In my extensive experience as an ophthalmologist and an ophthalmology expert witness, I’ve come to understand the common risks associated with LASIK and PRK surgeries. Fortunately, many of these risks are minor and/or correctable, hence the popularity of this quick outpatient surgery. PRK was the main laser eye surgery performed before the advent of LASIK. It is technically simpler and less invasive (since no flap is created), but lacks the quick return to clear vision, one’s usual activities, and the “wow factor” of LASIK.
Everyone having PRK surgery will require the wearing of a soft (“bandage”) contact lens for 3-5 days after surgery while the top layer of the cornea (epithelium) re-forms after its removal at the beginning of surgery. While necessary to help decrease patients’ discomfort after PRK surgery, all contact wear increases the chance of postoperative infection. The great majority of PRK patients will have variable vision, especially during the first month after surgery.
Delayed healing of the corneal epithelium can lead to postoperative infection, corneal irregularity, scarring, and corneal haze. The latter condition is probably the most worrisome of post-PRK complications, since this can cause long-term decreased vision, especially in patients with higher prescriptions and/or lack of/ shorter treatment times using Mitomycin C.
Since PRK patients heal slower than those having LASIK, they will use steroid eye drops for at least one month. Although very rare, long-term use of steroid eye drops can be associated with increased eye pressures and development of glaucoma and cataracts. Other items of concern for at least several months after PRK are using artificial tear drops, wearing sunglasses, and taking daily oral vitamin C to aid in healing and prevent corneal scarring.
The biggest difference between LASIK and PRK is the creation of a flap (either by a laser or a mechanized surgical blade). Very rarely, one can have a flap complication either during surgery (an incomplete flap, an irregular flap, a “buttonhole” flap, or a “free” flap) or after surgery (wrinkles in the flap, trauma to the flap). Infection after LASIK surgery is also very rare but can be devastating when severe. More common is one developing inflammation within the flap. This is called diffuse lamellar keratitis (DLK), and is treated with more frequent use of steroid drops until the inflammation is under control. DLK can occur in both LASIK and PRK, but the great majority of DLK occurs after the former.
Dry eyes, haloes, starbursts, and variable vision is common after LASIK surgery and, in almost all cases, taken care of by the passage of time while the eyes heal, with the continued use of artificial tear eye drops and/or anti-inflammatory eye drops such as Restasis, steroid, and non-steroid eye drops.
Almost all residual eye prescriptions after LASIK or PRK can be resolved with another laser treatment, called an enhancement. With LASIK enhancement, however, there is the risk of surface corneal (epithelial) cells migrating below the edge of the LASIK flap. This condition is called epithelial ingrowth and can cause blurred vision, foreign body sensation, and astigmatism. Luckily, it is relatively easy for the surgeon to re-lift the LASIK flap, remove the ingrown epithelial cells, and improve the patient’s vision.
Diagnostic testing after LASIK and PRK surgery can also be helpful in determining very rare, postoperative complications such as a decentered laser treatment, corneal irregularities, and ectasia, which is a rare but potentially severe thinning and bulging of the cornea. This can require additional surgeries such as corneal cross-linking and/or a corneal transplant.
What an Ophthalmology Expert Witness Can Help Determine
Probably the most important thing an ophthalmology expert witness can help a reviewing attorney within this category is the determination of proper surgical candidacy of someone having a preoperative exam and evaluation for refractive surgery (LASIK and PRK).
An ophthalmology expert witness may review a person’s personal and family medical and ocular history are important to review. Conditions of concern may include autoimmune diseases (rheumatoid arthritis, lupus, fibromyalgia), immunodeficiency disorders (AIDS, HIV), intracranial disorders (stroke, brain tumor, aneurysm), active diseases (cancer, TB, herpes, seizures), family history of eye diseases and poor vision, and pregnancy or lactation in women.
Eye conditions that are relevant include corneal dystrophies, keratoconus, pellucid margical degeneration, previous ocular herpes/”shingles” infection, previous eye surgeries, lasers, and injuries, severe dry eye syndrome, ocular surface disorders, optic neuritis, glaucoma, double vision, unstable eye prescription, significant glare and/or haloes, very large pupils, small eyelid openings, and an inability to keep eyes open and head/body still during eye testing.
Everyday considerations include a person’s occupation, hobbies, and sports involvement, as well as the visual requirements for these. Other visual requirements to consider are those who have special driving licenses (CDL) and/or those who drive a great deal at night. In addition, anyone with military ties may have to meet certain visual criteria and/or may be limited in their laser eye surgery possibilities. As such, they may require permission/clearance depending on their specific military requirements as proceeding with surgery may cause them to be disqualified from certain military positions.
There are a number of parameters and measurements pertinent to the preoperative laser eye surgery exam that an ophthalmology expert witness can bring to light. These include the patient’s eye prescription (before and after dilation), the stability of the prescription, and to what level of vision each eye can be corrected with the prescription (amblyopia). In addition to amblyopia (lazy eye”), a history of strabismus (“crossed eyes”) and/or eye surgeries and patching, as well as true double vision, are important to know before considering laser eye surgery. Other important items of concern are current and previous contact lens wear, type(s) of contacts worn, pupil sizes (room light and dim light), eye pressures, thickness of the cornea, and various measurements recorded when the eyes have a corneal mapping (topography).
One of the more important items to determine is whether the proper treatment prescription was delivered. Printouts of the laser treatment, surgery planning worksheets, and actual surgery treatment sheets will have this information. The name and type of laser used as well as the use of different software prescription treatment patterns (“custom” or “wavefront” vs. “conventional” or “broadbeam”) may also be helpful information. Most medical charts will also have areas for surgeon and/or technician comments, notes, drawings, and other specifics. These can include items such as patient cooperation during surgery, any surgical complications and how they were handled, the thickness of the flap in LASIK patients, and the use of Mitomycin-C for certain patients having PRK surgery.
As with practically all surgeries, the results of LASIK and PRK surgery depend to some extent on the postoperative course, both the follow-up exams (patients’ subjective comments, their vision, the doctor’s exam findings and discussions with patients) and, especially, patient compliance. The latter includes attending scheduled, postoperative exams, taking all recommended medications as directed, and taking proper precautions after surgery such as not rubbing the eyes, avoiding heavy physical exertion and swimming, and wearing sunglasses.
Millions of people around the globe have had successful laser eye surgery, and millions more will follow them in the future. LASIK and PRK may be among the most “popular” and “successful” surgeries, but, as with all medical procedures, there are benefits and risks involved. Over the past three decades, potential LASIK and PRK patients, as well as attorneys, have become more sophisticated and educated about these surgeries. Continuing to become more informed, as well as learning from and working with an ophthalmology expert witness, will help all involved deal with this complicated topic.
About The Author
EXPERT WITNESS E-002437
This article was authored by a board certified and fellowship trained ophthalmologist with additional certification in Corneal Disease. He has clinical ophthalmology practice experience spanning more than a decade and has extensive experience working as an ophthalmology expert witness.
A.B., University of Chicago
M.S., Georgia State University
M.D., Medical College of Georgia
Internship, Internal Medicine, Mary Imogene Bassett Hospital
Residency, Ophthalmology, Medical College of Georgia
Fellowship, Corneal Diseases and Surgery and Refractive Surgery (LASIK and PRK), Corneal Consultants of Indiana
Board Certification: Ophthalmology
Member, American Academy of Ophthalmology
Member, American Society of Cataract and Refractive Surgery
Former, LASIK Surgeon, Lasik Vision Institute
Former, LASIK Surgeon and Medical Director, LCA Vision/LasikPlus
Current, LASIK Surgeon and Medical Director, major medical center
Current, Ophthalmologist, major eye center