Despite these developments, these Despite in microkeratomes and the and microkeratomes in lasers femtosecond of development for flap creation have reduced surgical variability. regarding remains controversy most the and LASIK of limits the to technologies appropriate this In safety. corneal determine technology to image and analyze and image to technology being continually is cornea the improvements and upgraded, LASIK is the most widely known known LASIK is the most widely not always refractive procedure but the best choice. BY ALAN R. FAULKNER, MD; AND NEDA NIKPOOR, MD Fortunately, because LASIK because Fortunately, a large amount of data has been has data of amount large a Additionally, analyzed. and generated microkeratomes produced flaps with flaps produced microkeratomes deviations standard large relatively The diameter. and thickness in ectasia post-LASIK of appearance regarding concerns introduced safe for guidelines appropriate treatment. refractive main the remained has introduction, its since procedure | SEPTEMBER 2020

ince their introduction, cornealintroduction, their ince thebeen have procedures laser surgery.refractive of workhorse concerns1990s, late the In andtime, recovery pain, over

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IDENTIFYING LASIK CANDIDATES IDENTIFYING S CATARACT & REFRACTIVE SURGERY TODAY EUROPE

34 s WORDS MATTER CHOOSING A METHOD OF PRESBYOPIC CORRECTION IN PATIENTS WITHOUT VISUALLY SIGNIFICANT CATARACTS

BY DAN Z. REINSTEIN, MD, MA(CANTAB), FRCSC, DABO, FRCOPHTH, FEBO

Modern laser platforms can be used to treat nearly every monofocal IOLs that accommodate without decreasing contrast or increasing patient who walks through the door, including presbyopes.1-3 night vision disturbances. In the presence of a visually significant cataract, intraocular surgery is the only refractive surgical option, but I believe that corneal laser SAFETY AND GOOD RESULTS refractive surgery is safer for a patient with a clear lens. The outcomes that we can achieve with laser blended vision for Refractive lens exchange (RLE) is becoming more popular as a result of are equal to and generally better than the vast majority of reported RLE outcomes improvements in phacoemulsification, fluidics, and capsulotomy technology, but for , hyperopia, and .11,12 In our clinic 95% of myopic (up to safety remains my top priority. If it can be shown, for example by measuring the -8.50 D), 80% of hyperopic (up to +5.00 D), and 98% of emmetropic patients with optical scatter index on the HD Analyzer (Visiometrics), that a patient’s visual quality presbyopia end up with 20/20 at distance and can read newspaper print (J5) after remains high, then corneal laser surgery is the better, safer option. Presbyond LASIK (Carl Zeiss Meditec). In those same groups, 95%, 68%, and 96%, respectively, achieve 20/20 distance and J1 reading.13-15 MYTHS AND CONCERNS And these results are achieved without patients having to deal with There are several myths and inaccuracies in the information provided to patients glare and halos at night or worry about the other risks associated with RLE. regarding RLE. 1. Reinstein DZ, Carp GI, Lewis TA, Archer TJ, Gobbe M. Outcomes for myopic LASIK with the MEL 90 excimer laser. J Refract Surg. Myth No. 1: RLE provides permanent vision correction. Actually, the cornea is 2015;31:316-321. reshaped continuously after 40 years of age, and this change in cylinder will affect 2. Pradhan KR, Reinstein DZ, Carp GI, Archer TJ, Gobbe M, Dhungana P. Quality control outcomes analysis of small-incision 4,5 lenticule extraction for myopia by a novice surgeon at the first refractive surgery unit in Nepal during the first 2 years of opera- the prescription in about one-third of all patients. Therefore, although the lens tion. J Cataract Refract Surg. 2016;42:267-274. replacement itself is permanent, the procedure should not be sold as a permanent 3. Reinstein DZ, Carp GI, Archer TJ, et al. Long-term visual and refractive outcomes after LASIK for high myopia and from -8.00 to -14.25 D. J Refract Surg. 2016;32:290-297. correction of vision. 4. Ueno Y, Hiraoka T, Beheregaray S, Miyazaki M, Ito M, Oshika T. Age-related changes in anterior, posterior, and total corneal Myth No. 2: Everyone will develop a cataract, so replacing a clear natural astigmatism. J Refract Surg. 2014;30:192-197. 5. Hashemi H, Asgari S, Emamian MH, Mehravaran S, Fotouhi A. Age-related changes in corneal curvature and shape: The lens will prevent cataracts. In the United Kingdom, only 30% of the predominantly Shahroud Eye Cohort Study. Cornea. 2015;34:1456-1458. 6. Minassian DC, Reidy A, Desai P, Farrow S, Vafidis G, Minassian A. The deficit in in England and Wales and the escalating Anglo-Saxon population will develop a visually significant cataract requiring problem of visual impairment: epidemiological modelling of the population dynamics of cataract. Br J Ophthalmol. 2000;84:4-8. surgery.6 On the other hand, with laser refractive surgery, enhancements are 7. Ling R, Cole M, James C, Kamalarajah S, Foot B, Shaw S. Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes. Br J Ophthalmol. 2004;88:478-480. possible for most patients on an ongoing basis to keep vision optimized and patients 8. Day AC, Donachie PH, Sparrow JM, Johnston RL. The Royal College of Ophthalmologists’ National Ophthalmology Database out of spectacles until the day that a cataract develops. study of cataract surgery: report 1, visual outcomes and complications. Eye (Lond). 2015;29:552-560. 9. Daien V, Korobelnik JF, Delcourt C, et al. French Medical-Administrative Database for Epidemiology and Safety in Ophthalmol- Another issue in the choice of refractive surgical approach is the risk of visually ogy (EPISAFE): The EPISAFE Collaboration Program in Cataract Surgery. Ophthalmic Res. 2017;58:67-73. significant complications with phaco surgery compared to that with laser corneal 10. Clark A, Morlet N, Ng JQ, Preen DB, Semmens JB. Risk for retinal detachment after phacoemulsification: a whole-population study of cataract surgery outcomes. Arch Ophthalmol. 2012;130:882-888. refractive surgery. It is intuitive to most lay people that going inside the eye to 11. Power B, Murphy R, Leccisotti A, Moore T, Power W, O’Brien P. Maximising refractive outcomes with an extended depth of replace a lens that is still transmitting light (ie, no cataract) is more invasive than focus IOL. Open Ophthalmol J. 2018;12:273-280. 12. Chang JS, Ng JC, Chan VK, Law AK. Visual outcomes and patient satisfaction after refractive lens exchange with a single-piece performing an extraocular laser procedure on the surface of the eye; nonetheless, diffractive multifocal intraocular lens. J Ophthalmol. 2014;2014:458296. 13. Reinstein DZ, Archer TJ, Gobbe M. LASIK for myopic astigmatism and presbyopia using non-linear aspheric micro-monovi- this point is often overlooked or minimized by the surgeon. Catastrophic risks sion with the Carl Zeiss Meditec MEL 80 Platform. J Refract Surg. 2011;27:23-37. such as major bleeding or infection are rare.7,8 However, RLE patients are generally 14. Reinstein DZ, Carp GI, Archer TJ, Gobbe M. LASIK for the correction of presbyopia in emmetropic patients using aspheric abla- tion profiles and a micro-monovision protocol with the Carl Zeiss Meditec MEL80 and VisuMax. J Refract Surg. 2012;28:531-541. younger than patients undergoing cataract surgery, so the former must understand 15. Reinstein DZ, Couch DG, Archer TJ. LASIK for hyperopic astigmatism and presbyopia using micro-monovision with the Carl that they have a higher risk for retinal detachment and cystoid macular edema Zeiss Meditec MEL80. J Refract Surg. 2009;25:37-58. as a result of an attached vitreous. Two large national studies concluded that the risk for retinal detachment after lens surgery is highest for patients younger than 60 years of age, and the risk increases by a factor of 20 for a 50-year-old compared DAN Z. REINSTEIN, MD, MA(CANTAB), FRCSC, DABO, FRCOPHTH, FEBO to an 80-year-old.9,10 n Private practice, London Vision Clinic, London Finally, one must consider evolving IOL technology. Although current n Department of Ophthalmology, Columbia University Medical Center, New York presbyopia-correcting IOL technology is very good, there are still limitations, n Sorbonne Université, Paris including decreased contrast sensitivity and an increase in glare and halo at n Biomedical Science Research Institute, Ulster University, Coleraine, United Kingdom night. For patients with already decreased contrast and night vision disturbances n [email protected] due to cataract, these are reasonable side effects. But there will probably n Financial disclosure: Consultant (Carl Zeiss Meditec); Financial interest in Artemis be much better IOL options available in the next 10 to 20 years in the form of Insight 100 VHF digital ultrasound (ArcScan)

SEPTEMBER 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 35 .) We .)

Choosing a Method of Presbyopic Presbyopic of Method a Choosing For younger hyperopes, we are we hyperopes, younger For have patterns ablation Numerous Treatment of hyperopia depends hyperopia of Treatment or blended vision. (Editor’s note: (Editor’s vision. blended or vision, blended laser on more For see Without Patients in Correction Cataracts Significan Visually target myopic a using favor to tend usually D, -1.75 to -1.50 to up of on based eye, nondominant the in and demonstration preoperative LASIK, patients can end up with a with up end can patients LASIK, be can that cornea hyperprolate multifocality. for unsuitable optically for RLE prefer we reasons, these For presbyopic the in patients hyperopic range. age up hyperopia treating comfortable from comfortable less and D, 3.00 to to up treated have We D. 4.00 to 3.00 most the of Some rarely. but D, 6.00 were had have we patients successful mixed with and hyperopic highly the to up treat we which cylinders, we Although range. approved full flattest or minimum a have not do myopic with value (K) keratometry no K’s max keep to prefer we LASIK, after D 50.00 to 48.00 than steeper LASIK. hyperopic PRESBYOPIA of treatment the for proposed been any been have none but presbyopia, monovision than successful more significantly on age for a number of number a for age on significantly myopes, to contrast in First, reasons. progression, undergo hyperopes postpresbyopic the in especially hyperopic after Second, years. Up to -8.00 D Up to 6.00 D cylinder no steeper than Up to 3.00 D** (max keratometry 48.00 to 50.00 D) Up to -1.50 to -1.75 D Monovision, Near Eye Target - ICL 1,2 3,4 TABLE. IDEAL LASIK TREATMENT RANGE USED AT ALOHA LASER VISION RANGE USED AT ALOHA LASIK TREATMENT TABLE. IDEAL We are comfortable treating regulartreating comfortable are We Many surgeons advocate advocate surgeons Many In our opinion, a comfortable comfortable a opinion, our In Myopia Hyperopia/ Regular Astigmatism in Myopia or Mixed Astigmatism Hyperopia Presbyopia distance OU or refractive lens exchange OU treatment of more than +3.00 D in either eye, including near correction, LASIK **In presbyopic hyperopes who require are preferred on some laser platforms, increasing theincreasing platforms, laser some on aberrations. and glare induced of risks preferred ICL over LASIK. over ICL preferred be to found also was implantation patients for LVC than stable more myopia, extreme and high with of results the with consistent is which studies. previous D6.00 approved the to up astigmatism Certainly,myopia. and hyperopia both in morethe cylinder, the higher the desiredthe obtain to is it challenging ablationscylinder Higher outcome. zoneoptical effective reduced a in result performing PRK in patients with thin thin with patients in PRK performing LASIK, for range the outside corneas cautiously, done be should this but Hawaii) (like areas sunny in especially postoperative of risk higher a with the favor to tend we Therefore, haze. corrections high for PRK over ICL abnormal or thin with eyes in a including studies, Several corneas. conducted study eye contralateral myopia with that, showed ago, years patients D, -8.00 or -6.00 than greater range of myopia correction with with correction myopia of range Above D. -8.00 to up is LASIK lens-based favor to tend we that, as such IOL phakic procedures—a Surgical) (STAAR ICL Visian EVO the lens refractive or patients young in the in patients for (RLE) exchange Although range. age presbyopia as great as myopia treated have we treat these LASIK, with D -12.00 a have and predictable less are ments effects. side of incidence higher | SEPTEMBER 2020

Depending on the platform, in the in platform, the on Depending Although each element in element each Although We consider it essential to review essentialto it consider We Every patient we see for a refractive a for see we patient Every Depending on the applied treatment treatment applied the on Depending platform), laser the (ie, pattern those of extremes the at treatment aberrations, more induce may ranges and (DED), disease eye dry more dysphotopsias.more United States, current approvals for for approvals current States, United myopia of treatment allow LASIK to up astigmatism D, -12.00 to up D. 6.00 to up hyperopia and D, 6.00 primarily based is experience Our treatments. wavefront-optimized on every patient, we find that each that find we patient, every information valuable provides one certain in and patients certain for dilemmas. diagnostic RANGE OF TREATMENT corneal scars, we obtain epithelial obtain we scars, corneal anterior or mapping thickness OCT. segment imaging diagnostic of array this in essential be not may devices aberrometry and LipiScan dynamic LipiScan and aberrometry & (Johnson imaging meibomian patient, every on Vision) Johnson Analyzer HD the use we and than older patients in (Visiometrics) or corneas suspicious For years. 45 younger patients. younger corneal posterior and anterior the examine We topography. Ectasia Enhanced Belin/Ambrósio (Oculus Pentacam the on Display corneal perform We Optikgeräte). about hobbies, lifestyle, and visual and lifestyle, hobbies, about medical patients’ obtain We goals. perform and history eye and undilated an and testing diagnostic about inquire We exam. eye for especially stability, refractive to identify appropriate candidates appropriate identify to LASIK. for PATIENT WORKUP thorough a has screening surgery discussion a of consisting workup article, we outline the guidelines guidelines the outline we article, Hawaii in practice our at use we CATARACT & REFRACTIVE SURGERY TODAY EUROPE

36 s WORDS MATTER WORDS MATTER s

refinement. We find that monovision the risk of keratoconus.7 Although LASIK surgery. In that database, is better tolerated and longer lasting there is no evidence that the 250-µm only seven cases of ectasia had in myopes than in hyperopes. limit suggested by the US FDA is developed.11 In hyperopic presbyopes, we favor not adequate, many surgeons try to Although we try to respect RLE with trifocal IOLs as a definitive maintain 300 µm as the minimum the PTA and RST safety margins, treatment of both residual bed thickness. Many these numbers are guides and data and presbyopia. The Light Adjustable surgeons also limit LASIK to patients points to be used in combination Lens (RxSight) and other lens with preoperative corneal thickness with other factors. In our opinion, combinations, including monovision greater than 500 µm, but studies careful assessment of the cornea is corrections, can also be successfully have not supported increased risk the most important risk factor for used with RLE. based on this alone. One study avoiding ectasia. For patients with Although we sometimes correct found LASIK in corneas below mildly irregular topographies, we are only one eye in a monovision 500 µm to be safe.8 comfortable performing PRK. For true patient, it is important that the It is important to remember that keratoconus, we recommend CXL distance eye have excellent UCVA. these cutoff values assume that followed by ICL implantation or PRK. Poor distance UCVA is a common the cornea in question is normal, Studies have shown that PRK may be reason patients are dissatisfied with without preexisting keratoconus, safe in keratoconus.12 monovision. This requires treating as most instances of post-LASIK any hyperopia in the distance vision ectasia are now thought to be FURTHER SCREENINGS eye, even if the uncorrected vision is due to progression of preexisting All potential LASIK patients should good, because any keratoconus. Because the two be screened for DED and meibomian of the distance eye also affects the main risk factors for ectasia are gland dysfunction (MGD). Patients near vision eye. preexisting keratoconus and removal with DED secondary to systemic of excess tissue, it is worthwhile to disease should be assessed carefully SCREENING AND DETERMINING consider RST and PTA as additional and are more concerning. The CANDIDACY data points in assessing a patient’s majority of DED in potential LASIK Determining corneal health for candidacy for LASIK. These cutoff patients, however, is MGD or limbal LASIK remains an area of great values, however, should not be stem cell deficiency caused by contact challenge and controversy. Because taken as absolutes to be used lens wear. infections and severe inflammation in isolation. Demonstration of changes in after LASIK are exceedingly rare, the Based on a 2014 analysis, Santhiago the meibomian glands via imaging most feared complication today is and colleagues stated that, of the greatly assists in counseling patients corneal ectasia. risk factors they considered, a PTA regarding the risk of postoperative Numerous technologies and of 40% or more carried the greatest symptoms. We often explain analytical programs have been risk of post-LASIK ectasia (odds ratio, to patients with postoperative developed to identify corneas at 223).9 In such cases, those authors symptoms of dryness that they risk for ectasia. Nonetheless, careful said, they perform PRK. However, are recovering from both the evaluation of corneal tomography, other studies have failed to validate LASIK procedure and their contact looking at both the anterior and these results. lens wear. posterior corneal surfaces, is still the Relying on Randleman’s ectasia most accepted screening method score10 or using PTA or RST cutoffs OTHER ISSUES for signs of ectasia. There are some alone would have disqualified Breastfeeding. Breastfeeding proponents of epithelial mapping5 many patients who have had and pregnancy can cause refractive and ocular hysteresis measurement,6 LASIK successfully in the past, at instability and worsened DED and there are some data to support our practice and those of other symptoms. We do not perform LASIK these measures, but neither is in well-respected refractive surgeons. in pregnant women but will do so widespread use at this time. For instance, Reinstein and during breastfeeding if the patient Opinions and practice patterns colleagues performed a retrospective did not have refractive changes vary, but it is widely believed that analysis of more than 15,000 patients during pregnancy. Precautions such as maintaining a residual stromal treated since 2002. If they had encouraging the patient to pump and thickness (RST) of more than 250 µm applied 40% PTA as a cutoff, they dump their breastmilk or to avoid and percentage of tissue altered determined, 26.5% of their total oral anxiolytics may be needed in (PTA) of less than 40% can reduce database would have been denied these cases.

SEPTEMBER 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 37 . - - - - -

Curr Curr - Cornea. Cornea. J Cataract Refract J Cataract Refract n . 2008;115:37-50. J Cataract Refract Surg 2010;36:153-160. Acta Ophthalmol. 2007;144(2):181-185.

2014;158(1):87-95.e1. 2009;148:164-170.e1. May 2018. . 2011;27(7):473-481. . 2011;27(7):473-481. 2012;6:1827-1837. 2012;6:1827-1837. Ophthalmology Am J Ophthalmol. Am J Ophthalmol. Eyeworld. Am J Ophthalmol. J Cataract Refract Surg. J Refract Surg Clin Ophthalmol. 2013;6(1):12-17. 2013;6(1):12-17. 2017;28(4):337-342. 2017;28(4):337-342. 2013;39(1):66-73. 2013;39(1):66-73. Cataract, cornea, and refractive surgeon, Aloha Cataract, cornea, and refractive surgeon, Aloha [email protected] Financial disclosure: Consultant (Johnson & Founder and Physician CEO, Aloha Laser Vision, Founder and Physician CEO, Aloha Laser Vision, [email protected] Financial disclosure: Consultant (Alcon, Bausch Speaker (Bausch + Lomb) Laser Vision, Honolulu, Hawaii Johnson Vision); Speaker (Ziemer) Honolulu, Hawaii + Lomb); Research (Refocus, STAAR Surgical);     perform the surgeries themselves. themselves. surgeries the perform outlined guidelines the hope We right the make to you help will here patients your for recommendations correction. vision seeking Phakic intraocular lens implantation 1. Parkhurst GD, Psolka M, Kezirian GM. retrospective analysis of early clinical in United States military warfighters: A outcomes of the Visian ICL. 6. Moshirfar M, Edmonds JN, Behunin NL, Christiansen SM. Corneal bio mechanics in iatrogenic ectasia and keratoconus: A review of the literature. Oman J Ophthalmol. 7. Giri P, Azar DT. Risk profiles of ectasia after keratorefractive surgery. Opin Ophthalmol. 8. Kymionis GD, Bouzoukis D, Diakonis V, et al. Long-term results of thin cor neas after refractive laser surgery. 9. Santhiago MR, Smadja D, Gomes BF, et al. Association between the per cent tissue altered and post-laser in situ keratomileusis ectasia in eyes with normal preoperative topography. 2. Chen X, Guo L, Han T, Wu L, Wang X, Zhou X. Contralateral eye com 2. Chen X, Guo L, Han T, Wu L, Wang X, stability between implantable visual quality and parison of the long‐term for myopia. collamer lens and laser refractive surgery 2019;97:e471-e478. M. Visual performance after 3. Igarashi A, Kamiya K, Shimizu K, Komatsu laser in situ and wavefront‐guided implantable collamer lens implantation keratomileusis for high myopia. implantable collamer lens (ICL) 4. Sanders D, Vukich JA. Comparison of and laser-assisted in situ keratomileusis (LASIK) for low myopia. 2006;25:1139-1146. 5. Schallhorn JM, Tang M, Li Y, Louie DJ, Chamberlain W, Huang D. Distin guishing between warpage and ectasia: Usefulness of optical coherence tomography epithelial thickness mapping. 2017;43(1):60-66. NEDA NIKPOOR, MD n n n 10. Randleman JB, Woodward M, Lynn MJ, Stulting RD. Risk assessment for 10. Randleman JB, Woodward M, Lynn MJ, Stulting RD. Risk assessment for ectasia after corneal refractive surgery. 11. Hillman L. Presentation spotlight: Considering percent tissue altered as a risk factor for post-LASIK ectasia. 12. Guedj M, Saad A, Audureau E, Gatinel D. Photorefractive keratectomy in patients with suspected keratoconus: five-year follow-up. Surg. 13. Simpson RG, Moshirfar M, Edmonds JN, Christiansen SM, Behunin N. Laser in situ keratomileusis in patients with collagen vascular disease: a review of the literature. 14. Aref AA, Scott IU, Zerfoss EL, Kunselman MA. Refractive surgical prac tices in persons with human immunodeficiency virus positivity or acquired immune deficiency syndrome. ALAN R. FAULKNER, MD n n n There are many fantastic many are There In our practice, we have found that, found have we practice, our In Asking about occupation and occupation about Asking commonly most the is LASIK At our practice in Hawaii, we ask ask we Hawaii, in practice our At more nuanced, than learning to learning than nuanced, more proposing an alternative procedure— alternative an proposing patient a in ICL or PRK example for cornea—patients abnormal an with even and accepting generally are their prioritize we that appreciative convenience. over safety vision. correcting for procedures to is surgeons refractive as goal Our correcting by happy patients make the Choosing safely. vision their patient right the for procedure right and challenging, more arguably is procedure in the United States. United the in procedure refractive our of most that Given in come patients screening surgical all almost that and LASIK, seeking patient, LASIK happy a known have to try to us for tendency a is there them qualifying by patients satisfy being That candidates. LASIK as when times are there however, said, procedures correction vision other better. are for rationale the explain we when any flap injuries or infections. or injuries flap any insights provides also vocation may and activities patients’ into refractive of choice your influence potential to clues furnish and target as such issues postoperative other or use screen prolonged issues. environmental CONCLUSION correction vision performed Patients with a higher risk of direct of risk higher a with Patients the of are cornea the to trauma this Specifically, concern. greatest and artists martial most includes concern of sports Other fighters. those and basketball include injuries eye finger-induced which in common. are the of out remain to patients our the Despite week. 1 only for water seen not have we surfing, of extremes | SEPTEMBER 2020

Both Determining Of course, Of 13,14 Patients’ use of use Patients’ Patients should be should Patients Diabetes can cause can Diabetes Occupational issues. Occupational issues. Isotretinoin. Isotretinoin. Glaucoma. Diabetes. Diabetes. Autoimmune disease. disease. Autoimmune LASIK—if at all. at LASIK—if and occupation patient’s the important an is activities vocational assessment. preoperative the of part isotretinoin for treatment of acne can acne of treatment for isotretinoin postoperative worsen significantly least at wait to prefer We DED. this of discontinuation after year 1 considering before medication brief IOP rise during femtosecond femtosecond during rise IOP brief eliminates and creation flap laser syndrome. fluid interface of risk the patients most speaking, Practically have can and older are glaucoma with lens-based with corrected vision their procedures. testing, IOP is not the only data only the not is IOP testing, refractive Many involved. point PRK or LASIK perform will surgeons thorough a after patients glaucoma in argue Some risks. the of discussion the avoids it because safer is PRK that informed that any corneal refractive corneal any that informed measuring make could procedure However, challenging. more IOP their following and diagnosing that given diagnostic other requires glaucoma refractive instability, but, in our in but, instability, refractive has healing wound experience, patients in issue an been not For diabetes. well-controlled with autoimmune either with those LASIK prefer we diabetes, or disease PRK. over This has been our experience experience our been has This other by reported been has and surgeons. refractive must consent informed proper obtained. be autoimmune and immunodeficiency immunodeficiency and autoimmune contraindications as conditions may LASIK However, LASIK. for patients in safe reasonably be inactive or well-controlled with who HIV or disease autoimmune candidates. good otherwise are the AAO and the US FDA cite FDA US the and AAO the CATARACT & REFRACTIVE SURGERY TODAY EUROPE

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