I have enjoyed working in a laser referral center for the better part of my career. I have seen procedure volume grow, plummet, then grow and decline again, and now back to growing. The procedure currently uses a femtosecond laser for the cornea flap and an excimer laser guided by topography or wavefront aberrometry.
What has not changed is the fact that the first patient a new OD sends to our clinic is likely a non-candidate for refractive surgery. I know ODs want to find a solution to help patients, and we all have that patient who has struggled with glasses and contact lenses. So laser eye surgery (LASIK) must be the solution.
Previously by Dr. Owen: Choose your words carefully with surgery patients
In 2019, laser vision correction patient come in all ages, sizes, and prescriptions. Based on years of experience and learning from earlier errors, an OD today can determine if a LASIK patient is clinically a good candidate before he walks into the exam room. That leaves fear and expectations to talk about.
Let’s discuss high-level guidelines to help determine which patients may have the best outcomes from LASIK.
I first evaluate a patient’s age. The Food and Drug Administration (FDA)-approved age for LASIK is 18 years old. Linked to age is refractive stability.
While some 18-year-old myopes are refractively stable, many are not. Waiting until a patient has refractions within 0.50 D spherical equivalent a year apart is necessary to determine stability.
I have found that most patients are stable by age 25. They also have finished college and have a job. If LASIK were a new ophthalmic device, there would be a red mark next to those patients under 18, a yellow mark for those ages 18 to 25, and a green mark for those above 25.
Consider two other ages: the age of presbyopia and the age of cataracts. While presbyopia does not eliminate LASIK, it certainly changes the discussion. Treating both eyes for distance correction and needing glasses for closer vision is the most predictable result.
Monovision refractive surgery is successful in patients who have been successful with contact lens monovision prior to surgery. This is even more so if they are age 55 as opposed to age 45. The least successful are those patients who are successful with multifocal contact lenses. That visual world cannot be “recreated” with LASIK. The discussion with a -1.25 D 50-year-old patient can be difficult.
When these patients understand what they are gaining and what they are losing, they can be the happiest patients. However, only they can properly weigh out the difference.
Working backward, a visually significant cataract patient requires a lens-based surgery and can achieve the desired refractive outcome. Lens changes that are not yet affecting daily activities but are reducing vision fall into the most challenging situation. Medical insurance will likely not pay for cataract surgery. But I am not eager to perform LASIK. This patient may need cataract surgery in the next year or two.
1. Schallhorn JM, Schallhorn SC, Hettinger KA, Venter JA, Pelouskova M, Teenan D, Hannan SJ. Outcomes and complications of excimer laser surgery in patients with collagen vascular and other immune-mediated inflammatory diseases. J Cataract Refract Surg. 2016 Dec;42(12):1742-1752.
2. Hardten DR, Hira NK, Lombardo AJ.J Refract Surg. Triptans and the incidence of epithelial defects during laser in situ keratomileusis 2005 Jan-Feb;21(1):72-6.
3. Neudorfer M, Goldshtein I, Shamai-Lubovitz O, Chodick G, Dadon Y, Shalev V. Ocular adverse effects of systemic treatment with isotretinoin. Arch Dermatol. 2012;148(7):803-808.
4. Ortega-Usobiaga J, Llovet-Osuna F, Djodeyre MR, Bilbao-Calabuig R, Gonzalez-Lopez F, Llovet-Rausell A, Druchkiv V. Outcomes of laser in situ keratomileusis and photorefractive keratectomy in patients taking isotretinoin. Am J Ophthalmol. 2018 Aug;192:98-103.
5. Gharaibeh AM, Villanueva A, Mas D, Espinosa J, Alió JL. Corneal stability following hyperopic LASIK with advanced laser ablation profiles analyzed by a light propagation study. J Ophthalmol. Available at: https://doi.org/10.1155/2018/3060939. Accessed 4/15/19.
6. Plaza-Puche AB, Yebana P, Arba-Mosquera S, Alió JL. Three-year follow-up of hyperopic LASIK using a 500-Hz excimer laser system. J Refract Surg. 2015 Oct;31(10):674-82.
7. Kanellopoulos AJ. Topography-guided hyperopic and hyperopic astigmatism femtosecond laser-assisted LASIK: long-term experience with the 400 Hz eye-Q excimer platform. Clin Ophthalmol. 2012 Jun;6:895-901.
8. Hashemi H, Ghaffari R, Miraftab M, Asgari S. Femtosecond laser-assisted LASIK versus PRK for high myopia: comparison of 18-month visual acuity and quality. Int Ophthalmol. 2017 Aug;37(4):995-1001.
9. Feizi S, MS, Jafarinasab MR, Karimian F, Hasanpour H, Masudi A. Central and peripheral corneal thickness measurement in normal and keratoconic eyes using three corneal pachymeters. J Ophthalmic Vis Res. 2014 Jul-Sep;9(3):296-304.
10. Hirai H, Maruoka S, Yoshikawa T, Ogata N. Case of progressive hyperopia due to flattening of cornea. Am J Ophthalmol Case Rep. 2018 Feb 24;10:169-171.
11.de Ortueta D, Arba Mosquera S. Topographic stability after hyperopic LASIK. J Refract Surg. 2010 Aug;26(8):547-54.