March 2004

http://www.eyeworld.org/article.php?sid=445

The original article has some nice gory pictures.

Brent, which issue was this in?

by Matt Young EyeWorld Staff Writer

New evidence suggests that the most common complaint among dissatisfied
refractive surgery patients is a loss of quality of vision, said Terrence P.
O'Brien, M.D., associate professor of ophthalmology, Wilmer Eye Institute,
Johns Hopkins University School of Medicine, Baltimore.

However, the management of these complications shouldn't always involve
surgery, he said.

Sometimes, surgeons should simply wait for technology to advance for certain
cases, he said.

And while surgeons are already greatly concerned about good visual outcomes,
it's also important to raise awareness of other complications, such as dry
eye, which is often under-recognized, he said.

Finally, while incomplete flaps and buttonholes are rare, ophthalmologists
should heed recommendations about treatment, said Louis E. Probst, M.D.,
medical director, TLC Vision USA, Chicago.

Visual complaints

A loss of quality of vision after refractive surgery is probably the
greatest concern for ophthalmologists - a concern further justified by a
recent analysis of the most common complaints among dissatisfied refractive
surgery patients, performed by O'Brien and his colleagues at Johns Hopkins.

They found that patients complained of blurred distance vision in 59% of
eyes - the most common complaint recorded.

That was followed by complaints of glare (26.7%). And the fourth through
sixth most common complaints were blurred near vision (19.3%), night driving
problems (16%), and halos (11%).

The study included 101 patients (and 161 eyes).

"Non-surgical treatment was recommended in almost half of the patients and
included medications, spectacles, soft contact lenses, rigid gas permeable
contact lenses, and in many cases, punctal plugs," O'Brien said.

While non-surgical treatment was recommended for 47.2% of eyes, surgical
treatment was recommended for 52.8%. The most common recommended surgical
treatment was LASIK enhancement (for 8.7% of eyes).

"The single greatest recommendation was to wait and let technology catch up
to the problem causing dissatisfaction," O'Brien said. Waiting for future
technology was recommended for 32.9% of eyes.

Dry eye a major concern

Dry eye was the third most common complaint in O'Brien's study, surfacing in
21.1% of eyes.

"One of the complications that is very common and often under-recognized is
the dry eye syndrome after LASIK, and this can lead to unhappy patients
despite perfect refractive outcomes," O'Brien said.

O'Brien recalled one patient of his who attained 20/15 vision after LASIK
and was plano, but seven months after the surgery she was unhappy because of
dry eye.

"She was very unhappy with even filamentary changes to the ocular surface,"
O'Brien said.

"This is in part due to the severing of the corneal nerves that leads to a
temporary denervation keratopathy," O'Brien said. "Fortunately, there are
some expanding options that allow us to better diagnose these patients that
are at risk and to provide better treatments."

Kazuo Tsubota, M.D., assistant professor of ophthalmology, Keio University,
School of Medicine, Tokyo, Japan, said he readily uses artificial,
non-preserved tears, hyaluronic acid, and protective eyeglasses to prevent
dry eye in patients after LASIK.

If dry eye does develop after LASIK, Tsubota uses punctal plugs to increase
the tear volume and stabilize the tear film. He uses a warm compress to
improve the meibomian gland dysfunction and also stabilize tear film. He
also uses autologous serum.

"Autologous serum treatment can provide essential tear components such as
vitamin A or epidermal growth factor to the ocular surface, resulting in a
stable ocular surface," Tsubota said.

Flap complications

The rate of all flap complications is very low, Probst said. It was
demonstrated as 0.3% according to a study published in the Journal of
Cataract and Refractive Surgery.

But because they do occur from time to time, here are some tips on how to
prevent flap complications, Probst said:

· Prior to LASIK, check all equipment. Equipment failure could result in a
flap complication;

· If a buttonhole is identified immediately, the flap should not be lifted.
Gently irrigate the interface to allow the flap to be refloated into
position. If the flap has been lifted, it should be replaced and refloated
into position. The eye should be allowed to heal for at least three months,
but LASIK can be performed again using a deeper plate;

· When a thin flap occurs, evaluate the flap and stromal bed. If the stromal
bed and flap is smooth, LASIK can still be performed with superb results. If
the stromal bed is not smooth or the flap is perforated, LASIK will result
in irregular astigmatism with haze; and

· In the case of a free cap, if the suction level was low and the stromal
bed irregular, replace the flap and let it heal. Don't perform excimer laser
ablation. If the free cap was caused by a low pre-operative keratometry
reading, the stromal bed may be smooth and the thickness of the free cap of
normal. Therefore, the laser can be used with great results.
Editors' note: Tsubota has a patent for the use of albumin as an ophthalmic
drug.

Contact Information
O'Brien: 410-847-3508, fax 410-847-3519, tobrien[at]jhmi.edu
Probst: 608-249-6000, fax 608-245-4028, linda.foley[at]tlcvision.com
Tsubota: [81-47] 3226781, fax [81-47] 3226786, tsubota[at]tdc.ac.jp