When choosing refractive procedures, long-term planning is key

Image Credit: AdobeStock/EduardoCorcino

When patients ask me about refractive procedures, they tend to be impatient. They are tired of wearing glasses and contact lenses and want a procedure that will finally correct their vision.

But as optometrists, it is our job to ensure that patients do not make rash decisions about their sight. We must offer not only details about the procedures for which patients are eligible, but some perspective about how their choices will affect them—in the short term and over a lifetime.

Conversations about immediate issues should include recovery time after a refractive procedure, potential adverse effects such as eye dryness or reduced night vision, and lifestyle issues such as involvement in high-impact sports. Discussions about longer-term considerations should touch on the likely need for future ocular procedures, such as cataract correction, and how refractive surgeries may affect eligibility.

Choosing a procedure

My practice’s most popular refractive surgeries include LASIK, photorefractive keratectomy (PRK), and phakic intraocular lens (IOL) implantation. Of course, before considering how these options will serve our patients, we need to establish eligibility.

Patients are good candidates for LASIK or PRK if their myopia sits at – 6 diopters (D) or lower. Between –6 D and –12 D, LASIK is the preferred laser procedure, as PRK is associated with healing and stability issues at these levels.¹ Yet, IOLs have become our top choice for patients with myopia between –8 D and –20 D, as these patients would lose a significant amount of corneal tissue if they underwent LASIK.

Our surgeons use the EVO ICL (implantable collamer lens), a type of phakic IOL with monofocal and toric designs that were approved by the FDA in March 2022²; the lenses are indicated for patients aged 21 to 45 years with myopia ranging from –3 D to –20 D and astigmatism, if present, ranging from 1 D to 4 D. We prefer this easily foldable ICL—one of 2 choices on the US market—because it requires just a tiny incision for implantation and is placed in the posterior chamber rather than clipped to the iris, thus protecting patients against inflammation and ocular injuries.

Phakic IOLs may be the only choice for patients with thin or irregularly shaped corneas, scars from contact lens injuries, or dry eye, who are not well suited for laser surgery.^3,4 But in addition, our surgeons now routinely recommend ICLs instead of PRK to any patients eligible to choose either procedure. This new approach is driven by the comparative ease of ICL surgery and its ability to deliver great vision without compromising the cornea. I would encourage optometrists to discuss this strategy with candidates who have the appropriate range of vision, along with an anterior depth of 3 mm or greater, a suitable chamber angle, and sufficient endothelial cell density on the innermost corneal surface.⁵

Doctors may be reassured to know that patient comanagement is the same after ICL as it is after LASIK—and less complex than follow-up after PRK, when the more challenging recovery period may warrant extra visits. For patients who have undergone ICL or LASIK, checkups typically occur at 1 day, 1 week, 1 month, and 3 months after surgery. In some cases, follow-up can be handed off to referring optometrists as early as day 1.

Looking at lifestyle

Any conversation about procedural eligibility should touch on lifestyle, as LASIK may be contraindicated in certain patients, including those who engage in high-impact occupations, sports, or hobbies. This is due to concern about flap displacement, which can occur in rare cases after LASIK if a patient sustains blunt force to the eye.⁶

Fortunately, this complication is not a concern after PRK or ICL, as neither of these procedures creates a flap. This is why PRK was the preferred laser surgery within the US military for many years.⁷ Recently, that trend has begun to shift, with LASIK gaining popularity among service members⁸ and ICLs found to be safe and effective among their ranks.⁹ Nevertheless, my own inclination with patients who have a higher risk of strikes to the eye is to err on the side of caution, recommending against LASIK and opting instead for PRK or, ideally, ICLs.

Another immediate consideration for patients is recovery time, which is rapid with LASIK and ICLs but extended with PRK. With LASIK or ICLs, I tell my patients they will be able to resume their normal activities a day or two after surgery, although their eyes will still be healing. But when patients ask about PRK, I warn them that it will take at least 3 weeks before they feel happy with their outcomes, due to pain and vision that improves only gradually. These concerns may force patients to temporarily limit their activities, including work. Not surprisingly, potential adverse effects are also top of mind for patients and for their doctors.

Issues such as compromised night vision, persistent dry eye, and other negative outcomes have traditionally affected 3% to 5% of my practice’s appropriately screened patients who undergo LASIK or PRK. Although ICLs are associated with a similar rate of night vision issues, they are less likely to cause dry eye.¹⁰ That is important to know, especially in patients with a history of the condition.

A case in point is a patient I saw a few months ago who had longstanding dry eye despite medication. She could no longer tolerate contact lenses and was tired of wearing glasses, but her condition might have worsened had I treated her stressed ocular surface with a laser. Instead, I deemed this patient a perfect candidate for ICL, and she has been extremely happy with her results.

Planning for the future

Before choosing refractive procedures, patients should also understand how their choices will fit their needs in the years ahead. Optometrists should explain that a laser procedure earlier in life may stand in the way of optimal results if cataract surgery is needed later.

Because refractive laser procedures and cataract surgeries each raise the risk of dry eye,¹¹ some patients who undergo both may find that the problem compounds. In addition, once LASIK or PRK have permanently altered the ocular surface, doctors can find it more challenging to achieve predictable cataract correction. This does not occur with ICLs because implantation is reversible, enabling doctors to simply remove the lenses before performing cataract surgery.

Providing pivotal guidance

As our field advances, I am excited to be able to offer a variety of refractive surgery options, including choices for patients who cannot or should not undergo laser procedures—such as those with myopia in the –12 D to –15 D range. Among my patients in that population, most have previously been told that they are not good candidates for LASIK, and they do not expect even a glimmer of hope when they discuss refractive procedures with me. Yet, they end up thrilled when they learn that ICL is an option—and one with a demonstrated history of fantastic clinical outcomes, both in the US and in Europe.

By providing guidance about the pros and cons of each available procedure, optometrists can offer more than sharp vision; we can also support patients in achieving their long-term visual goals, from an acceptable recovery time to a low adverse effect profile to the prospect of simple, straightforward cataract surgery in the future. With this kind of commitment to long-term planning, we can help ensure that our patients feel satisfied with the outcomes of their refractive surgeries, both today and in the future.

References:

1. Somani SN, Moshirfar M, Patel BC. Photorefractive keratectomy. In: StatPearls [Internet]. Updated July 18, 2023. Accessed April 9, 2024. https://www.ncbi.nlm.nih.gov/books/NBK549887/

2. FDA approves Staar Surgical’s EVO Visian implantable collamer lenses. Eyewire. March 28, 2022. Accessed April 9, 2024. https://tinyurl.com/24bzh7as

3. Feldman BH, Huang D, Reddy V, Saad A, Shafer B. LASIK for myopia and astigmatism: safety and efficacy. American Academy of Ophthalmology: EyeWiki. February 13, 2024. Accessed April 9, 2024. https://tinyurl.com/3hh2a4k2

4. Gjerdrum B, Gundersen KG, Lundmark PO, Potvin R, Aakre BM. Prevalence of signs and symptoms of dry eye disease 5 to 15 after refractive surgery. Clin Ophthalmol. 2020;14:269-279. https://www.tandfonline.com/doi/full/10.2147/OPTH.S236749

5. EVO/EVO+ VISIAN Implantable Collamer Lens - P030016/S035. FDA. Updated April 18, 2022. Accessed April 9, 2024. https://www.fda.gov/medical-devices/recently-approved-devices/evoevo-visian-implantable-collamer-lens-p030016s035

6. Eubanks B. What if I get punched in eye after LASIK? Eye Mountain. March 21, 2022. Accessed April 9, 2024. https://eyemountain.com/punched-in-eye-after-lasik/

7. Lett B. PRK vs LASIK for the military. Eye Surgery Guide. Updated August 17, 2023. Accessed April 9, 2024. https://www.eyesurgeryguide.org/prk-vs-lasik-for-the-military/

8. Laser Eye Center. Laser eye surgery: Provides clarity for active duty service members. Health.mil. March 22, 2021. Accessed April 9, 2024. https://health.mil/News/Articles/2021/03/22/Laser-eye-surgery-Provides-clarity-for-active-duty-service-members.

9. Packer KT, Vlasov A, Greenburg DL, et al. U.S. military implantable collamer lens surgical outcomes: 11-year retrospective review. J Cataract Refract Surg. 2022;48(6):649-656. doi:10.1097/j.jcrs.0000000000000818

10. Ganesh S, Brar S, Pawar A. Matched population comparison of visual outcomes and patient satisfaction between 3 modalities for the correction of low to moderate myopic astigmatism. Clin Ophthalmol. 2017;11:1253-63. doi:10.2147/OPTH.S127101

11. Stephenson M. The relationship between dry eye and cataract surgery. Rev Ophthalmol. Published online November 21, 2007. Accessed April 9, 2024. https://www.reviewofophthalmology.com/article/the-relationship-between-dry-eye-and-cataract-surgery