Although optometrists do not perform laser vision correction here in the United States, they can still provide a valuable role in this procedure that is gaining unprecedented popularity.

1. By The Right Contact Team
http://www.therightcontact.com

2.  Although optometrists do not perform laser
vision correction here in the United States, they
can still provide a valuable role in this procedure
that is gaining unprecedented popularity.
 According to recent data, a record 16 million
people have had LASIK vision correction in the US
though 20111.
 This is an amazing opportunity for optometry.
Whether it is screening good candidates, co-
managing post-ops or managing complications,
there is a lot the optometric profession has to
offer.

3.  LASIK
 Wavefront LASIK
 Intralase
 LASEK
 EPI-LASEK
 PRK

4.  Pre-Op
 Post-Op
 Complications

5.  There many issues that a practitioner should
review when considering candidacy for laser
vision correction.
 The following are a few concerns to be
addressed prior to referring the patient for
the procedure.
◦ Candidacy as defined by the FDA
◦ Anterior surface concerns
◦ Patient habits

6. Who is a good candidate for laser vision correction?
Since its FDA approval in 19952, many factors have remained
unchanged
 INDICATIONS
*Age 18 years of age or older with stable refraction for one year.
*Myopia (nearsightedness) up to -14 diopters either without astigmatism or from -0.5 to -5
diopters of astigmatism
*Hyperopia (farsightedness) from +1 to +4.5 diopters with less than 1 diopters of astigmatism
*No history of eye disease, corneal scarring or retinal problems
*Not pregnant or nursing for 3 months and not planning a pregnancy in the 3 months
following surgery
 CONTRAINDICATIONS
Laser refractive surgery is contraindicated:
* in patients with collagen vascular, autoimmune or immunodeficiency diseases.
* in pregnant or nursing women.
* in patients with signs of keratoconus or abnormal corneal topography
* in patients who are taking one or both of the following medications: isotretinoin (Accutane®)
or amiodarone hydrochloride (Cordarone®).

7. Dry Eye
 Ideally you want to identify dry eye during the pre-op period
 Spend at least a few weeks to months treating it.
 Utilizing tools such as artificial tears, punctal plugs, cyclosporine
eye drops and nutritional therapy (omega-3 fatty acids) 3 can
prove very useful.
Blepharitis
 Laser vision correction causes significant inflammation in normal
eyes. Consider the consequences surgery can have when
handling patients that already suffer from anterior surface
disease.
 Treatment options include
◦ oral tetracycline
◦ topical macrolide antibiotics
◦ combination steroid/antibiotic drops
◦ nutritional options (such as flaxseed oil). 4

8.  Does the patient work or live in environments
of excessive heat?
 Does the patient suffer from allergies or
habits that pre-dispose them to eye rubbing?
Avoiding these issues can greatly
affect the potential outcome of
the procedure.

9.  Most surgeons recommend a very specific
follow-up schedule to ensure proper healing.
 An average schedule would include
◦ 1st day
◦ 1st week
◦ 1st month
◦ 3 – 6 months
 Each post-op appointment has very specific
concerns that are to be addressed.
 Each visit should take the opportunity to re-
educate the patient on their status and the
overall healing process.

10.  During this visit, the practitioner will access vision and make a
corneal evaluation. The corneal evaluation will obviously vary
depending on the procedure performed.
◦ If the patient has undergone LASIK, than flap evaluation will take place.
◦ If PRK or LASEK was performed, the corneal evaluation will be done under
the bandage contact lens.
 Patient instruction is very specific at this visit.
◦ Remind the PRK and LASEK patients that discomfort within the first few
days is common but will subside. After a discussion about all topical
post-op medications, patient’s activities need to be discussed.
 Aggressive rubbing should be addressed.
◦ The patient should be discouraged from performing any tasks that could
potentially hit the eye. Be specific, state avoiding things like water striking
the eye during bathing, make-up (no mascara or eyeliner), sports, and
exercise. The patient should wear a protective shield at night. Provided
the vision is adequate, the patient is definitely able to resume deskwork or
driving immediately.

11.  At this visit a re-assessment of vision and
corneal integrity is taken.
 As compared to their first post-op, patients
that underwent PRK and LASEK should note a
dramatic increase in comfort and vision.
 Many times topical medications are
discontinued at this visit.
 The patient is often informed that they can
begin a moderate level of activities including
exercise, swimming, hot tubs and contact
sports.

12.  The 1 month post-op evaluation again
evaluates the vision and corneal surface.
 At this stage the cornea should be completely
attached and the patient is able to resume all
activities.
◦ These activities would include those that were
previously restricted such as gardening, scuba
diving, etc.

13.  These visits are routine health evaluations.
 At this time, many doctors will have to
manage issues associated with dryness.

14.  When discussing any type of surgery you
always have to be aware of the risks
associated with the procedure.
 Even though laser vision correction has a very
good track record, sometimes there are
unfortunate results that have to be
addressed.
 The following is a listing of possible
complications that can occur with laser vision
correction.

15.  Doctors are trained not to be over concerned about
initial signs of overcorrection.
◦ This is because immediate post-ops can show correction
issues secondary to expected corneal swelling.
◦ The patient should be educated that these symptoms will
subside within a few days to two weeks.
 Despite extensive pre-testing, sometimes the eyes do
not respond in a predictable fashion. Regardless of
the reason, the patient still has options.
◦ If the patient is interested in additional surgery, an
enhancement may be considered.
◦ Non-surgical treatment options include glasses and
contacts.

16.  Visual distortion can arise from several areas.
Quite often this is related to the size of the
treatment zone5.
◦ If the pupil is wider than the treatment zone the
patients may report glare or haze.
 Retreatment is a possibility, but optic zone
size can also be addressed with topical drops.
◦ The patient may be given a drop that has mitotic
effects for things like night driving.

17.  Wrinkles
 Epithelial Ingrowth
 DLK (Diffuse Lamellar Keratitis)

18.  During surgery, if the flap is not made correctly,
either to thin or to thick, it may not correctly
adhere to the corneal surface.
◦ This can cause microscopic wrinkles, or striae which will
interfere with the patient’s visual outcome.
 Wrinkles may also occur due to patient
compliance issues. A patients rubbing or
squeezing the eye too tightly within the first few
hours of the procedure could also result in
wrinkles.
◦ Patients should be discouraged from this behavior for
the first 24-48 hours after the procedure.

19.  Epithelial ingrowth is another rare but
potentially serious complication.
◦ Studies continue to show that early detection is
vital.
◦ The use of optical coherence tomography has
proven to be a useful tool in diagnosing this
abnormal finding6.
 Not all cases of epithelial ingrowth need to be
treated and therefore careful monitoring is
required.
 Surgical removal of epithelial accumulation is
indicated before the formation of a scar7.

20.  Diffuse lamellar keratitis (Sands of Sahara) is accumulation of white
blood cells between the flap and stroma. These cells develop at the
stromal interface and create unwanted inflammation.
◦ This presentation is usually evident 1-5 days after LASIK but can occur many months
after the procedure8.
◦ With slit-lamp evaluation this finding appears as waves of sand.
◦ Patients present with pain, photophobia, foreign body sensation, and /or decreased
vision.
 The cause of diffuse lamellar keratitis is unknown.
◦ These infiltrates are sterile, but the cornea attacks them causing serious damage.
Because these infiltrates are not alive, these cells are able to elude proper sterilization
techniques.
 Quick diagnosis is a must, and topical or oral treatment is often
adequate. Common treatment would include topical antibiotics and
steroids.
◦ Accepted dosaging is every 2 hours on both, and possibly an ointment at night.
◦ If topical treatment is inadequate re-lifting the flap, and removal of the infiltrates
may be required.

21.  Subconjuntival hemorrhages
◦ These often occur with no long term side effects.
◦ No topical treatment is required.
◦ The most important issue would be educating the
patient on its presentation.

22.  Keratectasia is a very difficult complication to
mange. This finding results in an increase in
refractive error due to the progressive
steepening of the cornea9.
 Corneal ectasia can occur as quickly as one
week after the procedure but can also
manifest several years post-operatively.
 Managing this condition may eventually begin
with specialty contact lenses, but may mature
to the need for additional surgery like a
penetrating keratoplasty or intacs10.

23.  Technology continues to advance. One of the more recent
advances would involve wave front technology. These
methods now allow for an extremely precise individualized
vision correction.
◦ The procedure addresses higher order aberrations, something
earlier designs couldn’t come close to affecting.
 Post-operative care is also being modified. Researchers
are looking at developing contact lenses designed to
release a continuous supply of medication during the
post-op period. These designs use vitamin E to help
release the drugs automatically overtime11.
Although optometrists cannot perform
the procedure, as you can see, we can
play quite an active role in the patient
pre- and post care.

24. 1. 2011 Market Scope, LLC
2. FDA. (2010). FDA-Approved Lasers for PRK and Other Refractive Surgeries. Retrieved from
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm192110.htm
3. Saadia Rashid, MD; Yiping Jin, MD, PhD; Tatiana Ecoiffier, MSc; Stefano Barabino, MD, PhD; Debra A. Schaumberg, ScD, MPH; M. Reza Dana, MD, MSc, MPH. Topical Omega-3 and
Omega-6 Fatty Acids for Treatment of Dry Eye. Arch Ophthalmol. 2008;126(2):219-225.
4. Goldman D. Treating blepharitis to maximize surgical success. Cataract Refractive Surgery Today. 2009 May:61-3.
5. Gregory W. Schmidt, MD; Michael Yoon, MD; Gerald McGwin, PhD; Paul P. Lee, MD, JD; Stephen D. McLeod, MD. Evaluation of the Relationship Between Ablation Diameter, Pupil
Size, and Visual Function With Vision-Specific Quality-of-Life Measures After Laser In Situ Keratomileusis. Arch Ophthalmol. 2007;125(8):1037-1042.
6. Alissa Coyne, O.D., and Joseph Shovlin, O.D.AS-OCT Technology: Analyzing the Anterior Segment. Review of Optometry. Continuing Education. April 2012;
7. Irene Naoumidi, PhD; Thekla Papadaki, MD; Ioannis Zacharopoulos, MD; Charalambos Siganos, MD, PhD; Ioannis Pallikaris, MD, PhD. Epithelial Ingrowth After Laser In Situ
KeratomileusisA Histopathologic Study in Human Corneas. Arch Ophthalmol. 2003;121(7):950-955.
8. Bennie H. Jeng, MD; Jay M. Stewart, MD; Stephen D. McLeod, MD; David G. Hwang, MD. Relapsing Diffuse Lamellar Keratitis After Laser In Situ KeratomileusisAssociated With
Recurrent Erosion Syndrome. Arch Ophthalmol. 2004;122(3):396-398.
9. Beeran Meghpara, BA; Hiroshi Nakamura, MD; Marian Macsai, MD; Joel Sugar, MD; Ahmed Hidayat, MD; Beatrice Y. J. T. Yue, PhD; Deepak P. Edward, MD. Keratectasia After Laser In
Situ KeratomileusisA Histopathologic and Immunohistochemical Study. Arch Ophthalmol. 2008;126(12):1655-1663.
10. George D. Kymionis, MD, PhD; Charalambos S. Siganos, MD, PhD; George Kounis, BSc; Nikolaos Astyrakakis, OD; Maria I. Kalyvianaki, MD; Ioannis G. Pallikaris, MD, PhD.
Management of Post-LASIK Corneal Ectasia With Intacs InsertsOne-Year Results. Arch Ophthalmol. 2003;121(3):322-326.
11. Peng CC, Burke MT, Chauhan A. Transport of topical anesthetics in vitamin e loaded silicone hydrogel contact lenses. Langmuir. 2012 Jan 17;28(2):1478-87. Epub 2011 Dec 22.