Patient-Reported LASIK Outcomes on RealSelf: a Social Media Review Platform

Abstract

Purpose

Laser in situ keratomileusis (LASIK), the most commonly performed elective refractive surgery, has reported patient satisfaction rates of 95%–99%. RealSelf, a social media review platform, is a source of patient-reported narrative reviews. The goal of this retrospective study was to characterize patient reviews for LASIK on RealSelf and determine factors influencing patient satisfaction.

Patients and Methods

Reviews for LASIK posted 2007–2022 on RealSelf were extracted using a web scraper. Written reviews were categorized as positive or negative. Content was further categorized into primary themes: adverse effect, bedside manner, comfort, cost, office environment, and refractive result. Pearson’s chi-square and Fisher’s exact tests with Bonferroni correction were performed using the Python SciPy library, with p < 0.05 considered significant unless otherwise stated.

Results

Of 464 written reviews, 76.7% were positive. Refractive result was more likely than all other factors to be the primary theme of positive reviews, while cost was least likely (p < 0.001). Adverse effect and refractive result were more likely than other factors to be the primary theme of negative reviews (p ≤ 0.002). Positive reviews were more likely than negative reviews to cite refractive result as a primary theme (p < 0.001). The most common adverse effect mentioned was dry eye.

Conclusion

Refractive result was most likely to be a primary determinant of patient satisfaction; cost was least likely. Studying factors contributing to patient postoperative satisfaction can inform ophthalmologists seeking to improve patient care.

Introduction

Laser in situ keratomileusis (LASIK) is the most commonly performed elective refractive surgery. The National Eye Institute estimates that more than 105 million Americans have refractive error,¹ and an estimated 800,000 eyes undergo LASIK every year.² Since the FDA approval of LASIK in 1998,³ patients have undergone LASIK for the correction of myopia, presbyopia, and astigmatism,⁴ with postoperative satisfaction rates ranging from 95 to 99%.⁵ In addition to boasting high rates of patient satisfaction with refractive outcomes, LASIK has also been reported to have an association with improvements in patients’ subjective happiness and quality of life.^6,7

In the past decade, social media has become an increasingly prevalent avenue for patient engagement and information sharing.^8,9 Patients are increasingly using online platforms to convey and receive information about surgical procedures, including LASIK.^10,11 Studies have demonstrated that patients heavily consider physician ratings and reviews when choosing a surgeon.¹² In addition, online publicity about LASIK may contribute to trends in the number of patients pursuing LASIK surgery.¹³

RealSelf (Seattle, WA), established in 2006, is a social media review platform where patients can share their operative experiences, post before and after pictures, and inquire about various surgical procedures.¹⁴ While other popular review sites prompt patients to review the provider or practice, RealSelf allows patients to review the surgical experience as a whole and state whether they think the surgery was “worth it”. Existing literature has analyzed RealSelf reviews for various elective surgeries, including rhinoplasty, rhytidectomy, blepharoplasty, Mohs micrographic surgery, and breast reconstruction;^15–19 however, to our knowledge, no existing study has analyzed LASIK reviews on the RealSelf platform. The goal of this study was to evaluate patient-reported satisfaction of LASIK on RealSelf and identify factors that may influence positive and negative patient experiences.

Materials and Methods

Reviews posted from 2007 to 2022 under the LASIK category on RealSelf.com were extracted in February 2023. Due to the reviews being publicly available data, Institutional Review Board review was not required. A web scraper was used to extract available information from each review, including review title and content, year, rating (“worth it”, “not worth it”, and “not sure”), and cost. RealSelf allows patients to link registered physicians to their review; when a physician profile was included, geographic location was noted. Patient ratings (1 to 5) of categories provided by RealSelf were also collected: overall rating, “doctor’s bedside manner”, “answered my questions”, “aftercare follow-up”, “time spent with me”, “phone or e-mail responsiveness”, “staff professionalism and courtesy”, “payment process”, and “wait times”.

In addition to patient-reported ratings, the content of reviews was also evaluated. Reviews that indicated a patient had not undergone LASIK surgery or had undergone another type of refractive surgery were excluded. Two independent graders classified reviews as positive and negative based on overall tone, language, and self-reported satisfaction or dissatisfaction. To minimize interrater variability, reviewers first graded a training subset to refine classification criteria and establish consensus. Due to the nature of review content being skewed towards a positive or negative sentiment, no reviews met criteria for or were categorized as neutral. For reviews with mixed sentiment, grading was based on the predominant tone; for example, reviews mentioning adverse effects but expressing overall satisfaction were graded as positive. In cases of disagreement, consensus was reached through discussion and adjudication by a third grader.

Review content was categorized into primary and secondary themes to identify the major factors influencing the reviewers’ rating. Themes were determined by reviewing existing literature^5,12,20 to identify significant factors influencing patient satisfaction; approval was given by practicing ophthalmologist DZ. Positive themes included: bedside manner, refractive result, comfort, cost, and office environment. Refractive result pertained to satisfaction with visual acuity. Negative themes included the same factors as the positive themes, with the addition of an adverse effect category, encompassing complications including dry eye and visual aberrations. When applicable, the types of postoperative complications mentioned in the review were noted. Both primary and secondary themes were identified when applicable to account for reviews mentioning more than one reason for the positive or negative rating.

Descriptive analysis was performed using Pearson’s chi-square and Fisher’s exact tests with Bonferroni-adjusted post-hoc analysis to assess the distribution of themes in positive and negative reviews. Frequencies of primary themes and mention of adverse effects were compared between positive and negative reviews. Statistical analysis was performed using the Python (version 3.8) SciPy statistics computing library. A p-value < 0.05 was considered statistically significant unless otherwise stated.

Results

Our study included a total of 523 reviews from 2007 to 2022 (Table 1). Review volume increased from 2007 and peaked in 2015 (N = 50), with a notable drop in 2019 and 2020. Four hundred and forty-six gave a review of LASIK surgery as being overall “worth it”, “not worth it”, or “not sure”. Of these 446 reviews, 348 (78.0%) described LASIK as “worth it”, 56 (12.6%) as “not worth it”, and 42 (9.4%) as “not sure”. The median cost of the surgery reported by patients was $3500. Three hundred and eleven patients provided numerical ratings of various aspects of their experience. 241/311 (77.5%) patients rated their overall experience with the surgeon performing their LASIK surgery as 5/5, while 23/311 (7.4%) rated their experience as 1/5 (Supplemental Table 1).

Table 1.

Summary of Reviews

Patient “Worth It” rating
Worth it	348
Not worth it	56
Not sure	42
N/A	18
Cost
Cost given	332
No cost given	132
Mean	$4,114
Median	$3,500
Min	$500
Max	$99,999
Number of reviews per year
2007	5
2008	36
2009	40
2010	18
2011	26
2012	28
2013	43
2014	49
2015	50
2016	37
2017	19
2018	32
2019	16
2020	11
2021	26
2022	28

Of the 523 reviews included in our study, 464 included written reviews. Among 464 written reviews, 356 (76.7%) were positive (Table 2). The most common primary reason for positive reviews was refractive result (N = 272, 83.4%), followed by bedside manner (N = 35, 9.8%) and office environment (N = 28, 7.9%). In 108 negative reviews, the most common primary reason was refractive result (N = 54, 50.0%), followed by adverse effect (N = 31, 28.7%) and bedside manner (N = 12, 11.1%). The least common primary reason for both positive and negative reviews was cost (N = 3, 0.84%; N = 2, 1.85%).

Table 2.

Reviews Categorized by Primary and Secondary Positive and Negative Themes (%)

Category	Primary	Secondary	Total	Overall %
Positive	356			76.72%
Bedside manner	35 (9.8%)	55 (15.4%)	90 (25.3%)	19.40%
Comfort	18 (5.1%)	36 (10.1%)	54 (15.2%)	11.64%
Cost	3 (0.8%)	19 (5.3%)	22 (6.2%)	4.74%
Office environment	28 (7.9%)	12 (3.4%)	40 (11.2%)	8.62%
Refractive result	272 (76.4%)	25 (7.0%)	297 (83.4%)	64.01%
Negative	108			23.28%
Adverse effect	31 (28.7%)	16 (14.8%)	47 (43.5%)	10.13%
Bedside manner	12 (11.1%)	9 (8.3%)	21 (19.4%)	4.53%
Comfort	4 (3.7%)	1 (0.9%)	5 (4.6%)	1.08%
Cost	2 (1.9%)	6 (5.6%)	8 (7.4%)	1.72%
Office environment	5 (4.6%)	2 (1.9%)	7 (6.5%)	1.51%
Refractive result	54 (50.0%)	10 (9.3%)	64 (59.3%)	13.79%
Total	464

Among positive reviews, chi-square testing revealed statistically significant differences in the distribution of primary themes (p < 0.001). Bonferroni-adjusted post-hoc analysis (adjusted α = 0.005) revealed that refractive result was more likely than any of the other factors to be the primary theme of positive reviews (p < 0.001). Bedside manner, comfort, and office environment were all more likely than cost to be the primary theme of positive reviews (p < 0.001). Among negative reviews, we also found significant differences in the distribution of primary themes (p < 0.001). Post-hoc analysis (adjusted α = 0.0033) revealed that adverse effect was significantly more likely than comfort, cost, and office environment to be the primary theme of a negative review (p = 0.001, p < 0.001, p = 0.002, respectively). Refractive result was also significantly more likely than bedside manner, comfort, cost, and office environment to be the primary theme of a negative review (p = 0.002, p < 0.001, p < 0.001, respectively).

Using Pearson’s chi-square and Fisher’s exact tests to compare themes across positive and negative reviews, we observed that positive reviews (76.4%) mentioned refractive outcome as a primary theme significantly more often than negative reviews (50%, p < 0.0001). However, there were no significant differences between positive and negative reviews for bedside manner (p = 0.705), comfort (p = 0.796), cost (p = 0.331), or office experience (p = 0.293).

Of the 464 written reviews, 78/356 (21.9%) positive reviews and 72/108 (66.7%) negative reviews included specific surgical complications or adverse effects (Table 3). The most common adverse effect overall and for both positive and negative reviews was dry eye, appearing in 45/356 (12.6%) of positive reviews and 35/108 (32.4%) of negative reviews. Halo was the second most common adverse effect overall (32/150, 21.3%) and among positive reviews (20/356, 5.62%). Pain was the third most common adverse effect overall (22/150, 14.67%) and the second most common among negative reviews (17/108, 15.74%). Fisher’s exact testing revealed significant differences in reports of pain (p = 0.0047) and floaters (p = 0.0023) between positive and negative reviews. Of the 31 written reviews with adverse effects as the primary theme (Supplemental Table 2), dry eye was the most common overall, appearing in 18 (58.06%) reviews. It was also the only listed adverse effect in 6 (19.35%) of those reviews.

Table 3.

Frequency of Adverse Effects in Positive and Negative Reviews (%)

Adverse Effect	All Reviews	Positive Reviews	Negative Reviews	P-value (Fisher’s Exact Test)
Dry eye	80 (17.2%)	45 (12.6%)	35 (32.4%)	0.3260
Halo	32 (6.9%)	20 (5.6%)	12 (11.1%)	0.2319
Pain	22 (4.7%)	5 (1.4%)	17 (15.7%)	0.0047*
Poor night vision	21 (4.5%)	6 (1.7%)	15 (13.9%)	0.0323
Starburst	17 (3.7%)	8 (2.2%)	9 (8.3%)	0.7979
Photophobia	16 (3.4%)	6 (1.7%)	10 (9.3%)	0.2915
Foreign body sensation	9 (1.9%)	6 (1.7%)	3 (2.8%)	0.4976
Floaters	8 (1.7%)	0 (0.0%)	8 (7.4%)	0.0023*
Headache	8 (1.7%)	1 (0.3%)	7 (6.5%)	0.0286
Diplopia	4 (0.9%)	0 (0.0%)	4 (3.7%)	0.0508
Other	11 (2.4%)	2 (0.6%)	9 (8.3%)	0.0268

Note: *Significant at adjusted α = 0.005.

Our study found that 159/464 (34.26%) written reviews on RealSelf included post-operative visual acuity. Among these, some provided visual acuity outcomes for more than one eye, resulting in 196 total distinct visual acuity values reported (Table 4). Among positive reviews, 91 patients reported 20/20 vision, 56 reported 20/15 vision, and 5 reported 20/10 vision. Thirteen patients who wrote a positive review reported visual acuity worse than 20/20 vision: one reported 20/60 vision, 5 reported 20/40 vision, 4 reported 20/30 vision, and 3 reported 20/25 vision. Reviews that included visual acuity were more likely to be positive (88.05%, 140/159) than negative (p < 0.0001). Among negative reviews, one patient reported 20/60 vision, 3 reported 20/40 vision, 9 reported 20/20 vision, and 3 reported 20/15 vision.

Table 4.

Frequency of Post-Operative Visual Acuity Values Reported Among Positive and Negative Reviews (%)

Visual Acuity	Positive Reviews	Negative Reviews	Total
20/20	91 (51.1%)	9 (50.0%)	100 (51.0%)
20/15	56 (31.5%)	3 (16.7%)	59 (30.1%)
20/10	5 (2.8%)	0 (0.0%)	5 (2.6%)
20/40	5 (2.8%)	3 (16.7%)	8 (4.1%)
20/30	4 (2.2%)	0 (0.0%)	4 (2.0%)
20/25	3 (1.7%)	0 (0.0%)	3 (1.5%)
20/60	1 (0.6%)	1 (5.6%)	2 (1.0%)
Other	13 (7.3%)	2 (11.1%)	15 (7.7%)
Total	178	18	196

Of 523 total reviews on RealSelf, 179 reviews linked a physician profile, 139 (77.65%) of which were positive. Linkage of a physician profile was not associated with a significant difference in the ratio of positive/negative reviews (p = 0.07). Of the 84 physicians or practices whose profiles were linked, six were located outside of the United States: Mexico, Colombia, Canada, Australia, and the United Kingdom. The geographic distribution of practices in the United States was: 19 in the Northeast, 6 in the Midwest, 29 in the South, and 24 in the West. Chi-square testing revealed significant differences in the distribution across geographic location in the United States (p = 0.002). Bonferroni-adjusted post hoc analysis (adjusted α = 0.0083) revealed that significantly more reviews linked profiles of providers located in the South (37.18%) compared to the Midwest (7.69%) (p = 0.006). Post-hoc power analyses performed to assess the adequacy of sample size showed that all statistical analyses reported above were well-powered, with power > 0.95.

Discussion

Patient reviews are a valuable tool for physicians and patients, and social media is an increasingly popular way for physicians and patients to communicate and share healthcare-related information. RealSelf is one such popular social media platform where patients can discuss their operative experience and document if their experience was “worth it” or “not worth it”. The platform has over 2 million reviews and garners 10 million unique visitors per month.²¹ These social media reviews can be a valuable source of data for not only patients seeking information about a procedure but also physicians seeking to understand patient values and factors contributing to patient satisfaction. Thus, the goal of this study was to analyze patient-generated social media reviews on RealSelf and identify factors associated with positive and negative patient reviews.

Among our study of patient-reported reviews on RealSelf, refractive result and patient experience (physician interactions and office environment) were most commonly cited as primary factors contributing to patient satisfaction. In addition, refractive result and bedside manner were more likely to be cited as primary themes in positive reviews than negative reviews. LASIK has been reported to have high rates of success in terms of refractive outcomes, with 99.5% of patients achieving at least 20/40 vision and 90–95% of patients achieving 20/20 or better vision.² As improved vision is the primary goal of LASIK surgery, it is not surprising that refractive result is a primary determinant in patient satisfaction.^5,22 The high percentage of reviews in our study demonstrating the importance of the physician-patient relationship is also in accordance with previously published literature across not only refractive surgery but also other elective surgeries.²³ A study from Pham et al¹⁹ on breast reconstruction reviews on RealSelf found that surgeon demeanor could compensate for negative aspects of the patient experience, ie, surgeons who handled postoperative complications well were perceived more positively. Office environment, including appearance of the environment²⁴ and interactions with ancillary staff,²⁵ can also influence patients’ perceptions and satisfaction. Given that RealSelf allows patients to review their experience without identifying their surgeon, reviews may be less biased when discussing the physician-patient relationship and office environment, which were common themes in our study.

Cost was the least common primary reason for a positive or negative review. LASIK is usually considered an elective procedure and is thus rarely covered by insurance; costs can range from $1000 to $4000 per eye.² An economic analysis by Berdeaux et al²⁶ revealed that the direct and indirect costs of LASIK were less than contacts but not eyeglasses. Previous studies^2,13,26 have reported the influence of cost on whether patients choose to delay or not undergo LASIK. It is possible that because the patients in our study who underwent LASIK already considered financial cost and made the decision to pay for the procedure, other qualities of their experience were more important to their determination of whether LASIK was “worth it”. While cost is discussed with the patient upfront, other factors in the experience, such as post-op recovery and complications, are more likely to be unpredictable and surprising, which may leave a greater impression on the patient.

Our study was limited by several factors. While data was collected over a 15-year timeline, reviews were not evenly distributed over time. The majority of reviews were posted between 2013 and 2016, and there was a drop in reviews from 2019 to 2022, which may be attributed to the decrease in elective ophthalmic procedures performed during the COVID-19 pandemic.²⁷ Given that the reviews included in the study were retrospective, with a range of reports posted days to years post-LASIK, temporal analyses were not performed. However, it is important to consider that patient satisfaction with LASIK may change with the development of modern techniques leading to reduced complications and improved visual outcomes.²⁸ In addition, online reviews are subject to selection bias, as patients who have stronger opinions may be more motivated to share their experiences than those with moderate opinions.²⁹ This can result in overrepresentation of more polarized reviews, as not all patients choose to write reviews. As such, certain aspects of our study, such as patient-reported frequency of adverse effects, may not reflect the true clinical incidence in LASIK patients. In addition, the demographic profile of users who engage with online social media and review platforms is predominantly younger women,⁸ which limits the generalizability of our findings to the broader patient population, including older and non-English speaking patients. Due to limited demographic information provided by the platform and its users, patient characteristics (ie, age, gender, ethnicity, refractive error) could not reliably be identified. However, existing literature shows that women and younger patients tend to have higher satisfaction post-LASIK.^30,31 We also acknowledge that categorization of sentiment is subjective, and despite efforts to standardize grading criteria, the risk of misclassification may remain.

We chose to analyze reviews posted on RealSelf because patient reviews on this platform rate the operative experience holistically, compared to other popular review sites such as Yelp or Healthgrades,³² in which reviews are linked to the surgeon and thus may be more biased and prone to the Hawthorne effect. Another important limitation of our study is that although RealSelf claims that patient reviews are verified and authentic, the authors could not verify the authenticity of reviews. To mitigate these biases, RealSelf offers a reporting system for false reviews and does not allow physicians to alter or remove reviews. In addition, reviews are moderated by a team before being published, although details of the process and its efficacy are not disclosed to the public.³³ Comparison with other sources of patient reviews, including surveys and online platforms such as Yelp, can provide a broader perspective and also highlight discrepancies in reporting across various methods of soliciting patient satisfaction.

Patient satisfaction has become an important measure in evaluating and rating healthcare outcomes and physician performance. Studying factors contributing to patient postoperative satisfaction can inform ophthalmologists providing patient care. Both positive and negative reviews can influence patient behavior when making healthcare-related decisions.⁸ For example, a study conducted by Sanati-Mehrizy et al³⁴ found that positive patient reviews on RealSelf may have been a significant contributor to a clinic’s increased patient volume. In addition, a behavioral choice-based study performed by Carbonell and Brand found that a surgeon’s subjective profile on social media, documented by user-posted comments and ratings, have a greater impact on patient decision-making than objective characteristics of the surgeon, such as years of experience.¹² Other studies have shown that negative reviews can impact a patient’s decision-making when choosing a surgeon.^35,36 From the surgeon’s perspective, positive reviews can inform providers on the strengths of their practice and provide impetus to reinforce these behaviors. Meanwhile, negative reviews can inform providers about what patients care about, as well as prompt providers to reflect on best practices to optimize future patients’ satisfaction with their surgical experience.

Conclusion

Our study sought to analyze patient-reported satisfaction and contributing factors on RealSelf, an online social media review forum. While refractive outcome was most cited as the primary determinant behind a patient’s positive or negative review, non-procedural factors including patient interactions with the surgeon and comfort in the office were also noted to be of importance. Meanwhile, cost was not a strong influence on positive or negative patient reviews. Overall, most patients who reviewed their LASIK experience on RealSelf felt that LASIK was “worth it” and positively reviewed their surgery. Online reviews can offer insight into patient perspectives and inform ophthalmologists when counseling and providing patient care.

Funding Statement

No financial support was received for the production of this manuscript.

Disclosure

The authors report no conflicts of interest in this work.