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Home , Keratomileusis, Myopia, Radial keratotomy, Refractive surgery, Retinal detachment, Vitrectomy

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RETINA TODAY after LASIK. occur after refractive , with an emphasis on RD irregular . membrane, hole, retinal hemorrhage, tear, epithelial ingrowth, undercorrection and overcorrection, LASIK that have been reported include , to moderate worldwide. one of the most popular options for the correction of low corneal . Rodriguez et al, cal and clinical rhegmatogenous RD (RRD), or both after either or symptomatic retinal breaks, subclini and Ripandelli et al lar (Ophtec, 0%). (ICL; Staar Surgical, 0.7%) or an Artisan -fixated intraocu after implantation of a Visian implantable collamer lens recent series demonstrated much lower incidences of RD lens for the correction of severe myopia. Our own most after implantation of a phakic anterior chamber intraocular . after implantation of phakic anterior chamber intraocular clinically controlled study to investigate the rate of RD exchange for myopia correction. BY J.FERNANDOAREVALO,MD,FACS indicated incandidatesforrefractivesurgery. With currentknowledge,wecannotdeterminewhetherprophylactictreatmentis SURGERY REFRACTIVE DETACHMENTAFTER RETINALMANAGING This report reviews retinal complications that may -assisted in situ (LASIK) has become Ruiz-Moreno and associates reported the results of a

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22 APRIL RD, 9 serous macular detachment, In that report, there was a 4.8% incidence of RD 19 2017 21 retinal phlebitis, reactivation of ocular toxoplasmosis, reported on 14 (12 patients) that had reported on 14 eyes (12 patients) that had . Rodriguez and Camacho described (RD) after et al, ety of complications (Figures 1 - 4). correcting ametropias, but it can lead to a vari Refractive surgery has become popular for 2 Sanders et al, 8 15 have described RDs after refractive lens have described RDs after refractive lens 21 flap melting, macular hemorrhage, 36 20 corneoscleral perforation, 3 10,11,35 and Feldman et al 16 23 , 13 choroidal neovascular Complications of flap displacement, 6 Barraquer et al, 35 17 macular retinal 1-35 Hofman Hofman 24 4 have have and 5 21

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RD AFTERLASIK of 20/45 after retinal repair surgery. dence of 0.25% in myopic eyes after LASIK and mean BCVA 0.082%, correction of myopia. and associates reported a case of RRD after LASIK for the RD associated with giant retinal tear after LASIK. after LASIK. A number of studies have described the occurrence of RD A number of studies have described the occurrence of RD • • • myopic pathology can determinewhethertheprocedure exacerbates and onlycareful,large,prospective studiesinpatients Vitreoretinal complicationsinthese eyeswilloccur, corrects onlytherefractiveaspect ofmyopia. It isveryimportanttoinformpatientsthatLASIK change theshapeorlengthofglobe. appropriate becausetheseprocedurestendnotto without ascleralbandbeperformedwhen retinopexy, pneumaticretinopexy, orvitrectomy results, theauthorsuggeststhatcryopexy, argonlaser corneal shape,thusdamagingtherefractivesurgeon’s Because vitreoretinalsurgerycauseschangesin have beenassociatedwiththeprocedure. moderate myopia, varioustypesofcomplications popular optionsforthecorrectionoflowto Although LASIKhasbecomeoneofthemost 27 and Ruiz-Moreno and coworkers reported an inci 18,25,26 AT A Ozdamar et al reported a case of bilateral Ozdamar et al reported a case of bilateral 26 Faghihi et al reported an incidence of Faghihi et al reported an incidence of . GLANCE 19 Aras et al described Aras et al described 25 Stulting Stulting - GLOBAL PERSPECTIVES

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2017 APRIL days (range, 7 days to 3 months)3 to days 7 (range, days This finding may be explained be may finding This 3 This number is much lower than the incidence of incidence the than lower much is number This 33 The average age in the 19 patients with RRD after LASIKafter RRD with patients 19 the in age average The linesmore or 2 by improved surgery after BCVA Final in LASIK after pathology vitreoretinal of incidence The Figure 2. Postoperative photo of a myopic that eye myopic a of photo fundus Postoperative 2. Figure and LASIK. after PVR with RRD an developed performed. successfully were injection oil silicone 0.02%). general. in myopes in RRD institu the in patients surgery refractive that fact the by examinations preoperative underwent involved tions with funduscopy indirect dilated thorough very a including retinal peripheral any of treatment and depression scleral before RRD an of development the for predisposing lesion flap degeneration, lattice extensive study, this In LASIK. prophylactically were tufts retinal and holes, atrophic tears, funduscopy with scleral depression and treatment of anyof treatment and depression scleral with funduscopy RRD. an of development the to predisposing lesion retinal thisIn male. were (54.5%) 12 and years, 22-70) (range, 41.8 was lesionspredisposingretinal of treatment required 1.5% series, afterRRD an developed who patients no but LASIK, before peripheralof treatment prophylactic previous had had LASIK surgeryocular any of history a had patient No lesions. retinal cryoretino vitrectomy, with managed were RDs LASIK. after pneumaticand retinopexy, laser argon buckling, scleral pexy, wasLASIK after RRD repair to surgery Vitreoretinal retinopexy. 34.8 of mean a at performed afterfollow-up mean The symptoms. visual of onset the after years). 12 to month 1 (range, years 8.7 surgerywas retinal acu visual Poor eyes. of 57.1% in preoperative from forReasons eyes. of 31.8% in occurred worse) or (20/200 ity myopic membrane, epiretinal included acuity visual poor vitreoretinopa proliferative of development , oneafter success Anatomic atrophy. optic and (PVR), thy 100%. was surgery CAN WE PREDICT RETINAL COMPLICATIONS? incidence (annual 0.19% to 0.05% from ranged study our -

- 1 - 28 32 30 29 RD occurred at a meana at occurred RD 31 Patients were scheduled to be seen onseen be to scheduled were Patients The incidence of RRD after LASIK in ourin LASIK after RRD of incidence The 33 21 Patients underwent surgical correction of myopiaof correction surgical underwent Patients 33 In our 10-year follow-up study including a total of 11,594of total a including study follow-up 10-year our In Ruiz-Moreno et al studied the incidence of retinal diseaseretinal of incidence the studied al et Ruiz-Moreno No causal relationship between LASIK and RD can becan RD and LASIK between relationship causal No Figure 1. Fundus photo of a subtotal superotemporal andsuperotemporal subtotal a of photo Fundus 1. Figure LASIK.after RD macula-on nasal Preoperative examinations included a thorough dilatedthorough a included examinations Preoperative after. The clinical findings, frequency of RRD after LASIK,after RRD of frequency findings, clinical The after. sur and drawings), fundus of (evaluations characteristics report.that in presented were eyes 22 of outcomes gical frequency of RRD was 0.05% at 1 year, 0.15% at 5 years, andyears, 5 at 0.15% year, 1 at 0.05% was RRD of frequency years. 10 at 0.19% there yearly and months, 12 and 3 at 1, day postoperative LASIK. betweenoccurred RRD D). -4.50 (mean D -10.00 to -1.50 of LASIK,after months) 31.6 (mean years 13 and month 1 Theintervals. follow-up longer at frequency increasing with previous studies ranges between 0.04% and 0.05%. and 0.04% between ranges studies previous afterRRD an developed patients) (19 eyes 22 patients, and hyperopia. The incidence of vitreoretinal pathologyvitreoretinal of incidence The hyperopia. and RRDs14 including 0.06%, was study our in months 24 at 2). and 1 (Figures 24.6 ±20.4 months after LASIK in 11 eyes (0.36%). We have We (0.36%). eyes 11 in LASIK after months ±20.4 24.6 eyes29,916 including study 2-year a reported previously myopia both ametropias, of correction the for LASIK after observed in 9,239 consecutive eyes of 5,099 patients afterpatients 5,099 of eyes consecutive 9,239 in observed LASIK. including surgery, refractive particularly in highly myopic eyes. In myopic eyes, the yearlythe eyes, myopic In eyes. myopic highly in particularly to0.015% from range to estimated been has RD of incidence lique vitreous premature to related be to thought 0.075%, detachment. vitreous posterior early and faction LASIK surgery in a patient with -13 D of myopia. of D -13 with patient a in surgery LASIK RD,with associated be may LASIK studies. these from stated within 3 months of LASIK for correction of high myopia. high of correction for LASIK of months 3 within RDinferior an of development the details report case One afterhours 14 diagnosed tears horseshoe inferior two to due 10 RDs in myopic eyes after LASIK, an incidence of 0.22%. of incidence an LASIK, after eyes myopic in RDs 10 RRDhad that eyes four on reported colleagues and Farah GLOBAL PERSPECTIVES 38

RETINA TODAY they undergo LASIK; given the potential of the procedure to they undergo LASIK; given the potential of the procedure to could argue that this is prudent in myopes whether or not that requires treatment before LASIK is performed. One pupillary dilatation to detect any myopic peripheral lesion with indirect and scleral depression under gest that patients scheduled for LASIK be carefully examined preoperative evaluation for LASIK. Most practitioners sug should be treated differently from standard practice in a to scientifically determine whether peripheral retinal lesions didates for refractive surgery. At this time, it is not possible prophylactic treatment is indicated in patients who are can of post-LASIK vitreoretinal complications. pathology before LASIK does not guarantee the prevention ever they also noted, prophylactic treatment of vitreoretinal with pre-LASIK vitreoretinal pathology (lattice, breaks); how lesions (breaks, RDs) that may develop in highly myopic eyes might help predict locations of certain post-LASIK retinal sustained ocular trauma 19 months after LASIK. developed RRD except one patient without retinal breaks who During a mean 19-month follow-up, none of the patients were identified and treated in 39 eyes (2%) of 32 patients (3%). breaks in myopic patients undergoing LASIK. cy and safety of prophylactic laser photocoagulation for retinal and that no RD is present. exoplants early, after ensuring that all breaks have sealed in case of scleral buckling procedures is to remove the change the shape or length of the . Another option performed when appropriate because they tend not to matic retinopexy, or vitrectomy without a scleral band be We suggest that cryopexy, argon laser retinopexy, pneu neal shape, thus damaging the refractive surgeon’s results. by the fact that vitreoretinal surgery causes changes in cor treated regardless of symptoms. Such indication is justified Based on published data, we cannot determine whether Based on published data, we cannot determine whether Chan et al Lin and Tseng recently published a study assessing the effica “

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APRIL differently from standard lesions should treatedbe whether peripheral retinal to scientifically determine At this time, it is not possible evaluation for LASIK. in a preoperativepractice 2017 34 suggested that pre-LASIK retinal examination suggested that pre-LASIK retinal examination 18 Retinal breaks Retinal breaks ------the duration of follow-up. In our 10-year follow-up study, the duration of follow-up. In our 10-year follow-up study, when we evaluate our state of knowledge in this area is such pathology more aggressively. exacerbate preexisting pathology, it might be wise to treat LASIK. Patients with high myopia and lacquer cracks in the ophthalmologists may be unaware of this. the current practice patterns of shorter periods of follow-up, and other vitreoretinal problems. It is equally likely that, with years, these patients might have a higher incidence of RDs might accelerate vitreous liquefaction and that, over the incidence of 0.02%. It is possible that LASIK-induced trauma the incidence of RRD increased with time, with an annual atrophy and choroidal backscatter (B). High reflectivity of the RPE-choriocapillaris complex is due to are seen (A). OCT image shows features of RD and . pic chorioretinal and retinal pigment epithelium (RPE) atrophy and BCVA of counting fingers. Posterior and myo (arrow) associated with an RD localized to the posterior fundus Figure 4. shows a stage 4 macular hole of staining and no leakage (B). treatment, the CNV was totally closed with a small central area intravitreal (Avastin, Genentech) injection. After (A). The CNV was treated with one Figure 3. Subfoveal CNV after LASIK was diagnosed with Another important factor to take into consideration Another important factor to take into consideration Macular diseases may be a relative contraindication to B A A B - GLOBAL PERSPECTIVES 40

RETINA TODAY reoretinal specialist. pic degeneration, , or delayed referral to a vit optic atrophy. Final may be limited by myo of , PVR, myopic maculopathy, and sons for poor visual acuity included the development Despite high anatomic success with one surgery, rea may not be as good as expected after RRD surgery. pathologic changes in the myopic eye. to determine whether the LASIK procedure can exacerbate sibly photography and angiography of the macular region indirect ophthalmoscopy with scleral depression, and pos determination of risk factors, echography of the vitreous, formed using careful prospective examinations including exacerbates myopic pathology. Such studies must be per studies in patients can determine whether the procedure these eyes will occur, and only careful, large, prospective refractive aspect of myopia. Vitreoretinal complications in important to inform patients that LASIK corrects only the CONCLUSIONS is aware of and accepts his or her visual acuity limitations. depending on the refractive surgeon’s criteria, if the patient stable macular disease (scars), LASIK may be performed, contraindicated for LASIK. On the other hand, in eyes with of needing vitreoretinal surgery in the future are relatively terior pole during LASIK. In addition, eyes that are at risk 1 macular holes may progress due to traction in the pos choroidal ruptures are in the same category of risk. Stage the procedure. Patients with angioid streaks and traumatic sure is raised with application of the suction ring during choroidal neovascularization (CNV) after intraocular pres macula are at high risk to develop macular hemorrhage or In addition, our most recent study shows that results Serious complications after LASIK are infrequent. It is very “

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APRIL hemorrhage or CNV afterhemorrhage at to high risk develop macular lacquer cracks in the macula are Patients with high myopia and ring during the procedure. during ring with application of the suction is raised 2017 n ------2001;108(4):660-665. 37. CameronBD,SaffraNA,StromingerMB.Laserinsitukeratomileusis-inducedopticneuropathy. versus posteriorchamberphakicintraocularlensimplantationinamyopiccohort. 36. Al-AbdullahAA,Al-FalahMA,Al-RashaedS,KhandekarR,SuarezE,ArevaloJF.Retinalcomplicationsafteranterior astigmatism. 35. ZaldivarR,DavidorfJM,OscherowS.Laserinsitukeratomileusisformyopiafrom-5.50to-11.50diopterswith eyes. 34. ChanCK,TarasewiczDG,LinSG.Relationofpre-LASIKandpost-LASIKretinallesionsexaminationforLASIK diopters: 10yearsoffollow-up. 33. ArevaloJF,LasaveAF,TorresF,SuarezE.RhegmatogenousretinaldetachmentafterLASIKformyopiaofupto-10 (LASIK) forthecorrectionofmyopia. 32. ArevaloJF,RamirezE,Suarezetal.Rhegmatogenousretinaldetachmentafterlaser-assistedinsitukeratomileusis 2003;19(5):534-547. 31. Ruiz-MorenoJM,AlioJL.Incidenceofretinaldiseasefollowingrefractivesurgeryin9,239eyes. 30. MichelsRG,WilkinsonCP,RiceTA. ately followinglaserinsitukeratomileusis. 29. ReviglioVE,KuoIC,GramajoL,OlmedoMA,FalcoM,JuarezCP.Acuterhegmatogenousretinaldetachmentimmedi leusis forhighmyopia. 28. FarahME,Hofling-LimaAL,NascimentoE.Earlyrhegmatogenousretinaldetachmentfollowinglaserinsitukeratomi myopia. 27. FaghihiH,JalaliKH,AminiA,HashemiFotouhiEsfahaniMR.RhegmatogenousretinaldetachmentafterLASIKfor for thecorrectionofmyopia. 26. StultingRD,CarrJD,ThompsonKP,WaringGO3rd,WileyWM,WalkerJG.Complicationsoflaserinsitukeratomileusis laser-assisted insitukeratomileusis. 25. OzdamarA,ArasC,SenerB,OncelM,KaracorluM.Bilateralretinaldetachmentassociatedwithgianttearafter ment surgery. 13. BarequetIS,LevyJ,KlempererI,etal.Laserinsitukeratomileusisforcorrectionofmyopiaeyesafterretinaldetach 2000;129(5):668-671. 12. BushleyDM,ParmleyVC,PaglenP.Visualfielddefectassociatedwithlaserinsitukeratomileusis. myopia. 11. PallikarisIG,SiganosDS.Excimerlaserinsitukeratomileusisandphotorefractivekeratectomyforcorrectionofhigh Human studies. 10. PallikarisIG,PapatzanakiME,SiganosDS,TsilimbarisMK.Acornealflaptechniqueforlaserinsitukeratomileusis. intraocular lensestocorrectseveremyopia. 9. Ruiz-MorenoJM,AlióJL,Pérez-SantonjaJJ,delaHozF.Retinaldetachmentinphakiceyeswithanteriorchamber Retina 8. RipandelliG,BilliB,FedeliR,StirpeM.Retinaldetachmentafterclearlensextractionin41eyeswithhighaxialmyopia. Retrospective analysis. 7. BarraquerC,CavelierMejiaLF.Incidenceofretinaldetachmentfollowingclear-lensextractioninmyopicpatients. 1987;105(11):1522-1523. 6. RodriguezA,GutierrezE,AlviraG.Complicationsofclearlensextractioninaxialmyopia. 5. RodriguezA,CamachoH.Retinaldetachmentafterrefractivesurgeryformyopia. Refract CornealSurg 4. FeldmanRM,CrapottaJA,ST,GoldbaumMH.Retinaldetachmentfollowingradialandastigmatickeratotomy. 3. SandersDR,HoffmanRF,SalzJJ. 1985;1:226-230. 2. HofmannR,StarlingJC,HovlandKR.Casereport:retinaldetachmentafterradialkeratotomysurgery. Ophthalmic SurgLasers 1. ArasC,OzdamarA,KaracorluM,SenerB,BahceciogluH.Retinaldetachmentfollowinglaserinsitukeratomileusis. Surg 24. BarbaraA,Shehadeh-Masha’ourR,SartaniG,GarzoziHJ.ReactivationofoculartoxoplasmosisafterLASIK. keratomileusis. 23. SinghviA,DuttaM,SharmaN,PalVajpayeeRB.Bilateralserousmaculardetachmentfollowinglaserinsitu mol 22. ChanCK,LawrenceFC.Macularholeafterlaserinsitukeratomileusisandphotorefractivekeratectomy. situ keratomileusis. 21. ArevaloJF,RamirezE,Suarezetal.Incidenceofvitreoretinalpathologicconditionswithin24monthsafterlaserin 20. LinJM,TsaiYY.RetinalphlebitisafterLASIK. Ophthalmol 17. Perez-SantonjaJJ,SaklaHF,AbadJL,ZorraquinoA,EstebanJ,AlióJL.Nocardialkeratitisafterlaserinsitukeratomileu leusis. Frequency,characteristics,andmechanism. 16. ArevaloJF,RamirezE,Suarezetal.Rhegmatogenousretinaldetachmentinmyopiceyesafterlasersitukeratomi . 15. Najman-VainerJ,SmithRJ,MaloneyRK.InterfacefluidafterLASIK:misleadingtonometrycanleadtoend-stage 14. LeeAG.LASIK-inducedopticneuropathy. 19. Ruiz-MorenoJM,Perez-SantonjaJJ,AlioJL.Retinaldetachmentinmyopiceyesafterlasersitukeratomileusis. Surg 18. LinSC,TsengSH.Prophylacticlaserphotocoagulationforretinalbreaksbeforeinsitukeratomileusis. sis. J RefractSurg . 2001;131(5):666-667. n n n J. Fernando Arevalo, MD, FACS . 2005;21(6):759-761. . 2003;19(6):661-665. Br JOphthalmol

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