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Screen post-RK patients carefully for LASIK
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You’ve been comanaging laser vision correction patients for several years now. Because you are the expert, your patients expect you to take care of all refractive surgery issues, questions and problems. So now you are seeing a variety of radial keratotomy (RK) problems as well. You are inundated with patients who have consecutive hyperopia, irregular astigmatism, creeping hyperopia, visual fluctuations and disabling glare. These patients come to you hoping to find help for their worsening visual problems. What do you do?
In this column, we will discuss which RK patients will most likely benefit from LASIK. In future columns, we’ll address complications that LASIK cannot help, such as irregular astigmatism, glare, fluctuations and hyperopic creep.
LASIK is, by far, the best option available for post-RK patients. Photorefractive keratectomy (PRK) is not recommended, because the incidence of haze and irregular astigmatism is alarmingly high. Holmium laser thermoplasty (HLT) is not recommended because there have been reports of incision gaping and reopening, induced astigmatism and irregular astigmatism. We anticipate that conductive keratoplasty (CK) will have the same drawbacks as HLT, because the mechanism of action (contraction of stromal collagen) is the same.
Determine underlying cause
The first step in dealing with post-RK problems is to determine the underlying cause(s). Is this a simple overcorrection and the patient has been able to accommodate through the hyperopia until now? Has the patient been undergoing years of hyperopic creep? Is the patient currently stable? Is the patient experiencing fluctuations (diurnal and/or altitudinal)? Has there been a loss of best-corrected visual acuity due to irregular astigmatism? Is the patient complaining of glare? Is the glare due to optical zone issues, or is it associated with residual refractive error?
Clinical game plan
The clinical game plan consists of taking a meticulous case history, reviewing old records whenever possible, performing corneal topography, determining scotopic pupil size, determining a.m./p.m. cycloplegic refractions, performing careful slit lamp evaluation and performing an internal evaluation.
LASIK is a very good surgical option for patients with simple residual refractive errors that fall within the guidelines outlined in the accompanying table. Practitioners should stress that LASIK does not help irregular astigmatism or fluctuations. It is best to plan on only one enhancement, because lifting these flaps can lead to flap “piecemealitis,” whereas recutting will further weaken a multi-surgical cornea. Additionally, it is important to use an experienced surgeon.
For Your Information:
- Jimmy Jackson, MS, OD, FAAO, is president and director of clinical operations at InSight LASIK in Lafayette, Colo. He can be reached at 1120 W. South Boulder Rd., Suite 102, Lafayette, CO 80026; (303) 665-7577; fax: (303) 665-3633; e-mail: jimmy@insightlasik.com.
- Jim Montgomery, MD, is chief surgeon at InSight LASIK. He can be reached at 1120 W. South Boulder Rd., Suite 102, Lafayette, CO 80026; (303) 665-7577; fax: (303) 665-3633; e-mail: DrM@insightlasik.com.