Vision à la carte is a concept I would like to share with all ophthalmic surgeons wherein we can design vision for each patient individually, using all of today’s technologies and techniques, including combinations of these.
The cornerstone of success is the surgeon’s ability to customize their approach to each patient’s vision goal or best vision potential (BVP).
How do we arrange these techniques and pick the ones most suitable for each patient?
My approach has always been that we eye surgeons are all vision corrective surgeons (irrespective of cornea, LASIK, or cataract specialties).
In this armamentarium of vision corrective surgery—think of it as an umbrella term with about 48 techniques, i.e., there are nearly 9 different types of LASIK/laser vision surgery (10 now, with the recent SMILE technique I performed while abroad), 4 types of implantable lenses, 8 techniques of Cataract surgery, 6 types of premium lens implants, 7 types of corneal transplants, 5 types of intrastromal corneal ring segments, and about 3 ways of doing collagen cross linking, etc.
The combinations and permutations therefore exceed over a hundered. With these approaches at your fingertips, you can try various combinations and have unlimited permutations to tailor to each patient’s vision goal (Gulani AC: Designer Vision Surgery: BOA conference, Mumbai, 2013).
I like to teach this to surgeons and my patients as"Lego™ pieces. Arrange these surgery techniques like Lego™ pieces on shelves in your mind. Each category should have its own color.
or example, all laser vision techniques could be blue, all cataract surgery lens implant choices and techniques yellow, all corneal techniques green, adjunct techniques such as collagen cross linking (that can be used in combination with practically any surgery) white.
Now, say you are planning a combination of cataract surgery (yellow piece) with LASIK (blue piece). You now have a plan that can be visualized, and the colors can be used to explain your plan so much more easily. This approach also empowers you to pick whatever piece is best suited for the patient or even choose combinations.
AApply this concept to complex and complicated cases. For example, in the case of a LASIK ectasia, you can plan for lamellar corneal transplant (a green piece), followed by laser PRK (a blue piece) 6 months later. This needs to be followed by collagen cross linking (a white piece).
Customization further involves the proper consideration of three factors that I call the “3T’s”: target, technique, and technology.
Target. A specific target is a very important piece that I believe was missing from vision corrective surgery until the past few years. Surgeons performed surgeries and hoped for the best (or at least what they thought would be good for patients). Today, we need to plan for specific vision targets. If the patient is a pilot, he wants a certain vision at different illuminations (i.e., day and night). If he is a golfer, he wants certain vision at specific distances and often at multiple points. A dental surgeon or an architect’s desire for near vision is usually arms’ length, not 16 inches. We are now making our surgery accountable like never before. Set the target vision with patient counseling and education and work backwards to pick the technology and technique to achieve that. This is in synch with patient expectations today.
Technology. Technology in diagnostics provide us with information about nooks and crannies of the human eye we did not even know existed previously leaving us with little excuse to what I call “ Leaving Vision on the Table.” Study of vision impact factors besides refractive errors including spherical aberration and wave fronts, allows us to aim for our choice of the specific technology in surgery so we can address all adversely affecting vision factors (like aiming for a strike in bowling, and not just settling for a spare.
The Gulani 5S Classification System algorithm sets the background to my approach and makes any simple or complex case scenario lucid enough to understand and effectively treat.
This algorithm involves classification according to sight, scar, shape, strength, and site.
Sight.If the patient has potential vision, we as eye surgeons need to get to work.
Scar.Is the cornea scarred or clear? If scarred, we need to modify the scar in the interest of vision.
Shape.All laser vision surgery is based on shape. We flatten myopia, steepen hyperopia, and turn a football-shaped astigmatic cornea into a spherical basketball.
Strength.Is the cornea tectonically strong (i.e., of a normal thickness)? Is it thicker (Fuchs’ dystrophy, epikeratophakia)? Is it thinner (LASIK ectasia, keratoconus)? The surgeon must remove additional tissue, such as in a case of epikeratophakia in a thick cornea, or add a lamellar corneal transplant in a case of ectasia.
Site.Peripheral corneal problems are not as visually significant as central problems, unless they indirectly affect vision, such as with induced astigmatism.
You can address any virgin or complex case with a simplified understanding of the 5S system and a plan that not only you and your patient can understand but they can email this plan to their friends and families as well (Eyemaginations, Inc., Baltimore, MD, is working with me towards developing this 3D software prototype).
Today, with patient expectations, available technology options, and information resources, patients are literally coming in with their own vision goals, chosen technology, and researched techniques for the surgeon to perform.
With a global patient clientele in my practice, I am seeing patients every day who are willing to travel to a surgeon they have chosen, in their minds, to be the most capable to deliver their “Individualized Vision Goal.”
This concept may serve to relieve you of constantly being under the gun of oncoming technology promises coupled with prohibitive expenses and will not necessitate re-learning techniques and challenging your comfort zone.
Instead, this concept allows you to use all the surgical techniques you already have access to and are capable of performing and put them into a new perspective.
Additionally, this concept of planning with patients invigorates them to the fact that you are personalizing a plan in their best interests, and therefore, they become your teammate and choice of the 3Ts then becomes a welcome pleasure as opposed to a confabulating tradeoff towards choice for patients.
Patients are moving from the “burgers for everyone” concept and are asking for “à la carte” treatments. Are you ready to offer a menu of vision corrective options?
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