Addressing Postoperative Visual Complications

Despite progress in diagnostics and laser technology, visual aberrations may still arise after corneal laser refractive procedures. However, early diagnosis and treatment can provide excellent outcomes, and significant visual improvement is still possible with later interventions, said Vladimir Suvajac MD at an ESCRS eConnect Webinar titled “Tackling Postoperative Complications in Corneal Surgery.”

Dr Suvajac shared a few cases of postoperative visual aberrations, along with his management strategies and the treatment outcomes. The first case involved a patient who developed visual issues in their left eye two years after myopic LASIK, showing residual or regressed myopic astigmatism and BCVA of 0.5. Corneal topography showed superior asymmetrical steepening, while aberrometry identified mainly coma, trefoil, and some spherical aberrations matching the overall ocular findings.

To address residual myopic astigmatism and higher-order aberrations, Dr Suvajac performed corneal wavefront-guided transepithelial photorefractive keratectomy (PRK) with mitomycin-C. He said he prefers surface ablation over lifting an old flap in aberrated corneas, as it enables wider treatment zones, bigger postoperative optical zones, and less epithelial hyperplasia. Preoperative corneal epithelial mapping with OCT is crucial in these cases due to the epithelial hyperplasia or irregularities that are inherently present. Incorporating epithelial profiles in treatment planning allows for refractive outcomes that are, in most cases, comparable to the flap re-lift approach, he said.

Postoperatively, the patient’s operated eye had a decimal visual acuity of 1.0, with reduced lower- and higher-order aberrations. Coma reduced by almost 60% and spherical aberration by around 45%. Postoperative topography showed asymmetric flattening, as planned with the customized ablation.

Another case involved a 29-year-old male patient who underwent bilateral PRK in 2016. When he presented at Dr Suvajac’s clinic in 2023, he had corneal haze and mixed astigmatism (+3.0/-5.0 x 10) in his right eye with a best-corrected decimal visual acuity of 0.5. The haze induced higher-order aberrations as well as some opacity. His left eye had only mild astigmatism and a BCVA of 0.9.

Dr Suvajac treated the patient’s left eye with corneal wavefront-guided transepithelial PRK with mitomycin-C. At the two-year follow-up, the eye’s acuity was 0.9 with only 0.75 D of cylinder, and only peripheral clinically insignificant haze. Additionally, there was a reduction in both lower- and higher-order aberrations.

“Corneal haze can often be treated effectively with PTK or corneal wavefront-guided procedures,” he said. “Since it typically affects the anterior subepithelial cornea and is not severe, treatment is usually simpler than for corneal scarring from infections or pterygium surgeries. Conservative options like topical losartan drops exist, although these are not yet commonly available in pharmacies.”

Another case involved a patient who underwent bilateral LASIK for hyperopic astigmatism in 2023. Six months postoperatively, the patient reported blurry vision in the left eye, noting they saw better when they covered that eye. The left eye had experienced a free cap during surgery. Slit lamp exam and retroillumination revealed pronounced microstriae, and OCT showed several Bowman’s membrane ruptures. Aberrometry showed micro-scattering corresponding to the observed microfolds, and contrast sensitivity was normal in the right eye but poor at high frequencies in the left eye. Bilateral contrast sensitivity was nearly as low as in the left eye alone.

To achieve corneal regularization, Dr Suvajac and his team performed a phototherapeutic keratectomy (PTK) to a depth of 70 microns, followed by wet PTK smoothening, using an aberration-free, refractive-neutral ablation profile. Postoperatively, the patient had a one-line improvement in visual acuity and reported no ongoing visual symptoms with complete physiological contrast sensitivity. Both OCT and retroillumination imaging demonstrated minimal residual microfolds.

“It is not that rare to see some microfolds, and usually, they are not clinically significant. But when the patient complains, it is good to keep in mind that topography, aberrometry, or OCT images can sometimes underestimate their significance, as they are not that pronounced,” Dr Suvajac added. “And retroillumination images and contrast sensitivity testing can be helpful.”

The complete seminar is available here.

Vladimir Suvajac MD is chief surgeon at the Eye Clinic Professional in Belgrade, Serbia. v.suvajac@bolnicaprofesional.rs