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Refractive Surgery: Complex Case Management | Nov/Dec 2016

Mastering Postcataract Laser Enhancements

Pricing options, strategies for talking to patients, and clinical pearls from two surgeons who are learning as they go.


Every refractive cataract surgeon wrestles with the question of how to accommodate the occasional need for laser vision correction (LVC) after cataract surgery. The surgeon must determine the best way to price enhancements (included in a refractive package or not), convey enhancement policies upfront to patients, and choose the most appropriate procedure. This article discusses two ways of approaching enhancements and shares clinical pearls for performing LVC in a refractive cataract surgery practice.


Including LVC enhancements in a laser cataract surgery or premium IOL package is the “all-you-can-eat buffet” approach. Many surgeons find this method adds value to their refractive packages and simplifies patient counseling, but it can get expensive for the surgeon if the enhancement rate is high. The approach may work best for practices with an older patient population. These patients may be highly reassured by the all-inclusive rate. At the same time, they may be less likely to pursue enhancements, because they are willing to tolerate small amounts of residual refractive error or are simply more conservative about undergoing additional surgery.


Figure. Pricing strategies. A key difference between the “better” and “best” options on this pricing menu is the use of both a femtosecond laser and a premium lens in the “best” package, whereas the “better” package includes only one of those upgrades. Both the “better” and “best” packages include LVC enhancement if needed.

(Courtesy of Eva Liang, MD.)

A second approach is to charge patients a separate (but reduced) fee for LVC enhancement, making touch-ups an “á la carte” option that patients pay for only when needed. Many surgeons feel this is more fair to patients and that it reinforces the message that surgical services are not free. This method may make it easier to price the premium or laser cataract package competitively, and it gives the surgeon great discretion in waiving or reducing the enhancement fee in the case of an upset patient or surprise outcome (Figure).


Transparency in explaining the enhancement policy to patients is essential, particularly in practices taking the á la carte approach. It is prudent to discuss with patients the likelihood of needing LVC after cataract surgery and the price of the procedure before the initial cataract surgery is performed to avoid bad feelings when a touch-up is needed. When discussing refractive cataract packages, it may be helpful to show the portion of the procedure covered by Medicare or insurance for a medically necessary cataract as well so that patients realize they are getting a discount on refractive surgery because of their cataracts.

Practices taking the buffet approach may want to market the all-inclusive nature of their packages as a practice differentiator, or they may want to mitigate costs by simply performing enhancements at no charge but not encouraging enhancements by advertising that fact.


Refractive cataract surgeons who own an excimer laser and can perform the full range of LVC procedures are at a distinct advantage in terms of cost, flexibility, and patients’ perceptions. Even if referring enhancement patients to a colleague or performing just the occasional surface procedure, it is helpful to understand some common scenarios and considerations for LVC enhancement.


PRK is an effective LVC option and one that cataract surgeons may be more comfortable learning than LASIK, but the delayed healing is a disadvantage, especially in young patients with high expectations. If both are an option, in most cases, there is no reason not to do LASIK.


By Shannon M. Wong, MD

My staff and I have developed a great source of free marketing for our practice. Right after we remove the draping and the patient is sitting up, staffers take a smartphone photo of me with the patient, both of us smiling and giving a thumbs-up (Figure). In the photos, my practice’s website is clearly visible on the surgical microscope in the background. My staff emails these photos to patients so they can easily post them to Facebook, the most common social media platform for those aged older than 50 years. A patient might get 50 to 100 “likes” for that postoperative photo—likes that, more often than not, are coming from people in the same age group who are also potential surgical candidates.


Figure. Dr. Wong and a happy postoperative patient pose in front of the microscope.

Prior Refractive Surgery

A prior LASIK flap, even an old one, can usually be lifted for an enhancement. If the patient has had prior PRK surgery, any enhancement should also be a surface procedure. A slightly thicker-than-usual (120 µm) femtosecond laser flap can be created over old radial keratotomy incisions, as long as there are no more than eight incisions; otherwise, we opt for PRK. LASIK is also possible in the presence of astigmatic keratotomy (AK) incisions performed during laser cataract surgery. In many cases, the limbal relaxing/AK incisions will be located within the LASIK flap’s diameter, and the iFS femtosecond laser (Abbott) can easily cut through the limbal relaxing/AK incisions.

Custom Versus Conventional

We prefer custom enhancements where possible. Most pseudophakic eyes, including those with presbyopia-correcting or toric IOLs, can be captured and treated with either the WaveScan or iDesign aberrometer (both from Abbott). Taking extra care during refractive cataract surgery to polish the posterior surface of the anterior capsule will help prevent any opacification that might obscure wavefront imaging in the future.


Using the iFs laser, Eva Liang, MD, creates a LASIK flap in an eye with a previous limbal relaxing incision (A) and then lifts the flap (B).

liang_wong_win1 liang_wong_win2

Enhancement Timing

Timing may depend on the age and expectations of the patient population. Although many surgeons prefer to wait 3 months after cataract surgery, others perform enhancements as early as 1 month postoperatively to achieve the final visual acuity quicker. It is essential that refractive stability be reached prior to enhancement.

LVC After Crystalens Implantation

An Nd:YAG capsulotomy should almost always be performed prior to an LVC enhancement in an eye that has a Crystalens (Bausch + Lomb) to avoid a capsulotomy-related refractive shift after LVC. In these cases, if the patient is mildly myopic, it may also be beneficial to conduct a 1-week contact lens trial to make sure the patient understands the effect of losing near vision.


Becoming more comfortable with LVC enhancements will increase the surgeon’s confidence in performing laser cataract surgery and implanting premium IOLs. We have found it enormously freeing to know that, if the outcome of a refractive cataract surgery procedure is not as expected or desired, the problem can be fixed for the patient. As long as enhancement plans are thought out in advance and clearly communicated to the patient, everyone wins.

Eva Liang, MD
Eva Liang, MD
  • medical director of Center for Sight in Las Vegas
  • (702) 724-2056; eva.liang@c4slv.com
  • financial disclosure: consultant to Abbott and Bausch + Lomb
Shannnon M. Wong, MD
Shannnon M. Wong, MD
  • Austin Eye Clinic in Austin, Texas
  • (512) 250-2020; shannon@austineye.com
  • financial interest: none acknowledged
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