Understanding unhappiness post-LASIK provides basis for optimizing care

September 16, 2008

Results of a review of patients dissatisfied with LASIK who presented for consultation to a tertiary care center suggest that ophthalmologists should obtain a thorough medical history before surgery, particularly in regard to dry eye.

Baltimore-A retrospective study analyzing features of patients who seek referral care after undergoing LASIK because they are unhappy with their surgical outcomes may provide useful insight for mitigating patient dissatisfaction and managing it when it occurs, said Brett A. Levinson, MD, who is in private practice with Baltimore Eye Physicians.

The study was based on a review of 157 eyes of 109 patients who presented for post-LASIK consultation to the cornea service at the Wills Eye Institute, Philadelphia, between January 2004 and December 2006. Dr. Levinson collaborated on the study during his corneal fellowship.

"The vast majority of patients are very happy after LASIK, but our study showed that some remain unhappy for many years. Understanding of the reasons can facilitate better screening and preoperative counseling that emphasizes appropriate, realistic expectations," Dr. Levinson said.

Data from the preceding 10-year period showed that few eyes initially were seen on referral at the dawn of the LASIK era, but the number increased as LASIK gained in popularity. A peak was reached in 2001, when 81 eyes were seen, and the number dropped and seemed to plateau at about 50 eyes per year over the next 3 years.

The patients were about equally divided among men and women, with a mean age of 47 years and a range from 21 to 70 years. Less than one-third of patients had been referred by their LASIK surgeons, whereas just over half of them were referred from another eye-care professional. The remaining patients presented to Wills Eye by word of mouth or the Internet.

"The finding that most patients were not referred by their surgeon indicates that surgeons need to be making an effort to maintain long-term follow-up and to be sure that they and their staffs are prepared to provide customized support for patients with less-than-optimum outcomes," Dr. Levinson said.

The chief complaint for nearly two-thirds of patients was poor distance vision, whereas almost 20% complained primarily of dryness. The remaining chief complaints were almost equally divided into categories of redness and pain, glare and halos, and miscellaneous problems.

"This information reinforces the importance of obtaining a thorough history before surgery and particularly eliciting problems with dry eye because the patients with dry eye were the most unhappy group in our series," Dr. Levinson said.

The interval between the surgery and presentation to Wills Eye ranged from 1 day to 121 months, with a mean of 27 months. Less than half of the patients came within the first year after surgery, with only about 10% presenting within the first month.

"What we saw is that patients who are unhappy can remain persistently so," he said. "Of the patients presenting more distally from their procedure, half came to Wills Eye more than 4 years after the surgery."

Visual acuity



At referral, two-thirds of patients had uncorrected visual acuity (UCVA) of 20/40 or better, and about one-fifth had 20/20 or better UCVA. Vision was best overall in patients with dry eye; in that subgroup, almost all patients had UCVA of 20/40 or better. Patients with worse vision included those with intraoperative or postoperative complications such as epithelial ingrowth or ectasia. About 90% of patients had 20/40 or better best-corrected visual acuity (BCVA).

"The BCVA data reflect the fact that some patients were given hard contact lenses," Dr. Levinson said. "However, not all patients were willing to wear a hard contact lens after having LASIK."

The most common diagnosis in the group was dry eye/blepharitis (28%), followed by irregular astigmatism (12%), epithelial ingrowth (9%), ectasia (6.6%), haze and scarring (5%), and overcorrection (5%).

"It was interesting that over- and under-corrections were less common than we would have expected based on previous studies," Dr. Levinson said. "Perhaps in recent years the primary surgeons are doing a better job in dealing with these problems themselves and so the patients are kept away from referral centers."

Among patients with ectasia, most had been operated on in 2001 or earlier.

"Hopefully, this means ectasia has become less common than in the past," he said. "However, an alternate explanation may be that there is long lag time between the surgery and the time to ectasia development."

The most common management offered was medical therapy for dry eye. About one-fourth of eyes had surgery with an enhancement or a corneal procedure. Other management offered included vision correction with contact lenses or spectacles. Observation was recommended for only 13 eyes.

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