Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK

 

A variety of refractive surgery techniques, which reshape the corneal stroma using laser energy, have been marketed as simple and safe alternatives to glasses or contact lenses. Laser-assisted in-situ keratomileusis (LASIK) is the most common of these procedures. Although there are few high-quality prospective studies of long-term outcomes, complications, or stability for refractive surgery procedures, there is at least general agreement that more than 90% of appropriately selected patients achieve excellent uncorrected distance vision. In addition to well-recognized contraindications (e.g., unstable refraction, pregnancy and lactation, chronic eye disease, systemic illness, corneal abnormalities), there are other conditions that warrant caution (e.g., excessively dry eyes, contact lens intolerance, chronic pain syndromes). Postoperative dry eye, which may in part represent a corneal neuropathy, usually resolves after six to 12 months but persists in up to 20% of patients. Up to 20% of patients may have new visual disturbances, particularly with night driving. Vision-threatening complications are rare. Intraocular lenses, implanted following cataract extraction, may be an alternative to LASIK in older patients. Although the overall dependence on corrective lenses is markedly reduced, many patients still require glasses or contact lenses after LASIK, particularly in low-light conditions and as they age. Most patients report satisfaction with the results. Family physicians can help patients make informed decisions by exploring their values, preferences, expectations, and tolerance of uncertainty and risk.

Over the past two decades, a variety of refractive surgery techniques have been developed and marketed as simple and safe alternatives to glasses or contact lenses. Laser-assisted in-situ keratomileusis (LASIK) is the best-known and most widely performed technique.

WHAT IS NEW ON THIS TOPIC: REFRACTIVE EYE SURGERY

In the Patient-Reported Outcomes with LASIK (PROWL) studies, excellent visual acuity was routinely achieved, with few highly bothersome, persistent symptoms and very rare vision-threatening complications. However, data are limited about the long-term stability of correction.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Almost all appropriately selected patients achieve good vision with LASIK.

C

3, 18

Although most studies have been of limited quality, outcomes have been consistent over many years.

Caution individuals considering LASIK that dry eye symptoms affect up to 40% of patients following surgery.

B

3, 18, 19

Only 2% to 3% of patients consider dry eye symptoms to be bothersome.

Caution individuals with chronic pain syndromes (e.g., fibromyalgia, irritable bowel syndrome, migraine) or contact lens intolerance that patients with these conditions report more dry eye symptoms following LASIK.

C

20, 21

Dry eye symptoms are multifactorial, but some may be manifestations of corneal neuropathy.

Caution individuals considering LASIK that visual symptoms, such as a glare, halos, starbursts, and reduced contrast sensitivity, affect up to 20% of patients following surgery.

B

3, 18, 22

Less than 1% of patients reported “a lot of difficulty” in general with usual activities.

Ensure that individuals considering LASIK understand that they will still develop presbyopia and require reading glasses as they age.

C

3, 11

This must be thoroughly explained to patients.


LASIK = laser-assisted in-situ keratomileusis.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Almost all appropriately selected patients achieve good vision with LASIK.

C

3, 18

Although most studies have been of limited quality, outcomes have been consistent over many years.

Caution individuals considering LASIK that dry eye symptoms affect up to 40% of patients following surgery.

B

3, 18, 19

Only 2% to 3% of patients consider dry eye symptoms to be bothersome.

Caution individuals with chronic pain syndromes (e.g., fibromyalgia, irritable bowel syndrome, migraine) or contact lens intolerance that patients with these conditions report more dry eye symptoms following LASIK.

C

20, 21

Dry eye symptoms are multifactorial, but some may be manifestations of corneal neuropathy.

Caution individuals considering LASIK that visual symptoms, such as a glare, halos, starbursts, and reduced contrast sensitivity, affect up to 20% of patients following surgery.

B

3, 18, 22

Less than 1% of patients reported “a lot of difficulty” in general with usual activities.

Ensure that individuals considering LASIK u

The Authors

show all author info

JOHN M. WILKINSON, MD, is an associate professor in the Department of Family Medicine at Mayo Clinic College of Medicine, Rochester, Minn....

ELIZABETH W. COZINE, MD, is an instructor in the Department of Family Medicine at Mayo Clinic College of Medicine.

AMIR R. KHAN, MD, is an assistant professor in the Department of Ophthalmology at Mayo Clinic College of Medicine.

Address correspondence to John M. Wilkinson, MD, Mayo Clinic College of Medicine, 200 1st St. SW, Rochester, MN 55905 (e-mail: wilkinson.john@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Number of LASIK surgeries in the United States from 1996 to 2020 (in thousands). Statista. https://www.statista.com/statistics/271478/number-of-lasik-surgeries-in-the-us/. Accessed October 27, 2016....

2. Corcoran KJ. Macroeconomic landscape of refractive surgery in the United States. Curr Opin Ophthalmol. 2015;26(4):249–254.

3. Sandoval HP, Donnenfeld ED, Kohnen T, et al. Modern laser in situ keratomileusis outcomes. J Cataract Refract Surg. 2016;42(8):1224–1234.

4. Pasquali TA, Smadja D, Savetsky MJ, Reggiani Mello GH, Alkhawaldeh F, Krueger RR. Long-term follow-up after laser vision correction in physicians: quality of life and patient satisfaction. J Cataract Refract Surg. 2014;40(3):395–402.

5. Messmer JJ. LASIK: a primer for family physicians. Am Fam Physician. 2010;81(1):42–47.

6. Shortt AJ, Allan BD, Evans JR. Laser-assisted in-situ keratomileusis (LASIK) versus photorefractive keratectomy (PRK) for myopia. Cochrane Database Syst Rev. 2013;(1):CD005135.

7. Wu W, Wang Y, Xu L. Epipolis-laser in situ keratomileusis versus photorefractive keratectomy for the correction of myopia: a meta-analysis. Int Ophthalmol. 2015;35(5):757–763.

8. Ivarsen A, Asp S, Hjortdal J. Safety and complications of more than 1500 small-incision lenticule extraction procedures. Ophthalmology. 2014;121(4):822–828.

9. Li M, Zhou Z, Shen Y, Knorz MC, Gong L, Zhou X. Comparison of corneal sensation between small incision lenticule extraction (SMILE) and femtosecond laser-assisted LASIK for myopia. J Refract Surg. 2014;30(2):94–100.

10. Denoyer A, Landman E, Trinh L, Faure JF, Auclin F, Baudouin C. Dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus LASIK. Ophthalmology. 2015;122(4):669–676.

11. American Academy of Ophthalmology Preferred Practice Pattern Guidelines. Refractive errors & refractive surgery. July 2013. Accessed July 4, 2016.

12. Li SM, Zhan S, Li SY, et al. Laser-assisted subepithelial keratectomy (LASEK) versus photorefractive keratectomy (PRK) for correction of myopia. Cochrane Database Syst Rev. 2016;(2):CD009799.

13. Barsam A, Allan BD. Excimer laser refractive surgery versus phakic intra-ocular lenses for the correction of moderate to high myopia. Cochrane Database Syst Rev. 2014;(6):CD007679.

14. Huang D, Schallhorn SC, Sugar A, et al. Phakic intraocular lens implantation for the correction of myopia: a report by the American Academy of Ophthalmology. Ophthalmology. 2009;116(11):2244–2258.

15. Young JA, Kornmehl EW. Preoperative evaluation for refractive surgery. In: Yanoff M, Duker JS, Augsburger JJ, eds. Ophthalmology. 3rd ed. Edinburgh, Scotland: Mosby Elsevier; 2009:118–121.

16. American Academy of Ophthalmology. Comprehensive guidelines for the co-management of ophthalmic postoperative care. September 7, 2016. http://www.aao.org/ethics-detail/guidelines-comanagement-postoperative-care. Accessed October 20, 2016.

17. Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012;(3):CD007293.

18. Eydelman M, Hilmantel G, Tarver ME, et al. Symptoms and Satisfaction of Patients in the Patient-Reported Outcomes With Laser In Situ Keratomileusis (PROWL) Studies. JAMA Ophthalmol. 2017;135(1):13–22.

19. Raoof D, Pineda R. Dry eye after laser in-situ keratomileusis. Semin Ophthalmol. 2014;29(5–6):358–362.

20. Levitt AE, Galor A, Weiss JS, et al. Chronic dry eye symptoms after LASIK: parallels and lessons to be learned from other persistent postoperative pain disorders. Mol Pain. 2015;1121.

21. Galor A, Covington D, Levitt AE, et al. Neuropathic ocular pain due to dry eye is associated with multiple comorbid chronic pain syndromes. J Pain. 2016;17(3):310–318.

22. Albietz JM, Lenton LM, McLennan SG. Effect of laser in situ keratomileusis for hyperopia on tear film and ocular surface. J Refract Surg. 2002;18(2):113–123.

23. National Institute for Health and Care Excellence. Photorefractive (laser) surgery for the correction of refractive errors. March 2006. http://www.nice.org.uk/guidance/ipg164/chapter/1-guidance. Accessed June 2, 2016.

24. Dirani M, Couper T, Yau J, et al. Long-term refractive outcomes and stability after excimer laser surgery for myopia. J Cataract Refract Surg. 2010;36(10):1709–1717.

25. Lasikcomplications.com. http://lasikcomplications.com/index.htm. Accessed June 2, 2016.

26. Federal Trade Commission. The basics of LASIK eye surgery. August 2012. http://www.consumer.ftc.gov/articles/0062-basics-lasik-eye-surgery. Accessed June 2, 2016.

27. Consumer Reports. Lasik eye surgery: will you really get rid of your glasses? February 2013. http://www.consumerreports.org/cro/2013/02/lasik-eye-surgery/index.htm. Accessed June 2, 2016.

28. AllAboutVision.com. LASIK eye surgery cost. Updated September 2016. http://www.allaboutvision.com/visionsurgery/cost.htm. Accessed October 20, 2016.

29. Reyna VF. A theory of medical decision making and health: fuzzy trace theory. Med Decis Making. 2008;28(6):850–865.

30. U.S. Food and Drug Administration. LASIK. Updated June 9, 2014. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/. Accessed June 2, 2016.

31. Mayo Clinic. LASIK eye surgery. February 25, 2014. http://www.mayoclinic.org/tests-procedures/lasik-eye-surgery/basics/definition/prc-20019041. Accessed June 2, 2016.

32. Mayo Clinic. LASIK surgery: is it right for you? May 6, 2016. http://www.mayoclinic.org/tests-procedures/lasik-eye-surgery/in-depth/lasik-surgery/art-20045751. Accessed June 2, 2016.

33. Ottawa Hospital Research Institute. Decision aid summary: LASIK surgery: is it right for you? https://decisionaid.ohri.ca/AZsumm.php?ID=1366. Accessed June 2, 2016.

34. Ottawa Hospital Research Institute. Decision aid summary: nearsightedness: Should I have laser surgery? https://decisionaid.ohri.ca/AZsumm.php?ID=1170. Accessed June 2, 2016.

35. Bower KS, Weichel ED, Kim TJ. Overview of refractive surgery. Am Fam Physician. 2001;64(7):1183–1190.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


MOST RECENT ISSUE


Jun 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article