Laser Eye Surgery (LASIK) and How to Deal with Its Possible Complications

Most people know laser eye surgery as "LASIK" (laser-assisted in situkeratomileusis), but nowadays there are many variants and many laser alternatives to conventional LASIK, including PRK (photorefractive keratectomy). What all these procedures have in common is that they come with risks, though advances in technology and ophthalmological knowledge have reduced those risks.

The overwhelming majority of people are pleased with their laser eye surgery and are glad they had it done. For a certain number, though, the surgery fails. Different studies give different estimates, but for perhaps 2%-3% of patients, either their vision does not improve or they experience some significant side effect. In addition many of the 97%-98% who do improve without complications still do not achieve 20-20 or better vision. These "partial successes" occur most often amongst people who had the weakest vision prior to the surgery. The procedure helps them, but it doesn't get them all the way to ideal vision, so they may still need to wear glasses or contact lenses for some purposes.

I underwent laser eye surgery in February 2006. My surgeon explained both the failures and partial successes with a colorful analogy: Imagine a golfer attempting a putt. It's rare but not unheard of that his putt will end up farther from the hole than where he putted from. That's the 2%-3% who get worse. Sometimes he won't sink his putt, but in those cases he'll almost always end up a lot closer to the hole. Those are the partial successes who improve but not to 20-20. If he's putting from 5 feet, he's more likely to sink his putt than if he's putting from 40 feet (also more likely to come within six inches if he misses, more likely to come within a foot if he misses, etc.). That's analogous to the patients who start with weaker vision being less likely to come as close to ideal vision as the patients who needed less improvement to get there.

Before detailing how the surgery can fail and what can be done about that in response, it's worth emphasizing the point that the best way to counter any failure is through prevention.

Number one, think long and hard about having the surgery at all. This is elective surgery. If you would only have a slight preference for improving your vision and not having to wear glasses, perhaps just a slight cosmetic preference, you have to weigh that against the fact that there is a chance (albeit a very small chance) that the surgery will not only fail, but fail in a life-altering awful way, such as chronic eye pain, blindness, or significantly reduced vision. Don't go through with it unless the intended vision improvement would really be a big deal to you.

Second, if you are going to have the surgery, do your research and don't look just at cost. Even if in general there is a 2%-3% chance of failure with laser eye surgery, that doesn't mean that every case will have that same likelihood. If you go to one of the top eye surgeons in the field, who does maximal preparation and screening for every patient, has the absolute top of the line equipment, and so on, it might be a very small fraction of 1%. If you go to someone who's new but is already dodging multiple malpractice suits, who cuts corners on equipment, who takes pretty much any patient with minimal screening who'll pay, all because you were enticed by the discount rates on a billboard, it might be 5%-10%.

Don't bargain hunt. We're talking about your eyes here, not a bad haircut. If you can't afford to have it done right, if you don't have the time to do your homework and pick a top quality surgeon, this isn't the right time for you to have this surgery.

On the infrequent occasions there's a problem, what can go wrong with the surgery?

* Over or under correction, blurred vision from induced astigmatism

As noted with the putter analogy, even with modern techniques, the procedure is not always going to find that sweet spot that gives you 20-20 vision.

* Dry eyes

A mild version of this condition is actually a pretty normal temporary consequence of the laser surgery, but infrequently it can be more serious and permanent.

* Vision defects from higher order aberrations

The surgery can cause small imperfections in the corneal surface that give rise to ghosting, halos, loss of contrast sensitivity, multiple images, or starbursts.

* Corneal ectasia

The surgery can weaken the structure of the cornea, causing the eye to bulge out and causing serious vision problems.

When problems like these arise, different responses may be possible.

1. Repeat the procedure

Called "enhancement," often what is recommended is you wait for the eyes to heal, then let the surgeon go in and take another shot. If you improved but not quite to the degree you wanted, the surgeon will be putting from closer to the hole now, so there's a better chance of success. On the other hand, keep in mind that each time you cut into your eyes again with a laser beam, you're running that risk anew of one of the really bad complications. So if you're happy with your vision but it's not quite perfect, it's usually best to leave well enough alone.

Also, for some bad outcomes, such as corneal ectasia, enhancement is not an option. They can't be corrected by repeating the procedure.

The policies on enhancement will differ from surgeon to surgeon, so be sure to find this out ahead of time. Usually follow ups for a certain time period-six months, a year-will be free or discounted, but not always.

Enhancement is a good option for many patients. Taking enhancement into account, we can say that whereas there may be approximately 2%-3% of people who have unsatisfactory outcomes from the first procedure, a substantially smaller percentage of people have unsatisfactory outcomes after however many procedures they end up having.

2. Medication or assistive technology

If your vision is still short of 20-20, you can wear glasses or contact lenses, perhaps less often, in fewer situations than before the surgery. Corneal ectasia generally cannot be helped with glasses or contact lenses, except in some cases rigid gas permeable contact lenses can be beneficial. For dry eye, your ophthalmologist can recommend eye drops.

3. Other surgery

Corneal ectasia can be so bad as to require a cornea transplant to save your vision.

4. Lifestyle changes

You may be able to lessen or avoid having to deal with some of the complications laser eye surgery can cause if you refrain from driving at night, cut down on the amount of time you spend reading from a computer monitor, or make other behavioral changes that your ophthalmologist may recommend.

5. Lawsuit

The mere fact that the surgery turns out poorly is not a good basis for a lawsuit. Even if the surgeon does exactly what she's supposed to, a certain number of patients will suffer bad outcomes. That's why these matters are discussed with you in advance, and you sign informed consent forms.

In order to have grounds for a lawsuit, there would either have to have been something inadequate about the informed consent procedure such that you were not properly apprised of what you were getting yourself into and all the risks that entailed, or the surgeon would have to have done something wrong or negligent.

Laser eye surgery has significantly benefitted millions of people. It is a procedure with a high satisfaction rate, and a low rate of failure. But those failures can be very serious, and can only sometimes be corrected. Treat the decision of whether to have laser eye surgery as one of great gravity.

Sources:

Gary Heiting, OD, "LASIK Enhancement: When Additional Surgery is Needed." All About Vision.
Kenneth M. Keith, "LASIK Malpractice - Can You Sue?" Avvo.
"Failed LASIK Surgery - Complications, Depression, Suicide." LASIK Eye Surgery Correction.
"What Happens When Lasik Surgery Fails." Disability Secrets.