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When Plans for LASIK Fall Apart
By Melissa Bell, OD
PCLI—Lewiston, ID
Introduction
Probably almost every week patients interested in refractive surgery walk into your office. As their primary eye care physician, they trust you to help determine their candidacy. The careful screening and education that family ODs provide is very helpful. But sometimes in the evaluation and referral process, key screening factors are overlooked that result in last minute deferral or cancellation of surgery.
 When plans for LASIK fall apart late in the game (i.e. the day of surgery), motivated and excited patients can become frustrated and angry. The following guidelines may decrease the chance of disappointed patients and help them achieve a positive experience.
Absolute Contraindications
Most of the following conditions eliminate LASIK as an option because of unpredictable healing, increased risk of infection, compromised vision or uncertainty of refractive error:
- Advanced or uncontrolled glaucoma
- Corneal disorders (i.e. keratoconus)
- Early cataract formation
- Herpes simplex or herpes zoster infections in the eye
- Monocular patients
- Pregnant or nursing
- Unstable or uncontrolled diabetes
Relative Contraindications
The following conditions generally prevent patients from being ideal LASIK candidates. However, if managed appropriately they may be able to proceed—or consider an alternative refractive surgery.
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Amblyopia
LASIK will not provide better vision than achieved with corrective lenses and we generally prefer patients to be correctable to 20/30 or better. Before amblyopic patients proceed with surgery, they must understand the risks. Complications or side effects could compromise vision in their better eye and prevent compensation for their amblyopic eye. Decreased vision could negatively impact their lifestyle—such as prevent drivers’ license renewal.
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Autoimmune Disease
Autoimmune disorders such as lupus, Sjögren’s and rheumatoid arthritis, or medications that affect the immune system, may reduce the effectiveness of surgery and patients’ ability to heal. Unpredictable and variable healing may make LASIK questionable. Although patients with autoimmune disorders have had successful LASIK outcomes, individual circumstances need to be carefully considered.
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Dry Eye, Lid Disease, and Rosacea
To ensure proper healing, the corneal surface needs to be in optimum condition before LASIK. Dry eye management and lid hygiene is essential for success. In our experience, dry eye and lid disease can often be therapeutically managed so patients may be able to proceed. But if treatment is ineffective, LASIK will need to be reconsidered.
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High Refractive Error
When refractive error falls outside our current range of treatment for LASIK, patients can undergo partial correction, consider implantable contact lenses (ICLs), refractive lens exchange (RLE) or a combination of RLE and LASIK. Click here to view our range of correction for each.
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Irregular Astigmatism
Occasionally, topography shows corneal asymmetry. If contact lens wear is thought to be the culprit, it may need to be discontinued for several months. Pattern pachymetry readings may also be needed. Although there may be adequate central corneal thickness, if pattern pachymetry readings show significant asymmetry between paracentral points superiorly and inferiorly, LASIK may need to be reconsidered in order to preserve corneal integrity and decrease the chance of ectasia
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Keratometric Measurements
Keratometric measurements are important as an extremely flat cornea may make creation of the LASIK flap difficult. Patients unwilling to accept additional risk of flap complication may consider PRK.
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History of Keloid Formation
While this condition was once considered an absolute contraindication to LASIK, keloid formers can be reviewed individually. These patients are not well suited for surface treatments such as PRK or LASEK, but a number have achieved satisfactory results with LASIK.
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Large Pupils
Pupils over 7mm can cause problems with LASIK so size needs to be carefully measured in dim illumination. The larger the pupil the larger the ablation zone must be—but the ablation zone is limited by the size of the corneal flap. When large pupils prevent high degrees of LASIK correction, PRK may be a better option. If patients have large pupils, remember to discuss possible night vision problems, glare, and halos.
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Prior Refractive Surgery
When patients have had prior refractive surgery, undergoing additional refractive procedures may increase the risk of complications and unpredictable outcomes. For example, LASIK over RK may compromise flap integrity.
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Progressive or Unstable Refractive Error
Unstable refractive error can indicate underlying systemic disease, cataracts, dry eye, or contact lens induced changes. To achieve optimal surgical outcomes, refractions should be stable (less than 0.50D change) 1 year for low to moderate corrections and 2 years for high corrections.
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Strabismus
LASIK’s change of refractive error and image clarity can easily disturb fusion so any pre-operative anomaly of binocular fusion must be carefully considered. Extended testing should be pursued as diplopia is a key concern. LASIK or PRK may hold promise when traditional strabismus treatment has failed (i.e. for patients with high refractive accommodative esotropia when intolerance to glasses and contact lenses has been clearly established).
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Thin Corneas
When central corneal pachymetry measures less than 500 microns, LASIK is generally not recommended. In some instances, the surgeon can create a thinner flap or PRK can be considered. Also, when any point on the peripheral cornea is thinner than the center, LASIK should not be performed. Click here to use our corneal thickness calculator to determine if patients can safely proceed with LASIK or PRK.
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Unrealistic Expectations
Ideal candidates have realistic expectations and realize they may still require corrective eyewear. Also, they are aware that surgery involves risk and healing is different for each eye.
Conclusion
To maximize patient satisfaction and the chance of success with LASIK, it is important to recognize potential problems early in the screening process. Sometimes patients may be better suited for other refractive surgery procedures. Occasionally there may be no alternative but to reassure patients that they may become candidates in the future as technology advances and new techniques are developed.
 If you have any questions or need assistance, we are always happy to help. Please consider PCLI an extension of your practice. Whether or not you refer patients, please feel free to call and bounce cases or questions by us any time.
Refractive surgery tips:
- If monovision correction is desired, have patients undergo a contact lens trial to make sure they like what they see.
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Implantable contact lenses (ICLs) or refractive lens exchange (RLE) may be better options than LASIK for high degrees of correction. Click here to view range of correction for each.
- Hyperopic patients may be better suited for PRK than LASIK because the treatment area is not limited by the size of the corneal flap.
- PRK may be a better option than LASIK when corneas are thin, corneas are flat, pupils are large, or patients are unwilling to assume the risk of flap complications. Click here to use our corneal thickness calculator.
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