50 Tough Questions to ask your Lasik Eye Surgeon

Donalh

The Council for Refractive Surgery Quality Assurance's
50 Tough Questions For Your Lasik Doctor
and suggest responses.

How long have you been performing refractive surgery?
Not less than three years.
How many refractive procedures have you performed total, excluding mechanical surgeries like RK, ALK, and AK?
Not less than 500.
How many refractive procedures have you performed in the last 12 months?
Not less than 250
How many refractive procedures of the exact type you intend to use for me, with the same equipment, and the same refractive error, have you performed?
Not less than 100. This is a very important question. Even a doctor who has thousands of surgeries behind him or her is a rookie when using new technology, new technique, or a new refractive error correction. You don’t want eye surgery from a rookie.
What percent of your refractive surgery patients receive Snellen Uncorrected Visual Acuity (UCVA) of 20/40 or better?
According to our Quality Standards Advisory Committee (QSAC), about 90% is the norm. If the doctor gives a higher number, ask for proof.
What percent of your refractive surgery patients receive UCVA of 20/20 or better?
About 65% is the norm according to QSAC. If the doctor gives a higher number, ask for proof. If you have high myopia (greater than about 10.00 diopter), high hyperopia (greater than about +3.00 diopter), and/or high astigmatism (greater than about 2.00 diopter or more than half the myopia or hyperopia) expect the probability of achieving uncorrected 20/20 to be lower.
What percent of your refractive surgery patients report unresolved complications six months after surgery? This includes objective and subjective complications such as halos, starbursts, dry eye, etc.
Less than 3% is the norm according to QSAC, with less than 0.5% being serious complications that require either extensive maintenance or invasive treatment. If the doctor gives a lower number, ask for proof. Zero or a nebulous "almost never" should be cause for concern. No doctor is perfect. No surgical procedure is perfect.
What percentage of refractive surgery candidates do you decline?
Don’t be surprised if a solid number isn't readily available. The only wrong answer would be "none". Patients being properly screened away from refractive surgery indicates a doctor who is conscientious about providing refractive surgery only when it would meet the patient's needs.
Have you had a successful refractive surgery malpractice claim of greater than $30,000? Details if yes.
Not more than one for every 500 refractive surgeries. That's a 99.5% success rate. Not more than five in the last five years, even if the doctor has performed tens of thousands of surgeries. Discuss with the doctor the circumstances of any malpractice case. Consider how they were handled and how the circumstances may apply to you.
Will you perform a wavefront technology diagnostic (not wavefront guided ablation) of my higher order aberrations prior to recommending refractive surgery?
The answer should be yes as this is a very important evaluation, however not every doctor has the equipment to perform this test. The doctor should be willing to arrange for wavefront diagnostic at a different location and at your expense. Remember that this question is about a wavefront diagnostic evaluation preoperatively, not about wavefront guided laser ablation.
What percentage of your pervious patients have had enhancement surgery? Explain your enhancement policy.
Under ten percent is a ballpark number but the "why" is much more important than the percent. The doctor should explain his/her philosophy on enhancement. Techniques such as overcorrection for accommodation of regression should be discussed. You don't want a doctor who will almost never perform an enhancement, but you also don't want a doctor who must perform enhancements too often.
What is the worst refractive surgery outcome experienced by your own patient? How was it handled?
You want a doctor who knows how to get you out of harms way if something unusual occurs. You want a doctor that is cool under fire and is willing to work with other ophthalmologists who may have specific expertise outside of your doctor's realm of experience. All doctors with enough surgical experience have had a poor outcome. You need to feel comfortable that this particular doctor can handle problems appropriately. If your doctor says s/he has never had a poor outcome or a problem, politely excuse yourself to the nearest exit.
If you intend to use an excimer laser, is it broad-beam, variable spot, or flying spot?
The type of laser beam may be very important or may mean very little, depending upon your individual circumstances. Depending upon your circumstances, only a flying spot laser would be appropriate or maybe any laser would do. The laser used is much less important than the doctor’s proven abilities. An inexperienced doctor with the fanciest equipment is worse than the best doctor with an older laser. All good doctors understand the limitations of their tools and techniques and will not perform surgery (no matter what the laser) if there is not a high probability of you receiving a good outcome.
Have you ever had malpractice insurance coverage denied?
Answer should be no.
Are you currently under investigation by the agency that provides the license that allows you to perform refractive surgery? Has this license ever been revoked, suspended, or otherwise restricted? Are you on any sort of license probation.
Generally, the answer should be no, but if there are any licensing concerns, consider the circumstances. As an example, a doctor who five years ago was fined a few hundred dollars for an advertising problem may not need to be automatically excluded. Surgeons new to that state may be on probation for a period of time. Discuss any licensure issues with the doctor and come to your own conclusion about disqualification as a potential doctor.
Have you ever had hospital or surgical facility privileges revoked?
Answer should be no.
Have you ever had your Drug Enforcement Agency (DEA) certification revoked, suspended, or otherwise restricted?
Answer should be no.
Have you ever been convicted of a felony?
Generally, the answer should be no, but discuss the circumstances and come to your own conclusion about disqualification as a potential doctor. A problem 20 years ago when a college student may not be germane to today.
Have you ever been arrested for being under the influence of, or in the possession of, any controlled substance?
Generally, the answer should be no, but discuss the circumstances and come to your own conclusion about disqualification as a potential doctor. A problem 20 years ago when a college student may not be germane to today.
Have you ever been treated for substance abuse or mental illness as an adult?
Generally, the answer should be no, but discuss the circumstances and come to your own conclusion about disqualification as a potential doctor. A problem 20 years ago when a college student may not be germane to today.
Have your ever been refused participation as a provider in a health insurance plan?
Answer should be no, except in the case of managed care, which excludes doctors for reasons other than medical competency.
Is the laser and equipment you will use specifically approved by the Food and Drug Administration (FDA) for the recommended procedure and intended parameters? If no, explain why it is not FDA approved and/or off-label use.
The equipment should be FDA approved (hardware and software). The parameters may not be FDA approved. Surgeons are legally able to use FDA approved tools beyond FDA approved parameters in some circumstances. This is called off-label use and should be discussed with your doctor if applicable to your circumstances.
If an enhancement surgery is required, what will you charge for the additional procedure?
Answer should be no charge for an enhancement within a specified period of time, usually about a year after surgery. If there is a charge, consider the affordability if needed.
If another doctor will be comanaging pre- and/or postoperative care, can I see you at any time without my comanaging doctor’s authorization?
The answer should be yes. You should be able to go directly to the surgeon at any time you feel it is appropriate.
What should I expect my vision to be like for the first few weeks after surgery?
The answer should include an explanation of minor fluctuations, regression, minor halos, minor starbursting, etc. These side-effects may occur, but normally resolve during the six-month healing process.
Will you perform a complete refractive examination including evaluating the medical health of my eyes both before and after surgery?
The answer should be an unqualified yes and the medical component of the exam must be performed by an ophthalmologist (medical eye doctor).
Will my vision fluctuate after surgery? How long is the healing period?
If the doctor says, "Twenty minutes and all will be fine" you may want to move on. The surgery is quick but the healing and fluctuations may continue for months or longer. Refractive surgery is more of a six-month process than a 20-Minute Miracle even though it is possible you will have perfect vision immediately after surgery.
Will you perform a contrast sensitivity test before and after the surgery?
The answer will probably be no, but should be yes. Contrast sensitivity testing is not currently routine and not all doctors have the technology available. Your doctor should offer to arrange for you to receive this test at your expense at another location.
Will you perform a glare sensitivity test before and after the surgery?
The answer will probably be no, but should be yes. Glare sensitivity testing is not currently routine and not all doctors have the technology available. Your doctor should offer to arrange for you to receive this test at your expense at another location.
Will you perform corneal topography before and after the surgery?
The answer should be yes.
If you recommend Lasik, will you use a laser to create the flap or a mechanical microkeratome?
The femtosecond laser may be a better alternative than a flap created with a blade, however not all doctors have this equipment and it is not always be required. Like the different types of excimer lasers, it may be that only a laser created flap will be appropriate or a microkeratome created flap will be fine. Discuss this with your doctor.
Will you perform a test to determine tear volume (Schirmer) and tear breakup test (TBUT) prior to making a recommendation about surgery?
Answer should be yes. These tests help determine if you have unusually dry eyes.
Will you measure the size of my pupils when naturally dilated in a dimly lit room prior to making a recommendation about surgery?
The answer must be yes. This is an important test to determine if you my have a higher than normal probability of postoperative problems in low light environments. Dilation needs to be natural and without medication. The ruler method will work but the infrared pupilometer method is better. more
Will you use a different microkeratome blade (Lasik only) for each eye?
The answer may be yes, but many doctors use one blade for both patient's eyes. You may request a new blade for each eye, but don’t be surprised if the doctor asks you to pay a little more for the extra blade.
Will you require me to be without contacts for a period of time before the examination that will determine final calculations for surgery? What is this period of time?
The answer must be yes and for a significant period of time. We recommend four weeks without soft contact lenses, longer for hard contacts. Some doctors feel two weeks or even a few days is enough, we recommend longer. You want your surgery calculations determined after your cornea has returned to its natural state, no matter how long that takes.
Will my treatment prescription be based on cycloplegic refractive error as well as manifest refractive error?
The answer must be yes. Manifest examinations are always necessary, but the eye will "focus around" some error that cannot be measured unless a cycloplegic exam is also performed.
Will you measure the thickness of my cornea prior to making a recommendation about surgery?
The answer should be yes.
If an excimer laser is to be used, what size will be the optical ablation zone not including the transition zone? Is this larger or smaller than my naturally dilated pupil?
If the answer is less than 6.0mm or less than the size of your naturally dilated pupils (whichever is greater), ask for a clarification and discuss additional risks for low light aberrations such as halos, starbursts, glare, etc. more
Is a patient with more than ten diopters myopia, more than three diopters hyperopia, or more than two diopters astigmatism a good candidate for refractive surgery?
The answer must not be ideal, excellent, or anything of the like. Although correction at these levels can be accomplished, someone with this level of refractive error is not an "ideal" candidate and has a lower than average probability of success.
How often and when will you perform postoperative examinations?
Should be not less than the day after surgery, one week, 30 days, 90 days, and six months - or more if required. These exams might be performed by an eye care professional other than the surgeon.
When will you provide me with a copy of your written informed consent?
The doctor should offer to provide a copy immediately upon asking this question. A week before surgery is adequate. You need to read and understand every component. This is not just a legal formality, but an explanation of what can happen.
Will you provide contacts for me to wear to simulate monovision prior to surgery? How long will you want me to wear these contacts before I make my decision about monovision?
Contacts should be provided free with at least four weeks wearing time before monovision decision must be made.
Will you provide me the names and contact information of at least ten previous patients who have had the exact same surgery with similar refractive error?
Answer should be yes, and doctor should already have such a list compiled. Don't expect to get a list of dissatisfied patients, but these people can tell you what going through the procedure is like. You may want to talk with patients who had surgery recently and some who had surgery several months ago.
Will you allow me to observe a surgery?
Answer should be yes, however operating suite access restrictions may preclude surgery observation.
Does my occupation, leisure activities, and hobbies have any bearing on my candidacy for refractive surgery?
Answer should be yes. People who require exacting and detailed vision or rely heavily on good low light vision are possibly not good candidates for refractive surgery and should be screened appropriately.
Does my general medical and medication history have any bearing on my candidacy for refractive surgery?
Answer should be yes. Some conditions that have nothing to do with the eyes may complicate some types of refractive surgery. more
Does being pregnant or contemplating pregnancy have any bearing on my candidacy for refractive surgery?
Okay guys, you don't get ask this one but all women of child bearing age should ask. Fluctuations in refractive error are often related to pregnancy and lactation. more
Who will pay for multiple corrective lenses if I experience fluctuation in visual acuity while healing?
Whatever the answer, consider this as a part of the cost of the surgery.
Are there any reasons why I would not have excellent refractive surgery results?
A blanket question to provide you and your doctor an opportunity to discuss in more detail what you can reasonably expect from the proposed surgery. Whatever the answer, it needs to be the same as what you perceive to be an excellent result. If you cannot reasonably expect to receive what you consider to be a successful result, don’t have surgery.
What certification do you hold, if any, from the American Board of Ophthalmology, American Board of Eye Surgery, and/or the Council for Refractive Surgery Quality Assurance (USAEyes)? If not all, why?
It may be important for you to know if the doctor desires the additional oversight of these organizations. Some are more valuable than others

The American Board of Ophthalmology (ABO) does not provide any evaluation specific to refractive surgery. Certification is valid for a lifetime, or 10 years if recently certified. ABO certification would be conspicuous by its absence, but not terribly important by its presence.

The American Board of Eye Surgery (ABES) is an ophthalmic group that provides procedure specific certification. They do have peer-reviewed certification for Lasik, and RK, but not PRK, LASEK or any other refractive procedure. ABES Lasik certification is valid for seven years.

The Council for Refractive Surgery Quality Assurance (USAEyes) is a nonprofit consumer/patient organization that evaluates a doctor based upon actual patient outcomes. The doctor is reevaluated every three months.

Consider the relevance and value of these and other certifications the doctor may have achieved.