How to handle post-LASIK enhancement, refinement

Chevy Chase, MD-Understanding the difference between a LASIK enhancement and a refinement in the age of customized wavefront technology will go a long way toward patient satisfaction and modifying the public perception of LASIK, according to Roy Scott Rubinfeld, MD.

Although some LASIK cases may fall into a "gray zone," it is important to provide some guidelines to differentiate these two terms for the patient and the physician. Patients need to know when an additional fee may be warranted or if the procedure will be free under a global fee structure, noted Dr. Rubinfeld, a surgeon at Washington Eye Physicians and Surgeons in Chevy Chase, MD and on faculty at Georgetown University Medical Center and the Washington Hospital Center in Washington, DC.

Essentially, an enhancement can be defined as an aspect of the original refractive procedure, and, if it is part of the global fee structure, there should be no additional charge to the patient. It should be noted, however, that not all surgeons use a global fee system.

One such example is a patient with high myopia whose vision has been corrected to -2 D and can be refracted to a clear 20/20. "To get this patient where he or she wants to go, conventional technology will work," Dr. Rubinfeld said. "And in a global fee structure, there should be no charge for this procedure, which should be considered an enhancement."

In the case of a refinement, the patient understands that new technology is now available or the patient has now elected to use new technology for a quality "upgrade." Both the patient and the physician understand this and the patient should expect an additional charge.

Dr. Rubinfeld offered the example of a weekend golfer who wants to improve his golf game and underwent LASIK 3 years earlier. His uncorrected visual acuity is a good 20/30+, it is correctable to a crisp 20/20, and he now heard about custom LASIK. Performing custom ablation on this patient should be considered a refinement.

Not every patient's case will be so clear-cut, Dr. Rubinfeld said.

"This may be a less clear-cut example, but still I consider the following example to be an enhancement," he said. "A patient's vision was -10 D preoperatively and the patient has difficulty driving at night, with glare, halos, and some loss of best-corrected vision. The higher-order aberrations can likely be corrected. I suggest that this patient not be charged more for a custom enhancement if it will likely improve the quality of night vision."

To ease the potential for misunderstanding, he suggested providing patients with information on this topic in the form of patient education materials and, of course, one-on-one communication. "Anything that continues to improve the public perception of LASIK will grow the market and increase adoption of this technology," he said.OT