Surgical outcomes of photorefractive keratectomy and laser in situ keratomileusis by inexperienced surgeons

Outcomes of Resident-Performed FS-LASIK for Myopia and Myopic Astigmatism

PURPOSE

To evaluate the outcomes of resident-performed femtosecond laser-assisted in situ keratomileusis (FS-LASIK).

METHODS

Records of 138 eyes of 69 patients treated by residents for myopia or myopic astigmatism between March 2018 and June 2020 were reviewed. All preoperative visits, procedures, and postoperative visits were supervised by attending physicians. Follow-up examinations were performed 1 day and 1 month postoperatively. Complications and enhancements were noted. Outcome measures included postoperative uncorrected distance visual acuity (UDVA), refractive accuracy, and complications.

RESULTS

Eighteen residents performed FS-LASIK on a median of 8 eyes (interquartile range: 1.75). Fifty-nine patients (118 eyes) returned for a 1-month postoperative examination. UDVA was 20/40 or better in 117 eyes (99%) and 20/20 or better in 108 eyes (92%). The mean preoperative spherical equivalent (SE) refractive error was -4.01 ± 1.82 diopters (D) in 138 eyes, decreasing to -0.12 ± 0.35 D at 1 month after surgery in the 102 eyes that were refracted. The SE was ±1.00 D in 100 eyes (98%) and ±0.50 D in 94 eyes (93%). The CDVA change was within one line in 100% of eyes. Intraoperative complications occurred in 5 eyes (3.62%), enhancements were performed in 3 eyes (2.17%), and postoperative complications developed in 3 eyes (2.17%).

CONCLUSIONS

Resident-performed FS-LASIK is relatively safe and effective in comparison to published U.S. Food and Drug Administration premarket approval studies. Early resident experience performing LASIK can improve the training of ophthalmic surgeons while simultaneously increasing patient access to laser vision correction. [J Refract Surg. 2021;37(8):545-551.].

Resident surgical experience with lens and corneal refractive surgery: survey of the ASCRS Young Physicians and Residents Membership

A 43-question survey was e-mailed to all resident members of the American Society of Cataract and Refractive Surgery (ASCRS), ASCRS members in practice for 5 or fewer years, and residency program directors of 118 U.S. Accreditation Council for Graduate Medical Education-accredited ophthalmology programs (for distribution to their residents) in June 2010. Two hundred eighty-five of 2279 surveys sent were completed and returned, for a response rate of 12.5%. Most respondents (88.7%) had served as primary surgeon in more than 100 cataract surgeries. Fifty-two percent of respondents had not performed corneal relaxing incisions; 60% had no experience implanting a toric IOL. Twenty-two percent had experience implanting a presbyopia-correcting IOL. Over 75% had not performed any corneal refractive surgical procedures. Although basic cataract case numbers appear adequate, there are significant perceived deficiencies in current resident training models for surgical astigmatism management, implanting presbyopia-correcting IOLs, and corneal refractive surgery.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Resident laser refractive surgery training

PURPOSE OF REVIEW

The Residency Review Committee Ophthalmology of the Accreditation Council for Graduate Medical Education has recently established guidelines pertaining to the minimum operative requirements for training ophthalmology residents in refractive surgery. Despite being one of the most frequently performed ophthalmic surgical procedures, there is a paucity of literature on residency training in refractive surgery. Moreover, the literature indicates that only half of training programs offer surgical exposure to trainees. The purpose of this article is to review recent research on training ophthalmology residents in refractive surgery and offer an approach to incorporating laser refractive surgery curriculum in residency education.

RECENT FINDINGS

Kwon et al. performed a national survey to evaluate current trends in resident laser in-situ keratomileusis (LASIK) training in the USA. The result shows that 54% of respondents had resident-performed LASIK surgery with 9.1% of surveyed programs not offering any LASIK experience. In addition, residents in the study performed a mean of 4.4 LASIK surgeries (range 1-10) during residency training starting during the second year.

SUMMARY

The data emerging from the survey show that refractive surgery experience is fundamental to the education of the ophthalmology resident. Although the demand for refractive surgery continues to gain pace with millions of such procedures performed worldwide, only a little over half of ophthalmology residency programs offer residents the opportunity to gain surgical experience. With the current mandate, programs must now look for strategies to provide laser refractive surgical experience to residents.

Learning curve of laser-assisted subepithelial keratectomy

PURPOSE

To study the effect of the learning curve of laser-assisted subepithelial keratectomy (LASEK) on the visual and refractive results.

METHODS

This retrospective study comprised 56 eyes that had LASEK for myopia. The eyes were among the first 143 that had LASEK by the same surgeon with the same excimer laser and same nomogram. The 56 eyes were separated into 2 groups. Group 1 included the first 28 eyes to have LASEK by the surgeon. Group 2 comprised the last 28 eyes in the series whose refractive error could be matched with that in Group 1. The outcomes in the 2 groups were compared.

RESULTS

The mean preoperative spherical refraction was -3.90 diopters (D) +/- 1.90 (SD) in Group 1 and -3.70 +/- 2.53 D in Group 2 (P = .2). There were no significant differences in preoperative cylinder or best spectacle-corrected visual acuity (BSCVA) between groups. The postoperative uncorrected visual acuity (UCVA) was significantly worse in Group 1 on 1 day and 7 days postoperatively (P = .02 and P = .03, respectively); there was no significant difference at 1 month and 3 months. The safety index (postoperative BSCVA/preoperative BSCVA) and efficacy index (postoperative UCVA/preoperative BSCVA) were better in Group 2, although the difference was not statistically significant. The spherical refraction 3 months postoperatively was +0.50 +/- 0.83 D in Group 1 and +0.10 +/- 0.27 D in Group 2 (P = .02); 75.00% of eyes and 96.42% of eyes, respectively, were within +/-0.50 D of the intended correction (P = .01). Seven percent of eyes in Group 1 and no eye in Group 2 lost 2 or more lines of BSCVA.

CONCLUSIONS

Results indicate that the outcomes of LASEK depend on surgeon experience. Thus, caution is advised when interpreting LASEK results without knowing the surgeon's level of experience.

Results of resident-performed laser in situ keratomileusis

PURPOSE

To analyze the results of resident-performed laser in situ keratomileusis (LASIK).

SETTING

Rush University Medical Center, Department of Ophthalmology, Chicago, Illinois, USA.

METHODS

This retrospective study comprised 44 consecutive eyes of 22 patients who had LASIK performed from August 2000 through February 2002. Based on preoperative spherical equivalent, the eyes were divided into a low myopia group (A) (-1.0 to -6.0 diopter [D]) and a higher myopia group (B) (> -6.01 D). Preoperative and postoperative spherical equivalent (SE), best corrected visual acuity (BCVA), and uncorrected visual acuity (UCVA) were measured and analyzed within each group. Patients had at least 2 follow-up visits, with the second visit occurring between 1 and 9 months postoperatively.

RESULTS

Preoperatively, the mean SE in Group A was -3.93 D +/- 1.53 (SD) and in Group B, -8.49 +/- 1.70 D. At the final visit, the SE in Group A decreased to -0.29 +/- 0.55 D and in Group B, -1.09 +/- 0.87 D. The UCVA in Group A at the final visit was 20/20 or better in 43% of eyes and 20/40 or better in 100% of eyes. In Group B, the UCVA was 20/20 or better in 31% of eyes and 20/40 or better in 75% of eyes. In all eyes, the BCVA improved by 1 line in 16% or remained the same in 84%. No eyes lost any lines of BCVA. The SE taken at the last visit was within +/-0.5 D in 69% of all eyes and within +/-1.0 D in 82% of all eyes. The incidence of patients needing retreatment in resident-performed LASIK surgery was 3 of 44 (6.8%).

CONCLUSIONS

Laser in situ keratomileusis performed by residents is a safe and effective procedure for correction of refractive error. Postoperative UCVA, refractive error, retreatment rate, and loss of BCVA were consistent with published results from nonresident surgeons. These results also exceeded the U.S. Food and Drug Administration requirements for LASIK surgery.

The effect of corneal flap on optical aberrations

PURPOSE

To evaluate the changes in ocular aberrations induced by corneal flap creation.

DESIGN

Prospective interventional nonrandomized clinical trial.

METHODS

This study included 15 patients who were scheduled for laser in situ keratomileusis. A nasal hinge flap was created, using the Nidek MK-2000 microkeratome and then replaced without performing laser ablation. The ocular aberrations were measured before and after flap creation using the Nidek Optical Path Difference Scanning System ARK-10000.

RESULTS

The root mean square wavefront errors of the higher-order optical aberrations (third-, fourth-, fifth-, and sixth-order aberrations) were not significantly altered at 1 week postsurgery compared with the preoperative values (P >.35).

CONCLUSIONS

Creating a corneal flap with the Nidek MK-2000 microkeratome did not induce changes in higher-order optical aberrations as measured with the Nidek Optical Path Difference Scanning System ARK-10000 during the early postoperative period.

Update on laser subepithelial keratectomy (LASEK)

PURPOSE OF REVIEW

This study reviews current concepts in laser subepithelial keratectomy (LASEK), variations in LASEK techniques, the role of pharmacology in LASEK, and optimizing outcomes in LASEK.

RECENT FINDINGS

Recent studies continue to support the use of LASEK over that of LASIK in the correction of refractive error. In addition, the advent of pharmacological/biologic intervention, improved algorithms, and wavefront technology have expanded the armamentarium available to ophthalmologists in the maximization of LASEK outcomes.

SUMMARY

LASEK offers an excellent profile in terms of both final outcome (uncorrected visual acuity) and safety (best corrected visual acuity). Untoward effects of LASEK are readily prevented/treated with a variety of agents. Postoperative pain can be ameliorated using topical and oral analgesia. Infection can be most effectively addressed with the fourth generation of fluoroquinolones. Haze may be treated or prevented using numerous remedies namely autologous serum, steroids, ascorbic acid, mitomycin-c, and NSAIDS. Wavefront combined with LASEK rather than with LASIK may offer the best refractive outcome.

Outcomes of Laser in situ Keratomileusis in a Refractive Surgery Fellowship Program

PURPOSE

The purpose of this study was to document the learning curve and evaluate the success of laser in situ keratomileusis (LASIK) performed by fellows in a Cornea/External Disease and Refractive fellowship program.

METHODS

Two surgeons performed LASIK within a fellowship training program between July 2000 and August 2001. A retrospective review was conducted to determine the visual outcomes and operative complications from this non-comparative case series of 755 consecutive eyes. All LASIK procedures were performed using a Bausch & Lomb Technolas 217A laser and the Bausch & Lomb Hansatome or the Automated Corneal Shaper microkeratome. All eyes were evaluated for operative complications. Visual acuity was reported with a minimum of 1 month follow-up.

RESULTS

Data analysis revealed that uncorrected visual acuity of 20/40 or better was attained in 99.4% of treated eyes, and 20/20 or better in 77.2%. With both eyes open, 100% of patients saw 20/30 or better, 94% saw 20/20 or better, 70% saw 20/15 or better, and 5.5% saw 20/10. Flap related complications occurred in 7 of 755 eyes (0.9%) and all were successfully treated. Forty-two eyes (5.6%) were lost to follow-up prior to the 1-month examination and were excluded from analysis of visual acuity.

CONCLUSIONS

Favorable operative and visual acuity 1-month results in 755 eyes after LASIK with the Bausch & Lomb Technolas 217A laser were in part due to a well organized system of education, patient examination, execution of surgery, and postoperative care. A team approach was essential.

Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and photorefractive keratectomy surgery

PURPOSE

To identify physician predictors in LASIK and photorefractive keratectomy (PRK) surgery that correlate with a higher risk for malpractice liability claims and lawsuits.

DESIGN

Retrospective, longitudinal, cohort study.

PARTICIPANTS AND METHODS

A comparison of physician demographic and practice pattern data of 100 consecutive Ophthalmic Mutual Insurance Company (OMIC) LASIK and PRK claims and lawsuits with demographic and practice pattern data for all active refractive surgeons insured by OMIC between 1996 to 2002 was made. Background information and data were obtained from OMIC underwriting applications, a physician practice pattern survey, and claims file records. Using an outcome of whether or not a physician had a history of a claim or lawsuit, logistic regression analyses were used separately for each predictor as well as controlling for refractive surgery volume.

MAIN OUTCOME MEASURE

Malpractice claim or lawsuit for performance of PRK or LASIK surgery.

RESULTS

Logistic regression analysis demonstrated that the most important predictor of filing a claim was surgical volume, with those performing more surgery having a greater risk of incurring a claim (odds ratio [OR] = 31.4 for >1000 surgeries/year versus 0-20 surgeries/year, 95% confidence interval [CI] = 7.9-125, P = 0.0001). Having one or more prior claim was the only other predictor examined that remained statistically significant after controlling for patient volume (OR = 6.4, 95% CI = 2.5-16.4, P = 0.0001). Physician gender, advertising use, preoperative time spent with patient, and comanagement seemed to be strong predictors in multivariate analyses when surgical volume was greater than 100 cases per year.

CONCLUSION

The chances for incurring a malpractice claim or lawsuit for PRK or LASIK correlate significantly with higher surgical volume and a history of a claim or lawsuit. Additional risk factors that increase in importance with higher surgical volume include physician gender, advertising use, preoperative time spent with the patient, and comanagement with optometrists. These findings may be used in the future to help improve the quality of care for patients undergoing refractive surgery and to provide data for underwriting criteria and risk management protocols to manage proactively and perhaps reduce the risk for claims and lawsuits against refractive surgeons.

An outbreak of Mycobacterium chelonae infection after LASIK

OBJECTIVE

To describe an outbreak of mycobacterial keratitis after laser in situ keratomileusis (LASIK), including the microbiologic investigation, clinical findings, treatment response, and outcome.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Patients (n = 10) who underwent LASIK surgery between August 22 and September 4, 2000, and developed mycobacterial infection.

METHODS

Patients were prospectively followed in relation to microbiologic investigation, clinical findings, treatment response, and outcome.

MAIN OUTCOME MEASURES

Most patients underwent bilateral simultaneous LASIK. Postoperative infection was signaled by the appearance of corneal infiltrates in the third postoperative week. The microbiologic workup was performed on cultures obtained either by direct scraping of the cornea or by lifting the flap. Medical therapy was instituted based on drug susceptibility testing. Surgical interventions such as corneal debridement and flap removal were performed during recurrences or when there was no satisfactory clinical response.

RESULTS

Cultures revealed Mycobacterium subspecies chelonae. Patients were treated with topical clarithromycin (1%), tobramycin (1.4%), and ofloxacin (0.3%). Oral clarithromycin (500 mg twice a day) was prescribed for those patients who did not respond clinically to topical treatment. Four eyes healed on this regimen. Flap removal was necessary in seven eyes.

CONCLUSIONS

This report highlights mycobacteria as an etiologic infectious agent after LASIK. Diagnosis can be difficult and is often delayed. The treatment mainstay is prolonged antibiotic therapy. Surgical debridement and flap removal may shorten the disease course.

Decreased incidence of epithelial defects during laser in situ keratomileusis using intraoperative nonpreserved carboxymethylcellulose sodium 0.5% solution

PURPOSE

To evaluate the incidence of epithelial defects that occur with laser in situ keratomileusis (LASIK) using nonpreserved carboxymethylcellulose sodium 0.5% solution (Refresh Plus(R)) intraoperatively.

SETTING

Community-based refractive center.

METHODS

This retrospective study comprised 105 patients (210 eyes) who had primary bilateral LASIK by 1 of 2 surgeons between October 1 and December 1, 2000. The 114 eyes treated subsequent to November 1, 2000, received Refresh Plus intraoperatively, and the 96 eyes treated before this date did not. The incidence of epithelial defects and diffuse lamellar keratitis (DLK) in both groups was recorded. The preoperative keratometry measurements of all cases were also recorded.

RESULTS

There was a statistically significant decrease in the incidence of epithelial defects in the group that received Refresh Plus intraoperatively (P =.02). No statistically significant between-group difference in the incidence of DLK was detected. Analysis of the keratometry measurements revealed no statistically significant association between the amount or axis of astigmatism and the incidence of epithelial defects or DLK.

CONCLUSION

The intraoperative use of nonpreserved Refresh Plus significantly decreased the rate of epithelial defects that occurred during LASIK.