How ODs & MDs Should Co-Manage LASIK Surgery Complications

Co-managing refractive surgery, namely LASIK, is an opportunity to increase patient satisfaction as well as build relationships between ophthalmologists and optometric providers.^1,2 When done successfully, this team approach can lead to an elevated patient experience.

Even though patient outcomes are very positive in a high percentage of LASIK cases, it is very important to be able to properly handle potential problems that can arise.^1-6 Some issues are normal and transient in the postoperative period and, for these, reassurance and patient education will often be all that is needed. However, undesirable symptoms and infectious or anatomical complications may require additional treatment.

Strategies for co-management and patient education

The patient who is part of the co-management relationship needs to be aware of what this relationship means.¹ They should understand that it is to best enhance their care between the referring optometrist and surgeon; both providers will be available to them should any questions or issues arise.¹ Patients should also be specifically educated on the relationship nuances, such as fees, schedule of visits, and how each provider can be reached in cases of questions as well as emergencies.

Fees

Elaborate discussion of fees in co-management is beyond the scope of this article, but it is generally an agreed-upon percentage between the referring provider and surgeon, which may vary between surgeons, practices, cities, and states.¹

It is important to discuss the concept of co-management with patients—some may misinterpret this as a kick-back, which it is not.¹ It is important for the co-managing optometrist to speak to how they are a partner with the surgeon to help optimize and best care for their patients’ vision and eyes. Be as clear as possible as to the schedule and frequency of follow-up visits.

It is also important to inform the patient that they do have a choice in regards to participating in a co-management relationship.

Schedule of visits

Usually, the optometric partner will refer patients to the ophthalmic surgeon for evaluation and surgery.¹ Depending on the comfort of the referring provider, preoperative testing and counseling may be done prior to referral to the refractive surgeon.

After the consultation, a surgery date is set, and a postoperative visit is scheduled either with the surgeon or optometrist, depending on the relationship and co-management agreement.¹ Typically after this, as long as the postoperative result is successful, the patient will continue to follow up with the referring optometrist but may return to the surgeon at the patient or optometrist’s discretion (e.g., in cases of dissatisfaction or complications).¹

Knowledge and clear communication is key—on all fronts

It is important for optometrists who wish to co-manage LASIK patients to familiarize themselves with the LASIK procedure in detail, including risks, benefits, and alternatives as well as standard postoperative care.^1,2 Optometrists may want to spend some time at the refractive surgery center to observe surgery and pre-and-postoperative exams as well as learning what is “normal” and of potential concerns or complications.¹

Patients can lose confidence in their eyecare providers if something is either missed on the preoperative exam (e.g., ectasia or keratoconus should not be missed!) or is detected on postoperative care.^1,7

All providers must be on the same page. Open communication lines between eyecare providers are very important in the perioperative and postoperative periods.

Both sides of the partnership should be easily able to get in touch with each other to discuss concerns and treatment options if necessary. Educating support staff is also important; they can help make the surgical patient feel at ease and may help answer some questions surrounding the surgery and postoperative care.^1,2

Preoperative counseling and agreement on a treatment plan should be well-defined and the patient should be left with no doubts surrounding the surgery and what their postoperative expectations should be.^1,2

Complications to watch out for

Dry Eye

Dry eye following LASIK is a very common symptom that is reported–this includes complaints of burning, itching, and discomfort.⁸ It is important to treat any dry eye signs and symptoms prior to LASIK surgery and discuss this potential side effect preoperatively so that the patient does not become alarmed if they develop these symptoms.^2,3,5,6,8

In addition, it is a good practice to encourage the use of artificial tears in the postoperative period whether or not dryness is reported—this can also help with the healing process.^2,3,5,6,8 Both sides of the co-management team should be on the same page regarding this issue.

In the (rarer) case where LASIK patients may require more than just over-the-counter tears, prescription medications for dry eye may be used (e.g., cyclosporine, liftegrast). It is important to counsel patients regarding possible side effects of medication, duration of therapy, and delay in symptom relief for some of these drops.^2,3,5,6,8

In general, dry eye symptoms usually resolve within 6-12 months post-surgery, though a small percentage may have persistent, bothersome symptoms.⁸ Do not neglect these patients! It is important to make sure that concerns and discomfort is addressed as best as possible–this may be through medications, punctal plugs, or even amniotic membrane in severe cases.⁸

That being said, avoidance of severe dry eye may not be 100% possible, but this falls back to the need to perform a comprehensive history and physical prior to surgery.^1,2,8 Patients with pre-existing severe dry eye, Sjogren’s syndrome, and other autoimmune diseases that may contribute to keratitis, lagophthalmos, or poor blink response are not ideal candidates for LASIK.^1-3,5,6,8

Glare/Halos/Other visual aberrations

Thankfully, due to significant advances in technology surrounding laser refractive surgery, the incidence of severe glare and haloes is quite low but, unfortunately, can still occur.^2-6,9,10 Like dry eye symptoms, these symptoms usually fade over the first few postoperative months–and patients should be educated to not be alarmed if they experience these symptoms in the early postoperative period. ^2-6,9,10

However, if symptoms persist and are debilitating (occurs in less than 1% of patients), it is important to look for underlying causes–such as LASIK flap abnormalities, decentered ablations, and dry eye.^2-10

Identifying potential causes for these complaints and addressing them promptly is key. Should symptoms be due to a possible surgical complication–or require diagnostic equipment that may only be available in the surgeon’s office–it is imperative to communicate this with the patient and the co-managing surgeon as soon as possible.

Flap complications (folds, striae, dislocation)

Flap striae or folds may occur post-LASIK. This can occur due to excessive irrigation during the surgery, poor flap repositioning, excessively thin flaps, or deep and highly myopic ablations with flap/bed mismatch as well as eye rubbing post-LASIK.^2,9,10 Striae are typically noted within the first week of surgery. ^2,9,10

Macrostriae are full-thickness stromal folds due to flap malposition and slippage. They typically result in decreased vision and possible diplopia if central in nature.^2,9,10 These striae can be seen under direct illumination at the slit lamp and have a negative staining pattern with fluorescein.^2,9,10 Treatment is typically required for these striae, therefore, prompt referral back to the co-managing surgeon is necessary for possible flap re-float and smoothing out the corneal folds.

Microstriae are fine optical irregularities that can occur due to a mismatch of the LASIK flap to the surgical bed or flap contracture.^2,9,10 Retroillumination on slit lamp exam will help make these striae more obvious; patients may or may not have visual symptoms.^2,9,10 If symptomatic, referral back to the treating surgeon is necessary for possible surgical intervention, as in the case for macrostriae.

Flap dislocation is rare but can occur, especially early on if the patient accidentally rubs his/her eyes. Preoperative counseling to not touch the eyes as much as possible in the early postoperative period is crucial; timely treatment is necessary to avoid permanent visual compromise due to flap irregularities that may result.^1,2,9,10 These patients need to be referred back to the treating surgeon as soon as possible for flap refloat and smoothing of any flap striae, if present.

Diffuse Lamellar Keratitis (DLK)

DLK in a noninfectious inflammatory complication that can occur post-LASIK and is characterized by inflammatory infiltrates in the flap interface.^1-3,10,11 DLK may present within the first one to two days post-LASIK and requires early initiation of intensive topical steroid therapy.^1-3,10,11 Referral back to the treating surgeon is necessary here—delay in treatment can lead to vision-threatening complications such as stromal melt and corneal scarring.^1-3,10,11 Thankfully, the incidence of DLK is low, at 2-4%.^1-3,10,11

Epithelial ingrowth

Albeit rare, ingrowth of epithelial cells under the corneal flap interface can occur.^2,3,10,11 However, many cases may be peripheral in nature and do not cause visual compromise, unless the cells migrate centrally.^2,3,10,11 Epithelial ingrowth may be slightly more common in LASIK enhancement cases.^2,3,10,11 Recognition of epithelial ingrowth is essential, as this requires referral back to the surgeon for at least recognition if not treatment.^2,3,10,11 Visually significant ingrowth may require treatment by lifting the flap to scrape the interface and undersurface of the flap.^2,3,10,11 Asymptomatic cases may solely require close monitoring.^2,3,10,11

Flap interface debris

Sometimes there may be oils from the ocular surface or even a fiber from a surgical sponge that may end up underneath the LASIK flap. However, the eye may not have any sort of inflammatory reaction to this, and it may not be visually significant. In that case, observation is all that is necessary. However, if symptoms such as visual decline and foreign body sensation are noted, flap lifting and irrigation may be necessary–and referral back to the treating surgeon is prudent.^1-3,10,11

Infection

Thankfully, infection post-LASIK is rare (<1/1000 cases) but it can be one of the most vision-threatening complications and requires immediate and aggressive treatment, usually with the treating surgeon.^1,2,5,6,10 If infection under the LASIK flap is suspected, the surgeon will need to lift the flap, culture the interface, and irrigate with antibiotics—this may need to be done several times.^1,2,5,6,10 Fortified antibiotics may be necessary, and flap amputation may need to be performed in very severe cases.^1,2,5,6,10

Under/overcorrection:

With current technology and appropriate patient selection, studies have shown that 98% of patients who undergo LASIK achieve at least 20/40 uncorrected vision, and 90% achieve 20/20 uncorrected vision.^2-6,9

Great surgeons with modern technology often report a higher percentage of patients with 20/20–or better–vision post-LASIK.^2-6,9

The Patient Reported Outcomes with Laser in Situ Keratomileusis (PROWL) study reported that 93% of patients were completely satisfied with LASIK; only 2% were dissatisfied with their vision postoperatively.^3-6 In addition, 97% of patients stated that, in retrospect, they would still have LASIK done.^3-6

Proper patient education both pre-and-postoperatively will help ensure patients are happy with their decision to proceed with LASIK.^1-6 Careful screening and discussions of risks, including those patients at higher risk of enhancement, is key.^1-6,9 Need for enhancement is always a risk that should be discussed preoperatively, even in patients at low risk for it.^1-6,9

Ectasia

We know that there are certain patients who are at higher risk for developing ectasia post-refractive surgery, and they are, therefore, not candidates.^1,2,7 And, of course, patients with pre-existing keratoconus and pellucid marginal degeneration should never be considered for LASIK surgery. A comprehensive preoperative assessment, such as corneal topography and tomography, pachymetry, and family history of ectatic disease (e.g., keratoconus, pellucid marginal degeneration, post-LASIK ectasia) should be documented and investigated.^1,2,7

There are even new genetic tests that can be performed to detect the risk of developing keratoconus in certain suspect patients or those with family history (AvaGen, Avellino Labs, Menlo, CA). In the rare case that ectasia develops post-LASIK, the patient should be counseled appropriately regarding treatment options, such as glasses, contact lenses, and corneal crosslinking.^1,2,7

Presbyopia

Patients should be aware that presbyopia is something that may not be fully corrected (or corrected at all) in LASIK surgery, especially in patients age 40 and older.^1-3,6 This point needs to be strongly reinforced with patients before surgery is performed.^1-3,6 It can be difficult for some patients to understand that they are having a “corrective procedure” only to have to continue to need to use reading glasses in the postoperative period.^1-3,6

Discussions regarding monovision and pinhole technologies (e.g., corneal inlays) are important to have preoperatively.^1-3,6 Other surgical options, such as clear lens exchange with multifocal intraocular lens implantation may better serve these patients who are presbyopic and wish to be free of glasses.^1-3,6

Conclusions

Successful co-management of LASIK patients between optometrists and ophthalmologists can optimize the patient experience as well as their outcome.

However, communication between all parties is essential, and patient access to their optometrist and surgeon is necessary to enforce the strength of these relationships.

It is important for both sides of the co-management team to educate their patients properly regarding the LASIK procedure and expectations. Procedural knowledge, and most importantly, open communication between referring and co-managing providers is essential.

References

Geffen D. How to make co-management of LASIK patients a practice builder. Review of Optometric Business. 2018
Wilkinson JM, Cozine EW, Kahn AR. Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK. Am Fam Physician. 2017; 95 (10): 637-644
Eydelman M, Hilmantel G, Tarver M, Hofmeister E, May J, Hammel K, Hays R, Ferris F 3rd. Symptoms and Satisfaction of Patients in the Patient-Reported Outcomes with Laser In Situ Keratomileusis (PROWL) Studies. JAMA Ophthalmol. 2017; 135 (1):13-22
Hays RD, Tarver ME, Spritzer KL, Reise S, Hilmantel G, Hofmeister EM, Hammel K, May J, Ferris F 3rd, Eydelman M. Assessment of the Psychometric Properties of a Questionnaire Assessing Patient-Reported Outcomes with Laser in Situ Keratomileusis (PROWL). JAMA Ophthalmol. 2017; 135 (1): 3-12
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Solomon KD, Fernandez de Castro LE, Sandoval HP, Biber JM, Groat B, Neff KD, Ying MS, French JW, Donnenfeld ED, Lindstrom RL; Joint LASIK Study Task Force. LASIK world literature review: quality of life and patient satisfaction. Ophthalmology. 2009;116 (4): 691-701
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Lee JB, Ryu CH, Kim EK, Kim HB. Comparison of tear secretion and tear film instability after photorefractive keratectomy and laser in situ keratomileusis. J Cataract Refract Surg. 2000; 26: 1326-1331
Randleman JB, White AJ, Lynn MJ et al. Incidence, outcomes and risk factors for retreatment after wavefront-optimized ablations with PRK and LASIK. J Refract Surg. 2009; 25:273-276
Spadea L, Giammaria D, Trabucco P. Corneal wound healing after laser vision correction. Br J Ophthalmol. 2016; 100:28-33
Teal P, Breslin C, Arshinoff S,Edmison D. Corneal subepithelial infiltrates following excimer laser photorefractive keratectomy. J Cataract Refract Surg. 1995; 21: 516-518