LASIK SURGERY . . . Things that can go wrong.

Based on an article by B. Kent Buckingham, O.D., J.D. printed in TRIAL Magazine

"THROW AWAY YOUR GLASSES!" the article begins...

But problems may await. Millions of people are having this surgery, when in fact the long term outcome is unknown. The surgery is that new!

...there have been a number of documented surgical complications, ranging in severity from simply bothersome to devastating. This article will discuss the three primary refractive surgery modalities and the possible complications that can accompany this sought-after surgical repair.

Refractive surgery and complications
Anatomy and physiology of the ocular system
The cornea

Eyes work like cameras. There is a lense. It does the focusing. It allows a picutre to be made on the film. In your eye, there is a lite sensitive area that acts as the "film". The pupil allows you to let less light, or more light, into the eye. After going past the pupil, the light goes through a lense. This is what focuses the light on the back of the eyeball. Once there, nerve tissue that is connected to light sensitive tissue, sends signals to the brain. A picture is then formed by the brain.

"The cornea consists of five cell layers, which moving from the front of the eye inward are the Epithelium, Bowman's Membrane, Stroma, Descemet's Membrane, and Endothelium. The most important of these for purposes of this article are the Epithelium, the Stroma, and the Endothelium."

It sounds sinple enough, so ...
What can go wrong? Can the surgery be a failure?
A refractive error means that the optics of the eye do not refract the light properly, so that the image formed on the retina is blurred. While refractive errors are called eye disorders, they are not diseases. There are three primary refractive errors which are addressed by refractive surgery: myopia, hyperopia, and astigmatism. Myopia is by far the most prevalent of the refractive errors and comprises the bulk of the refractive surgeon's patient base.

"In Refractive Surgery, there are a number of complications that should be anticipated by the surgeon and explained to the patient. The nature of these complications range from problems that, at best, are quite bothersome to those who suffer from them to the worst case scenario . . . the loss of an eye. As the procedures of refractive surgery have been refined over the last two decades, the incidence of the worst case scenario has decreased to almost being nonexistent; however, the lesser problems continue to plague some unfortunate patients who experience a less than perfect outcome."

Complications are substantially more common, and potentially more devastating, with RK than with laser refractive surgery. This is due to the procedure itself as the corneal incisions go almost all the way through the cornea. During the RK incision procedure, it is quite easy have perforations of the cornea where the fluid between the cornea and the iris (the aqueous) leaks out.(1)

Bacteria can enter the eye, breach the natural corneal barrier, cause infection, leading to total blindness.(2)

Also, corneal ulcerations can and may ultimately require a corneal transplant (penetrating keratoplasty) in order to obtain clear vision.(3)

Also, a cataract can form and cause the to become so cloudy that light no longer can pass through to reach the cornea.(4)

"In the past, some surgeons used a retrobulbar (behind the eyeball) injection of anesthesia to numb the whole eye prior to performing RK. Not only is this overkill (as it is only the cornea which requires anesthesia), but it led to acute optic atrophy in a number of cases. This results in complete loss of vision in that eye."(5)

Laser surgery is somewhat safer and more predictable than RK. (6)

Patients with bad outcomes complain of:
haze
glare and
halos.(8)

These side effects can be disabling to a patient, where night driving is impossible.

"A more common problem with the flap is loss of suction during the microkeratome cut. This may cause an incomplete cut or a thin flap. If this occurs, most surgeons will replace the flap and abort the procedure for the time being. The surgery can be attempted again in approximately three months with no reduction of expected success."

"One final complication of LASIK is that of epithelial growth into the cornea stroma which can produce significant vision problems.(9) "

"There is a wealth of information available on the Internet. In addition to the usual medical literature sources, there are a number of sites created by various associations interested in the area of refractive surgery that can provide relevant information, i.e. http://www.usaeyes.org/ and http://www.eyenet.org/. In addition, there are sites set up by folks who had less than ideal outcomes from refractive surgery and are eager to warn others of the dangers of refractive surgery. Examples of this type of webpage can be found at http://www.surgicaleyes.org and http://members.aol.com/eyeknowwhy/.

"Also consider using illustrations from various webpages as trial exhibits which, with the help of your experts, will allow the jury to visually understand what your client sees. Several sites use digitally altered photographs to depict the visual problems seen by patients with bad surgery outcomes, i.e. http://www.surgicaleyes.org, http://home.pacbell.net/kensian1/moon.htm, and http://hem.passagen.se/rhn/eyes/."

1. Sawelson H, Marks RG: Two-year results of radial keratotomy. Arch Ophthalmol 103 (4):505-10, 1985 2. Gelender H, Flynn HWJ, Mandelbaum SH: Bacterial endophthalmitis resulting from radial keratotomy. Am J Ophthalmol 93 (3):323-6, 1982. 3. Mandelbaum S, Waring GO, Forster RK, Culbertson WW, Rowsey JJ, Espinal ME: Late development of ulcerative keratitis in radial keratotomy scars. Arch Ophthalmol 104(8):1156-1160, 1986. ; O'Day DM, Feman SS, Elliott JH: Visual impairment following radial keratotomy. A cluster of cases. Ophthalmology 93 (3):319-26, 1986. 4. Gelender H, Gelber EC: Cataract following radial keratotomy. Arch Ophthalmol 101 (8):1229-31, 1983 5. Jindra LF: Blindness following retrobulbar anesthesia for astigmatic keratotomy. Ophthalmic Surg 20 (6):433-5, 1989. 6. Rowsey JJ, Morley WA: Surgical Correction of Moderate Myopia: Which method should you choose? Surv. Ophthalmol 43:151, 1998 7. Seiler T, Wollensak J: Myopic photorefractive keratectomy with the Excimer laser, One Year follow-up. Ophthalmology 98: 1156-1163, 1991. 8. Loughnan M: Laser Refractive Surgery. Australian Family Physician 27(3):154 1998. 9. Helena MC, Meisler DM, Wilson SE. Epithelial growth within the lamellar interface following laser in situ Keratomileusis. Cornea 16:300 1997.