Is LASIK an option for older patients?

Surgeons debate LASIK advantages, discuss other possible approaches

A Thornton-Fine fixation ring with a guide going down the middle that the surgeon rests his diamond blade up against so that his incision is perfectly radial Source: Mastel
Image shows two incisions in the cornea from the 5- to 8-mm optical zones. One incision is at about the 10 o'clock position, and the other is at about the 2 o'clock position. This demonstrates an alternative technique to use for residual refractive errors Source: Mastel

It's no secret that LASIK is typically associated with younger patients. However, is LASIK a viable option for patients over the age of 60? "In our current society, a lot of patients in their 60s are 'young' 60s," said Louis E. Probst, M.D., national medical director, TLC Laser Eye Centers, Ann Arbor, Mich. "I'm amazed by patients in their 60s and late 50s who are physically active, still working, have healthy eyes, and have no signs of significant cataract. In that group of patients, refractive surgery is reasonable."
On a weekly basis, Dr. Probst, who focuses exclusively on refractive surgery, does indeed have patients age 60 and older who will inquire about LASIK and sometimes go on to have the procedure done. If the patient appears to be a possible candidate—no cataracts are seen and there is no contraindicated ocular pathology—he will discuss the benefits and risks, pointing out that the patient will likely develop cataracts one day. "However, LASIK will not make that happen any slower or faster," he said. Dr. Probst will add a handwritten note to the patient consent form to indicate that the pros and cons of the procedure were discussed.
Then, he lets the patients make the decision.
"It's not our decision [as surgeons] to decide if they deserve LASIK. It's our job to inform them," he said.
Despite the risk for cataract growth, some patients are more concerned about the short-term quality-of-life benefits that LASIK can deliver to them, Dr. Probst said.
Even with the possible advantages of LASIK in some older patients, Uday Devgan, M.D., chief of ophthalmology, Olive View–University of California, Los Angeles Medical Center, believes the procedure should be approached with caution. "In any patient, particularly those over age 60, it is imperative to check for early signs of cataract. Even with mild nuclear sclerosis, where the patients are still correctable to 20/20 vision, corneal refractive surgery may not be the best choice," Dr. Devgan said. "A refractive error induced or influenced by cataractous changes will tend to progress with time, and the patient will perceive that the benefit from LASIK is 'wearing off.'"

LASIK for residual refractive error?

LASIK might be a better option to correct residual refractive error after cataract surgery and multifocal or accommodative IOL implantation, some surgeons said.
"LASIK can be an appropriate procedure for senior patients to deliver a specific refractive outcome and minimize the use of spectacles," Dr. Devgan said. He recommended a YAG laser capsulotomy in patients with posterior capsule opacities or contraction and in patients with accommodating IOLs because the effective lens position—and hence the refraction—can change afterward.
Richard L. Lindstrom, M.D., adjunct professor emeritus, ophthalmology department, University of Minnesota, Minneapolis, and founder, Minnesota Eye Consultants, Minneapolis, will perform PRK or LASIK in older patients with a post-op residual refractive error. He prefers this because the laser is more precise and predictable than other options. Although post-op dry eye is a concern in this patient group, he typically prepares the ocular surface pre-operatively, prescribing a dual antibiotic/steroid four times a day for a week. Perhaps because of this, he has not seen any meaningful problems with post-op dry eye in these patients.
Dr. Lindstrom said that while side effects such as wound healing and infection are always possible, the chance of these occurring is low, which is why he prefers to correct residual errors with the laser versus other methods.
However, he does add that these corrections come with a cost to use the laser, and surgeons often have to absorb that cost.

An incision approach: A LASIK alternative in older patients

Some surgeons select a non-laser approach to correct residual refractive error in premium IOL patients. This alternative involves two small radial incisions made with a diamond blade, can be performed under the slit lamp, and does not involve additional costs. J.E. "Jay" McDonald II, M.D., Fayetteville, Ark., refers to this particular technique as an "incisional enhancement" or "mini-touchup" when speaking with patients, although he will call it "two-incision radial keratotomy" (RK) or "mini-RK" when speaking with other surgeons. However, Dr. McDonald is quick to say that another term for this procedure may be more appropriate, as what he is performing is not actually RK at all. The use of the term "RK" might initially scare away potential users of this approach, he said.
"I have been doing these mini-touchups for several years. I believe the reason I am successful in my premium channel is that I know how to correct these leftover refractions and do it without all the time, money, and corneal issues surrounding laser vision correction in those 55 and older," Dr. McDonald said.
He has used his laser only once in the past 5 years to correct residual refractive error; he performs mini-RK or astigmatic keratotomy in 15% of his premium IOL patients.
John Sonntag, M.D., Boise, Idaho, also believes that an incisional approach is more appropriate than laser use to treat mild myopic residual refractive errors. "LASIK works, of course, but it is like using a fire department hook-and-ladder truck for a fire that is only as big as a small trash can," Dr. Sonntag said. "I make one or two 3-mm radial incisions, both of them under the upper lid." This contrasts with some surgeons' understanding that the incisions have to be 180 degrees opposite of each other, Dr. Sonntag said.
Like Dr. McDonald, Dr. Sonntag pointed out that calling this procedure RK is misleading. The only thing that the procedures have in common is their instrumentation. He instead calls the procedure "micro-incisional advanced technology enhancement." "Previously I had termed it 'multifocal incisional enhancement,' but the technique works well for advanced technology lenses—for instance, toric IOLs—as well as multifocals," Dr. Sonntag said.
To perform this technique, Dr. Sonntag said that most often, only one incision is needed from the 5- to 8-mm optical zones. "If a second incision is needed, it need not be placed 180 degrees opposite the first. In fact it can be placed just a few clock hours from the first incision," Dr. Sonntag said.
"In the right hands, for an experienced surgeon, this is a simple and cost-effective technique," said Dr. Probst. This particular approach may not be as well-known as some surgeons began to use it around the same time the excimer laser was introduced; naturally, ophthalmologists paid more attention to the laser, Dr. Probst believes.
"With one or two incisions, you can easily correct 1 or 1.5 diopters of myopia," said Dr. Lindstrom. Dr. Lindstrom, who published on the mini-RK approach about 20 years ago and developed nomograms for its use, no longer performs this technique but does not discourage others from doing it.

Editors' note: Drs. Devgan and Sonntag have no financial interests related to this article. Dr. Lindstrom has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.), Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Bausch + Lomb (B+L, Rochester, N.Y.), and Merck (Whitehouse Station, N.J.), among other ophthalmic companies. Dr. McDonald has financial interests with Alcon and B+L, among other ophthalmic companies. Dr. Probst has financial interests with AMO.

Contact information

Devgan: 800-337-1969, devgan@gmail.com
Lindstrom: 612-813-3633, rllindstrom@mneye.com
McDonald: 479-521-2555, mcdonaldje@mcdonaldeye.com
Probst: 708-562-2020, leprobst@gmail.com
Sonntag: 208-377-3937, Jsonn12345@aol.com