LASIK and Age:

Pushing the Limits

By Lori Baker Schena
Can you ever be too old or too young for LASIK? The answer is changing.

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.

Dont 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.

Rethinking Age
Roy S. Rubinfeld, MD, echoes Dr. Kornmehls 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 proceduresa 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 wont 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 hasnt 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.

Youre 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 livesfrom tennis to boatingwould 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. Kornmehls
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 patients 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.

Youre 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 dont think so; it happened in her
good, untreated eye. While the retina was eventually reattached, the girls 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 childrens eyes are not little adult
eyesthey 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 dont have enough data to conclude that a pediatric cornea responds in a
similar manner to refractive surgery as an adult cornea, so we cant 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.

Youll 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 Tourettes syndrome who could not tolerate glasses or contact lenses.

Dr. Rubinfeld agreed with Dr. Kornmehl, although he makes exceptions for certain occupational
requirementsfor 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.

Bottom Line
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.

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1 J Cataract Refrac Surg 2000;26(11):15671568.