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OD PERSPECTIVE

Lasik Surgery Complications

Refractive surgeries have been around since 1974 when the Russian ophthalmologist, Svyatoslav Fydorov began correcting myopia with a procedure called radial keratotomy (RK). Fydorov began using radial keratotomy after removing glass from the eye of a young boy. He saved the boy’s vision by making numerous radial incisions which extended from the pupil to the periphery of the cornea. After the glass was removed and the cornea healed, Fydorov found that the boy’s visual acuity had actually improved significantly. In 1936, Japanese ophthalmologist Tsutomu Sato conducted research in anterior and posterior keratotomy. This was an early form of RK that attempted to treat keratoconus, myopia, and astigmatism by making incisions in the cornea.

There are corneal surgeries, refractive surgeries, lens replacement surgeries including corneal ring implantation surgeries, photo refractive keratectomy (PRK), collagen cross-linking, laser epithelial keratomileusis (LASEK), refractive lens exchange or clear lens extraction (RLE), laser-assisted in situ keratomileusis (LASIK), epi-LASIK, phakic intraocular lens implant surgery, presbyopic lens exchange (PRELEX), intracorneal ring segments (ICR or INTACS), phakic intraocular lens implants, and astigmatic keratotomy (AK).

There are many patients who are good candidates for refractive surgery. Those patients include people who do not want to wear contact lenses or glasses. There are patients who cannot put a contact lens in their eye or are fearful of the process. There are those people who have not been successful with their contact lenses. There are patients who have big, thick eye glass lenses who may benefit, cosmetically from a refractive surgery alternative. There are people who want to work in the military or for a police force who may not be able to wear glasses or contact lenses when working.

These people must absolutely know what their specific vision requirements are before going through any refractive surgery procedure. Regulations and requirements may vary from state to state. And the requirements for the Coast Guard may be different from the Air Force or the Marines. Also, police forces on the local, state, and federal level may have different vision requirements that every ECP should be familiar with before suggesting any eye surgery. 

According to the website, http://usmilitary.about.com/od/joiningthemilitary/a/eyes2.htm, the military requirements for enlistment and commission are listed. The website http://www.aoa.org/Documents/optometrists/recommended-vision-standards-police-officers.pdf provides an extensive explanation concerning vision requirements for police officers. Depending upon what state you live in and which police force someone is interested in, this information is available from state optometric societies or from specific websites.

Anyone considering LASIK must be at least 18 years of age, be in good health, must not have uncontrolled diabetes or any auto-immune disease, should not have keratoconus, cataracts, glaucoma, herpes simplex, herpes zoster, or retinal diseases. Candidates should make their eye doctor aware of any amblyopia, strabismus, problems with healing, back problems, or claustrophobia. Prospective candidates should not have any eye infections, eye injuries, or be pregnant or nursing. Candidates should not have dry eyes and they must be out of any contact lens wear for a time to be determined by the eye doctor. Any LASIK procedure requires that the central corneal thickness be at a minimum of 0.5mm.

LASIK complications include under-corrections, overcorrections, re-onset of nearsightedness, farsightedness, or astigmatism over time, vision loss due to surgical complications, glare, halos, double vision, and dry eyes. There have also been reports of more serious problems such as retinal detachments and blindness occurring after LASIK has been done. There have been problems with the corneal “flaps” that can be displaced or can move. According to Dr. Henry Edelhauser of Emory University as presented in the Review of Ophthalmology, 2/1/2009, “there was evidence that the LASIK flap never actually heals onto the underlying stroma, especially centrally”.

According to John Marshall, a professor of ophthalmology at St. Thomas Hospital and one of Great Britain’s top experts on LASIK, “there is growing evidence of long-term damage. The cornea can be eroded so that it starts bulging and that parts of the cornea may even become dislodged. There have been a number of reports of erosion of tissue with people having to have their corneas transplanted.” 

There have been reports of complications after refractive surgery due to pressure changes that occur at increased altitudes. In 1990, it was reported that incisional refractive surgery (RK) could affect vision in higher altitudes. An example of this occurred to Dr. Beck Weathers in 1996 while ascending Mt. Everest.

 He noted a decrease in his vision early in his ascent then realized that his vision had become so bad that he could not see more than a few feet in front of him. There is ongoing evidence that this altitudinal exposure on post-RK eyes may be due to the changes in oxygen in the atmosphere. Other problems that can create pre-operative refractive surgery problems include axial length measurement errors, incorrect transposing of refraction numbers from minus cylinder to plus cylinder, and incorrectly identifying the dominant eye.

Lasik eye surgery costs are based per eye and can vary depending upon location and available technology. Nationally reported prices have been from $995-$2700 per eye. Refractive surgeries have recently been evaluated more closely by medical professionals and eye care professionals due to the fact that there have been many reported complications. If you GOOGLE, “Federal Trade Commission Investigates Eye Laser Surgery”, over 2 million sites can be viewed.

Obviously, if there are this many sites that can be viewed, then there must be many complaints by consumers and patients who have not been satisfied with the results of the refractive surgeries. In 1998, the Federal Trade Commission (FTC) was investigating Summit Technology and the Visx companies due to the fact that they had allegedly conspired to exclude rival companies and to fix the prices for laser eye surgery. According to http://www.wsj.com/articles/SB890703878571642500, the focus of the FTC probe was based on the fact that “most doctors must pay a royalty of $250 an eye to the partnership (Pillar Point), each time they use a laser from either company adding to the price of the surgery which is already $2000 or more per eye.”

In 2009, the Federal Drug Administration issued warning letters to 17 LASIK ambulatory surgical centers after inspections revealed inadequate adverse reporting systems at all of the centers. In 2003, the FTC again announced 2 complaints against Lasik Plus and the Laser Vision Institute for making false claims concerning laser eye surgeries. The FTC charged that these companies could not substantiate the claim that LASIK eye surgery would eliminate the need for glasses or contact lenses for life. In addition, the complaint added that there were no substantial facts to the claim that the procedure eliminated the risk of glare, halos, and star-burst effects around lights at night that can be caused by LASIK.

There is a site on Facebook called “Lasik Complications Facebook Group”. I decided to join this site in order to get an idea as to the amount and scope of the problems that people are having after refractive surgery. I have read hundreds of the posts on this Facebook site. The post-surgical problems are real and are frustrating to those people experiencing them. These members of this Facebook site are seeking any relief from their dry eyes, pain, vision complications, and yes, their depression caused by the vision trauma that they now experience. Many of these patients are very upset that they have spent thousands of dollars for a surgical procedure that over-promised and under-performed. The peak of LASIK surgeries occurred in 2000 with 1,400,000 people in the U.S. undergoing this refractive surgery. Between 2004 to2007, the average number of LASIK surgeries in the U.S. was 1,300,000 per year.

That number has dropped considerably to 693,000 per year in 2014. As eye care professionals, we must keep up with the latest technology on refractive surgeries and always advise our patients as to the costs, risks, and benefits on any therapy or surgical procedure that is recommended. We must advise our patients to “do their homework” and to make them aware of the fact that serious problems can occur under the best of circumstances. 

There are certainly many happy patients that have achieved freedom from glasses or contact lenses and their success will never be discounted. But unfortunately, there are numerous problems that have occurred during refractive surgery or sometimes afterwards. And there may be problems that can occur in the future that we are not aware of today. 

Technological advancements in all areas of eye surgeries will continue to allow ECP’s new, and hopefully improved ways to enhance and to change our patients’ vision. But we must be aware that sometimes unknown problems can occur years later with the best guidelines and with the most current supportive research and evidence.

Jason Smith
OD, MS

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