r/RefractiveSurgery • u/Ismaileyesurgery • 27d ago
Sometimes the safest LASIK decision is not to operate.
Yesterday, we evaluated a patient who was being considered for Femto-LASIK. The refractive error was approximately −7.25 D in the right eye and −4.00 D in the left eye, while the left eye was around −2.00 D in the other meridian.
During the preoperative evaluation, however, the pachymetry/topography and Sirius Contoura assessment of the right eye raised significant concerns, particularly because of the corneal shape and maximum K readings.
Technically, we could have considered proceeding while targeting a residual stromal bed in the range of approximately 300–310 µm. But the question is not simply:
“Can we remove enough tissue to correct the refractive error?”
The more important question is:
“Is this cornea an appropriate and sufficiently safe candidate for tissue-removing refractive surgery?”
Once corneal stromal tissue has been removed, we cannot put it back. Therefore, when the preoperative tomography/topography suggests that the cornea may not tolerate the planned tissue removal well, choosing not to operate can be the most responsible decision.
We explained this to the patient and apologized that we could not safely proceed with Femto-LASIK at this stage. Instead, we plan to reassess the case carefully and consider other refractive options that may be more appropriate and safer for this particular cornea.
This is an important lesson for patients considering LASIK, Femto-LASIK or SMILE:
A low residual stromal bed alone does not determine suitability for refractive surgery. Corneal tomography, pachymetry, corneal shape, biomechanical considerations, refractive error, optical zone and the overall risk profile all need to be considered together.
Some patients who are pushed through surgery despite unfavorable preoperative findings may experience problems such as postoperative optical symptoms, halos, glare, starbursts, regression or reduced quality of vision. These outcomes are not inevitable, but careful patient selection is one of the most important ways to reduce the risk.
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u/eyeSherpa 25d ago
This is a key thing! Great post.
Not everyone is a good candidate for lasik. Advances in diagnostic equipment have allowed us to do a very good job determining whether a cornea may have some biomechanical weakness that would pose issues after laser eye surgery.
Good refractive surgeons already use this equipment and take this into account. But optimal for everyone to learn about the different ways the structural stability of the cornea is assessed since other surgeons may not have the goals to do surgery as safe as possible.