Pre & Post-Operative Care – Lasik

Pre-Operative Care

The overwhelming majority of patients who have had LASIK surgery are fully satisfied with their results; having experienced the significant benefits of improved vision. However, as with any medical or surgical procedure, for certain patients the outcome of the procedure may not seem “ideal” or meet all of his/her expectations. A small minority of patients may also experience complications. Therefore, it is crucial that LASIK surgery candidates thoroughly discuss the procedure; its benefits, risks and probable outcomes with their physician prior to undergoing the surgery. Each patient should be fully informed and feel comfortable that they are making an educated decision based upon facts. Candidates should be aware that:

1. LASIK cannot provide perfect vision every time for every patient. However, for the majority of LASIK candidates, the surgery improves vision and reduces or eliminates the need for distant corrective eyewear. In fact, the vast majority of patients with low to moderate nearsightedness achieve 20/40 vision or better, and many can expect to achieve 20/20 vision or better.
2. Re-treatments (enhancements) may be required to achieve optimal outcomes. Fortunately, it is possible to repeat the laser treatment by lifting the flap, typically about three months after the original procedure. Even after enhancements, vision after LASIK may not be as good as it was with glasses or contact lenses before the procedure.
3. There may be visual aberrations after LASIK; most commonly, glare and halos under dim lighting conditions. Usually, these are not significant, and resolve within several months of surgery. Rarely, they are severe enough to interfere with normal activities.
4. Monovision is a technique in which one eye is corrected for distance vision and the other is left nearsighted to focus on near objects without glasses. Today, it is the only way that LASIK candidates older than about 45 years can avoid reading glasses. LASIK will not cure presbyopia, the aging changes that prevent older people from seeing near objects through the same glasses that they use for viewing distant objects.
5. LASIK surgery, as all surgical procedures, has the risk of complications. Fortunately, the likelihood of visual loss with LASIK is very small. In the many millions of LASIK procedures done so far, less than one percent of patients have experienced serious, vision threatening problems. Most complications represent delays in full recovery and resolve within several months of surgery.

Initiating a Dialogue: What Should I Ask My Doctor?

The decision to have LASIK should be an informed one, made in close consultation with an eye care professional. In order to understand whether LASIK is right for them, patients considering the procedure should ask the following questions of their doctor:

1. What type of testing will you do in order to determine whether I’m a candidate for LASIK?
2. Has my glasses or contact lens prescription been consistent for at least two years?
3. Does my nearsightedness, farsightedness or astigmatism fall within the accepted levels established for surgery by the FDA?
4. Are my corneas thick enough to perform LASIK surgery?
5. Do I have cataracts, glaucoma or other corneal diseases?
6. Are my corneas scarred?
7. Do I have any diseases that would affect the outcome of the surgery or my ability to heal properly?
8. Are there any other reasons why I may not be a candidate for LASIK surgery?
9. Am I at risk for complications?
10. What can I expect during the procedure?
11. What outcome can I expect from the surgery?

Post-Operative Care

While the majority of patients who have LASIK are very pleased with their results from the first day, some do have questions during the healing period. This section is designed to provide some general information that may be of use to patients in the immediate post-operative period.

We remind all patients that it is very important to adhere to their doctor's suggested follow-up schedule and to keep all post-operative appointments.

Additionally, it is important to let your doctor know if you have any questions about your vision or your eyes. Only a doctor who has performed an examination of your eyes and has a complete medical history can accurately determine if your situation is within normal limits or requires additional care.

While we provide information regarding the overall expectations for the surgery, we understand that there are specific questions that arise in the first few weeks following the surgery.

Visual Recovery

Most patients notice an improvement in their vision immediately upon completion of their surgery. By the next day vision is often dramatically improved. However, patients should understand that, while fast visual recovery characterizes the operation, it can take several months before some patients achieve their final vision after LASIK. Several studies demonstrate that the vision of a number of patients continued to improve up to six months post-operatively. During that time, patients may experience slight fluctuations in vision throughout the day. These symptoms generally diminish with time.

Crispness of Vision

For some patients, vision after LASIK matches the sharpness of vision they had with glasses or contact lenses before LASIK. However, many patients notice that 20/20 vision after LASIK can be different from 20/20 vision with contact lenses before LASIK, especially gas permeable contact lenses. The images seen through eyes treated by LASIK are often described as not being as "crisp" as those seen through glasses. This condition, referred to in ophthalmic literature as "loss of contrast sensitivity," may not affect your acuity as it is measured on an eye chart, but it can be noticeable in your daily life as a slight loss of sharpness.

The majority of patients do adjust to this change; however some do have difficulty in the first few months following surgery. Fortunately, these symptoms often dissipate within the first six months of surgery. Several published scientific papers have measured patients' pre-operative and post-operative contrast sensitivity, and nearly all have reported that it returns to pre-operative levels within the first six months.

Dry Eyes

Some patients experience dry eyes post-operatively. The symptoms can vary widely - from being relatively asymptomatic, to intermittent dryness at certain times during the day, to feeling the typical dry sensation much or all of the day, sometimes accompanies by blurry vision or an increase in glare and halos. When the dry eye is treated, those symptoms diminish.

Clinical dry eye is comparatively easy to diagnose and the great majority of patients respond well to treatment options ranging from use of preservative-free eye drops to insertion of punctal plugs, depending on the severity of the case. For almost all patients, dry eye symptoms gradually subside over the first few weeks or months after LASIK surgery. If you suspect that you may have post-operative dry eye, you should contact your doctor's office for an evaluation.

Glare/Halos/Starbursts

Many LASIK patients notice a temporary decreased in night vision with symptoms that include glare and halos. The experience of the phenomena can range from mild to severe. These symptoms usually subside within six weeks or so for the vast majority of patients who experience them. However, some will continue to experience them for a greater length of time.

There are several potential causes of decreased night vision. The most common is the normal mild swelling of the LASIK flap, which resolves within a few weeks of surgery. Many researchers believe that patients who have pupils that exceed the ablation zone may be more likely to experience decreased night or low-light vision following LASIK than the general population. Another cause is incomplete correction of the nearsightedness, farsightedness or astigmatism. Clinical dry eye can also contribute to the experience of glare and halos. Rarely the cause is mild irregularities that the LASIK surgery produces in the shape of the cornea.

Depending upon the cause, those patients who experience significant, persistent glare or halos have several treatment options. Enhancement procedures may be an option, but not everyone is eligible for an additional procedure. Eligibility for enhancements depends on a number of factors that a doctor must evaluate. For some patients, prescription eye drops to prevent dilation of the pupil at night to reduce the symptoms of decreased night vision may be an option. However, this pharmaceutical approach is not successful for all people, and it also can represent a significant expense over time. Diagnosis and treatment of clinical dry eye may alleviate many of the symptoms. Toric contact lenses may be prescribed for those who have astigmatism. Advances in laser technology have greatly lessened these symptoms.

Overcorrection, Under correction & Regression

Nearsighted patients who experience an overcorrection will become farsighted and will notice immediately that they can no longer see near objects as well. Conversely those who have been under corrected will notice that objects in a distance are still not perfectly clear. Farsighted patients who experience an overcorrection will become nearsighted and will notice immediately that they can no longer see objects at a distance clearly. Those who have been under corrected will notice that near objects are still not totally in focus.

If an over or under correction has occurred, your doctor will discuss your treatment options. Generally, surgeons prefer to wait approximately 3-6 months to perform an enhancement to ensure that the final vision has been achieved. As that point, either a hyperopia or myopia LASIK procedure will be performed to correct the residual error, if the patient and doctor believe it is appropriate.

Conventionally, regression is defined as a shift in initial visual outcome. In this situation, the sharpness of vision that occurs soon after surgery diminishes as the eye regains a small amount of its original nearsightedness, farsightedness, or astigmatism. Regression can occur quickly, within the first few weeks after surgery, but it also can occur slowly over time. Patients who experience regression will notice their vision changing progressively (not a fluctuation during the day). Typically, the optometrist will evaluate the regression to determine its cause and review treatment options with the patient. Typically, an enhancement procedure can be performed to correct the residual error, just as is done to treat an under correction or overcorrection.

DLK

Diffuse lamellar keratitis (DLK) is a unique and relatively rare post-operative condition following LASIK. Non-severe forms have been estimated in 1% of cases; severe cases comprise only about 1 in 5,000 surgeries.

Patients should understand that at the early stages of the condition, they most likely will not experience symptoms they would be able to discern, and only upon examination by a doctor could this condition be detected. When caught early, the inflammation associated with DLK is easy to treat. Patients should be aware, however, that while approximately 80% of the condition will clear up within the first 24 to 48 hours, it could take several weeks until the condition completely subsides.

We emphasize that this condition can be treated without significant visual loss when it is detected and treated early. Therefore it is imperative that all patients maintain their doctor's recommended post-operative follow-up examination schedule.

Patients should carefully review their immediate post-operative expectations with their optometrist prior to the surgery. They should discuss the follow up schedule and all post-surgical instructions. Then, if you notice something about your vision that deviates from your doctor's expectations, you should notify his/her office immediately.

Other Potential Complications

We emphasize that all patients should notify their doctor at once if they have any questions about their recovery after surgery. Only a doctor who has performed an examination of your eyes and has a complete medical history can accurately determine if your situation is within normal limits or requires care.

Post-Operative Care Frequently Asked Questions

We understand that most people have a choice in refractive surgeons in their area and make an effort to determine which doctor they should choose. We provide a list of questions for you to ask your optometrist. As non-surgical eye care professionals your optometrist is better equipped to guide you in your decision in choosing the most qualified surgeon. The decision regarding a surgeon is a very personal one, and ultimately, patients need to decide for themselves how comfortable they are with any answers they receive from their optometrist.

Contact lenses can temporarily change the shape of the cornea, and patients should understand that operating on a cornea that is not in its natural shape can affect outcomes and create complications. Therefore, the vast majority of patients who have worn contact lenses will need to keep their contact lenses out of their eyes for some period of time before surgery so that the cornea can return to its natural shape.

The amount of time it will take for the cornea to return to its natural shape will depend upon a number of factors. These include the kind of contacts worn (soft, hard, gas permeable), the number of hours a day the contacts have been worn, and how long you have worn them over your lifetime. It can take two weeks to several months without wearing contact lenses before you are ready for the operation. Generally speaking, patients who have worn hard or gas permeable contacts for long periods of time throughout the day for many years will need to be without them for several weeks or longer.

A corneal topography examination will be used to determine if your cornea has been affected by contact lens wear, and if it has, when it has returned to its natural shape and surgery is indicated.

Our surgeons use the Visx S4IR excimer laser to reshape the cornea and IntraLase FS60 to create the corneal flap, an all laser approach. Although the microkeratome is use by some centers, we feel the all laser approach in the safest and most consist performing technology.

Some patients prefer a great deal of contact with their optometrist. Others feel more comfortable dealing with nurses or refractive surgery coordinators. Patients must gauge their own needs with respect to access to the surgeon.

Doctors should turn away patients if they are not good candidates. Some patients will have medical or anatomical conditions that contraindicate surgery. Other patients have unrealistic expectations, and a physician would decline to perform surgery if a patient would not be satisfied with the outcomes. This is a somewhat unusual question and therefore you should not be surprised or upset if your doctor does not have the answer immediately available.

: Patients need to feel comfortable with the volume a practice does. Some patients may prefer a practice with a great deal of access to the surgeon. Others may prefer a high volume practice where LASIK is the only procedure performed. Still others may choose an option somewhere between these. A patient's comfort level with volume is very personal, and patients must determine for themselves what is important for them.

Given circumstances related to staffing or volume at some practices, providing formal statistics on outcomes may be difficult. An alternative to the formal results would be to discuss the individual experience with staff members or previous patients. While you will probably not speak with unhappy patients, you may get some insight into happy patients' decision-making process and their choice to be treated by the doctor.

Given that there appears to be a correlation between wide pupils and the frequency of night vision symptoms, and that newer lasers offer a range of treatment zone sizes, it is important that patients obtain accurate measurements of their pupils. Although the symptoms of this condition do not necessarily interfere with visual acuity as it is measured by an eye chart, for some patients, the experience can interfere with daily activities and driving at night. Therefore, you want to be sure that your doctor measures the pupil in both bright and dim light to simulate day-to-day lighting situations. We use a pupil gauge that is compared to the eye to determine the pupil size, and at the laser center use infrared detectors that can measure the pupil size in the dark.

Viewing a surgery provides patients with a first-hand look how the doctor operates and can be very helpful. However, patients should understand that sometimes viewing a surgery is not possible, given logistics and space within the laser center.

We would also recommend that patients look to ophthalmic boards and societies regarding licensure and professional records. Taking this route ensures that patients achieve an honest and accurate profile of the surgeon's professional history and those circumstances directly related to their medical practice. Patients need to decide for themselves how comfortable they are with any answers they receive from their eye doctors.  Ask for specifics about the doctor's training, practice pattern, and career. If a claim is made about the doctor being a "developer" of the technique, performing important research, giving lectures, or teaching, ask for specifics. Truthful positive answers to these items may indicate a doctor who is truly up-to-date and skilled; vague answers may indicate that these claims are not very accurate.

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