What to Ask Before You Have LASIK or PRK in 2017: LASIK Risks and Complications

What to Ask Before You Have LASIK or PRK in 2017: LASIK Risks and Complications
by Sandra Lora Cremers, MD, FACS

LASIK, PRK, LASEK are methods to shape the Cornea (the window of the eye) with a Femtosecond Laser to decrease your need for contact lenses and glasses and, in many cases, become glasses free for the first time in your life. These procedures have excellent safety profiles and very high success rates in the right patients.

They are designed to treat myopia (nearsightedness), hyperopia(farsightedness) and astigmatism, and can allow you to live without glasses or contacts in most cases.

However, there are some patients that should NEVER have LASIK, PRK, LASEK.

Sight-threatening complications, such as significant loss of vision or infection from LASIK, PRK, etc surgery are thankfully extremely rare, and many side effects, such as residual (left over) astigmatism or refractive error and laser eye surgery complications (such as folds, inflammation, flap dislocation, small infections, which are rare) can be resolved with additional surgery or medical treatment.

Like any other surgery, however, there are potential risks, side effects and limitations you should be fully aware of before choosing to undergo LASIK, PRK, LASEK, or any surgery.

First, choose a skilled, experienced, ethical LASIK/PRK eye surgeon can help reduce these risks and enable you to achieve the best possible results from laser eye surgery. I have seen too many patients have LASIK when they should not have had it performed on their eye. 

Second, be sure to ask the right questions to be sure you are an Excellent Candidate for LASIK/PRK. You need to know what your own risk profile is and see if you are happy to accept the risk or not.

Questions to Ask Your Surgeon: 
by Sandra Lora Cremers, MD, FACS

1. Do I have Dry Eyes? Dry Eyes represents a large percentage of unhappy LASIK/PRK patients. Thus it is important to get an assessment of your Dry Eye risk.

2. What do my Meibomian Glands look like?: be sure you see your own LipiScan or LipiView or Meibography for yourself. 
3. Do I have any risk of Sjogren’s Syndrome: if you do not have dry eye, dry mouth, and/or arthritis, your risk is low. If you have any of these symptoms, be sure you tell your surgeon. We order an SJO test if a patient has any 2 or 3 of these symptoms with Meibomian Gland Loss or recalcitrant (not improving with treatment) dry eyes.
4. Is my refraction stable? If you have varing glasses prescriptions, you should ask why and be sure it is addressed before signing up.
5. Is my refraction error too high for my corneal thickness? Patients who have too high of a prescription can develop ectasia: which is a thinning and bulging of the central cornea because too much corneal tissue was removed with the laser.

6. Do I have any signs of cataract? Usually, this is for older patients, but any signs of cataract makes it likely that you should not have LASIK/PRK but instead have the cataract addressed to try to be relieved of glasses/contact lens use. 
7. Do any of my medications I take by mouth increase my risk of dry eye after LASIK?
8. Are my pupils of a good size and shape to have LASIK/PRK?
9. Is my Pentacam regular or are there any signs of Keratoconus (KC) or Forme Fruste Keratoconus (early KC). Ask to see your Belin-Ambrosio map. Will post about this soon.  if this little box on right of photo is red, you should not have LASIK/PRK. If it is yellow, you are at risk of developing ectasia after LASIK/PRK. The risk depends on how thin your cornea is in relation to the amount of refractive error (your glasses RX) the surgeon thinks should be treated. 
10. What are my cup to disc ratios and do I have any sign of “Disc at Risk” (Cup to Disc is 0.1 or 0.0) [see https://drcremers.com/2016/07/disc-at-risk-what-you-need-to-know-if.html
or “Glaucoma Suspicion or Glaucoma” (Cup to Disc Ratio is above 0.5)
11. Are my angles open on Pentacam: this is rarely an issue in young patients, but in patients who are hyperopic (you have a smaller than normal eye and your Rx starts with a “+”), it is important to take 2 seconds to be sure you do not have an Anterior Chamber Volume ACD less than 113-124: see https://drcremers.com/2013/08/narrow-angles-instruction-sheet-for.html?q=narrow+angle
12. Did I have a fully dilated peripheral retinal exam? Be sure you were checked for any holes or tears in the retina. Retinal holes, tears, retinal detachment can occur after LASIK, PRK, but will always be a risk in myopic (eye larger than normal and Rx starts with a “-“) patients even after LASIK, PRK. See references below.

13. This one is not a question you need to determine on your own, but you can ask your surgeon: Is your (the patient) personality the type of personalities that do well after LASIK. Many surgeons know that a type AAA++ personality will notice every imperfection and will not be satisfied unless everything is perfect. Many have noted that doing LASIK on engineers, lawyers, physicists, is generally a higher risk procedure because they will notice everything. It is not a contraindication, but know many times everything is not perfect, and some people have to live with slight, noticebale imperfections in their vision and/or in how their eye feels. If you cannot imagine such a possiblity, do not have LASIK/PRK.

Even if you are not a good candidate for LASIK, you might still be able to have your vision fixed with other vision correction surgery such as PRK, LASEK or implantable lenses.

LASIK Eye Surgery Risk Factors And Limitations

Certain conditions, diseases, and anatomical factors can increase your risk of an undesirable outcome or limit optimal LASIK results. These include:
  • Too thin or irregular corneas
  • Large pupils
  • High refractive error
  • Unstable vision: changing Rx
  • Dry eyes: gritty eyes?
  • Your age
  • If you are pregnant
  • If you have certain degenerative or active autoimmune disorders

Complications Symptoms Treatments
Incomplete corrections (undercorrection, overcorrection, residual astigmatism) or regression of effect Poor quality vision; Blurry, less-than-perfect vision Glasses or contact lenses; eye drops; re-treatment with laser
Decentered ablations Visual aberrations* Eye drops; re-treatment with laser
Oversize pupils Visual aberrations* Eye drops; re-treatment with laser
Haze Visual aberrations* Eye drops; re-treatment with laser
Irregular flap (folds, wrinkles, striae) Visual aberrations* Surgical correction; second laser procedure
Dry eye Dry, itchy or scratchy eyes, often with redness and sense of foreign object in eye, and sometimes pain Warm Compresses (see below video); Prescription dry eye medication; artificial tears; Xiidra, Restasis, punctal occlusion (blockage of tear ducts in order to retain tear film on eye), Omega 3, autologous serum, LipiFlow, IPL, Meibomian Gland Probing; Steroid drops
Diffuse lamellar keratitis (eye inflammation) Visual aberrations* Eye drops; surgical rinsing of cells if severe
Epithelial ingrowth Visual aberrations* Surgical removal of epithelium
Infection Discharge, Redness, oozing of eyes, sometimes pain Eye drops; oral medications
*Visual aberrations include symptoms such as glare, double vision, ghosting, halos, starbursts, loss of contrast sensitivity, and problems with low-light or night vision. Most patients do not experience these symptoms, and some patients with these complications experience no symptoms and require no treatment. 

How Common Are LASIK Complications?

The safety and effectiveness of LASIK surgery continues to improve, thanks to increasingly sophisticated technology, surgical skill and optimal patient selection.
Complications generally were more common in the early years of LASIK, when studies in the late 1990s indicated that up to 5 percent of people undergoing laser vision correction experienced some type of problem. These days, this number is under 1 percent for serious complications.
A worldwide review of LASIK published in 2009 showed that more than 95 percent of people who had LASIK surgery between 1995 and 2003 were satisfied with their outcome.
Public confidence in LASIK has grown in recent years due to the solid success rate of LASIK surgery outcomes. The U.S. military also has adopted widespread use of laser eye surgery to decrease reliance of troops on corrective eyewear. As of 2008, more than 224,000 military personnel had undergone laser vision correction. Since the procedure first was introduced in the military in 2000, researchers have conducted more than 45 studies regarding safety and effectiveness of LASIK and other procedures.
LASIK outcomes have been overwhelmingly positive. Most military patients see 20/20 or better after the procedure without corrective eyewear, and the rate of complications has been very low. According to one study, only one in 112,500 patients required medical disability retirement due to complications from laser vision correction during this eight-year period.
In another study, 100 percent of pilots and other aircraft personnel from the U.S. Navy and U.S. Marine Corps who underwent custom (wavefront-guided) LASIK attained 20/20 uncorrected visual acuity within two weeks after surgery.
When questioned about their satisfaction one month after surgery, 95 percent of these patients said the procedure was helpful to their effectiveness, and 100 percent said they would recommend it to other aviators. Study results were presented at the 2008 ASCRS annual meeting.
Laser eye surgery has successfully treated millions of patients and has high patient satisfaction rates. However, as with any surgery, LASIK involves potential complications. It is important for you to weigh the benefits and risks before choosing to go ahead with surgery.
What are Meibomian Glands And What Yours Should Look Like?

Normal Meibomian Glands on left above——->Significant Disease————>-Severe Disease


What is SPK? Superficial Punctate Keratitis

Superficial Punctate Keratitis means that the surface of the Cornea is so dry from Inflammation (-itis…thus keratitis: -kera means Cornea), that the Cornea’s surface epithelial cells have died and left a bare area of underlying Bowman’s membrane (the layer under the epithelium). When we put a yellow drop called Fluoresceine, it stains Bowman membrane cells and not healthy epithelial cells. This is how we can see under the microscope that a patient has dry eyes. 

Why do Corneal Epithelial Cells Die?

Corneal Epithelial Cells die from:
1. Direct trauma, like a scratch on your eye or corneal abrasion.
2. Chemicals: getting an acid or base will kill these cells and many other important eye surface cells.
3. LASIK and PRK: we cut the cornea in LASIK or remove the epithelial cells in PRK, and thus purposely remove these cells to sculpt the shape of the cornea to help get a patient glasses free. The risk of doing this is that in some patients, especially if they have decreased Meibomian Glands and/or Dry Eye, the epithelial cells and maybe even the corneal nerves, do not grow back “normally” and the patient feels dry eyes that does not go away.
4. Dry Eye: this is a big issue. Dry Eye can be caused by many things, genetics, aging, hormonal changes, chronic computer use (see below), Meibomian Gland Dysfunction
5. Meibomian Gland Dysfunction: I think a patient can hit a tipping point where the extent of Meibomian Gland loss and oil production loss is significant enough to directly kill corneal epithelial cells. Likely with decreased meibomian glands and oil production, the corneal epithelial cells hit a point chemically where they behave as if to say “I can’t take this milieu/environment any more: I guess I will just disappear.” This then shows us SPK.

We can now image Meibomian Glands clearly for the first time ever. I would venture to say that a patient should not have LASIK or PRK unless they see for themselves their Meibomian Glands on LipiView or LipiScan. This will give them a better idea of what the risk is of having chronic dry eye, chronic halos/glare, chronic discomfort/foreign body sensation, chronic decreased quality of vision even with 20/20 vision which is a real complaint in LASIK and PRK patients.

If the meibomian glands loss is severe, I do not think that patient should have LASIK or PRK. The risk is too great of chronic debilitating eye discomfort, pain, and vision loss.

Normal Meibomian Glands should look like “White Piano Keyes Filled with Oil” On Meibography or LipiScan or LipiView Machines seen on bottom left.

Aging, genetics, chronic blepharitis and meibomian gland dysfunction, poor diet, smoking, inflammatory issues and disease, radiation, chemotherapy, previous surgery, and I must add Chronic computer/video game/cell phone use (ie, Computer Vision Syndrome or a new term I will coin called Decreased Blinking Quality Syndrome or Decreased Blinking Rate Syndrome which can happen to even avid readers, skiers, etc)  can destroy these precious glands and cause them to never function again. This loss of meibomian glands, decreases the ability of the tears to lubricate the cornea properly, which then leads to the death of the corneal epithelium, thus giving SPK. The death of the corneal epithelium, though is reversible.

To date, I have had 5 patients whose Meibomian Glands showed “growth” or improvement after LipiFlow or Intense Pulse Light or Meibomian Gland Probing. The current thought, though is that once a meibomian gland is gone, it is gone for good. I hope I am right.

On the right you can see:


Normal above—————————->Significant Disease———————–>-Severe Disease


Refractive surgeries, such as laser in situ keratomileusis (LASIK) and laser-assisted subepithelial keratomileusis (LASEK), have been popularized for correction of low to moderate myopia.6 ;  7 Vision-threatening posterior segment complications can occur after refractive surgeries; they include macular hemorrhages, macular holes, and rhegmatogenous RD.8910111213 ;  14 The reported incidence of rhegmatogenous RD in those with histories of LASIK is not high, ranging from 0.033% to 0.25%.111516 ;  17However, many have regarded a suction ring application during LASIK to be a potential risk factor for rhegmatogenous RD because this procedure may induce vitreous traction and detachment resulting from sudden decompression of the eye.18 ;  19 A previous study found that retinal breaks were more commonly located in the inferotemporal quadrant in rhegmatogenous RD after LASIK.20 Whether this feature is characteristic of rhegmatogenous RD after LASIK is unclear because this finding was not compared to rhegmatogenous RD without prior LASIK.

      • 7
      • R. Zaldivar, J.M. Davidorf, S. Oscherow
      • Laser in situ keratomileusis for myopia from −5.50 to −11.50 diopters with astigmatism
      • J Refract Surg, 14 (1) (1998), pp. 19–25
      •  | 

      • 9
      • A. Ozdamar, C. Aras, B. Sener, M. Oncel, M. Karacorlu
      • Bilateral retinal detachment associated with giant retinal tear after laser-assisted in situ keratomileusis
      • Retina, 18 (2) (1998), pp. 176–177
      •  | 


      • 11
      • J.F. Arevalo, E. Ramirez, E. Suarez, et al.
      • Rhegmatogenous retinal detachment after laser-assisted in situ keratomileusis (LASIK) for the correction of myopia
      • Retina, 20 (4) (2000), pp. 338–341
      •  | 


      • 16
      • B. Qin, L. Huang, J. Zeng, J. Hu
      • Retinal detachment after laser in situ keratomileusis in myopic eyes
      • Am J Ophthalmol, 144 (6) (2007), pp. 921–923
      • 20
      • J.F. Arevalo, A.F. Lasave, F. Torres, E. Suarez
      • Rhegmatogenous retinal detachment after LASIK for myopia of up to −10 diopters: 10 years of follow-up
      • Graefes Arch Clin Exp Ophthalmol, 250 (7) (2012), pp. 963–970

 2014 Mar;157(3):666-72.e1-2. doi: 10.1016/j.ajo.2013.12.004. Epub 2013 Dec 7.

Characteristics of rhegmatogenous retinal detachment after refractive surgery: comparison with myopic eyes with retinal detachment.

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