The OD’s Role in Postoperative Refractive Surgery Care

Optometrists play a valuable role in refractive surgery care. In many cases, optometrists perform the preoperative examinations to determine whether a patient is a candidate for laser vision correction. Initially deciding whether a patient is a candidate for refractive surgery and further determining which surgery may be right for the patient can be a complex process. However, with advances in technology and the increasing success rates of refractive surgery, postoperative care has become more manageable than it was in the past.

Fortunately for us and for our patients, the risk of significant postoperative complications has decreased over the past several years to a less than 0.8% chance for all refractive surgeries.¹ However, complications can arise, and optometrists need to know which they should treat, how to treat them, and which they should refer back to the surgeon.

POSTOPERATIVE LASIK PATIENTS

Examining a patient after uncomplicated LASIK can be gratifying. With LASIK’s fast recovery time, the patient can be seeing well the very next day. However, a thorough examination is still required to verify that the patient is healing on schedule.

Complications That Should Be Referred Back to the Surgeon

On the initial postoperative day 1 visit, it is important to ensure that the flap is in the proper position and healing correctly. Flap dislocation or full-thickness stromal folds, known as macrostriae (Figure 1), can occur due to poor flap repositioning, thin flaps, deep or highly myopic ablations, or eye rubbing.² In any of these situations, a prompt referral back to the surgeon is necessary to refloat and smooth the flap.² Macrostriae can be detected using direct illumination at the slit lamp and will cause a negative staining pattern when fluorescein is used.

The interface should be clean and free of debris. If debris is significant or is causing decreased vision, the surgeon will likely need to lift the flap and clean the interface. It is important to note that each time the LASIK flap is lifted it increases the risk for epithelial ingrowth; nonetheless, the risk remains less than 2%.³ Epithelial ingrowth can cause irregular astigmatism or flap melting, in which case surgical intervention is necessary.

The risk for infection after LASIK is less than 1 in 1,000 cases.² However, because it is the most vision-threatening complication, it should be monitored by the referring surgeon. If the infection is located under the LASIK flap, the surgeon may have to lift the flap, culture it, and irrigate it with antibiotics in order to achieve full resolution.²

Complications the OD Can Manage

Ingrowth that is peripherally located and that does not affect vision can be simply monitored closely. Once epithelial ingrowth is noted (Figure 2), patients should be monitored every few months initially to ensure it is not progressing.

Diffuse lamellar keratitis (DLK) is a noninfectious inflammatory complication characterized by infiltrates beneath the LASIK flap interface.⁴ Typically, no referral is necessary, as DLK responds well to topical corticosteroid therapy.⁴ This can be seen as early as the day 1 postoperative visit. Central vision can become affected within 3 to 4 days after surgery. Resolution of DLK usually occurs within 5 to 8 days after the initiation of therapy with a corticosteroid.

After LASIK, dry eye is a common symptom that can cause complaints of burning, discomfort, itching, and blurred vision. It is important to treat any preoperative dryness prior to surgery and to discuss the potential risks that can follow surgery so the patient is aware that dryness can occur. The use of artificial tears, prescription medication, or punctal occlusion may be warranted in the early postoperative period. In general, most dry eye symptoms resolve within 6 to 12 months postoperatively, with only a small percentage of patients still bothered with persistent symptoms past that time period.⁵

Studies have shown that 98% of patients who undergo LASIK achieve at least 20/40 or better uncorrected vision, and at least 90% achieve 20/20 uncorrected vision.² With advances in technology, these numbers continue to improve; however, it is important to discuss with patients before surgery the possible need for enhancement. Optometrists should monitor patients for any residual prescription following surgery, and if that prescription remains stable, then a referral back to the surgeon is necessary.

Ectasia

For patients who have experienced a decrease in BCVA but for whom dryness is not the culprit, topography should be performed to detect potential ectasia. Ectasia can occur as early as 1 week after surgery or can take years to develop.⁶ Postoperative refractive surgery patients who are deemed borderline (eg, those with thin corneas, mild posterior float changes) should have topography performed yearly to monitor for changes.

POSTOPERATIVE SMILE PATIENTS

Patients who undergo small-incision lenticule extraction (SMILE) have postoperative recovery times similar to those of LASIK patients.⁷

Complications the OD Can Manage

Complications that typically have minimal clinical implications include epithelial defects, microstriae, dry eye, interface inflammation, and bleeding at the incision site.⁷ Because there is a small, 2 mm to 3 mm incision rather than a large LASIK flap, there is less corneal nerve severance to cause postoperative dry eye.⁸

Complications That Should Be Referred Back to the Surgeon

Clinicians should refer patients to the surgeon immediately if they observe severe interface inflammation, epithelial ingrowth, or if they note irregular topography on examination.⁷

POSTOPERATIVE LENS SURGERY PATIENTS

Patients who are unable to proceed with corneal refractive procedures have additional options such as the Visian ICL (STAAR Surgical) or refractive lens exchange (RLE). It is important to stress proper expectations to these patients before surgery. They are typically paying a lot more for surgery and therefore have higher expectations. RLE is performed and managed much like cataract surgery; therefore, patients tend to have similar complications.

Management of patients with the Visian ICL requires a slightly different approach. For example, the Visian ICL will most often be placed in the posterior chamber and should have a vault between 250 µm and 750 µm over the crystalline lens.⁹ The vault can easily be estimated at the slit lamp using an optic section beam and comparing it to the thickness of the cornea (Figure 3).

Complications the OD Can Manage

Noting the placement and position of the ICL is important because it can decrease the risk of future vision-threatening complications. If the ICL is rubbing against the iris or crystalline lens, it can lead to pigment dispersion syndrome, secondary glaucoma, or anterior subcapsular cataracts.¹⁰ A prompt referral to the surgeon is necessary if the ICL is not properly placed. Yearly exams should be performed to monitor IOP, check corneal integrity, and ensure angles are open via gonioscopy.

Complications That Should Be Referred Back to the Surgeon

Rare complications that may require a second surgery include rotation of a toric ICL, pupillary block, retinal detachment, cataract development, and elevated IOP.¹¹ Typically, the surgeon will perform a prophylactic peripheral iridotomy (PI) before surgery to eliminate the potential for some of these complications.

The latest version of the Visian ICL, the Evo Visian ICL, has a central port located on the lens (Figure 4) that would eliminate the need for a PI.¹² The central port helps maintain the health of the crystalline lens by preserving the natural flow of aqueous humor across the anterior lens capsule.¹²

POSTOPERATIVE PRK PATIENTS

Proper patient education is critical for patients about to have PRK, as they can be uncomfortable for up to 4 days postoperatively. The epithelium can feel irritated and painful while it is healing and remodeling. Typically, a bandage contact lens is placed at the time of surgery, and on day 4 it can be removed if no epithelial defect is present.

Complications the OD Can Manage

If a defect remains after bandage lens removal, a new bandage contact lens should be placed. Optometrists should continue monitoring the patient to watch out for postsurgical haze. Topical steroids can prevent corneal haze for the first 3 months postoperatively but are not effective beyond that.¹³ If significant haze is affecting visual potential, the patient’s surgeon should be consulted.

COMMUNICATION IS KEY

When a potential refractive surgery candidate is sitting in your chair, whether a life-long patient or one you have just met, they trust that you will provide them a proper referral that ensures the best chances of success. Information such as the patient’s ocular history, current status, and visual goals and demands should be passed along to the surgeon to allow him or her to create the best surgical plan for the patient.

One of the most important responsibilities of a referring optometrist is to build a good rapport with local corneal surgeons. Introducing oneself and getting to know how each surgeon manages refractive surgery patients ensures that everyone will be on the same page and that no surprises will be thrown to the patient. Making a visit to the surgeon’s practice allows you to observe how the staff interacts with patients and enables you to make sure they will receive a high standard of care. This also shows the surgeon that you have the patient’s best interests in mind.

Providing the surgeon with feedback and updates about the patient postoperatively can also help to ensure future successful outcomes. Sharing each other’s phone numbers, emails, and direct lines of contact can help improve efficiency in the care and treatment of patients in case of emergencies. The optometrist plays a critical role in postoperative care in refractive surgery, and communication is key.