After 25 years of surgeon experience and technological innovations, LASIK has one of the highest success rates of any elective procedure. Complications are rare. So, when we asked several surgeons to share a challenging or memorable LASIK case, we weren’t sure what they’d choose to discuss—but they did not disappoint. Here, for your enlightenment, are the recollections of 4 surgeons who were faced with some unexpected incidents.
The Case of the Mysterious Haze
About 3 years ago, T. Hunter Newsom, MD, founder of Newsom Eye & Laser Center in South Tampa, Florida, occasionally had patients referred back to him 1 to 3 months after LASIK because comanaging doctors had detected interface haze. These were not consecutive patients; they popped up randomly, one every few months or so. Curiously, this haze affected only the second eye, and patients weren’t aware of it at all.
“We saw maybe 8 to 10 such patients over a 2-year period,” recalled Dr. Newsom. “Fortunately, there were no visual consequences, but it was definitely something we could see. It looked like a pie-shaped haze, starting at the edge of the flap progressing centrally. It always seemed to start right where we began to lift the flap, and it always appeared only in the second eye.”
As the cases began to add up, Dr. Newsom set out to try to isolate the cause. He started by methodically changing or eliminating a single element from his surgeries, but when a patient showed up in his office with this haze, sometimes months later, he changed something else.
“Almost everything we used was disposable, except for the Sinskey hook to initially lift the flap edge,” Dr. Newsom said. “So, we bought multiple hooks so that one Sinskey hook was used only on one eye.”
Despite these efforts, another patient was referred to his practice with interface haze 6 months later, so the lifting instrument was set aside. Then Dr. Newsom started using a separate disposable cannula to lift each flap. “We used literally nothing that was reprocessed, absolutely nothing, other than a brand-new cannula for each eye,” he said. “Basically, we were down to a syringe, a cannula, and balanced salt solution, and at the end of each case, we would instill steroid, antibiotic, and NSAID drops.
“In January, another patient was referred,” Dr. Newsom continued. “At that point, I decided nothing should touch the eyeball, so we stopped all eye drops at the end of our LASIK cases. All of a sudden, that little bit of interstitial haze at the opening site of the second eye went away. I still don’t know why that is. In the meantime, all the affected patients are doing well. You can see a small residual haze in some eyes, but essentially everything resolved after a year.”
Dr. Newsom hasn’t yet declared victory over this baffling postoperative anomaly. “It’s been about a year and a half since we had our last [haze] case, and I still don’t use any drops at the end of any LASIK cases,” he said. “These cases taught me that when you see something [strange] happening, you need to change only one thing at a time to try to determine what the cause is. I can’t explain why the medications that were instilled in the second eye immediately after completing the procedure were causing an interface haze. Nonetheless, now we don’t start any drops until at least an hour after surgery.”
The Flap Over a Flap
One day, Clayton A. Patrick, MD, of Williamson Eye Center in Baton Rouge, Louisiana, had just completed straightforward femtosecond LASIK on his patient’s right eye and had turned his attention to the left eye, expecting a similar outcome. In his second year of practice at the time, Dr. Patrick admits that what happened next was something he had only read about in textbooks.
The patient, a man about 40 years old, had myopic astigmatism. Due to his large size, positioning him under the laser was a challenge for Dr. Patrick.
“During the case, there was a suction break on the left eye, causing the conjunctiva to infiltrate about 4 clock hours during the flap sidecut,” Dr. Patrick recalled. “I paused to work through the algorithms and decided to recut the flap. The protocol called for adjusting the flap measurements slightly, and we confirmed these inputs, but that was the extent of our timeout.
“I perform LASIK with a superior hinge, which was programmed for the first pass, but through a combination of circumstances, a nasal hinge was unknowingly programmed for the second pass,” he said. “When we repositioned the patient under the treatment laser after a deliberate, controlled dissection, I realized while lifting the flap superiorly that the full flap had come off. In that moment, I was silently freaking out. Free caps aren’t supposed to happen with femtosecond lasers!
“It’s one thing to know what answer to circle on a test, or to rely on an experienced surgeon behind you to assist,” Dr. Patrick said. “It’s totally different when the patient is in front of you, his family is observing you through the glass, the extra minutes seem like hours, and the technicians are staring at you, waiting for you to make a call.”
Assessing the situation, Dr. Patrick decided that with the amount of preoperative astigmatism present, among other factors, proceeding with treatment would not be in the patient’s best interest.
“Harking back to the Hippocratic Oath of ‘Do no harm,’ I replaced the flap where it was without applying laser treatment,” he said. “Because this was such an unexpected complication, I hadn’t marked the cornea preoperatively (something I’ve since added to my preoperative checklist), and I knew this was my only shot at placing that flap where it was supposed to be. I relaid the flap, applied a bandage contact lens, and aborted the case.”
Three months later, Dr. Patrick performed successful PRK on the patient’s left eye. His uncorrected visual acuity was the same as for the right eye, and the patient was happy with the final outcome.
“This was an important learning experience for me, as it taught me about taking full ownership of refractive surgery,” Dr. Patrick said. “It’s not always about how well you do when things go right. It’s knowing how to manage when things go wrong. Most importantly, the patient did well, and secondly, I learned a lot. I think this experience made me a better surgeon.”
A Pilot Crashes
Experienced LASIK surgeons seem to quickly identify personality traits shared by patients from certain walks of life. So, when Audrey R. Rostov, MD, founder of Bellevue Precision Vision in Bellevue, Washington, was scheduled to perform surgery on a pilot, she thought she knew what to expect.
“Usually pilots are easy patients,” she said. “They understand procedure. They’re really good at following instructions, and they’re usually exceedingly calm. This patient seemed fine in the examination room, but once he was under the laser, he turned pale and suddenly started to shake.
“He was having a vasovagal response and a mild seizure,” Dr. Rostov explained. “We immediately broke suction, removed the speculum, and moved him from under the laser. He had fainted, so we placed cold towels and an ice pack behind his head and elevated his feet to help restore blood flow to his brain.
“Once we had revived him, I asked if he felt okay, and I commented that he seemed like such a calm person. He said he’s calm in a doctor’s office, but he always feels faint when having blood drawn or during any medical procedure. I offered to postpone his surgery or perform PRK instead of LASIK, explaining that PRK is a somewhat easier procedure. He said, ‘Nope. I want to have LASIK today.’”
If distraction were an Olympic sport, Dr. Rostov delivered a gold medal performance that day. “I can talk to just about anyone,” she said. “I can talk to a rock, like many of us can.” As she asked about the patient’s family, hobbies, and pets—she even asked about his plane—she was met with monosyllabic responses at best. “I was talking to him nonstop, reaching for anything of interest to him as a distraction, while 2 of my assistants held his hands.
“It was a very challenging case from the patient’s emotional perspective,” Dr. Rostov said, “and I had never had anyone become vasovagal under the laser and then have a seizure. I don’t know how we got through it, but somehow—after an hour and 40 minutes—we managed.”
The patient was pleased with the outcome of his surgery. Since then, Dr. Rostov’s team has added a question to their preoperative questionnaire: “Have you ever felt light-headed or faint during a medical or dental procedure?” OM
