Importance of Careful Patient Selection for LASIK

Ozdamar et al.1 should be congratulated for their iconography; however, their article underlines the importance of an exhaustive patient evaluation and an exact definition of the patient's selection criteria before any medical act is performed. One should select only those who have a chance of a successful outcome and eliminate those with risk factors or with a doubtful safe outcome, so as not to betray the hippocratic rule of action “primum non nocere.” Refractive surgery aims at a functional improvement, treating eyes with acceptable best corrected visual acuity (BCVA). Any complication can lead to a worsening in the quality of vision; thus, it is extremely important not to induce any avoidable harm. We should leave aside the patient's expectations, sometimes impossible to fulfill, and the economic facts when choosing patients for laser in situ keratomileusis (LASIK). Since Seiler's 1998 publication2 and those of other authors on the same topic,3–5 it has become widely accepted that the minimum residual corneal stroma after LASIK should be thicker than 250 μm and the total corneal thickness, more than 400 μm to avoid iatrogenic keratectasia. Trying to correct a refraction such as −13.00 −6.25 × 165 (getting a BCVA of 20/63) using LASIK, as in the case reported, would be questioned by many ophthalmologists nowadays, as it is not considered an ideal indication for LASIK. The patient should not have had a LASIK procedure because the laser would ablate 184 μm in a cornea of only 520 μm, leaving a cornea of little more than 300 μm, as the author says. If we do not take into account the flap thickness, the residual stroma would be 140 to 150 μm. This is not enough to maintain the biomechanical structure of the cornea, and it will lead to iatrogenic keratectasia that will reduce the BCVA. In cases like this, we think the most appropriate way of correcting the refractive error would be to use a phakic lens, adding or not adding a LASIK procedure to correct the possible residual ametropia (bioptics). Although we consider the publication of this case interesting, we think a comment similar to the one above should be attached to it to highlight what happened is an iatrogenic fact, foreseeable and avoidable. This way, we will fulfill our educational task to prevent others from incurring the same mistake and from performing a deficient medical practice. Daniel Elies MD Andreu Coret PhD Lluis Cavero PhD aBarcelona, Spain