March 01, 2004

Loss of Vision Quality Top Complaint of Refractive Patients

Matt Young
EyeWorld Staff Writer

New evidence suggests that the most common complaint among dissatisfied refractive surgery patients is a loss of quality of vision, said Terrence P. O'Brien, M.D., associate professor of ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

However, the management of these complications shouldn't always involve surgery, he said.

Sometimes, surgeons should simply wait for technology to advance for certain cases, he said.

And while surgeons are already greatly concerned about good visual outcomes, it's also important to raise awareness of other complications, such as dry eye, which is often under-recognized, he said.

Finally, while incomplete flaps and buttonholes are rare, ophthalmologists should heed recommendations about treatment, said Louis E. Probst, M.D., medical director, TLC Vision USA, Chicago.

Visual complaints

A loss of quality of vision after refractive surgery is probably the greatest concern for ophthalmologists - a concern further justified by a recent analysis of the most common complaints among dissatisfied refractive surgery patients, performed by O'Brien and his colleagues at Johns Hopkins.

They found that patients complained of blurred distance vision in 59% of eyes - the most common complaint recorded.

That was followed by complaints of glare (26.7%). And the fourth through sixth most common complaints were blurred near vision (19.3%), night driving problems (16%), and halos (11%).

The study included 101 patients (and 161 eyes).

"Non-surgical treatment was recommended in almost half of the patients and included medications, spectacles, soft contact lenses, rigid gas permeable contact lenses, and in many cases, punctal plugs," O'Brien said.

While non-surgical treatment was recommended for 47.2% of eyes, surgical treatment was recommended for 52.8%. The most common recommended surgical treatment was LASIK enhancement (for 8.7% of eyes).

"The single greatest recommendation was to wait and let technology catch up to the problem causing dissatisfaction," O'Brien said. Waiting for future technology was recommended for 32.9% of eyes.

Dry eye a major concern

Dry eye was the third most common complaint in O'Brien's study, surfacing in 21.1% of eyes.

"One of the complications that is very common and often under-recognized is the dry eye syndrome after LASIK, and this can lead to unhappy patients despite perfect refractive outcomes," O'Brien said.

O'Brien recalled one patient of his who attained 20/15 vision after LASIK and was plano, but seven months after the surgery she was unhappy because of dry eye.

"She was very unhappy with even filamentary changes to the ocular surface," O'Brien said.

"This is in part due to the severing of the corneal nerves that leads to a temporary denervation keratopathy," O'Brien said. "Fortunately, there are some expanding options that allow us to better diagnose these patients that are at risk and to provide better treatments."

Kazuo Tsubota, M.D., assistant professor of ophthalmology, Keio University, School of Medicine, Tokyo, Japan, said he readily uses artificial, non-preserved tears, hyaluronic acid, and protective eyeglasses to prevent dry eye in patients after LASIK.

If dry eye does develop after LASIK, Tsubota uses punctal plugs to increase the tear volume and stabilize the tear film. He uses a warm compress to improve the meibomian gland dysfunction and also stabilize tear film. He also uses autologous serum.

"Autologous serum treatment can provide essential tear components such as vitamin A or epidermal growth factor to the ocular surface, resulting in a stable ocular surface," Tsubota said.

Flap complications

The rate of all flap complications is very low, Probst said. It was demonstrated as 0.3% according to a study published in the Journal of Cataract and Refractive Surgery.

But because they do occur from time to time, here are some tips on how to prevent flap complications, Probst said:

  • Prior to LASIK, check all equipment. Equipment failure could result in a flap complication;
  • If a buttonhole is identified immediately, the flap should not be lifted. Gently irrigate the interface to allow the flap to be refloated into position. If the flap has been lifted, it should be replaced and refloated into position. The eye should be allowed to heal for at least three months, but LASIK can be performed again using a deeper plate;
  • When a thin flap occurs, evaluate the flap and stromal bed. If the stromal bed and flap is smooth, LASIK can still be performed with superb results. If the stromal bed is not smooth or the flap is perforated, LASIK will result in irregular astigmatism with haze; and
  • In the case of a free cap, if the suction level was low and the stromal bed irregular, replace the flap and let it heal. Don't perform excimer laser ablation. If the free cap was caused by a low pre-operative keratometry reading, the stromal bed may be smooth and the thickness of the free cap of normal. Therefore, the laser can be used with great results.

Editors' note: Tsubota has a patent for the use of albumin as an ophthalmic drug.

Contact Information
O'Brien: 410-847-3508, fax 410-847-3519,
Probst: 608-249-6000, fax 608-245-4028,
Tsubota: [81-47] 3226781, fax [81-47] 3226786, Posted by Admin at March 1, 2004 11:54 PM