Journal of Refractive Surgery

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Report on Psychosocial Findings and Satisfaction Among Patients 1 Year After Excimer Laser Photorefractive Keratectomy

Gunther Kahle, MD, PhD; Theo Seiler, MD, PHD; Josef Wollensak, MD

Abstract

ABSTRACT

BACKGROUND: The first 26 patients who underwent photorefractive keratectomy with an excimer laser in our clinic with a 1-year follow up voluntarily answered a questionnaire.

METHODS: It was intended to get information about their social status, motivation, expectations, and satisfaction with myopic excimer laser photorefractive keratectomy.

RESULTS: All patients wore corrective lenses before surgery; 74% wore no optical correction after the photorefractive keratectomy. "To improve general vision" was the highest ranked motivation while "looking better" was only of minor importance. Seventy-two percent reported that their subjective vision became better; 28% felt that it didn't change, but none reported deterioration of subjective vision. Seventy-five percent of the patients reported improvement of their lifestyle after surgery, whereas 21% reported no change and one patient stated that his lifestyle got worse. On a scale ranging from 1 to 5, early postoperative course was painful with a mean score of 2.25; the treatment itself was considered as professional (1.42 ± 0.8) and well done (1.54 ± 0.8). Eighty-four percent of the patients reported that they were satisfied with the overall results.

CONCLUSIONS: All patients would decide again to have photorefractive keratectomy for myopic correction. [Refract Corneal Surg 1992;8:286-289.)

Abstract

ABSTRACT

BACKGROUND: The first 26 patients who underwent photorefractive keratectomy with an excimer laser in our clinic with a 1-year follow up voluntarily answered a questionnaire.

METHODS: It was intended to get information about their social status, motivation, expectations, and satisfaction with myopic excimer laser photorefractive keratectomy.

RESULTS: All patients wore corrective lenses before surgery; 74% wore no optical correction after the photorefractive keratectomy. "To improve general vision" was the highest ranked motivation while "looking better" was only of minor importance. Seventy-two percent reported that their subjective vision became better; 28% felt that it didn't change, but none reported deterioration of subjective vision. Seventy-five percent of the patients reported improvement of their lifestyle after surgery, whereas 21% reported no change and one patient stated that his lifestyle got worse. On a scale ranging from 1 to 5, early postoperative course was painful with a mean score of 2.25; the treatment itself was considered as professional (1.42 ± 0.8) and well done (1.54 ± 0.8). Eighty-four percent of the patients reported that they were satisfied with the overall results.

CONCLUSIONS: All patients would decide again to have photorefractive keratectomy for myopic correction. [Refract Corneal Surg 1992;8:286-289.)

Photorefractive keratectomy is an elective laser surgery of the cornea to correct myopia. In contrast to radial keratotomy, where an indirect flattening of the central cornea is induced by performing radial cuts in the peripheral cornea, during photorefractive keratectomy the central cornea is directly flattened by removing a concave convex lenticule with the excimer laser.1 The refractive results after photorefractive keratectomy compare favorably with those after radial keratotomy showing, in addition, less sequelae like refractive and visual fluctuations. However, visual acuity recovers more slowly.2,3 Several reports about satisfaction and other psychosocial findings after radial keratotomy have been published,4"6 demonstrating that three major factors influence satisfaction: uncorrected visual acuity, residual refractive error, and subjective daily fluctuation in vision. In this study, we evaluated satisfaction 1 year after surgery reported by the first 26 patients who participated in our prospective photorefractive keratectomy study.

PATIENTS AND METHODS

The procedure itself was carried out with an Argon Fluoride laser (193 nm) medical excimer laser (Summit Technology, Waltham, Mass) using the standard nontouch technique with an ablation diameter of 3.5 mm. Only the first operated eye was included in this pilot study. The second eye was operated when the uncorrected visual acuity in the first eye was 20/30 or better, but not earlier than 3 months after the first eye. At 1 year, 20 patients had both eyes operated; 6 patients did not need a second operation because of preoperative anisometropia. As published before,3 average preoperative refraction in the first operated eye was -4.50 ± 1.80 diopters which was reduced to - 0.32 ± 0.61 D after 1 year. Emmetropia was attempted in 23 cases.

In all patients, the postoperative follow up of 1 year was completed. About 2 months later, the patients received a questionnaire in German language with 45 questions including a cover letter that explained the study and asked the patients for their cooperation. It was emphasized that participation was totally voluntary. The questionnaires were numbered and masked. Twenty-three patients returned the questionnaire within 4 weeks. At that point, a second questionnaire was sent to the nonresponders. Two weeks later, all of the 26 forms had returned.

We designed the questionnaire to include items concerning demographic characteristics (6 questions), motivation for and expectations of photorefractive keratectomy surgery (12 questions), the operation and early postoperative phase (5 questions), comparison of visual ability before and after surgery (14 questions), and ratings of satisfaction with the outcome of surgery (8 questions). Most of the 44 questions asking for rating were written with five-point answer formats, as shown in the following example:

During the first days after surgery, I had pain: very much 1...2...3...4...5 not much

RESULTS

Table 1 lists the demographic characteristics of the patients. The average age at the time of surgery was 36.0 ± 10.6 years (range, 21 to 63 years).

Motivations for Surgery

About half of the patients (51%) heard about excimer laser photorefractive keratectomy from radio/TV, 24% from newspapers, 11% from friends, and only 14% from ophthalmologists. Most candidates decided immediately to have that surgery (57%) and only 16% needed more than 30 days to make this decision. Fifty percent did not consult someone else before surgery, 43% consulted ophthalmologists, and 7% asked friends for their opinion.

All patients wore contact lenses or eye glasses prior to surgery (67% glasses only, 13% hard contact lenses or glasses, 20% soft contact lenses or glasses). Eighty-three percent had their corrective optics to wear all day, 17% more than 50% and 6% less than 50% of the day.

Fifty-nine percent of the patients had complications with lenses or glasses such as allergic reactions, eczema on the nose or behind the ear, or dry eyes.

Table

Table 1Demographic Characteristics of 26 Consecutive Patients Receiving Excimer Laser Photorefractive Keratectomy

Table 1

Demographic Characteristics of 26 Consecutive Patients Receiving Excimer Laser Photorefractive Keratectomy

From the four potential reasons for surgery which had to be rated between 1 (very important) and 5 (very unimportant), "to improve vision" was ranked highest (1.53 ± 1.0). Better vision in sports and job (each 2.03 ± 1.4) was also of high preference. "Looking better" was only of less importance (2.45 ± 1.6), not significantly different in male and female patients (males: 2.6 ± 1.8; females: 2.31 ± 1.5) (Table 2).

Operation and Side Effects

The procedure itself and the days after were experienced to be moderately painful (score, 2.24 ± 1.5 on a scale ranging from "very much* [1] to "not painful" [5]) and the patients felt to be under psychologic stress. The treatment was considered as professional ( + 1.42 ± 0.8) and well done (1.54 ± 0.8).

Seventy-four percent of the patients never wore glasses or contact lenses again, two patients use glasses about 50%, and three patients less than 25% of the day. However, 1 year after surgery, some patients reported problems (Table 2). Halos and problems during night driving are ranked highest (2.73 and 2.86), 6.1% had a score of 5 indicating severe trouble. Reading problems and diurnal vision changes had mean scores of 2.18 and 2.24, indicating mild problems. Not important were ghost images (1.25 ± 0.8), dry eyes (1.56 ± 1.1), and aching eyes (1.47 ± 0.9).

Satisfaction

Eye difficulties and special vision problems of the patients 1 year after surgery are listed in Table 2. Seventy-five percent of the patients reported improvement of their lifestyle after surgery, 21% reported no change, and 4% (one patient) stated that their lifestyle got worse. Subjective vision (10-point bipolar answer format - 1: much better, 5: unchanged, 10: much worse) was stated to be "better" (score 1 to 3) in 72% and "worse" (score 8-10) by none of the patients.

Table

Table 2Responses to Selected Questions of 26 Patients

Table 2

Responses to Selected Questions of 26 Patients

A high percentage (84.6%) reported that they were satisfied with the overall results (index scores 1 and 2); 11.5% claimed dissatisfaction (index scores 4 and 5). The mean index score was 1.88 ± 1.3, indicating overall satisfaction. Surprisingly, 100% of patients stated they would decide again to have photorefractive keratectomy and 96% recommend this procedure to myopic friends.

Of the three patients who were dissatisfied with the results, two had haze with a consecutive myopic regression to - 1.75 D and - 1.50 D, and one patient was overcorrected to + 0.75 and had difficulties with reading. Also, a 54-year-old female patient with a piano refraction elected a score of 3 (indifferent) because of reading problems.

DISCUSSION

Photoablation of the cornea with an excimer laser for reduction of myopia is currently under clinical investigation.2,3,7 One year after photorefractive keratectomy for myopia correction, patients were generally satisfied with the results. However, 11.5% (three patients) had problems with their operated eyes: two because of recurrence of myopia due to subepithelial scarring and one patient lost the ability to read without correction. This is about the same fraction of patients who were dissatisfied after radial keratotomy.5,6 On the other hand, all patients would decide again to have photorefractive keratectomy. So, even the dissatisfied patients must have had some benefits.

When we started to select our patients, one of the criteria was that the candidates had difficulties using glasses or contact lenses. Somewhat contradictory, 1 year later, only 59% remember that they had such problems. Twenty-six percent of the interviewed patients wore glasses or contact lenses again after surgery, approximately half of them less than 25% of the day.

To "improve vision" was the most important motivation for refractive surgery and "looking better" and "convenience" were ranked last. Seventy-two percent of the patients found 1 year after surgery that their vision had improved, but the convenience not to need corrective lenses most of the time was ranked higher. Although it is hard to transfer conclusions from other studies because of differences in design and patient selection, these findings could be explained by the expectation of the candidates for refractive surgery to become independent on corrective lenses which was found to be the most important motivation of participants of the PERK study.4

In the PERK study, uncorrected visual acuity and fluctuation in vision were important determining factors in postoperative satisfaction while glare was only of moderate importance.5 In the present population, the mean postoperative refraction was about - 0.50 D 12 months after excimer laser treatment resulting in an uncorrected visual acuity of 20/23 on average.3 This first series of patients was treated with an ablation zone 3.5 mm in diameter. Therefore, it is not surprising that in our study halos and problems during night driving advanced to the highest ranked problem, similar to the results of the PERK study.5 In all following patients, the zone ranged from 4 to 5 mm. Although the halo-effect is very much dependent on the ratio of pupil diameter to ablation zone diameter, some other parameters may have influence also. The incidence of halos as well as the strength of the halo itself decreases with time after surgery.3 This may indicate that some cortical adaptation might be involved.

In contrast to radial-keratotomy patients where 33.5% complained about fluctuating vision,5 our patients reported little trouble with periodic fluctuations of vision. Only 7% had severe trouble (score 5), but 60% had little or no trouble with fluctuation (scores 1 and 2). This indicates that the biomechanics of the cornea may be impaired less by the photorefractive keratectomy operation than after radial keratotomy.

Most of our patients were middle-class, employed, and young. Although these patients may be representative of those who had photorefractive keratectomy within the last 2 years, they probably are not representative of myopes in general. Powers et al6 found that there is no evidence that persons who elect radial keratotomy had obvious psychosocial problems in areas that might be relevant radial keratotomy. On the other hand, we feel that the patient population asking for photorefractive keratectomy is different from the patients referred to our clinic because of other indications. Photorefractive keratectomy patients seem to be more critical and they are better informed about the planned operation. Only in few cases (14%) did they initially learned about photorefractive keratectomy from their ophthalmologists, but 44% consulted them.

Although the fraction of patients satisfied after photorefractive keratectomy is fairly high, improvements in technique to minimize complications such as scarring and residual refraction errors and side effects such as halos by increasing the ablation zone and optimizing postoperative medical treatment may enhance satisfaction.

REFERENCES

1. Marshall J, Trokel S, Rothery S, Krueger R. Photoablative reprofiling of the cornea using an excimer laser: photorefractive keratectomy Lasers in Ophthalmology. 1986;1:21-48.

2. Seiler T, Kahle G, Kriegerowski M. Excimer laser Í193 nm) myopic keratomileusis in sighted and blind human eyes. Refract Corneal Surg. 1990;6:165-173.

3. Seiler T, Wollensak J. Myopic photorefractive keratectomy with the excimer laser. Ophthalmology. 1991;98:156-1163.

4. Bourque LB, Rubenstein R, Cosand BB, et al. Psychosocial characteristics of candidates for the Prospective Evaluation of Radial Keratotomy (PERK) study. Arch Ophthalmol. 1984;102:1187-1192.

5. Bourque LB, Cosand BB, Drews C, Waring GO, Lynn M, Cartwright C. Reported satisfaction, fluctuation of vision and glare among patients one year after surgery in the Prospective Evaluation of Radial Keratectomy (PERK) study. Arch Ophthalmol. 1986;104:356-363.

6. Powers MK, Meyerowitz BE, Arrowsmith P, et al. Psychosocial findings in radial keratotomy patients two years after surgery. Ophthalmology. 1984;91:1193-1198.

7. McDonald M, Shofher S, Klyce S, et al. Clinical results of central photorefractive keratectomy (PRK) with the 193 nm excimer laser for the treatment of myopia. Invest Ophthalmol Vis Sci. 1989;30:216-222.

Table 1

Demographic Characteristics of 26 Consecutive Patients Receiving Excimer Laser Photorefractive Keratectomy

Table 2

Responses to Selected Questions of 26 Patients

10.3928/1081-597X-19920701-08

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