My staff and I have had the WaveLight Allegretto Wave Eye-Q excimer laser (Alcon Laboratories, Inc., Fort Worth, TX) since 2007, when we upgraded from the LadarVision platform (Alcon Laboratories, Inc.). The Allegretto Wave Eye-Q has improved our rate of postoperative refractive enhancements and enabled us to treat a wider range of corneal errors.

EXPERIENCE
We use the Allegretto Wave Eye-Q laser predominantly for LASIK; we do not perform much PRK. We use its Wavefront Optimized ablation profile for most of our patients, because its preprogrammed, phoropter-based set of ablation profiles avoids and reduces corneal aberrations. The Wavefront Optimized profile is excellent. My staff and I find it very accurate, and it induces very little aberration. It has significantly reduced our enhancement rate from that of our previous laser, from approximately 11% to currently 2% to 3% in standard cases. We are fairly aggressive in offering retreatments to patients who need them. We generally aim for initial undercorrections and try to promote monovision to our patients. Most of the enhancements we perform are in highly myopic/astigmatic and hyperopic eyes—the type of corrections that are more challenging for all lasers. Even so, the Allegretto Wave Eye-Q laser has allowed my staff and me to treat a wider range of corneal errors than we could previously. Our highest correction is now approximately 10.00 D, accounting for all variables, of course.

I attribute our low enhancement rate to the laser’s speed. It fires at 400 times per second, thus minimizing corneal exposure and treatment variability, especially in high myopes. The ablations are consistent and stable, and our patients’ corneas look impressively clear the next day.

CONCLUSIONS
In short, we are very pleased with our outcomes and lower rates of enhancements with the Allegretto Wave Eye-Q excimer laser. The laser makes refining LASIK treatments easy for us and our patients.

Stephen G. Slade, MD, FACS, is in private practice in Houston. He is a consultant for Alcon Laboratories, Inc. Dr. Slade may be reached at (713) 626-5544; sgs@visiontexas.com.

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If you want to improve outcomes and reduce enhancements, it is absolutely vital to record acuities and manifest refractions for post-LASIK patients on a daily basis. I recommend using the desktop application Datagraph-Med (Ingenieurbüro Pieger GmbH, Wendelstein, Germany) for entering outcomes quickly and accurately, or the online program DataLink from SurgiVision Consultants Inc. (Scottsdale, AZ), which is provided free to users of Alcon lasers. Capture your patients’ acuities at the 1-day, 10-day, 2-month, and 6-month postoperative visits. Capture their manifest refractions at the 2-month and 6-month visits and at the 10-day visit if their vision is worse than expected.

CAPTURE 100% OF OUTCOMES
I have found that the best people to capture and maintain outcomes data are front-desk personnel. They can place charts into a rack or bin after patients check out and enter data between patients. If your practice uses an EMR system, one staff member must be tasked with updating outcomes at the end of each day by reviewing the types of appointment visits, pulling electronic acuities and refractions from the EMR system, and entering data into the outcomes software. This system ensures that you do not miss capturing any key visits and that your nomogram reflects results from every patient. Unfortunately, such systemized outcomes collection is missing in most LASIK practices. Let’s look at the common problems preventing a 100% capture of outcomes.

CHARTS ARE NOT RETURNED TO A CONSISTENT LOCATION
Often, charts are held by a tech or are placed on the surgeon’s desk for review of something unrelated to outcomes tracking. Thus, the chart is bypassed for daily data entry and gets re-filed without its results being reported. I recommend that a designated staff person record the outcomes immediately upon the patient’s check out, before the chart is rerouted. When the technician or surgeon walks the patient to the front desk, he or she must hand off the chart, along with the patient, to this staff person. If rerouting is required, it is noted in the chart and will be transferred by the outcomes person(s) once the data entry is complete. Set up a three-bin system—Outcomes Entry Pending, To Be Filed, and Transfer To—to ensure compliance. Once the staffer enters the outcomes, he or she should initial the bottom corner of the postop form for quick viewing in case a chart does get out of sequence. Only 1-day, 10-day, 2-month and 6-month postoperative visits (or similar) for both primary and enhancement cases require data entry. All other visits can go into the To Be Filed or Transfer To bins. My surgeon clients generally use the 2-month visit as the most reliable for nomogram calculations.

MANIFEST REFRACTIONS ARE NOT CAPTURED
If a patient is happy postoperatively, practices often forget or neglect to perform a manifest refraction. However, these are the most important patients to incorporate into your surgical nomogram, because they are the ones who ended up (almost) perfect! A nomogram is a regression line of expected versus achieved results, and you must make sure to account for those that were spot-on. Because it is challenging to get happy patients to attend their postoperative visits beyond 2 months, it is especially important to capture their refraction data when you can.

The difference between good LASIK outcomes and great LASIK outcomes is +/- 0.25 D. When a 23-year-old presents with 20/20 vision, he or she still may have slight residual sphere or cylinder. A monovision patient will never have 20/20 vision in the near eye, yet you absolutely must know what the refraction is that allows him or her to read easily. This information is vital to your dataset for future surgical planning. You are trying to create a nomogram in which the expected versus achieved regression line is as tight as possible. Having 100% of patients with acuities (distance and near) and consistently timed refractions is the key.

COMANAGER RESULTS ARE NOT SENT BACK
Data gaps often exist in practices that comanage LASIK cases with referring optometrists. In these arrangements, the surgeon usually sees the patient only at the 1-day postoperative visit, and the comanager performs all other visits. Commonly, the only comanaged data that exist in the surgeon’s database are those of unhappy patients whom the comanager has returned.

I use two methods to ensure comanager outcomes data is returned to the surgeon’s practice. The simplest is a fax form with a table showing the patient’s name and key visits missing. At the beginning of each month, your outcomes entry staff checks off what they are missing, faxes it to the optometrist’s office, and requests postoperative forms be returned via fax to you. I have found faxing more effective than a phone or e-mail reminder for most optometric offices. You should be able to easily run a Missing Data report in your outcomes tracking system to create the fax. Have your staff member send it at the beginning of each month to minimize the data lag for your nomogram.

If you try the fax-reminder approach and still have trouble with outcomes data return, tie comanagement payment to outcomes. Inform poor reporting optometrists that their comanagement payment will be made upon return of the 2-month postoperative data instead of the more customary 30-day payment. This strategy usually solves the problem quickly.

NO ONE IS RESPONSIBLE FOR MAINTAINING THE OUTCOMES DATABASE
The final problem I encounter in practices that have trouble accurately maintaining an outcomes database is that no one is made responsible for 100% compliance. Outcomes entry and tracking has been positioned as a difficult, mystical, surgeon-only activity, either by surgeons or by vendors providing the tracking software. I have found that it is not that complicated. Simplify or clarify your postoperative form so that the area for recording acuities and refractions is crystal-clear and impossible to miss in the technician’s work-up. Teach every staff member what refractions and acuities mean so they understand what they are entering into the computer and they can logic-check the information promptly. Data entry is usually offered in simple row/column formats, similar to an Excel spreadsheet, which does not require surgeon expertise or time. We do our practices a disservice by limiting understanding and participation to surgeons or head technicians. In my experience, surgeons desperately want an accurate outcomes database and nomogram with which to improve their surgical results, but they do not want to be responsible for the mundane daily entry of this data. Assign a computer-literate, detail-oriented individual or team of individuals the responsibility for data entry. Senior members of the clinical team can quality-check the data before developing a surgical plan and before outcomes data is published for use in LASIK consultations.

If you get the collection step right, all other uses and interpretations of this incredibly valuable data will create better LASIK outcomes (and happier LASIK patients) for you.

In the next edition, I will discuss the preparation of surgical plans. If you have specific questions or topics you would like to see covered in the practice development steps of surgical planning, please e-mail them to kay@electivemed.com.

Kay Coulson is the President of Elective Medical Marketing, a consulting group based in Boulder, Colorado, that helps surgeons grow their elective vision service lines. Visit www.electivemed.com for patient education and practices development tools discussed in this article. Ms. Coulson may be reached at kay@electivemed.com.

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