A 60-year-old patient bounds into the office of corneal specialist Ernest W. Kornmehl, MD, seeking a consult. Given his age, it would be natural to assume that this patient needs cataract surgery.
Don’t be so sure.
In an era when Baby Boomers continue to redefine aging, this patient wants to talk about LASIK. And he is not alone. Dr. Kornmehl has witnessed a dramatic increase in the number of older patients requesting LASIK, a trend he not only welcomes but also considers inevitable. “As trite as this sounds, age is only a number,” Dr. Kornmehl said. “If a patient in his 50s or older is carefully selected and stable, there is no reason he cannot undergo LASIK.”
Roy S. Rubinfeld, MD, echoes Dr. Kornmehl’s viewpoint. While Dr. Rubinfeld voices several caveats, the bottom line is that the changing demographics in the United States will force ophthalmologists to rethink previous age parameters. “People are living longer and, frankly, they have more money,” he said. “They are undergoing more plastic surgery procedures, and LASIK is a natural progression. Indeed, it is an alternative that is becoming increasingly popular among people over 50 or 55.”
The plastic surgery craze is also taking hold at the other end of the age spectrum. Younger and younger people are seeking cosmetic procedures—a trend that is spilling into ophthalmology practices. “I see the demand constantly,” said Dr. Kornmehl. “Mothers are asking for LASIK consults for their 15-year-old daughters. Our office won’t even book the appointment if there is not a compelling reason. But while LASIK is not FDA-approved and certainly ill-advised for pediatric patients, this certainly hasn’t stopped parents from trying.”
Yet, according to many ophthalmologists, there may be a role for LASIK in a selected subset of younger patients. Thus, with continuing advances in LASIK surgery that may prove to benefit some young patients, a demanding public seeking broader vision options and an aging population, it is inevitable that previous age limits on both sides of the spectrum will shift. The key to keeping these trends under control, agree ophthalmologists, is more research and extremely careful patient selection.
You’re Never too Old
Is there an upper age limit on refractive surgery procedures? Not necessarily, said Dr. Kornmehl. “It depends on the state of the eyes. The lens has to be clear and the patient must understand that LASIK will not prevent a cataract from developing in the future.”
Jonathan M. Davidorf, MD, who performs refractive surgery on patients at both ends of the age spectrum, said that his oldest refractive surgery patient was 85 years old with otherwise extremely healthy eyes. “The ideal candidates are hyperopes or myopes with a lot of astigmatism who require a low correction,” Dr. Davidorf said. “These older people want better vision, just like anyone else. I think it is a great population to treat.”
And Dr. Kornmehl recalled one patient, a 73-year-old woman. “She came into our office and looked 50,” he said. “She had perfect skin, her lenses looked good, she had stable vision and there was no evidence of cataract. Despite her age, we considered her an excellent candidate for LASIK.”
He added that, as a group, this “new generation” of older patients is well-educated in terms of healthy lifestyles. They have worn sunglasses most of their lives, are nonsmokers, consume balanced, healthy diets, and their eyes look “fantastic” with clear lenses and little yellowing. Their eyes have stabilized, and their active lives—from tennis to boating—would be greatly enhanced if they did not have to wear glasses for distance. “These patients know they will most likely need reading glasses, even with the surgery, but really want to be free of their glasses during activities,” he said.
Considerations in Seniors
As with any other patient population, education is essential and Dr. Kornmehl recommends preparing older patients for the vision they can expect, as well as any potential complications. For example, Dr. Kornmehl’s incidence of corneal abrasion resulting from the microkeratome is about 0.2 percent. However, in patients over 60, this number increases to 0.5 percent. “This is not a major problem,” he said, “but patients should be informed.”
Other issues to consider:
Pre-existing disease. “Each older person seeking refractive surgery must be considered on a case-by-case basis,” Dr. Rubinfeld cautioned. “Prior to moving forward with any LASIK surgery, it is imperative to pay careful attention to their maculas and look for basement membrane abnormalities that may suggest LASIK is problematic.” Other considerations include a family history of corneal disorders, diabetes and glaucoma.
Drug side effects. Some medications taken by older patients could pose a problem, Dr. Rubinfeld warned. He cited amiodarone (Cordarone), which is contraindicated in LASIK. Amiodarone is an antiarrhythmic that slows nerve impulses in the heart and acts directly on the heart tissues. The National Registry of Drug-Induced Ocular Side Effects cites a number of side effects associated with amiodarone, including photosensitivity, corneal microdeposits, hazy vision, glare and colored haloes around lights. “Probable” side effects can include corneal ulceration, interior subcapsular lens opacities and nonarteritic ischemic optic neuropathy.
Interestingly, according to Dr. Rubinfeld, amiodarone is even more dangerous in LASEK and PRK. “The bottom line is that the surgeon must be acutely aware of a patient’s medical history and any prescription drugs he or she is taking prior to doing any refractive surgery.”
Accommodation issues. Dr. Kornmehl leaves the nondominant eye undercorrected when doing a refractive surgery procedure on an older patient. He aims for giving them enough near vision to see a watch, name tag or price tag while reserving reading glasses for books and newspapers.
Dr. Rubinfeld noted that giving seniors monovision is an alternative to the presbyopia challenge. Seniors seem to adapt well, especially those who previously have worn contact lenses fitted for monovision.
Cataract surgery. Those patients who have already started developing cataracts may be better served with a cataract extraction followed by implantation of an accommodative IOL, Dr. Rubinfeld noted.
Dr. Davidorf added that advanced technologies are giving seniors with cataracts more options. “When we examine these patients,” he said, “we need to decide the degree of cataract, how LASIK will influence the developing cataract or how it will impact future cataract surgery. Do you choose a clear lens exchange or LASIK? A patient who is a low myope or a low hyperope or who has some astigmatism may make a great LASIK patient. However, if the patient is starting to exhibit some cataract formation, I lean toward clear lens exchange.”
Perhaps the most important aspect of refractive surgery and seniors is the very real possibility of cataract formation months or years following the procedure. Without question, said Dr. Rubinfeld, previous LASIK surgery skews calculating a subsequent IOL. To address this problem, he will often record a preoperative topography measurement prior to the LASIK procedure, and then keep this information on file. “This baseline measurement taken before the surgery can be extremely helpful for the IOL calculation down the road.”
Finally, for Dr. Davidorf, previous cataract surgery does not represent a contraindication for LASIK, LASEK or PRK in an otherwise healthy eye. He has performed refractive surgery on patients who have already undergone cataract surgery with good results.
You’re Probably Too Young
While Dr. Davidorf is an enthusiastic advocate of refractive surgery in select older patients, he expresses reservations about performing LASIK at the other end of the age spectrum, although he does see a place for it.
Dr. Davidorf was one of the first U.S. ophthalmologists to report a pediatric LASIK case in a peer-reviewed journal.1 The patient, who was intolerant to glasses and contacts, underwent LASIK to correct bilateral high hyperopia (+7.25 D) and 20/70 UCVA. Because her full correction was outside the limit of safety of hyperopic LASIK, a +5.25 D correction was performed, which left her intentionally undercorrected with +1.75 D of residual hyperopia and 20/25 UCVA.
“When we originally performed this procedure, the patient was a junior in high school. She made it all the way through college without needing glasses,” noted Dr. Davidorf. “However, we knew from the start that because of the undercorrection, she would eventually need re-treatment. And in fact, toward the end of college, she started noticing trouble with her reading.” Dr. Davidorf performed a re-treatment in both eyes for 2 D of hyperopia to address the undercorrection, and the patient continues to do well without needing glasses.
Dr. Davidorf also performed refractive surgery on a 7-1/2-year-old girl; she had treatment-resistant amblyopia, as well as high myopia and astigmatism in both eyes, although one was dramatically worse than the other. Dr. Davidorf did refractive surgery on the “bad” eye, bringing her vision from –15 D to –3 D. “A few years down the road,” he said, “she ran into a problem and experienced a retinal detachment that left her basically with only hand-motion vision. Was it caused by the LASIK? I don’t think so; it happened in her ‘good,’ untreated eye.” While the retina was eventually reattached, the girl’s vision has not as yet improved. “Essentially, her bad eye [which Dr. Davidorf treated] became her good eye,” he said.
Despite these successes, Dr. Davidorf continues to “totally agree” with the Preferred Practice Pattern that states younger age (especially under age 18) is a contraindication for LASIK. “Refractive surgery continues to be experimental and only benefits a select group of children. However, we are lagging behind on conducting research in children. Yet for some, refractive surgery represents a vision-saving alternative that should be considered.”
Considerations in Children
Jennifer L. Simpson, MD, views refractive surgery as a “potentially useful” tool for children with severe anisometropic amblyopia who fail conventional treatment modalities. “To date, roughly 15 clinical case studies have been published that report results of refractive surgery” in such patients, Dr. Simpson said. “While these preliminary data are promising,” she noted, she cautioned that the studies “need to be confirmed in a randomized, prospective comparison with the current standard of care of spectacle and/or contact lens correction.”
In considering pediatric refractive surgery, Dr. Simpson pointed out that “children’s eyes are not little adult eyes—they respond differently to surgical manipulation. This is especially true following pediatric penetrating keratoplasty and pediatric cataract surgery.” She also noted that “the rates of both graft rejection and posterior capsular opacification are much higher in the pediatric than the adult population.”
Dr. Simpson added, “We simply don’t have enough data to conclude that a pediatric cornea responds in a similar manner to refractive surgery as an adult cornea, so we can’t draw the same conclusions about the safety and efficacy of refractive surgery in children that we can for adults.”
Would Dr. Simpson ever consider refractive surgery in a child? “To date, I would only consider it in a child with severe anisometropic amblyopia who could not tolerate contact lenses or glasses and who would otherwise have essentially nonfunctioning vision in that eye. But the best way to answer this question is with a prospective randomized study.”
You’ll Just Have to Wait
Finally, there is a group of patients whose eyes are not quite ready for LASIK yet who are old enough to make a legal decision to undergo surgery: those individuals between the ages of 18 and 24. “While refractive surgery is approved for patients age 18 and above, the only ones I will do at that younger age are professional athletes or someone with an unusual circumstance,” said Dr. Kornmehl. “For example, I treated a young Harvard student with Tourette’s syndrome who could not tolerate glasses or contact lenses.”
Dr. Rubinfeld agreed with Dr. Kornmehl, although he makes exceptions for certain occupational requirements—for instance, an individual who plans to become a pilot in the military or wants to join a law enforcement agency.
Dr. Kornmehl added, “If someone needs the surgery for a job, that is one thing. However, while individuals attend college, we know that their eyes are inevitably going to change and they will need an enhancement down the line. We explain to these young patients that their eyes are likely to change and they should not undergo this surgery until there is a greater stability. Nine times out of 10, they will understand the wisdom of waiting and choose to return when they reach their mid-20s.”
While there are no concrete guidelines on refractive surgery at both ends of the age spectrum, it is a topic that can no longer be ignored. Younger people who are resistant to traditional treatment may benefit from advanced technologies. And an older population who continues to defy the stereotypes of aging will persist in demanding access to the latest refractive surgery alternatives.
To address the changing needs of pediatric patients, Dr. Davidorf has developed a personal framework when considering refractive surgery. He said refractive surgery might be a viable alternative in pediatric patients under 7 years of age with anisometropic amblyopia who are intolerant to spectacle and contact lenses, and patients over age 7 with significant anisometropia, refractive accommodative esotropia or higher corrections who have contact lens intolerance.
Dr. Rubinfeld, when assessing the future needs of older patients, takes a broad perspective. “In the not-too-distant future, maintaining good vision over the course of decades will involve more than one procedure in a lifetime,” he predicted. “This is an inevitability that we must address, especially as the Boomers continue to redefine youth and aging.”
1 J Cataract Refrac Surg 2000;26(11):1567–1568.
Meet the Experts
Jonathan M. Davidorf, MD Director of the Davidorf Eye Group, West Hills, Calif.
Ernest W. Kornmehl, MD Medical director of Kornmehl Laser Eye Associates, Brookline, Mass.
Roy S. Rubinfeld, MD A corneal specialist with Washington Eye Physicians, Washington, D.C.
Jennifer L. Simpson, MD Assistant professor of ophthalmology at the University of California, Irvine.