Measuring patient outcomes after refractive surgery

from the editor

Measuring patient outcomes after refractive surgery

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isual outcomes following refractive surgery are generally excellent and steadily improving. Results of laser in situ keratomileusis include a 50% or better chance of achieving an uncorrected visual acuity (UCVA) of 20/20 or better and an incidence of severe visual loss of well below 1 in 1000. However, the inevitable has occurred: Patients’ demands and expectations have grown, and in some instances they exceed current technological capabilities. We cannot guarantee a UCVA of 20/16 to all patients, nor can we ensure that the quality of vision will match all patients’ desires. To continue to progress, we of course need to improve the technology, but we also need more sophisticated methods of analyzing our results. This analysis falls into 2 categories: (1) scientific analysis of data, such as the approaches to analyzing astigmatism that were published in the January 2001 issue of the journal, and (2) outcomes analysis, which will also be an essential element of progress in refractive surgery. Outcomes analysis is likely to be important in at least 4 areas: (1) assisting in screening patients as candidates for refractive surgery; (2) determining the effect of specific parameters (eg, amount of correction, pupil size) on specific types of outcomes (eg, driving at night); (3) comparing various technologies; and (4) evaluating the impact of new advances such as wavefront-guided ablation on quality of life. In this issue, Schein and coauthors describe their first use of the Refractive Status and Vision Profile (RSVP) to study refractive surgical outcomes. The RSVP is a validated questionnaire for measuring functional status and quality of life in individuals with refractive error, and it was developed because of the perceived deficiencies in other outcomes questionnaires in evaluating the effect of refractive error on patients’ lives. It is important to point out that this paper is not an evaluation of refractive surgery per se; rather, it is an evaluation

of the possible applications of this questionnaire in analyzing these outcomes. Several findings are striking. One echoes what we have learned in the realm of cataract surgery: Visual acuity is not the sole criterion of patient satisfaction following surgery (see Figure 1, page 672). Admittedly, in this study the authors only looked at UCVA of 20/40 or better when the standard for many patients today is 20/20 or even better. Regardless of the visual acuity threshold, it is almost certain that postoperative UCVA will only partially correlate with patient satisfaction following refractive surgery. Another striking finding, again seen in the article’s figure, is that there was only modest overlap among patients who expressed dissatisfaction with vision without lenses and those who reported statistically significant worsening in 3 or more of the 7 RSVP subscales. In other words, patients may report overall satisfaction with their surgical outcome and yet indicate a decrease in quality of function in 1 or more areas. This prompts an obvious question: Does the RSVP ask patients the correct questions? Presumably, the answer is yes. This dichotomous response makes the crucial point that even for many satisfied patients, there are areas in which refractive surgery must improve to further enhance quality of life. For example, in this particular study, the percentage of patients who reported significant worsening in RSVP subscales ranged from 2.3% in the subscale trouble with corrective lenses to 29.5% in the subscale driving. The NEI-RQL is another outcomes instrument that will soon be available. The NEI-RQL was jointly developed by the National Eye Institute, the Rand Corporation, the American Academy of Ophthalmology, and several academic departments. Its overall objectives are similar to those of the RSVP, but there are several differences between the 2 questionnaires (Peter J. Mc-

J CATARACT REFRACT SURG—VOL 27, MAY 2001

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FROM THE EDITOR

Donnnell, MD, personal communication, March 2001). We look forward to seeing peer-reviewed analysis of the usefulness of this questionnaire. What will be the role of instruments such as these in clinical practice? Concerns are the length of the questionnaire—the RSVP has 42 questions—and the time required to grade and analyze patients’ responses. Ultimately, the clinician might best benefit from an abbreviated version of the questionnaire, particularly one that focuses on questions that help in screening refractive surgical candidates. Another option might be a hybrid questionnaire that combines

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some clinical outcomes questions with questions regarding the quality of care that the patient receives in that practice. With the development and evaluation of the RSVP, Schein and coauthors are addressing an area of great importance to the ongoing development of refractive surgery. As refractive surgeons, we wish to properly select patients and provide them with the best possible outcomes. Questionnaires such as the RSVP will be essential to achieving these goals. Douglas D. Koch, MD

J CATARACT REFRACT SURG—VOL 27, MAY 2001