Comanaging doctors play key role in handling LASIK complications

Practitioners’ knowledge of LASIK complications has increased over the years and, as a consequence, detection and treatment of these anomalies has improved. Comanaging doctors play a key role in preventing LASIK complications, both preoperatively and in follow-up care.

“There is an increased awareness that LASIK is not just a ‘point and shoot’ procedure, but real surgery,” said Vance Thompson, MD, director of refractive surgery at Ophthalmology Limited here. “It should be treated like real surgery. You need to have quality surgery with the best technology, a very good preoperative evaluation and excellent follow-up care.”

Complications such as flap striae, epithelial ingrowth, dry eye and diffuse lamellar keratitis (DLK) should be quickly detected and aggressively treated, Dr. Thompson said. “If there’s any evidence of infection or any question, the patient should be evaluated immediately,” Dr. Thompson said. “It’s critical.”

Dry eye

Some degree of transient dry eye is quite common after LASIK, but dry eye should not be trivialized as a complication, practitioners claim. According to Jeffrey M. Augustine, OD, FAAO, director of clinical operations at Clear Choice Laser Eye Center, nearly all of his patients experience dry eye for the first few weeks postoperatively. “By 3 to 6 months, fewer than 1% are still experiencing it,” he said.

Dr. Thompson said, if neglected, postoperative dry eye can develop into a serious problem for the patient.

“I think that dry eye must be respected with aggressive use of lubricants and punctal plugs,” he said. “These eyes have been compromised; the corneas have just been denervated. So, especially at night, when there’s minimal tear production, they can really get into a hypoxic state.”

Dr. Augustine said his approach to postoperative dry eye depends upon the stage at which he sees the patient.

“If you see the patient at day 1, you will see some staining on the epithelium. At that point, I will advocate lots of preservative-free artificial tears,” he said. “If the patient comes back again a week later with more staining, still showing dry eye symptoms, then you might lean toward gels or consider plugs.”

If the problem persists 3 to 4 weeks later, it is then time to step up the treatment, Dr. Augustine said. “We certainly take it to another level at that point – that’s when I start using cyclosporine or vitamin therapy, and certainly plugs,” he said. “Then I might recommend the patient get laser cannuloplasty.”

Laser cannuloplasty seals off the nasal puncta, Dr. Augustine said, in order to retain tears. In most cases, postoperative dry eye is controlled fairly easily, he said. But practitioners should advise patients predisposed to dry eye that the condition could worsen after LASIK.

“Many patients who come in for their preop examination have to be told that LASIK doesn’t cure dry eye,” Dr. Augustine said. “A lot of them are coming in with dry eye, and it’s exacerbated during the postoperative period. Knowing that they have dry eye ahead of time, you can better educate them as to what they’ll have to deal with postoperatively.”

Flap striae

Flap striae after LASIK is fairly common, although some practitioners find it to be more prevalent than do others.

“As long as someone performs a nice LASIK and there’s no decentration, I think striae is probably the most significant complication short of an infection and scarring,” Dr. Thompson said. “If someone has reduced best-corrected vision postoperatively, it’s usually due to striae. I feel that striae is being undermanaged in our country.”

Dr. Augustine said a good deal of the flap striae he sees could have been prevented – by the patient. “A lot of flap striae is patient-induced,” he said. “On the day after surgery, a lot of patients squeeze their eyes, rub their eyes or malposition their protective eye shields.”

Dr. Augustine stressed the importance of patient compliance with their postoperative instructions. “It’s all printed out in black-and-white in their postop sheets,” Dr. Augustine said. “But patients have a tendency not to follow the instructions.”

Bernard C. Tekiele III, OD, director of cornea and refractive services at Michelson Laser Vision Inc. in Birmingham, Ala., said he does not encounter a great deal of flap striae in his practice. However, if striae “are affecting best-corrected vision or not allowing the flap to be aligned properly, then it would be necessary to lift the flap, refloat it and reflect it back into place,” Dr. Tekiele said. “The flap would have to be hydrated again and stretched. Occasionally, a patient may present excellent subjective visual acuity status post-LASIK and exhibit a few microstriae. Generally, microstriae do not cause a relative decrease in visual acuity and may be noted and monitored. It is important, however, to intervene quickly with true striae or folds to optimize the surgical outcome.”

Dr. Thompson said he deals with striae first by lifting the flap and smoothing it, preferably as early as day 1. If this does not work, Dr. Thompson then sutures the flap with a minimum of five 10-0 nylon sutures.

“Those typically will take care of the striae very nicely,” he said. “If they’re long-term striae that were not managed, and there is still a visual reduction from them, I will do phototherapeutic keratectomy and essentially remove Bowman’s membrane and smooth out the surface. That can be very effective.”

Diffuse lamellar keratitis

With the growing popularity of LASIK, there has also been an increased incidence of diffuse lamellar keratitis (DLK). Many cases of post-LASIK DLK are transient and relatively mild, according to Dr. Tekiele.

“I personally have never seen a 4+ DLK where a patient has been treated very aggressively,” Dr. Tekiele said. “The worst I’ve ever seen is maybe a 1 to 2+ DLK. It’s not very common. But when we do see that, as soon as topical anti-inflammatories are administered, it goes away rapidly.”

Dr. Thompson said DLK is quite rare in his practice, but added that he handles it aggressively when he does see it. “I lift the flap, culture, aggressively rinse the interface with balanced salt solution and get the patient on an antibiotic and steroids,” he said.

Dr. Augustine also reported a low incidence of DLK, claiming that he sees this condition in “less than 1%” of his patients. He said he prescribes Pred Forte (prednisolone acetate, Allergan) for preventing DLK.

“Immediately following surgery I use Pred Forte every 2 hours,” Dr. Augustine said. “The next day, if the cornea looks normal, I reduce the dosage to four times a day for 1 week. If DLK appears 1 day postop, I continue the Pred Forte every hour and see the patient in 24 to 48 hours. If the condition worsens or has not responded to the therapy, I schedule the patient for interface washing.”

Epithelial ingrowth

Although uncommon, epithelial ingrowth is considered quite harmful because of its potential to result in a corneal melt.

“Once again, this is rare,” Dr. Tekiele said. “But you’ve got to watch it very carefully. If a progressive epithelial ingrowth problem is left unchecked, you can induce a focal corneal melt.”

Dr. Thompson said, in cases where there is a small amount of epithelium that is not growing, and there is no staining, the condition is safe to observe.

“But if there is staining on the edge or it is growing or affecting vision, it must be managed,” he said. “Growing epithelium releases hydrolytic enzymes, which can create a corneal melt, so growing epithelium must be handled aggressively.”

This would entail lifting the flap, cleaning out the epithelium and placing a bandage contact lens for a few days, Dr. Thompson said. This will promote rapid re-epithelialization, he said.

Dr. Tekiele said, in his experience, epithelial ingrowth is most common in patients who have had radial keratotomy (RK) in the past.

“Interestingly, we see the ingrowth right along the original RK line,” he said. “We just watch patients, make sure the cornea is stable and make sure the visual axis is not being affected. We make sure they’re not progressing. That’s the most important part.”

Due to the correlation he has noticed between epithelial ingrowth and previous RK patients, Dr. Tekiele said he would recommend PRK, not LASIK, for these patients. “The reason for that is stability,” he said. “We want to be very careful.”

Dr. Tekiele noted that while the risk of haze in the general PRK population is 4%, he would still consider it on a case-by-case basis.

Central islands

Central islands are a problem typically associated with broad-beam laser technology, in which a “high spot” occurs on the cornea in the ablated zone. Dr. Tekiele said he has seen this complication in patients who have been referred to him. “This could cause some very serious visual anomalies, particularly in terms of multiple imaging — maybe diplopia, triplopia and all types of halos,” he said.

Dr. Tekiele said when he sees a case of central islands, he performs a procedure called “manual custom ablation.” “This is not being done very often – we’ve had eight cases where we’ve had to fix central islands,” he said. “We have found that we were able to get most of the patients to 20/20 or 20/15.”

Dr. Thompson, who previously worked with a broad-beam laser, said he no longer uses this equipment.

“When the ablation is performed with a broad-beam laser, the plume is actually blocking the next pulse from hitting the cornea,” he said. “With the scanning laser, the plume is much smaller, and the spots are moving all over, so by the time it gets back to that spot, the plume has dissipated.”

Dr. Tekiele said that although his practice has a broad-beam laser, 99% of his cases are done with a flying spot laser. “We choose to use a flying spot technology vs. a broad beam, because it’s really the latest generation in laser technology,” he said. “We reserve our broad-beam laser for manual custom ablation cases.”

Prevention and detection

Doctors agree that thorough pre- and postoperative examinations are an integral part of successful LASIK.

“The best way to minimize the chance of complications is a good, comprehensive preoperative evaluation,” Dr. Thompson said. “It is so critical, and doctors are becoming more aware of that. I think pre- and postoperative exams are improving nicely.”

Dr. Augustine said that as LASIK becomes more popular, complications are bound to increase. But similarly, as doctors gain more experience with LASIK, they learn to treat complications more effectively.

For Your Information:

• Vance Thompson, MD, is director of refractive surgery at Ophthalmology Limited in Sioux Falls, South Dakota. He can be reached at 1200 S. Euclid Ave., Sioux Falls, SD 57105; (605) 336-6294; fax: (605) 336-6970.
• Jeffrey M. Augustine, OD, FAAO is clinical director of Clear Choice Laser Centers. He can be reached at 6255 Old Royalton Rd., Brecksville, OH 44147; (440) 740-0400; fax: (440) 740-0660.
• Bernard C. Tekiele III, OD, can be reached at 1201 11^th Ave. South, Birmingham, AL 35205; (205) 930-0930; fax: (205) 970-6823.
• Drs. Thompson, Augustine and Tekiele have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.