Quality improvement in refractive surgery
The College recommendations for supporting information in the field of refractive surgery are as follows:
It is expected that ophthalmologists who perform laser of surgical procedures whose primary aim is to correct refractive error should provide as minimum supporting information for each revalidation cycle.
“An audit of at least 50 consecutive refractive procedures performed over the past 2 years. Larger audits are acceptable. Data may be subdivided into consecutive cases of a particular type if desired. All audit cases should have been examined by the candidate before, and after treatment.” Both laser and surgical refractive procedures may be included in this audit.
Many refractive surgeons already routinely collect much more comprehensive outcome data on their refractive surgery than the minimum requirement specified above and alternative data sets which meet or exceed the minimum requirement are also acceptable as supporting information for appraisal.
Ophthalmologists who undertake refractive surgery may also consider the following optional topics for audit:
- Perceptions by patients of the quality of care provided by the refractive surgery service
- Retreatment or treatment enhancement following laser refractive surgery
It is particularly recommended that refractive surgeons are familiar with the minimum data sets discussed by George Waring in “Standard Graphs for Reporting Refractive Surgery” (Journal of Refractive Surgery, 16:459-466, 2000).
Refractive surgery has become very popular with the public and most patients are happy with the results. However, around 2005, increasing public concern that refractive surgery was insufficiently regulated caused Gwyneth Dunwoody MP to table a Private Member’s Bill which proposed that The Royal College of Ophthalmologists should assume a regulatory role in laser refractive surgery. The bill did not become law, but ensuing discussions between the College and organisations representing providers of refractive surgery resulted in the development of the Certificate in Laser Refractive Surgery.
A number of organisations which provide laser refractive surgery require their surgeons to sit the Certificate, and routinely provide surgeons with feedback on the accuracy of refractive corrections and the occurrence of complications. Commendably, some providers seek feedback from all patients on their perceptions of the quality of care they have received, including the professional attributes of the surgeon who treated them. This information is fed back to surgeons at their annual appraisal.
NICE guidance document IPG64 (Photorefractive (laser) surgery for the correction of refractive error – guidance (2006) concludes that laser refractive surgery is safe and efficacious for use in appropriately selected patients but that clinicians should have adequate training before performing these procedures.
NICE guidance document IPG385 (laser correction of refractive error following non-refractive ophthalmic surgery) concludes that laser refractive surgery is safe and efficacious when used to correct refractive error following other forms of ophthalmic surgery (eg following cataract surgery or penetrating keratoplasty), but that patient selection and treatment should be carried out only by ophthalmologists who specialise in corneal surgery.
Complications of laser refractive surgery include reduction of best-corrected visual acuity, infection, displacement of the corneal flap, and corneal ectasia (distortion of the thinned cornea).
Complications of refractive lensectomy with intraocular lens implantation are similar to those of cataract surgery. However, eyes with high myopic and hyperopic refractive errors can be at higher risk of operative or post-operative complications than eyes with small refractive errors.
NICE guidance document IPG289 (Intraocular lens insertion for correction of refractive error with preservation of the natural lens (2009)) notes that there is good evidence for the short term efficacy and safety of phakic intraocular lens insertion, but that the long term risks (eg cataract, corneal endothelial damage and retinal detachment) remain uncertain and require ongoing audit.