ERR ON SIDE OF CAUTION WITH LASIK SURGERY

This month's issue of EuroTimes is devoted to refractive laser surgery and features a number of stimulating articles on the subject. Our Cover story focuses on the issue of complications in LASIK surgery and looks at how advances in technology and surgical techniques, allied to more rigorous patient selection, have helped to reduce the more common complications associated with refractive laser surgery.

There seems to be a broad consensus that the introduction of the femtosecond laser has played a major role in reducing intraoperative flap-related complications associated with LASIK surgery. Certainly, that view accords with my own personal experience. since making the transition to femtosecond-laser assisted LASIK in 2006, I have experienced none of the issues with buttonholes, torn or incomplete flaps that we regularly encountered with flap creation using mechanical microkeratomes. The ability of the femtosecond laser to deliver a more regular and accurate flap architecture has also largely eliminated problems of epithelial ingrowth that occurred regularly with mechanical blades in primary LASIK procedures. A fundamental factor in reducing the complications associated with LAsiK has been better patient selection. This essentially means respecting the safety limits concerning the correction of higher refractive errors, limiting myopic LASIK treatments up to around -8.0 D or very rarely -10.0 D and up to +3.0 or 3.5 D in the hyperopic range. My own personal view is that it is better to err on the side of caution and to never go above these thresholds, because there are other viable and safe refractive options such as phakic iOLs or refractive lens exchange for those patients that fall outside the safe limits for LASIK.

While corneal ectasia remains one of the most feared complications of refractive corneal laser surgery, we have seen significant progress in reducing its incidence in recent years. This again is down to more careful screening of patients, the use of thinner femtosecond flaps, and better use and understanding of corneal topography and wavefront aberrometry to identify forme fruste keratoconus at an early stage. Patients with a combination of high vertical coma values and abnormal topography present a higher risk of ectasia and are not good candidates for LASIK.

As technology progresses very quickly, there is an understandable trend towards speeding up refractive surgical procedures and perhaps taking less time than we should to analyse fully each patient's needs and goals. We need to resist this temptation to rush things and never forget that we are dealing with the most important visual organ of the human body. The bottom line is that if we don't take our time at all phases of the preoperative, intraoperative and postoperative care of our patients, we inevitably increase the risk of complications. There is no doubt that enhanced laser technology has yielded considerable progress in recent years. in addition to better flap creation with the femtosecond laser, important advances in aspheric ablation profiles have also helped to reduce the problems of glare, haloes and night vision issues that occasionally occurred with first generation LASIK treatments. I now almost exclusively use aspheric profiles with larger optical zones if the mesopic pupil size is too large. As a result, I very rarely see any mesopic-related problems and this has been a significant evolution for the quality of vision of our patients. Moving forward, we are likely to see continued advances in excimer laser technology in the years ahead. The technology is increasingly sophisticated but there is always scope for improvement. Better integration of preoperative data with the actual laser ablation would be of immediate benefit to refractive surgeons, as would efforts to combine the femtosecond and excimer lasers in one seamless platform. LASIK has come a long way in a relatively short period of time. I have every confidence that improved technology, better patient selection and refined surgical techniques will continue to translate into a reduced rate of complications and better outcomes for our refractive surgery patients in the future.