patient with LVC. Fantastic results from 15-20 years ago
cannot always be replicated.
 Cataract patients who were previous FEC patients can
have PRK for a fee. FEC assumes all follow-up care for one
year.

19. Candidates for retreatment
 20/40 visual acuity or worse at distance or near
 >-/+1.00D myopia, hyperopia or cylinder
 Stable ocular health, minimal lens changes
 RLE option can be discussed with optometrist
(fee reduced for previous LVC patient)
 Benefits for the patient should clearly outweigh
the risks of retreatment.

20. Seeing Eye to Eye
 Optometrists know their patients best.
 Your input is essential when evaluating
candidates for surgery or when
contemplating retreatments.

21. THANK YOU