Better technology and growing surgical experience are improving the results of refractive surgery. Wavefront-guided ablation, supernormal vision, and improvements in lifestyle are benefits of refractive procedures that are frequently described in the media. However, with the increasing number of refractive surgical interventions is a concomitant increase in the number of cases with postoperative complications, even if the overall rate is less than 1%.
A recent journal editorial highlights the importance of reporting refractive surgery complications.1 We all learn from these reports and in this way improve our technique and outcomes. The estimated risk of refractive surgery is influenced by these reports, but a realistic picture is helpful for us and our patients. It does not matter that refractive surgery techniques will have different complication rates. Overall, bad publicity about refractive surgery will harm the field. Nevertheless, by providing peer-reviewed information and data, the journal can help minimize the occurrence of complications.
In this issue, 5 cases of microbial keratitis after excimer surgery are reported. A MedLine search in January 2002 revealed 20 peer-reviewed articles dealing with infections after photorefractive keratectomy and more than 35 articles, after laser in situ keratomileusis. (And these represent only the published cases.) Fortunately, not all infections will affect the visual outcome of surgery, but some will decrease the visual acuity in the treated eye over the long term.
What are the most important factors in preventing infections as a complication of refractive surgery?
- We as surgeons should do everything we can while performing surgery to prevent an infection. Unsterile conditions must be carefully avoided. This has implications for the room in which surgery is performed.
- We should not treat 1 patient with instruments used in another patient. Although this should be the standard of care, it is important enough to reiterate.
- Should we reconsider the concept of sequential and simultaneous bilateral surgery? The peer-reviewed data state, “Simultaneous bilateral LASIK is as safe and effective as sequential surgery. … [and] may offer several benefits to the patient”2; “[t]he outcomes and complications of performing bilateral simultaneous LASIK were not significantly different from those of sequential treatments, with the unexplained exception of more frequent epithelial ingrowth in the simultaneous group.”3 Cases of bilateral infections after all types of refractive surgery, however, may undermine these statements.
In this issue, Suresh and Rootman report that infections can occur even after a simple enhancement procedure. These are difficult for the patient to accept and should not be accepted by the surgeon. If we perform simultaneous bilateral surgery, the second eye should be treated as a new intervention with sterile instruments, including the microkeratome and the blade. This will not prevent bilateral infections in all cases, but it will at least reduce the risk.
4. Sophisticated follow-up of the patient, starting on the first postoperative day, should be routine. We need to educate patients about the risk of postoperative infections so they are aware and can react appropriately.
Other factors may be identified and should be studied to make refractive procedures even better than they are today. Sight is one of the most important human senses. We should not forget that the surgical correction of refractive errors is still seen as cosmetic surgery in many countries; hence, information about and prevention of infections is necessary if we want to increase confidence in refractive surgery for our peers and for future patients.
1. Kohnen T. Importance of reporting complications of refractive surgery. (editorial) J Cataract Refract Surg 1999; 25:1
2. Gimbel HV, van Westenbrugge JA, Penno EEA, et al. Simultaneous bilateral laser in situ keratomileusis: safety and efficacy. Ophthalmology 1999; 106:1461-1467
3. Waring GO III, Carr JD, Stulting RD, et al. Prospective randomized comparison of simultaneous and sequential bilateral laser in situ keratomileusis for the correction of myopia. Ophthalmology 1999; 106:732-738