Refractive surgery aims to correct errors related to the refractive media of the eye by means including corneal reshaping with an excimer laser (PRK and LASIK), refractive lens exchange (RLE), and phakic IOL implantation. This article describes the preoperative macular conditions that can affect surgical outcomes and details the occurrence and management of postoperative macular complications following refractive surgery.
Myopia is more commonly related to retinal and macular pathology than is hyperopia. Pathologic high myopia is associated with macular lesions such as foveal retinoschisis and macular retinal detachment, macular hole formation, diffuse or patchy myopic macular degeneration, lacquer cracks, macular scars due to previous macular hemorrhage related to Bruch membrane breaks, and choroidal neovascular membranes.
Hyperopia is not usually associated with macular disease. In cases of hyperopia associated with anisometropia, even in the presence of an anatomically healthy macula, it is important to exclude amblyopia.
A full clinical assessment of the macula, including biomicroscopy and macular optical coherence tomography, should be included in the preoperative work-up of any patient being considered for refractive surgery. Further investigations such as fundus fluorescein angiography, indocyanine green angiography, and fundus autofluorescence imaging may be required in the presence of conditions such as diabetes, uveitis, and retinal pigment epithelium (RPE) changes.
In such cases, an assessment of the best potential final visual acuity should be performed, and a full discussion with the patient should take place, informing him or her of the benefits and potential risks of the proposed procedure.
After PRK, LASIK, and phakic IOLs. A number of complications following refractive surgical procedures have been reported in the literature; these include macular hemorrhage,1-4 lacquer crack formation,5 choroidal neovascularization,6-10 retinal vein occlusion,11 subhyaloid hemorrhage,12 and Valsalva-like retinopathy.13 There are also case reports14,15 and series16 describing macular hole formation after refractive surgery. Additionally, transient macular edema17 and serous macular detachment18 have been reported after refractive procedures. In one study, the reported incidence of choroidal neovascularization was 0.01% after PRK, 0.33% after LASIK, and 2.38% after phakic IOL implantation.19
Lesions following LASIK are considered to result from the rapid changes of intraocular pressure (IOP) during application and release of suction, producing mechanical stress and causing ruptures of Bruch membrane in the cases of macular hemorrhages and choroidal neovascular membranes. In macular hole formation, it is suggested that the IOP increase during suction application causes mechanical changes to the vitreoretinal interface. It is also possible that shock waves produced by the excimer laser may play a role.
Following lens extraction. Cystoid macular edema (CME) is the most common macular problem compromising final visual outcome following cataract surgery.20 Other complications include new choroidal neovascular membranes21 in eyes predisposed due to dry age-related macular degeneration, drusen, or macular RPE changes.
Phakic IOL implantation, as an intraocular surgical procedure, can potentially cause CME, especially in eyes with chronic inflammation. However, this has not been reported in the literature. It is unlikely that implantation of a phakic IOL will cause any other macular pathology.
MANAGEMENT OF COMPLICATIONS
The management of macular complications depends on the nature, complexity, and severity of the lesions. CME following RLE and phakic IOL implantation—if not associated with diabetes or uveitis and in the absence of small, retained nuclear fragments—can initially be treated with topical steroids in combination with topical NSAID drops. If this fails, orbital floor injection of steroids can be considered. Patients with persistent CME should be referred to a retina specialist for further investigation and management.
Macular hemorrhage following surface ablation or LASIK should be investigated with fundus fluorescein angiography in order to establish its cause. For choroidal neovascular membranes, treatment options include photodynamic therapy and intravitreal injection of a vascular endothelial growth factor inhibitor.22-28
Macular hole formation requires further work-up and possible macular hole repair surgery. A retrospective series29 reported that the prognosis for closure of such macular holes is usually good; however, the final visual outcome was not favorable in that series of patients, with only 35.7% of 14 eyes that underwent surgery achieving a visual acuity of 20/40 or better.
Refractive surgery has evolved beyond excimer laser surface ablation procedures to include intraocular surgical interventions with the aim of providing patients with good UCVA. Macular complications of refractive surgery, although rare, can result in decreased vision, sometimes irreversible and permanent, causing significant distress and impairment.
Patients with preexisting macular lesions and patients at higher risk of complications, such as those with high myopia, preexisting lacquer cracks, history of previous macular lesions, and early macular RPE changes or drusen, should undergo a full and thorough assessment of the macula, including photography, optical coherence tomography, and fundus fluorescein or indocyanine green angiography if indicated, before a refractive procedure is undertaken.
The risks, benefits, and alternatives should be discussed in full with each patient, explaining that macular lesions can result in a possibly irreversible worsening of vision.
Panagiotis Georgoudis, MRCOphth, FEBO, is a fellow at Emmetropia Mediterranean Eye Clinic in Greece. Dr. Georgoudis states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: firstname.lastname@example.org
Ioannis M. Aslanides, MD, PhD, MBA, FRCOphth, is an Assistant Professor at Weill Cornell Medical Center and Medical Director at Emmetropia Mediterranean Eye Clinic in Greece. Dr. Aslanides states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: email@example.com.
- Ellies P, Pietrini D, Lumbroso L, Lebuisson DA. Macular hemorrhage after laser in situ keratomileusis for high myopia. J Cataract Refract Surg. 2000;26(6):922-924.
- Kim HM, Jung HR. Laser assisted in situ keratomileusis for high myopia. Ophthalmic Surg Lasers. 1996;27:S508-S511.
- Luna JD, Reviglio VE, Juárez CP. Bilateral macular hemorrhage after laser in situ keratomileusis. Graefes Arch Clin Exp Ophthalmol. 1999;237(7):611-613.
- Principe AH, Lin DY, Small KW, et al. Macular hemorrhage after laser in situ keratomileusis (LASIK) with femtosecond laser flap creation. Am J Ophthalmol. 2004;138:657-659.
- Ruiz-Moreno JM, Montero J, Alio JL. Lacquer crack formation after LASIK. Ophthalmology. 2003;110:1669-1671.
- Sobha S, Rajan MS, Jackson H. Choroidal neovascularization following hyperopic LASIK surgery. Clin Experiment Ophthalmol. 2004;32(4):443-445.
- Pinto RV, Smiddy WE, Culbertson W. Choroidal neovascularization following laser in situ keratomileusis. Ophthalmic Surg Lasers Imaging.2004;35(1):63-66.
- Maturi RK, Kitchens JW, Spitzberg DH, et al. Choroidal neovascularization after LASIK. J Refract Surg.2003;19:463-464.
- Chen YC, Ma DH, Yang KJ, Chen TL, Li CY, Lai CC. Bilateral choroidal neovascularization after laser-assisted in situ keratomileusis. Retina.2001;21:174-175.
- Al-Dhibi H, Chaudhry IA, Al-Assiri A, Shamsi FA. Development of early choroidal neovascular membrane in a young myope after LASIK. Eur J Ophthalmol. 2007;17(2):262-265.
- Smith BT, Park CH, Fekrat S. Hemi-retinal vein occlusion following LASIK. Ann Ophthalmol (Skokie). 2006;38(2):139-140.
- Mansour AM, Ojeimi GK. Premacular subhyaloid hemorrhage following laser in situ keratomileusis. J Refract Surg. 2000;16(3):371-372.
- Moshfeghi AA, Harrison SA, Reinstein DZ, Ferrone PJ. Valsalva-like retinopathy following hyperopic laser in situ keratomileusis. Ophthalmic Surg Lasers Imaging. 2006;37(6):486-488.
- Chan CK, Lawrence II FC. Macular hole after laser in situ keratomileusis and photorefractive keratectomy. Am J Ophthalmol. 2001;131:666-667.
- Ruiz-Moreno JM, Artola A, Perez-Santonja JJ, et al. Macular hole in a myopic eye after laser in situ keratomileusis. J Refract Surg. 2002;18:746-749.
- Arévalo JF, Mendoza AJ, Velez-Vasquez W, et al. Full-thickness macular hole after LASIK for the correction of myopia. Ophthalmology. 2005;112:1207-1212.
- Yang B, Wang Z, Huang G, Liu X, Ling Y, Zheng X. Transient macular edema after laser in-situ keratomileusis. Yan Ke Xue Bao. 2003;19(1):20-24.
- Singhvi A, Dutta M, Sharma N, Pal N, Vajpayee RB. Bilateral serous macular detachment following laser in situ keratomileusis. Am J Ophthalmol. 2004;138(6):1069-1071.
- Ruiz-Moreno JM, Alió JL. Incidence of retinal disease following refractive surgery in 9,239 eyes. J Refract Surg. 2003;19(5):534-547.
- Flach AJ. The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. Trans Am Ophthalmol Soc. 1998;96:557-634.
- Oztürk BT, Kerimoglu H, Kamıs U, Gönül S, Okudan S. Choroidal neovascular membrane following clear lens extraction. Clin Ophthalmol. 2007;1(4):559-561.
- Ruiz-Moreno JM, López-Gálvez MI, Montero Moreno JA, Pastor Jimeno JC. Intravitreal bevacizumab in myopic neovascular membranes: 24-month results. Ophthalmology. 2013;120(7):1510-1511.
- Manayath GJ, Narendran V, Ganesh A, Arora S. Low-fluence photodynamic therapy for early onset choroidal neovascular membrane following laser in situ keratomileusis. Indian J Ophthalmol. 2012;60(6):584-585.
- Qureshi F, Saeed MU, Kamal A. Primary intravitreal ranibizumab for myopic choroidial neovascularisation. Semin Ophthalmol. 2011;26(2):52-54.
- Desco MC, Mataix J, Garcia-Pous M, Palacios-Pozo E, Navea A. Combined therapy photodynamic therapy and bevacizumab to treat myopic neovascular membranes. One-year follow-up. Retina. 2011;31(3):475-481.
- Kumaran N, Sim DA, Tufail A. Long-term remission of myopic choroidal neovascular membrane after treatment with ranibizumab: a case report. J Med Case Rep. 2009;28(3):84.
- Arevalo JF, Ruiz-Moreno JM, Fernandez CF, Mendoza AJ, Ramirez E, Montero JA. Photodynamic therapy with verteporfin for subfoveal choroidal neovascular membranes in highly myopic eyes after laser in situ keratomileusis. Ophthalmic Surg Lasers Imaging. 2004;35(1):58-62.
- Blinder KJ, Blumenkranz MS, Bressler NM, et al. Verteporfin therapy of subfoveal choroidal neovascularization in pathologic myopia: 2-year results of a randomized clinical trial--VIP report no. 3. Ophthalmology. 2003;110(4):667- 673.