This article is more than 5 years old. Information may no longer be current.
Special care needed for glaucoma patients undergoing LASIK
Practitioners find preexisting glaucoma to be a relative contraindication to LASIK, stressing that preoperative counseling and postoperative monitoring require special attention in these patients.
“I would consider glaucoma to be a relative contraindication, but not an absolute. Some patients with glaucoma can have refractive surgery,” said Stephen G. Slade, MD, FACS, national medical director of The Laser Center of Houston.
Thomas W. Samuelson, MD, of Minneapolis told Primary Care Optometry News, “I don’t believe it is an absolute contraindication. Indeed LASIK may be an excellent option for patients with glaucoma under certain circumstances.”
The circumstances that Dr. Samuelson often encounters in his practice that allow glaucoma patients to benefit from LASIK entail patients who are highly myopic and are in need of glaucoma filtration surgery.
“These patients benefit from LASIK prior to their filter, because they will not need to wear contact lenses after their glaucoma surgery,” Dr. Samuelson said. Contact lenses can increase the risk of traumatizing the bleb or a bleb-related infection after the filtration surgery. However, LASIK in glaucoma patients requires extreme diligence and more careful follow up than in non-glaucoma patients.
“In those patients who have early glaucoma, as long as you get a good baseline intraocular pressure before and after surgery, LASIK is worthwhile,” said Alan Robin, MD, of Baltimore, in an interview. Dr. Robin does not believe patients who are glaucoma suspects or those with advanced glaucoma should undergo LASIK. For patients who are glaucoma suspects, LASIK alters the patient’s corneal thickness and intraocular pressure making it more difficult to assess or predict the development of glaucoma.
Preoperative concerns
These practitioners emphasized the need to communicate the risks and benefits of LASIK in relation to glaucoma with this group of patients.
“For glaucoma patients who are considering LASIK, extensive counseling is necessary, and it is probably best to err on the side of caution,” Dr. Samuelson said. “If you are in doubt or the patient is in doubt, it is better to not perform LASIK. However, if the patient is counseled carefully and he or she understands the risks and potential benefits, then I believe it is safe to proceed.”
The increased IOP that occurs during the LASIK procedure raises some concern although it is very unlikely to cause injury. However, probably far more important is that the ultimate change in corneal thickness may make it difficult to monitor certain patients.
Also, glaucoma medications may alter wound healing and should not be taken the night after surgery.
“We don’t really know the true risk of LASIK to the optic nerve or nerve fiber layer. However, we can make a very educated guess, and I believe the risk is very low,” Dr. Samuelson said, “Our data suggests it is very low.”
Intraoperative concerns
During surgery, it is important to limit the length of time the maximum vacuum is applied. “LASIK is very safe when you minimize the vacuum time,” Dr. Samuelson explained. “The vacuum time for the microkeratome rings when creating the LASIK flap should be less than 20 seconds, and it can often be kept to 8 to 10 seconds. Nine seconds of increased IOP is really of very little consequence in the overwhelming majority of patients.”
Dr. Samuelson also said that the ocular surface should be watched carefully during surgery. “If a patient is on long-standing glaucoma medications, the ocular surface can be more easily irritated,” he said.
The patient would be instructed not to use the glaucoma drugs the night after surgery.
Postsurgical concerns
Monitoring glaucoma patients may be more difficult after the patient has had LASIK surgery.
“While I don’t believe LASIK causes glaucoma to progress, LASIK can certainly make it more difficult to follow and manage patients with glaucoma, because once the cornea is thinned, the pressure may be artificially lowered. It is very important to keep that in mind when assessing glaucoma patients postoperatively,” Dr. Samuelson said.
Dr. Samuelson said that he monitors these patients carefully. “I look at patients who have glaucoma and have had LASIK as if they are in the intensive care unit,” he explained. “I monitor them more carefully than I monitor my other patients simply because we don’t have the red flag of increased IOP to help the monitoring. We need to be very careful in looking at the patient’s disc, field and nerve fiber layer.”
For Your Information:
- Stephen G. Slade, MD, FACS, is in private practice in Houston. He can be reached at The Laser Center of Houston, 3900 Essex Lane, Ste. 101, Houston, TX 77027; (713) 626-5544; fax: (713) 626-7744; info@sladevision.com.
- Thomas W. Samuelson, MD, can be reached at Park Avenue Medical Office Building, 710 E. 24th St., Ste. 106, Minneapolis, MN 55404; (612) 813-3600; fax: (612) 813-3656; twsamuelson@mneye.com.
- Alan Robin, MD, a Primary Care Optometry News, Editorial Board member, can be reached at 6115 Falls Road, Third Floor, Baltimore, MD 21209-2226; (410) 377-2422; fax: (410) 377-7960; Glaucomaexpert@cs.com.