Refractive Surgery for a Lifetime

The vast majority of patients who undergo refractive surgery are very satisfied with their results. Yet some – particularly those who underwent surgery with earlier technologies, who did not have a full correction at the time of surgery, or who may have developed conditions such as presbyopia (the need for reading glasses) or dry eyes (especially common in middle-aged women) – may benefit from additional care.

The RSA is working to make it possible for every appropriate candidate access the benefits of refractive surgery. Refractive surgery benefits do not end with the procedure—every patient who had refractive surgery in the past should continue to benefit from ongoing advances over time. Visual needs evolve as we age, and refractive surgery can offer vision solutions throughout life.

Some people may have the impression that their refractive surgery “wore off” over time. Refractive surgery does not “wear off.” We continue to age, and can develop conditions such as presbyopia that cause the need for reading glasses even though distance vision remains good. This happens whether or not we have refractive surgery. For example, presbyopia is a condition that affects everyone and has an onset in the mid-forties. Several options exist to treat presbyopia, and RSA members are committed to providing services to provide vision that offers independence from glasses and contact lenses throughout life.

    Applying Modern Technology over Prior Procedures

As with many technologies, such as cell phones, automobiles and the Internet, technical advances in refractive surgery technology have been rapid. In addition to faster, more accurate lasers and software, the optical results after modern refractive surgery have dramatically improved.

Today, the vast majority of refractive surgery patients have independent vision after surgery that is at least as good—or better—than it was before surgery using glasses and contact lenses. Visual quantity—the ability to see the eye chart—is not the only improvement. Visual quality is also better. For example, about 90% of patients report no change or improved night driving after current-day refractive surgery such as LASIK. (see http://www.accessdata.fda.gov/cdrh_docs/pdf2/P020050S004b.pdf, Table 16 on page 33).

As well, some who were treated with earlier technologies may also experience glare and halos with night driving. Night driving complaints seldom occur today. Patients with night driving symptoms from prior surgery can often be helped with current technologies.

The most common cause of visual complaints in post-refractive surgery patients is simply residual refractive error. In other words, the initial treatment improved vision and focus but not completely. This generally occurred before the advent of modern nomogram technologies and new laser platforms. Despite good daytime vision, these patients may experience problems with night driving. Most if not all of these patients can be helped with a minor “enhancement” procedure using current lasers.

Regardless of the cause, patients who had refractive surgery in the past who are not completely satisfied with their vision or who experience problems with night driving can often be improved. The refractive surgeons in the RSA welcome patients who seek additional care and can provide solutions to treat most complaints.

    Dry Eyes

The RSA is also committed to caring for patients with dry eyes. Age-related dry eyes occur commonly after the age of 45 to 50, independent of whether refractive surgery was done, and are reported by 18% or more of patients. Transient dry eyes are common after LASIK, and typically resolve as the eyes heal after surgery.

Many treatments exist for patients with dry eyes. The best treatments work by addressing the cause. Eyelids may be infected or inflamed. Tear secretion may be inadequate. Surface inflammation may require medication in the form of cyclosporine-A or other agents. Systemic hormonal replacement may be needed after menopause. Untreated allergies (and sometimes allergy medications) can cause symptoms that mimic dry eyes and make pre-existing dry eyes worse. Better allergy management can help. In other patients, nutritional supplements such as omega-3 fatty acids may be of benefit.
The right treatment depends on the patient and the cause of their dry eyes. RSA surgeons are experts in ocular surface management and dry eyes, whether in the context of prior refractive surgery or not. Dry eyes can impair vision and comfort, and are a refractive condition. If you have dry eyes, seek out an RSA physician. Help is often available.

    Collagen Cross Linking

In rare cases the front surface (cornea) of the eye can weaken and bulge forward. When this occurs as primary condition it is known as keratoconus. When it occurs after laser refractive surgery it is known as corneal ectasia. In either case, vision is impaired.

In the past, it was difficult to predict which patients were susceptible to corneal ectasia after laser refractive surgery. Today, sensitive imaging techniques allow surgeons to detect very slight abnormalities that act as markers of potential ectasia. These technologies are exquisitely sensitive. They should be used by all refractive surgeons with every patient, to protect them against complications. OCT, corneal topography and corneal tomography are examples of the technologies used.

Many treatments are available for patients who have already developed keratoconus or ectasia. Contact lenses are often used early on, and can help stabilize progression. In the past, corneal transplants were often performed, replacing the thinned cornea with new tissue. Corneal transplants (also known as penetrating keratoplasty or PKP) work well but require several months to heal and are considered major eye surgery.

Today, a procedure known as “collagen cross-linking” is used in most cases instead of surgery. Cross linking strengthens the chemical lattice in the cornea and slows or stops progression of keratoconus and ectasia. Cross linking is commonly used outside the United States and has largely replaced corneal transplants as the primary treatment for keratoconus. Within the United States, corneal collagen cross-linking is undergoing extensive study and FDA approval is expected soon. Several RSA physicians are taking part in these studies and currently offer cross-linking in their practices, consistent with the RSA commitment to innovation and patient care.