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Define a treatment plan for common LASIK complications
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Laser in situ keratomileusis (LASIK) is the favored mode of refractive surgery among many practitioners today, in part because the procedure results in fewer complications than photorefractive keratectomy (PRK).
How ever, comanaging optometrists should have a plan of action formulated for those common complications that can occur.
Primary Care Optometry News asked three comanaging ODs about the post-LASIK care they provide and how they handle problems such as epithelial ingrowth, flap wrinkles, undercorrection and overcorrection.
Complication #1: Epithelial ingrowth.
When do you most often diagnose this?
When do you begin treatment?
How is it treated?
Jeffrey Augustine, OD, FAAO: Epithelial ingrowths are most commonly seen with poor surgical techniques where epithelial cells are inadvertently implanted into the interface. They are more common in patients older than 50, those with undiagnosed corneal dystropies and patients with previous incisional surgery. Risks for ingrowth postoperatively are serrated or ragged flap edges; this may allow epithelial cells to migrate under the flap.
The reasons for ingrowth removal include: induced irregular astigmatism, growth into the visal axis and stromal melt. The surgical procedure for ingrowth removal is to lift the flap and use a blade to scrape epithelial cells. Surgical intervention varies depending on the severity of the growth; if unsure, send the patient back for a consult.
Lee S. Peplinski, OD, FAAO: Usually, the practitioner will see this around the 1-week visit. When you begin treatment depends on the severity. Sometimes, this condition can be self-limited in minor instances, but if it’s central, causing visual acuity change or flap edema over the ingrowth, then it must be treated. The only treatment is to send the patient back to the surgeon for a scraping. We’ve seen about five or six cases in the past year, or about a 0.5% incidence.
Maynard S. Pohl, OD, FAAO: Typically, epithelial ingrowth may be diagnosed within the first few weeks following surgery. Treatment usually is indicated if epithelial ingrowth extends inward beyond 2 mm from the cap edge or when it becomes visually significant. Often, these two go hand in hand. Also, if the anterior cornea overlying the area of epithelial ingrowth is compromised, that’s another reason to treat. The edges of the flap are cleared of the epithelium using a spatula, making sure everything is clean around the cap edge before it’s actually lifted. Once it’s lifted, then both the stromal bed and the undersurface of the flap are gently scrubbed or debrided. Once clean, care must be taken to reposition the flap well to prevent recurrence of epithelial ingrowth. If the patient is planning to have a refractive enhancement, any minor epithelium may be cleaned out at that time.
Complication #2: Flap wrinkles.
Do you wait a period of time and see if the condition resolves itself or send the patient back to the surgeon to have the flap lifted?
How do you determine what to do?
Dr. Augustine: The loss of best-corrected visual acuity and slit lamp evaluation help the clinician diagnose corneal striae. Dilation of the pupil with neosynephrine and retroillumination can also help. Carefully evaluate the keratectomy edge; it may be pulled away, like carpet pulled away from the baseboard. The striae will be 90º away from the direction of the displaced edge.
The surgical technique for corneal striae repair involves lifting the flap, moving the gutter into realignment and stroking out the corneal folds, like stretching out a bed sheet. Corneal striae can be repaired at any time, but prompt referral is most beneficial.
Dr. Peplinski: If it’s very minor and the patient is enjoying excellent acuity, I don’t worry about them. Sometimes, I will try to put a lens on to see if they’ll smooth out a little bit. If it looks like there’s a pretty significant wrinkle and if it’s having an impact on acuity, then I don’t wait; we send the patient right back to the surgeon to have the flap repositioned. It depends on the severity of the wrinkle and any effect on visual acuity.
Dr. Pohl: I divide flap wrinkles into microstriae and folds. If the patient has rubbed or squeezed the eyes or encountered some trauma or the cap hasn’t fully adhered, and if a gape at the cap edge has been created by the fold, or if microstriae involve the central portion and it’s clear that vision is affected, then repositioning the cap is indicated as soon as possible. The ideal treatment is to float the cap and reposition it, being careful to completely cover the stromal bed.
Microstriae may or may not need treatment. If there is no apparent visual compromise and the cap is otherwise well-positioned, those cases may be monitored. If there is potential visual compromise due to microstriae coursing through the center of the cap, smoothing out the cap is recommended. These patients may come in 2, 3 or 4 weeks out. The cap at that time can still be lifted, hydrated, stretched and repositioned, provided there’s a potential visual benefit. Fortunately, we encounter very few of these due to preventative measures, including good patient education and frequent lubrication in the immediate postop period.
Complication #3: Undercorrection.
What is the minimal amount of time, postoperatively, that you wait to refer a patient for an enhancement?
The maximum?
Is there a window of opportunity in which to address the problem?
Dr. Augustine: Undercorrection is much more common in the higher myopic attempted ablations, especially above –10 D. Wait for corneal and refractive stabilization before retreatment. The minimum time for retreatment is approximately 90 days; exceptions may be made in accordance with each individual case.
Dr. Peplinski: I’ll usually try to have patients ride it out for a good 3 to 4 weeks, at least. Depending on their amount of undercorrection and their age, we often wait to see if they’re undercorrected in just one eye, with excellent acuity for distance in the other eye, and this could provide unplanned monovision in the presbyopic patient. Patients may find that they actually enjoy that flexibility, so they’re not really in a hurry to get anything else done. If it’s an older patient or there is a significant amount of undercorrection and you know it’s not going to get any better, there’s no reason to wait on the enhancement. The biggest limitation on the window of opportunity is when the flap starts sealing down. Usually, that’s between 3 and 6 months.
Dr. Pohl: We would consider enhancement as early as 1 month if the refractive error is stable, requiring at least two consistent refractions and stable corneal topography. That typically would be the case for low to moderate refractive error. If the patient is a higher myope, for example, more time may be needed. There’s actually no maximum amount of time that we stipulate. If the flap is difficult to lift, it can be recut, although my surgeons prefer to lift, so theoretically sooner is better. Given today’s typical laser patients, most want to get on with their lives and their best possible vision, so they usually come back in as soon as possible once they’re stable. Our referring doctors provide that direction.
Complication #4: Overcorrection.
How do you handle the situation in which a patient goes from myopic to hyperopic?
How long do you wait before another procedure?
In the postoperative phase of PRK, some ODs will stop steroids right away and switch to nonsteroidal anti-inflammatory drugs. Is LASIK handled differently?
Dr. Augustine: Overcorrection with any refractive surgical procedure is difficult to manage, but with the approval of hyperopic laser treatment, overcorrection is much more forgiving. I no longer use pharmaceutical management to alter refractive outcomes on the LASIK patient like that of the radial keratotomy or PRK patient of the past. The same principles for over- and undercorrection apply; wait for the cornea and the refraction to stabilize, then ablate for residual refractive error.
Dr. Peplinski: Again, it’s partly stability-driven. Some colleagues have treated the patient with a low-plus contact lens, which incites a little bit of hypoxia resulting in some inflammatory action. This stirs up the healing cascade, which can actually make low amounts of overcorrection drift back toward plano. We’ve tried that on a few of our overcorrected patients, and usually it will take about 1 week or slightly longer if it’s going to steer them back around. If it does get turned around and they drift back toward plano, patients will state that their distance vision is starting to get blurry again. That’s when you know you can pull the contact lens off and, hopefully, stabilize them at that level.
We use steroids for a week. With PRK, obviously, you’ve got to ride the steroids out a lot longer. With LASIK, there’s very little to manipulate with the drops. They don’t affect the refractive error, so if patients are undercorrected, you can use all the steroids you want and they’re going to stay undercorrected. It’s really just to help minimize the initial response and keep the patient comfortable. By 1 week, you’ve pretty much accomplished that, so you can stop the drops and use some tears if patients are still having some surface irritation.
Dr. Pohl: For overcorrection, I use the same enhancement criteria as for undercorrection. Patients should be off topical corticosteroids to ensure refractive stability; however, I do not use them to modulate regression of refractive error as with PRK. Postoperatively, our LASIK patients, are given a topical mild corticosteroid to be used one drop four times a day for a week. Extended or more frequent usage is only indicated if inflammation has developed. The steroid is used, in my opinion, to prevent inflammation including interface edema and potential complications such as epithelial cell ingrowth may be prevented. Sometimes, you’ll see regression in a LASIK patient, possibly more likely in the higher myope, but in my experience the use of steroids has not been clinically influential.
For Your Information:
- Jeffrey Augustine, OD, FAAO, is the director of optometric services at the Toledo LASIK Center. He may be reached at 1500 North Superior, Toledo, OH 43604; (419) 729-8781; fax: (419) 729-8919.
- Lee S. Peplinski, OD, FAAO, practices consultative optometry at Bennett & Bloom Eye Centers, a referring comanagement center. He can be reached at 4500 Churchman Ave., Ste. 203, Louisville, KY 40215; (502) 364-0033; fax: (502) 361-4488; e-mail: admin@eyecenters.com.
- Maynard S. Pohl, OD, FAAO, is the clinical director of Pacific Cataract & Laser Institute. He may be reached at 10500 NE 8th Street, Ste. 1650, Bellevue, WA 98004-4332; (800) 926-3007; fax: (425) 462-6429; e-mail: mpohl@pcli.com.