Term Paper: Safety of Laser Eye

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[. . .] Patients must adhere strictly to post-operative follow-up care and to other instructions issued by the physician.

As is the case with all other types of surgery, one of the most disastrous complications is infection at the site of the incision. In the case of laser eye surgery, there are two elements that render any type of infection particularly dangerous: the fact that eyesight might be damaged beyond repair by any infection that is not treated immediately, and by virtue of some of the procedures' involving flaps of tissue that are re-secured for post operative healing. Tissue flaps always present greater infection risks than incisions, as a function of the greater surface area potentially exposed to bacteria, and because they constitute such perfect "incubation" conditions for any infectious organism introduced to the site.

The risk of infection can be minimized to approximately 0.02% by a course of oral antibiotics in conjunction with topical antibiotic drops applied pre-operatively and post-operatively to the eye. In the relatively rare case where an infection develops, it is almost always resolved by aggressive treatment, but time is of the absolute essence as any delay in seeking appropriate medical attention could have devastating consequences.

Patients must follow instructions religiously to disinfect their hands when touching or changing any surgical dressing and when applying drops to the eye.

Since infections are most likely to occur in the first 48 to 72 hours, patients must be counseled with respect to diligent care and observation for any signs of infection particularly during this time, and must understand the importance of contacting their physician immediately if necessary.(4)

Over/Under Correction:

One of the most common post surgical complications associated with LASIK surgery relates to the degree of residual refractive error, which is more common in patients with high prescriptions at the upper limits of that which is appropriately treated with available technology. Even with the precision afforded by lasers, a residual error of approximately 10% is typical, which translates to a noticeable degree of blurred vision in patients starting out with a high degree of nearsightedness or farsightedness. In patients starting out with much lower prescriptions, the same degree of residual error is not noticeable at all. The term "error" is something of a 4. Ambrosio R, Jr., Wilson SE, Complications of Laser in Situ Keratomileusis: Etiology, Prevention and Treatment. J Refract Surg. 2001;17:350-79 misnomer, since the phenomenon relates more to the biology of healing and the uncertainties arising from natural changes in post-operative corneal curvature than from anything the surgeon caused through "error."

Ultimately, nearsighted patients may experience some loss of vision up close overcorrection), or some loss of ability to see far away (undercorrection). The exact opposite is true in patients who are initially farsighted. Either way, if the distortion is significant, it is usually addressed in a subsequent surgical enhancement performed after at least three to six months post-surgery.

Regression:

Closely related to over and undercorrection is the issue of regression, characterized by minor deterioration in vision compared to the immediate results of surgery. It is caused when the eye reverts to some degree of near or farsightedness upon healing, and like over/undercorrection, it is treated by a post-operative enhancement procedure a few months after the original surgery when present to a sufficient degree.

Diffuse Lamellar Keratitis (DLK):

DLK is statistically much more rare than correction error complications, but it occurs in approximately 1 in every 500 cases. It consists of a sterile, non-infectious inflammation underneath the corneal flap. Normally, it resolves with application of prescription of medicated eye drops, but occasionally it requires a surgical procedure whereby the underside of the flap is physical rinsed out. DLK represents another example of the importance of follow-up care, since it is usually asymptomatic and readily treatable, but can result in the loss of vision if it is not addressed in timely fashion. DLK is not apparent except through the use of a specialized instrument called a slit lamp, which is of crucial importance, since detailed statistical analysis reveals incidence of some degree of DLK in as many as one in every twenty-five

LASIK procedures, the vast majority of which resolve spontaneously without treatment. Approximately 1 in 5000 cases develops into potentially serious consequences, so all LASIK patients must be observed very carefully for this particular potential complication.

Dry Eyes:

Patients who experienced symptoms of dry eyes pre-operatively are markedly more likely to present with symptoms of dry eyes after certain laser procedures in which sensory nerve fibers involved in tear production (lacrimation) are severed.

Other suspected causes of the condition include (temporary) damage to structures called "goblet cells" which play a role in maintaining proper ocular lubrication. (5)

Symptoms vary in degree, and often resolve spontaneously after a few months, but it is for this reason that ideal prospective laser surgery patients are those who have not experienced dry eyes previously. Severe cases can result in symptoms of another set of complications, namely, glare, halos and starbursts for the duration of the dry eyes condition. Treatment for dry eyes usually consists of oral Doxycycline and specialized lubricating drops or sterile ointments.

Reduced Night Vision, Glare and Halos:

Even patients without dry eye symptoms typically experience at least mild symptoms of night vision problems and the sensation of glare or "halos" and starbursts" in the visual field. In principle, these symptoms resemble some of the experiences of (non-surgical) contact lens wearers, particularly at night, even though the mechanism of causation differs slightly. Visual quality generally declines somewhat when the pupil dilates, as it does in dimmer light. In post-operative LASIK

5. Smirennaia E, Sheludchenko V, Kourenkova N, et al. Management of Corneal EpithelialDefects Following Laser in Ssitu Keratomileusis. J Refract Surg 2001 Mar-Apr;17(2 Suppl):S196-9.

A patients, this is most often caused by temporary corneal swelling and changes in the newly forming shape of the corneal surface. Symptoms that don't abate after initial recovery, are sometimes related to residual refractive error (over/undercorrection). In other instances, the suspected cause is decentered ablation.(6)

Decentered Ablation:

Decentered ablation is one potential complication that results from issues that can arise during surgery, rather than as a function of healing idiosyncrasies and variation in the pre-operative state of the eye. It occurs when the laser is not properly positioned, or centered, over the eye during surgery.

The main cause of decentered ablation relates to the patient's inability to maintain proper focus during the laser surgery procedure. Depending on the degree of the patient's failure to hold the gaze required for surgery, the physician may simply wait for the eye to realign itself before continuing, or he may employ a sophisticated instrument that is designed to immobilize the eye for the duration of the procedure.

The latest technological developments include a laser that is capable of tracking the eye automatically, but further testing is necessary, because the evidence of its ability to do so accurately enough, in practice, to eliminate decentered ablations is inconclusive.

Central Islands:

Central islands result in the center of the visual field, either when tissue is not removed completely uniformly. Another cause of central islands is thought to be related to the vaporization of corneal tissue under the laser, causing a plume that partially blocks the laser. This was much more common before the advent of the latest generation of excimer lasers.

6. Miller AE, McCulley JP, Bowman RW, Cavanaugh HD, Wang XH. Patient Satisfaction after LASIK for Myopia. CLAO J. 2001 Apr; 27(2):84-8

Epithelial Erosion:

One of the more common reported complications is epithelial erosion, which occurs as often as five to ten percent of LASIK patients. It occurs when portions of the outer layer of the epithelium (the outermost layer of the cornea) sloughs off after surgery. Epithelial erosion is different than most other potential complications in that it does not normally affect vision, and in that it does result in moderate discomfort.

Elderly patients are more prone to this complication but often it occurs for no apparent reason that can be predicted beforehand.(7) Luckily, the surface of the cornea regenerates within a few days, either on its own or with the assistance of a therapeutic soft contact lens that the surgeon may apply to protect and sooth the area while assisting tissue regrowth simultaneously.

Keratectasia:

Patients with thin corneas are particularly susceptible to losing too much tissue during laser surgery, which is precisely why scrupulous physicians devote so much effort to carefully screening them out of consideration.(8) Sometimes it occurs nevertheless, in which case there is no surgical fix, since further laser procedures would thin the cornea even further. In that event, the usual treatment consists of prescribing rigid gas permeable contact lenses to provide corrected vision.

7. Dastgheib KA, Clinch TE, Manche EE, et al. Sloughing of Corneal Epithelium and Wound Healing Complications Associated with Laser in Situ Kerato Mileusis Patients with Epithelial Basement Membrane Dystrophy. Am J. Ophthalmol 2000;130:297-303.

8. Steinart, RF, Swami, AU. Diffuse Interface Keratitis. Review of Refractive Surgery, Jan 2000: 46-52

Unscrupulous Practitioners:… [END OF PREVIEW]

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Safety of Laser Eye.  (2004, January 29).  Retrieved March 24, 2019, from https://www.essaytown.com/subjects/paper/safety-laser-eye/8218781

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"Safety of Laser Eye."  Essaytown.com.  January 29, 2004.  Accessed March 24, 2019.
https://www.essaytown.com/subjects/paper/safety-laser-eye/8218781.