Eyeworld

EW REFRACTIVE 152 April 2017 half of those in the PRK group had experienced dry eye symptoms after surgery, Dr. Schallhorn noted. For a small percentage, this was more severe. "About 3% of patients with LASIK, had more severe dry eyes, with surface epitheliopathy that last- ed for longer than 1 year," she said. For Dr. Schallhorn, the most surprising thing was how few inflammatory complications there were in this cohort after refractive surgery. "Not a lot of people had DLK [diffuse lamellar keratitis], and there was only the one rheumatoid arthritis patient with an inflam- matory process," she said. "In this very large group of patients with known inflammatory disease, I was surprised by how infrequent that complication was." This shows that in these stable, well-controlled patients the risk of having a severe complication is very low, she said. On the other hand, she added that it does show that even in these patients, practitioners need to pay attention to their surface since they are at risk, in some cases, of develop- ing vision-limiting dry eye. Overall, Dr. Schallhorn views these results as promising. "I think that refractive surgery can be safe in patients with collagen vascular disease and the immune-medicat- ed inflammatory diseases that we studied with the caveat that they're well controlled, have no history of ocular involvement, are under the advisement of their rheumatologist or primary care physician, and may need a little bit more care to the ocular surface after surgery," she concluded. EW Reference 1. Schallhorn JM, et. al. Outcomes and com- plications of excimer laser surgery in patients with collagen vascular and other immune-me- diated inflammatory diseases. J Cataract Ref Surg. 2016;32:42:1742–1752. Editors' note: Dr. Schallhorn has no financial interests related to her com- ments. Contact information Schallhorn: Julie.Schallhorn@ucsf.edu by Maxine Lipner EyeWorld Senior Contributing Writer disease. Those who had inflammato- ry bowel disease, however, were not included, Dr. Schallhorn stressed. While the study was a retrospective one, Optical Express had specif- ic criteria for those with collagen vascular disease to meet prior to refractive surgery—they had to have stable well-controlled disease for at least 2 years prior to surgery with no history of ocular involvement and documentation from either their rheumatologist or primary care physician showing their disease was stable, she said. When investigators considered the results, they found that these patients fared well in terms of visual outcomes. "We didn't see the kind of dramatic melts or terrible out- comes that people were afraid of," Dr. Schallhorn said. "We did have one patient with rheumatoid arthri- tis with a mild peripheral flap melt that responded to topical steroids." However, that was just one out of 622 patients, 315 of whom had rheumatoid arthritis, she said. In addition, refractive predict- ability was good. "Of the people that were targeted for emmetropia, 82% of LASIK patients and 82% of PRK were within 0.5 D of emmetropia, and 92% of LASIK and 98% of PRK were within 1 D of emmetropia," Dr. Schallhorn said. Likewise, the pro- cedure was found to be safe in this population, with just 1% of LASIK eyes losing 2 lines of corrected acu- ity and no eyes in the PRK group los- ing this amount of corrected acuity, she reported. Sizing up surface issues "The ones who lost acuity in the LASIK group were all due to surface issues postoperatively," Dr. Schall- horn said. "It seemed that in this group at least, that the most severe complications we saw were not melts, they weren't people losing their eyes, but instead problems with dryness afterwards." When investigators looked back at people who had reported dry eye symptoms postoperatively, they found that a little over two-thirds of patients who underwent LASIK and a little over Considering complications Some practitioners, however, such as those at Optical Express (Glasgow, United Kingdom) have allowed patients with stable, well-controlled disease with no evidence of ocular involvement to undergo refractive surgery, Dr. Schallhorn points out. "We wanted to look at the out- comes and see if they were good or, if they were having complications to see if we really should be doing the surgery on these patients," she said. "There are reports on patients developing necrotizing keratitis and scleritis after surgery." These particularly occurred in those with rheumatoid arthritis and inflamma- tory bowel disease, Dr. Schallhorn said, adding that most occurred after cataract surgery, but there were also reports of it after refractive proce- dures as well. "We wanted to look at this in a broader context to look at patients with known and well-con- trolled disease to see how they fared after surgery," she said. Included in this study were patients with a variety of collagen vascular diseases such as those with lupus, rheumatoid arthritis, and psoriatic arthritis, as well as patients with other systemic autoimmune diseases such as sarcoidosis, multi- ple sclerosis, and HLA-B27-related Contending with the shadow of collagen vascular disease W hile many patients come in for refractive surgery with a clean bill of health, from time to time practi- tioners will encounter a patient with collagen vascular disease interested in undergoing a procedure, accord- ing to Julie M. Schallhorn, MD, assistant professor of clinical oph- thalmology, University of California, San Francisco. When investigators, led by Dr. Schallhorn, considered how such patients fared in a recent study pub- lished in the December 2016 issue of the Journal of Cataract and Refractive Surgery, they found that complica- tions were mostly in keeping with what occurred in typical cases. 1 Concern over having such pa- tients undergo refractive procedures has been around from the start. "The FDA trials of the excimer laser specifically excluded patients with rheumatoid arthritis and collage vas- cular diseases," Dr. Schallhorn said, adding that some of the labeling on the laser does not include patients with such diseases. Performing refractive surgery in patients with pre-existing problems Research highlight Peripheral flap melt in a 53-year-old male with a recent diagnosis of relapsing polychondritis who is 12 years post-myopic LASIK Source: Julie Schallhorn, MD

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