LASIK RETINAL ASSESMENT AND LASER TO LATTICE

1. Dr. Ajay Dudani

2.  Type of peripheral retinal dystrophy
 Patches of retinal thinning

5.  Axial length increase with anterior displacement of the vitreous base during suction
ring placement might predispose susceptible eyes to anterior retinal tears during and
after LASIK.1
 Laser-tissue interaction creates acoustic pressure waves, which propogate through
vitreous and theoretically could cause retinal breaks.2

6.  Incidence of lattice degeneration as found by Byer in a population of 1300 patients
was 7.1%3
 Lam et.al found the incidence of lattice degeneration as 12.2%4

7.  Atrophic holes in lattice degeneration
contribute to 2.8% of phakic retinal
detachment.5

8.  The incidence of vitreoretinal pathologic conditions post LASIK is about 0.06%.6,7

9.  Prophylactic treatment of vitreoretinal
pathology (lattice degeneration, retinal
breaks) before LASIK does not
guarantee the prevention of post-
LASIK vitreoretinal complications in
highly myopic eyes.8

10.  Increased incidence of retinal breaks post laser -- treatment of visible lesions may
modify the natural history of PVD by increasing vitreoretinal traction at unknown
locations.9
 In a review conducted by Charles P Wilkinson, no conclusions could be reached about
the effectiveness of interventions to prevent retinal detachment in eyes with
asymptomatic retinal breaks or lattice degeneration, or both- COCHRANE REVIEW
2014.10

11.  IT IS UNNECESSARY
 TOTALLY USLESS
 PRIMUM NON NOCERE
 DON’T MAKE THE TREATMENT WORSE THAN THE DISEASE

12.  PREVENTION AND CURE OF DISEASE : THESE ARE OUR AMBITIONS

13.  THE SECRET OF THE CARE OF THE PATIENT IS IN CARING FOR THE PATIENT

14.  IN THE CARE OF SUFFERING THE PHYSICIAN NEEDS TECHNICAL
SKILL,SCIENTIFIC KNOWLEDGE ,AND HUMAN UNDERSTANDING WITH TACT
,SYMPATHY AND UNDERSTANDING AS THE PATIENT IS HUMAN ,FEARFUL AND
HOPEFUL ,SEEKING RELIEF HELP AND REASSURANCE.
 Don’t make these young people neurotic ,depressed and scared to do anything living
with the sword of detachment on their heads

15.  1. Flaxel CJ, Choi YH, Sheety M, Oeinck SC, Lee JY, McDonnell PJ. Proposed
mechanism for retinal tears after LASIK: an experimental model. Ophthalmology
2004;111:24–7.
 2. Charles S. Vitreoretinal complications of refractive surgery. In: Boyd BF, editor.
LASIK and Beyond LASIK; Highlights of Ophthalmology. 2001. page 317.
 3.Byer NE. Cystic retinal tufts and their relationship to retinal detachment. Arch
Ophthalmol (Chicago, Ill 1960) 1981;99:1788–90.
 4. Lam DSC, Fan DSP, Chan W-M, Tam BSM, Kwok AKH, Leung ATS, et al.
Prevalence and characteristics of peripheral retinal degeneration in Chinese adults
with high myopia: a cross-sectional prevalence survey. Optom Vis Sci 2005;82:235–8.
 5. Tillery W V, Lucier AC. Round atrophic holes in lattice degeneration--an important
cause of phakic retinal detachment. Trans Sect Ophthalmol Am Acad Ophthalmol
Otolaryngol 81:509–18.

16.  6. Arevalo JF, Ramirez E, Suarez E, Morales-Stopello J, Cortez R, Ramirez G, et al.
Incidence of vitreoretinal pathologic conditions within 24 months after laser in situ
keratomileusis. Ophthalmology 2000;107:258–62.
 7. Arevalo JF, Ramirez E, Suarez E, Cortez R, Antzoulatos G, Morales-Stopello J, et al.
Rhegmatogenous retinal detachment in myopic eyes after laser in situ keratomileusis.
Frequency, characteristics, and mechanism. J Cataract Refract Surg 2001;27:674–80.
 8. Chan CK, Tarasewicz DG, Lin SG. Relation of pre-LASIK and post-LASIK retinal lesions
and retinal examination for LASIK eyes. Br J Ophthalmol 2005;89:299–301.
 9. Byer NE. Rethinking prophylactic treatment of retinal detachment. In: Stirpe M. editor.
Advances in vitreoretinal surgery. Acta Third International Congress on Vitreoretinal
Surgery. Rome, 12–14 September. 1991. page 399–411.
 10. Wilkinson CP. Interventions for asymptomatic retinal breaks and lattice degeneration
for preventing retinal detachment. Cochrane database Syst Rev 2014;9:CD003170.

17. DR. AJAY I. DUDANI
M.S., DNB, FCPS, DOMS(Bom)
Vitreoretinal specialist
Assoc. Proff. K.J. Somaiya Hospital & Medical College
Consulting eye surgeon ,
Bombay Hospital & Research Centre

18.  Lasik which combines keratomileusis with excimer laser stromal ablation has become
the most popular refractive procedure performed today due to its
 Advantages:
 Safety
 Efficacy
 Quick visual recovery
 Minimal patient discomfort

19. LASIK SURGERY

20.  RRD following lasik is infrequent
 A study reported 0.05% incidence at mean 24 mths after lasik
 Occurred 1-36 mths(mean 12.6mths)after lasik
 Occurred in eyes with mean -6.96 D of myopia before lasik
 No cause effect relationship between lasik & RRD was proven

21. SUCTION RING EFFECT DURING LASIK

22. RETINAL COMPLICATIONS AFTER REFRACTIVE
SURGERY----
PAPER BY DR. VIDAURRI LEAL
Study of 6000 eyes subjected to lasik,
RD developed in 3 eyes
pre-op myopia RD after lasik(mths)
1st case 30/M -6D 6mths
2nd case 40/F -12D 24mths
3rd case 27/F -3D 1mth
(who had an asymptomatic retinal hole that was not treated)

23. A study by Arevalo J F, Ramirez E et al
(journal of refractive surgery 2002 nov-dec)
38,823 eyes underwent lasikfor myopia of
-0.75D to -29D(mean -6D)
33eyes(0.08%) developed RRD after lasik,between 12 to 60
mths
Eyes had mean -8.75D myopia before lasik
Most RRD & breaks occurred in temporal quadrants(71.1%)

24.  Surgery to repair the RRD was performed in 31 eyes
 Final BSCVA of 20/40 or > was seen in 38.7% of 31 eyes( 2 pts refused surgery)
 Poor final VA of 20/200 or worse occurred in 22.6% eyes
 45.8% eyes lost 2 or more lines of VA after vitreo retinal surgery

25. VITREOUS CHANGES ASSOCIATED WITH LATTICE DEGENERATION

26. HOLES WITHIN LATTICE
LARGE TEAR ASSOCIATED WITH
LATTICE

27.  In which all retinal lesions were treated before lasik
 Of 1554 eyes in series preop prophylactic retinal treatment was carried out in 109 eyes with
lattice degeneration, 77 eyes with atrophic retinal holes, & 31 eyes with flap tears
 Post lasik RD developed in 2 of 217 eyes treated(0.92%) & in 2 of untreated eyes(0.15%)
 There was a paucity of evidence based data regarding value of treating asymptomatic lesions
predisposing an eye to retinal detachment

28.  Thus the incidence of RD post lasik in patients of both groups(treated & untreated) for
lattice appears to be almost same,

29. Byer has shown a very low detachment rate in population with
lattice degeneration
Vast majority of patients were emetropic or highly myopic
Assuming that prophylaxis is actually effective , 1000 emetropic
lattice patients in 30-39 yr age group would have to be treated to
prevent single detachment over a 10 yr period.
Lattice patients with low to moderate myopia tend to develop
detachments between 40 -60 yrs caused by premature posterior
vitreous separation & tractional tears

30. However myopes > -5D with lattice degeneration have
extraordinarily high risk of detachments during their life time which
tend to cluster in 2nd ,3rd , 4th decades & are typically caused by
atrophic holes which are slowly progressive & often simultaneously
bilateral
Enhanced vigilance & consideration for prophylactic treatment is
certainly appropriate for this group
This again is no small task as, in 1 million persons 1150, aged 10-
39 yrs with myopia> -5D & with lattice, 4 detachments annualy &
40 detachments in 10 yrs would be expected in this highest risk
group

31.  Annual incidence of nontraumatic phakic RD -6.1/1 lac population
 Although only 40% population exceeds 40 yrs, 80% detachments occur in this age group
 Pts with lattice degenerations have detachments at younger ages & have more myopia than
pts with detachments caused by simple retinal tears or holes

32.  Higher degrees of myopia are associated with detachments at younger ages of onset
than emetropia or hypermetropia
 About 20 % of u.s. population is myopic to some extent ,
 60% of detachments are associated with myopic refractive error & patients with higher
degrees of myopia are at greater risk of detachment than those with low or moderate
degree

33.  Myopic RE are common in eyes that develop RD
 Myopic changes may also be induced by RD surgeries due to changes in axial length
, anterior chamber depth or position of lens
 A study has shown improvement in UCVA in all eyes & no decline in BCVA in any of
them
 No retinal complication was found in post-op period although follow up is required

34. Thus although it may not be easy , it is very much necessary
to counsel pts with lattice degeneration undergoing lasik
Although the two may not be related at present the only way
to definitely determine if there is a link between lasik & RD is
to conduct a large prospective multicentric trial
But in the meantime we need to manage these pts
appropriately BY NOT OVERTREATING THEM