Choosing a Refractive Surgeon

Obviously, I cannot give each and every reader specific advice on the surgeon they choose.  And there are many, many great eye surgeons, from the smallest towns to the biggest cities.  But, there are some not so good ones and there are some surgeons who probably shouldn't be practicing.  Some surgeons have done 20,000 surgical cases similar to yours.  Some have done one!  You don't want the one who has done one!  But, do you want the one who has done 20,000?   Read on and I'll try to answer that question and a few others to help you determine how to choose a great surgeon.

Let me start by saying that, in the U.S. for example, there are approximately 17,000 practicing EyeMDs (ophthalmologists).  There may be as many as three to five thousand or more ophthalmologists that offer one or more refractive surgical procedures.  However, there is a much smaller number that actually practice comprehensive refractive surgery.  If you've read much of this website, you obviously realize by now that there are quite a few refractive procedures that are available and we are definitely not in the era where "one size fits all".  If you're seeing an ophthalmologist who only offers traditional LASIK, and he or she tries to make LASIK the procedure of choice for every refractive surgical candidate who walks through the door, then there's a huge problem!  You should know by now that LASIK, in my opinion, is never suitable for anyone who has over +4.0 diopters of hyperopia or greater than about –8.0 or –10.0 diopters of myopia.  So, if you're seeing a surgeon who tells you that it works great in your range and you fall into one of those categories, be wary.  Just because the procedure is FDA approved for those individuals doesn't mean it is the best for them!  Again, that is the purpose of this website… That is, to steer you to the best procedure and surgeon for your eyes.

Should Your Eye MD (Ophthalmologist) Be Board Certified?

Many of you reading this website probably don't realize that board certification is an elective process.  That is, a physician may elect to take the extra steps and often invest hundreds of additional hours of self-education after formal training, in order to prepare for board exams.  The American Board of Ophthalmology requires a high score on a stringent written examination be achieved in order to receive a passing score.  This is followed approximately six months to one year later by a rigorous six-part oral board examination.  For those who complete this daunting task, a 10-year time-limited certificate is issued.  Had I myself never been board-certified, I wouldn't give this much thought when choosing a physician.  However, having undertaken this enormous additional hurdle in my own training, I can appreciate it in every specialty.  The bottom-line for you, in my opinion, is just this:  choose a board-certified ophthalmologist.  It shows his or her dedication to the specialty.  This alone doesn't make for a good refractive surgeon, but to me, it's an important element. 

Should Your Surgeon Be Experienced, or Fresh Out of Training?

Sometimes I hear patients say, "I want a young doctor – one fresh out of training – up on all the latest".  As a physician myself, I know what they're driving at.  Their belief is that a physician's practice is probably the most state-of-the-art immediately out of training.  This belief has some truths, but it has faults as well, especially when it comes to surgery.   Let me explain.

Speaking from personal experience, when it comes to surgery, I would always prefer the surgeon with the experience and years under his belt to the recently trained surgeon.   As much as it hurts me to say that regarding my slightly younger colleagues, I know that experience is a great teacher.  In general, I would advise you to find a surgeon who has been out of residency or fellowship training (not medical school) at least four to eight years or more.  In fact, I believe that many of the very best surgeons are well into their 50's and 60's, and occasionally beyond.  Why?  Again, experience. 

If you asked me, when it comes to surgery, would I rather have the surgeon fresh out of training, who was top of his medical school class and had every honor in the book, or the bottom of his medical school class, never-been board-certified, but highly experienced 58 year-old surgeon, I would choose the latter surgeon every time (assuming we had to make a decision on those criteria alone).  Why?  Experience, of course!  

Should You Seek Out a High-Volume or a Low-Volume Surgeon?

The highly esteemed New York refractive surgeon, Eric D. Donnenfeld, MD, makes some very insightful observations regarding this topic in an article published in Cataract and refractive surgery Today, February, 2004[i].  Dr. Donnenfeld analyzed the data submitted by the Ophthalmic Mutual Insurance Company regarding a series of 100 consecutive claims and lawsuits filed against ophthalmologists. In the study of these claims and lawsuits, published in the journal Ophthalmology, an attempt was made to draw conclusions regarding surgical volume as it relates to risk of lawsuits, as well as other risk factors for a lawsuit[ii].  The study authors asserted that high-volume surgeons had a greater risk of lawsuits.  However,  Dr. Donnenfeld asserts that the study's authors never addressed the question:  "will a patient achieve the best result with a high-volume or a low-volume surgeon?  Stated another way," he adds, "instead of the absolute number of complications or lawsuits, what is the rate of complications or lawsuits per patient encounter?"  According to Dr. Donnenfeld, the answer to this question lies within the data obtained in the study.

The study did confirm that surgeons who performed 20 or fewer surgeries per year were at a lower risk for malpractice litigation than surgeons who performed more than 1,000 procedures per year.  But Dr. Donnenfeld points out that the risk to the patient was quite the opposite!  That is, and I'll quote, "The cumulative surgeries performed by the highest-volume surgeons were, at a minimum, more than 19,000 procedures (and most likely much higher).  Of that number, only six complications led to litigation, an incidence of less than 0.03% (or one in 3,167 procedures).  By contrast, the lowest volume surgeons had an average complication rate of 0.12% (or one in 863 procedures)."  In fact, if one does the math, this does indeed confirm that the patient's risk of incurring an outcome that leads him or her to seek litigation is 3.7 times higher when a low-volume surgeon does the surgery than when a high-volume surgeon does the surgery.  In general, this indicates that the more volume a refractive surgeon has, the lower his or her risk of having a complication. 

In another study completed by Yo et al[iii], which analyzed the visual outcomes of beginning refractive surgeons, the investigators examined the outcomes of just 33 procedures completed by a beginning refractive surgeon who was proctored by an experienced surgeon.  In this study, the researchers noted an intra-operative complication of a free cap during a LASIK procedure "which was replaced under the guidance of the proctor".  A free cap indicates that the flap was cut entirely free from the eye, that is, no hinge was left – a potentially major complication.  However, the study authors draw the following conclusion: "Out data suggest that results achieved by beginning surgeons are comparable to those reported by experienced surgeons."  In my own analysis, I would submit to you that a "free cap" complication is exceedingly unlikely to occur in any 33 consecutive cases by an experienced surgeon.  The authors who made the aforementioned statement regarding this study, in my opinion, truly had blatant disregard for the facts of the study itself.  One could have just as easily made the statement that "beginning LASIK surgeons have a much greater complication rate, although the visual outcomes in this small case series were comparable to those of more experienced surgeons." 

In a much larger study completed by Stulting, et al, 1530 refractive surgical procedures were evaluated and the study authors found that the rate of complications was 1.1% with experienced refractive surgeons, 3.1% with low-volume refractive surgeons, and 9.1% with inexperienced refractive surgeons[iv].  This study much more clearly demonstrates the decreasing risk as the surgeon's volume increases.  And why wouldn't it?  Think of your own job, whatever it is that you do.  Didn't you make the most mistakes as you first learned your job?  After you performed those tasks over and over, didn't you learn the skills that decreased your incidence of mistakes?  I would certainly hope so!  Whether you're waiting tables or performing brain surgery, experience is the best teacher, in my opinion. 

Eye surgery, although not entirely related to the dexterity of one's own hands, requires that a skill be learned.  Can't you imagine that, as a surgeon's level of experience increases, so does his mastery of that surgical skill?  Obviously, being a great surgeon requires much more than just surgical technique.  There's as much cognitive skill (knowledge) involved in being a good surgeon as there is manual dexterity.  The great surgeon's have mastered both.

Needless to say, you should only allow a highly experienced surgeon to complete your eye surgery.  Ask how many refractive surgical procedures your prospective surgeon has completed.  In fact, find out before you ever go for a consult if possible.  If he or she has completed less than one thousand refractive procedures, I would advise that you keep looking! Let others be that surgeon's first thousand or more cases.      You know better – which is why you're reading this website.  In fact, I would advise that you try to find an eye surgeon who has completed several thousand refractive procedures.  Your risk will be lower, period.

Other Not So Petty Details In Choosing a Refractive Surgeon

Do not let your emotions drive your decision.  Don't choose a surgeon because he did your friend's or family member's surgery.  Don't choose a surgeon because he did your Aunt's cataract surgery and "she loved him".  Don't choose a surgeon just because he's a nice guy.  Don't choose a surgeon because his advertising looks impressive.  Don't choose a surgeon based on anything other than your own thorough investigation. 

Yes, you will need to do some investigation.  Take your time and be as thorough as you can be.    Ask how many refractive procedures he's completed.  Ask what kinds of refractive procedures your surgeon provides.  Ask how long he's been in practice.  Ask about board-certification.  Ask for patient references, if you wish.  If you have a general ophthalmologist who does not offer refractive surgical procedures, ask who he would choose if he were going to have a refractive procedure.  That may be your very best opinion!   Finally, use the internet and educate yourself about your prospective surgeon as much as possible.   

Conclusion

Choosing your refractive surgeon is one of the most important decisions that you have to make.  You must be diligent in your investigation.  Remember, above all, choose a highly experienced surgeon to provide your care.  You cannot afford to have your eyes operated on by an inexperienced surgeon.  You cannot afford the risk.  You've only got two eyes.  Make this decision only after careful consideration and thorough investigation.