The laser-assisted in situ keratomileusis (LASIK) post-operative process is known to be very quick, with patients returning to their normal daily activities with improved vision, typically within the first 24 hours of surgery.
However, just like any surgical procedure, LASIK recovery comes with a series of expected short-term symptoms that often resolve within the first week. At Parkhurst NuVision LASIK Eye Surgery, patient education is always a top priority.
Short-term symptoms of LASIK
While not every patient will experience every symptom, setting proper immediate post-operative expectations will help alleviate concerns and help grow patient confidence in their care team and results.
We tell our LASIK patients within the first week of surgery that they should expect the following symptoms:
- Fluctuations in vision
- Foreign body sensation or scratchiness (like an eyelash in the eye)
- Light sensitivity
- Altered night vision to include glare, halos, starbursts
- Eye redness
LASIK patient post-care instructions
For the first week after surgery, patients are instructed to not rub or touch their eyes, to avoid eye makeup and facial products around the eyes, and to wear the provided eye goggles each night while sleeping. They are encouraged to shower normally but should avoid swimming and using a hot tub or sauna to help decrease the risk of infection.
Patients are provided with a bottle of antibiotic and steroid eye drops to be used four times per day in each eye for 7 days. They are sent home with multiple vials of preservative-free artificial tears and are encouraged to use them at least four times per day for a minimum of 1 month following surgery.
At the 1-week post-operative exam, the restrictions are lifted, and the patient can return to normal activities. It is at this exam where patients may express their concerns about any remaining visual symptoms, glare or light sensitivity or any symptoms of foreign body sensation.
We check to make sure no additional dry eye therapy outside of lubrication is needed and we reassure the patient by discussing the neuroadaptation process that was also reviewed pre-operatively.
Addressing more serious side effects of LASIK
While much less likely, there are more serious side effects that can occur within the first month of LASIK that need to be discussed with your patient prior to surgery.
Infection
Infection after LASIK is considered the most sight-threatening complication. While much less likely to occur in LASIK than photorefractive keratectomy (PRK), LASIK has an infection risk ranging from 0.0046 to 0.034%.1
Infection can be broken up into two categories:
- Early (within 2 weeks): Onset is often caused by gram-positive organisms, like Methicillin-resistant S. aureus.
- Late (after 2 weeks and up to 3 months): Onset is usually caused by atypical mycobacteria and fungi.2
Infection tends to present with dense, grey-white corneal infiltrates with indistinct margins and conjunctival hyperemia. The standard of care for treatment involves culturing with a flap lift, and some will augment that by treating empirically with antibiotics while awaiting culture results.1
Even with aggressive treatment, some flaps require amputation. This allows for better penetration of topical antibiotics and removes any necrotic tissue that could be harboring microorganisms.
Halos and glare
Halos and glare are visual phenomena that can frustrate patients even after a successful LASIK procedure resulting in 20/15 visual acuity. These symptoms are most often noticed at night or in poor lighting conditions and often peak in severity around one month postoperatively before decreasing over time.3
When patients report halos and glare, they may be experiencing short-term surface-related effects or possibly high-order aberrations, as only the lower-order aberrations are treated unless using wavefront-guided or topography-guided LASIK technology.4
It is important to educate pre-operatively on the expectation of seeing halos and glare with the reassurance that they are likely to resolve over time with neuroadaptation. Post-operatively making sure the patient’s tear film is optimized can help reduce symptoms.
Macrostriae
Macrostriae are often caused by eye-rubbing or injury resulting in flap dislocation and are almost always visually significant. This may occur during the procedure because of an uneven flap alignment, or it can occur after surgery if the patient rubs their eye or pokes their eye while instilling post-operative eye drops.
It is an unlikely complication as the incidence of macrostriae ranges from 0.2 to 1.5% of LASIK cases.5 Upon exam, macrostriae presents as broad undulations of parallel lines accompanied by a widened gutter.6 Instillation of sodium fluorescein helps reveal the gutter and highlights the macrostriae as areas of negative staining.
Figure 1: Slit lamp image of macrostriae.
Figure 1: Courtesy of Lily Arendt, OD, FAAO.
Macrostriae needs to be differentiated from microstriae, a more common, less serious manifestation. Microstriae have a more random pattern of fine irregularities and are best seen using retroillumination.6
Unlike macrostriae, they are unlikely to cause visual symptoms and often do not require treatment. Macrostriae are ideally identified within the first 24 hours to prevent the folds from becoming fixed due to a filling-in of the epithelium and contracture of the corneal collagen.6
Treatment of macrostriae requires flap lift and irrigation with a balanced salt solution, and the flap should be repositioned gently while smoothing it back into place. A bandage contact lens is often placed to help stabilize the flap and reduce the potential for epithelial ingrowth.
Diffuse lamellar keratitis
Diffuse lamellar keratitis (DLK) is an early post-operative complication following LASIK that is most often diagnosed at the 1-day post-operative exam and may be mistaken for infections.
Unlike infectious keratitis, with DLK, it is uncommon for patients to experience foreign body sensation, pain, or a decrease in vision in the early stages. Rather, it is characterized by whitish, granular, diffuse inflammation within the LASIK interface and corneal stroma, as seen in Figure 2.
The most common cause of DLK is contaminants introduced into the LASIK interface during surgery, such as bacterial endotoxins, chemicals, or foreign particles, though post-LASIK trauma can also stimulate the condition.
There are four stages of severity, with stages 1 and 2 presenting as mild inflammation that responds well to frequent topical corticosteroid treatment, and stages 3 and 4 as severe inflammation requiring surgical intervention, such as LASIK flap lifting and irrigation.
Figure 2: Slit lamp image of diffuse lamellar keratitis.
Figure 2: Courtesy of Lily Arendt, OD, FAAO.
Corneal neuralgia
During LASIK, the sensory sub-basal nerve plexus is altered, which can lead to an impaired blink rate, altered corneal sensation, and increased dry eye symptoms.7 While dry eye is typically a transient symptom following LASIK, it typically peaks within 1 week to 3 months after surgery and then resolves within 6 months. An extremely small minority of patients may develop persistent corneal neuralgia.7
This condition is described as an intractable dry eye syndrome after LASIK that presents with clinical signs inconsistent with the patient’s symptoms and is unresponsive to standard therapy.7 Common symptoms of neuralgia are burning, pain, soreness, achiness, and light sensitivity.
If you suspect your patient may have corneal neuralgia, the Proparacaine Challenge Test may be performed in office, which simply requires the instillation of proparacaine 0.5%. If the patient has complete relief of symptoms, it means you should continue treating with ocular surface management, as this is more consistent with discomfort related to ocular surface disease and dry eye.
If there is no relief or symptoms worsen, the patient should be assessed by a neurologist to examine nerve function and may need systemic therapy for relief.8
Contending with complex complications
At our clinic, patients return to us 2 months post-operatively for a final visit to assess their ocular surface, to make sure they are pleased with their vision, and to collect refractive outcomes for our laser nomogram by performing a dry manifest refraction.
If they are doing well and pleased with their vision, we refer them out to their primary eyecare provider for annual eye examinations. Outside of the 2-month post-operative exam, there are a few serious conditions that may occur and are important to discuss with patients.
Retinal detachment
The risk of developing a retinal detachment in low to moderate myopes is three to five times higher than hyperopes and 15 times higher for high hyperopes, and that risk remains after LASIK.9 A study evaluating LASIK for myopes up to -10.0D found over a 10-year period that the risk of rhegmatogenous retinal detachment was 0.05% at 1 year, 0.15% at 5 years, and 0.19% at 10 years.10
A thorough dilated fundus exam should be performed pre-operatively and patients with any retinal lesions should be referred to a retinal specialist for treatment prior to surgery.
Patients should be educated that although they will no longer have a myopic prescription after surgery, due to the progressive changes that can occur in myopic eyes, they should watch out for the symptoms of retinal detachment and should be instructed to seek medical care immediately with new onset symptoms of flashes, floaters, curtain or veil, or sudden decrease in vision.
Ptosis
Commonly discussed as a post-operative complication of cataract surgery, ptosis is also a risk of LASIK, albeit exceedingly rare. First, it is important to assess for ptosis pre-operatively as your contact lens-wearing patient may not notice that one is already present from years of stretching the upper eyelid upon contact lens removal.
During surgery, a ptosis may be induced by the lid speculum used to hold the eyelid open, causing stretching, dehiscence, or disinsertion of the levator muscle.10 Ptosis is often categorized as either transient or persistent. Transient ptosis typically resolves within 6 months of surgery and is classified as a mechanical ptosis caused by swelling or inflammation.10
Persistent ptosis is unresolved by 6 months and is considered an acquired aponeurotic ptosis. Treatment for persistent ptosis is surgery to repair the levator aponeurosis to its normal position.10 A nonsurgical option is oxymetazoline hydrochloride ophthalmic solution 0.1% (Upneeq) if your patient prefers a temporary solution.
Ectasia
Corneal ectasia after LASIK is a rare but serious complication that can lead to progressive steepening of the cornea, inducing irregular astigmatism and reduction in vision and visual quality.
While there are likely multiple variables involved, including genetic predisposition and eye rubbing, ectasia after LASIK is thought to be induced partially by removal of anterior stromal lamellae, which can weaken the cornea’s integrity. The prevalence of post-LASIK ectasia ranges from 0.04 to 0.09%.11
The best way to prevent post-LASIK ectasia is to do a thorough screening at the pre-operative exam with the help of tools like corneal tomography and epithelial thickness mapping. Post-operatively, corneal collagen cross-linking (CXL) can be used to stabilize the cornea and slow or eliminate progression.
Myopia regression
When myopic regression occurs, it can limit long-term patient satisfaction with LASIK. It is considered myopic regression when there is a change of 0.50 diopters or more of myopia post-operatively.
While the exact mechanism of post-LASIK myopic regression is unknown, multiple risk factors have been associated with the condition, such as axial length greater than 26mm, high astigmatism, corneal steepness, and older age.12
Consistent with previous studies, a study from 2024 found that myopic regression occurred at a rate of 16.1% when patients were evaluated 6 years after their LASIK surgery.13-15 The treatment for myopic regression is often a LASIK enhancement, although it is important to confirm refractive stability prior to treatment and rule out other reasons for a myopic shift, such as cataract development, myopic degeneration, or post-LASIK keratoconus.
Conclusion
The post-operative period for a LASIK patient can be one of the happiest times in their lives as they experience their new vision. If the patient doesn’t know what to expect, it can also cause anxiety. By setting the correct post-operative expectations, surgeons can help set the patient up for success while alleviating any concerns.
Knowing the expected common, short-term, and long-term side effects and complications of LASIK surgery allows the eyecare provider to better educate their patients and help them enjoy a successful overall LASIK experience.
