Aggressive refractive surgery practices?

May 21 2012

I write to describe two cases of aggressive practice by a “leading” refractive surgery provider.

The first involves a low myopic (-3.00DS) patient in her late 50s, who was told that she was unsuitable for laser refractive treatment (because she has cataract) and that instead, she should have refractive lens exchange, for the bargain price of £3,500. The fact that this lady has (very minimal) lens changes surely doesn’t prevent her from having laser refractive surgery?

The majority of patients having laser refractive surgery will be aged 20-45 years, all of whom will go on to develop cataract anyway should they be fortunate enough to live long enough.

The second case relates to another myope, who has a history of atopy, dry eyes, and recurrent corneal epithelial erosion syndrome. When she attended this company for a sight-test arranged through her employer, she was very unhappy at the aggressive tactics employed by the optometrist for her to attend a “free” consultation for laser surgery. Apparently, her history of dry eyes and recurrent epithelial erosion syndrome were not considered to be a problem.

Both patients were seen by the same company, albeit in different parts of the country. I think both cases are a little disturbing.

Anthony T Clarke, specialist optometrist in glaucoma

OT clinical editor, Navneet Gupta responded and said: “The first case of the lady in her late 50s and with early lens changes is actually quite typical. Corneal refractive surgeons make refractive lens exchange (RLE) their primary recommendation for treatment in patients with early lens changes for the following reasons (although this does not preclude the option of laser corneal treatment, it would not be in the patient's best interests):

1. Lenticular changes which indicate the start of a cataract will most certainly lead to refractive changes in the lens and therefore the eye overall, in the coming years. As such, a corneal laser corrective procedure will only likely produce short-term post-op correction of vision, to be spectacles-free.

2. If the cataract were to develop rapidly, the patient would then need to go through two procedures in a relatively short period of time (laser corneal treatment, followed by cataract extraction) – the latter may be at extra expense privately or via the NHS.

3. If a patient were to have a RLE/cataract procedure, although emmetropia is the aim, this may not be achieved. In such instances it is normal practice for a "top-up" corneal refractive surgery procedure to be performed to remove any residual error, to make the patient spectacles-free, if the patient has RLE privately through a refractive surgery provider, this is not offered on the NHS and so the patient may be left with the need for spectacles again.

4. If a patient has had a corneal refractive procedure done prior to RLE, and recently, then the patient may not be suitable for a "topup" corneal procedure if the corneal characteristics are outside the required limits. As such, they run the risk of requiring spectacles again in the near future.

Based on the above, RLE is clearly a preferred initial option for treatment in all patients with early signs of cataract.

Regarding the second case, I agree that patients with an atopic condition, dry eye and recurrent corneal epithelial erosion syndrome do not make ideal candidates for corneal laser refractive surgery. The patient could perhaps opt for LASIK treatment (not LASEK as that would potentially make the corneal epithelial erosions worse), but there is a risk of the dry eye becoming worse".

Navneet Gupta, OT clinical editor