Patient Satisfaction After LASIK

LASIK satisfaction under the magnifying glass

Lee T. Nordan, MD: "Happy usually means that the patient’s visual function is poorer than desired, but he isn’t complaining … today."

The LASIK industry reports that most patients are satisfied with their visual outcome after LASIK. However, a large percentage of "satisfied" patients report troubling "side effects" such as chronic dry eyes and night vision problems. Were these patients adequately warned about the frequency of these complications? Are these patients satisfied with the trade-off... dry eyes and poor night vision in exchange for reduced dependency on glasses and/or contacts? Or are these patients in denial, experiencing the psychological phenomenon of cognitive dissonance?...

Patient initially considers LASIK a miracle, but later develops post-LASIK ectasia

Excerpt: After hearing about the results of her surgery, I became quite excited about getting rid of my myopia and being able to look at my son in the mornings without having to wear glasses. So I went to get Lasik, with supposedly one of the best Lasik surgeons in Austin... I deemed the surgery a miracle. Within minutes I had 20/10 vision in my left eye and 20/20 vision in my right eye. Sadly within 2 years of the surgery, I developed mild astigmatism... He did not tell me 1) that the astigmatism was caused by the surgery and 2) that I had developed ectasia...

Read comment #615 on the online petition to stop LASIK

"What happens if you don't succeed, if you turn off patients? General marketing studies show that an unhappy customer will complain to 11 people and 13% will complain to more than 20. About 95% of these unhappy patients never let the company know."

Tom Harbin, M.D. What Every Doctor Should Know But Was Never Taught In Medical School. 2011

Surgeon blames poor LASIK outcomes on patients' minds

Quote: Marguerite McDonald, MD, said that while patients can be ablated perfectly, some will simply never be happy. "Some patients have 20/20 vision but 20/400 minds," Dr. McDonald said. She suggested that surgeons need to evaluate their patients closely to see who will make good candidates, not just physically but psychologically as well.

Source: Michael J. Walsh, OCULAR SURGERY NEWS U.S. EDITION. Some foresee limitations in wavefront technology. August 1, 2002.

Patient initially 20/15 and thrilled, now regrets having LASIK - email to webmaster 7/19/2011

I had LASIK eye surgery done in September of 2005 by Dr. [redacted] in Commack, NY. I had 20/15 vision after the surgery, and I was thrilled. About five years after the surgery I began having trouble seeing. I have been to four eye doctors over the last several months, and I cannot seem to fix this problem. I have developed an astigmatism, and I see blurry all the time. My night vision is especially bad. I am so annoyed and frustrated about this. Many people are telling me the astigmastism probably developed from the surgery. I have glasses that help, but I cannot find a contact lens that fits properly now, and I have tried 4 lenses already. I wish I would have never gotten LASIK, and just kept my vision the way it was six years ago. I am so frustrated now with tyring to treat this.

"95% of LASIK patients are satisfied" is a deceptive marketing soundbite - Get the facts

Excerpt: Solomon et al report; "Although this database [of 19 articles] also includes information on visual outcomes, night vision symptoms, and dry eyes, for the purpose of this paper, the analysis of the database focuses specifically on patient satisfaction and quality of life." In other words, the authors chose not to disclose complication rates. Only two articles in the literature review actually report quality of life after LASIK... All levels of satisfaction in this review, ranging from "very" to "somewhat" were grouped and reported as "satisfied" patients. An inspection of articles cited in the 'global LASIK literature review' reveals alarmingly high LASIK complication rates...

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Dr. Leo Maguire of the Mayo Clinic warns that "happy" LASIK patients may have degraded vision

From the article: "A [LASIK] patient may simultaneously be happy with the result of surgery and have degraded vision – how can refractive surgery be a potential public health problem if patients are happy with the results? Inherent in this question is the assumption that a patient without complaint is a patient without optical degradation. That argument does not hold up to closer scrutiny. The [LASIK] literature contains disturbing examples of patients who have visual handicaps that place themselves and others at significant risk for nighttime driving accidents and yet they are happy with the results".

Source: Maguire LJ. Keratorefractive surgery, success, and the public health. Am J Ophthalmol. 1994 Mar 15;117(3):394-8.

LASIK patient extremely satisfied, develops corneal ectasia years later

"When I woke up the next morning I felt like it was the greatest thing I'd ever done in my life -- never have to wear glasses again. This is a good thing... Over the years the surgery apparently is falling apart, declining..."

Patient with 20/15 vision initially after LASIK - Five years later reports problems to the FDA

"I had LASIK eye surgery done by Dr. [redacted] in [redacted] in [redacted] 2005. I had 20/15 vision after the surgery, and I was thrilled. About five years later, I developed blurry vision and now have a lot of trouble with my eyes. I have developed an astigmatism, and I have been having a lot of trouble getting this corrected. I have been to four eye doctors over the last six months."


Classic example of a "successful outcome" after LASIK - Patient reports adverse outcome to the FDA

"I had LASIK surgery nine years ago performed by a Dr [redacted]. At first it was great, I could see 20/20 if not better. However, I never felt comfortable driving at night because as a result of the surgery, I had difficulties with white signs appearing very blurry, as well as the halos and so forth. After three years, I required glasses to drive. My prescription has continued to increase, requiring me to where glasses all the time. In addition, I do not drive at night, even with the glasses, unless extremely necessary. I can not see at night - it's terrible-."


"Initially all seemed fine"... now right eye "technically blind" - Reported to the FDA

"I had LASIK procedure performed [in] 2007 on both eyes. I was astigmatic and suffered from myopia. After undergoing topography, my doctor confirmed I was fit to undergo LASIK procedure. Initially, all seemed fine and I was convinced my surgery was a true success. Unfortunately, I started losing vision on my right eye 3 months after the seemingly successful procedure. All along I never missed any appointment with my doctor and he assured me I was fine and need no worry as what I was experiencing was normal and a reflect of my brain. Unfortunately the condition continued to deteriorate and 2 yr after undergoing the procedure, my doctor claimed I suffered from keratokonus. I sought second and third opinion from other specialist and both have concluded I suffer from post-LASIK corneal ectasia. I returned to my doctor who advised me to undergo cornea cross linking in order to stop further progression of ectasia. I believe I am a victim of misinformation and unnecessary surgery which has rendered my right eye technically blind. I am hoping there is a way I can restore my vision to return to normal life. I regret going for the LASIK procedure and believe this technology is not safe and cannot be guaranteed."


Letter to the Editor 1/31/2010

Happy LASIK patients may not realize or acknowledge the harm they suffered from LASIK for years; nonetheless, the damage is there. Medical research demonstrates (a) that the LASIK flap never heals and may be accidentally dislodged for the rest of a patient's lifetime, (b) that the cornea is permanently weakened and may develop ectasia weeks, months, or years later, leading to vision loss, (c) that corneal nerves which stimulate tear production are severed and destroyed during LASIK, and that these nerves never fully recover -- potentially leading to permanent dry eye disease, (d) that having LASIK causes problems in the future for glaucoma screening and cataract surgery -- prompting the FDA to recommend that LASIK patients obtain a copy of their LASIK medical record, (e) persistent decrease in corneal cells (keratocytes) -- it is unknown how this decrease affects long-term viability of the cornea, and (f) that visual quality at night is permanently reduced after LASIK, even when the patient has 20/20 or better daytime vision. To add insult to injury, visual outcomes of LASIK decline over time. "LASIK success" is like saying "the surgery was a success but the patient died".

Patient suffers flap dislocation in both eyes, reported to be "very happy".

A 31-year-old white man came for consultation seeking refractive surgery... The procedure was uneventful in both eyes. Two hours after surgery, the patient returned because of a sudden loss of vision in the right eye. The flap was inferiorly dislocated, presumably because of an unknown blunt trauma. Immediately, the flap was replaced surgically and a bandage contact lens applied. One hour later, a similar complication occurred in the left eye and the same therapeutic strategy was used. At the first consultation 24 hours later, the patient was very happy... Slitlamp examination showed a completely normal left eye; however, long striae and peripheral folds were seen in the right eye.

Source: Consultation section. Refractive surgical problem. Flap dislocation. J Cataract Refract Surg. 2009 Jul;35(7):1317-8.

Patient reports bad outcome to the FDA after reporting satisfaction to the surgeon

I had lasik eye surgery from Dr. [redacted]. In 2006. It was the biggest mistake of my life. Here is a list of my concerns: - my last checkup occurred last year, and I still remained at 20/15 on my right eye and 20/20 on my left eye. This is very misleading as things over 20 feet are blurry. They're especially blurry in medium to low lighting... I thought since 20/20 was very likely, my vision could remain perfect at far from it. My vision also fluctuates depending on how much rest I get...The treatment zone simply did not cover my entire eye. I have big pupils... The outer area of my pupils remains untreated. I was not warned of this... I was simply warned about the possibility of getting starbursts and halos. I have a severe case of both... dry eyes are a constant problem for me. I've experienced loss of sleep and lack of sleep, due to extreme dryness that wakes me up or severe crust formations that did not exist before surgery... I have to put several eye drops a day- probably for the rest of my life. This is very costly, embarrassing, and bothersome. - I had red eye for about one month on my left eye. I had no idea that this could happen. It was very embarrassing to have it when I wanted to prove to co-workers and friends that lasik was safe and recommendable, but was I simply showing them proof that I made a mistake. The reputation of my judgement has probably been significantly damaged. -it takes a long time focusing on different distances. If I'm reading something and look up to something, it takes seconds to focus on it. This was always instant before. I was not warned of this. -the stats provided by the media and the ads are absurd. My surgeon asked me if I was glad to have done the surgery the day after. I said I was. He may have put that on record. No one's asked my how I'm doing now. Based on my own personal survey of people having done the surgery, most have regrets.

Read full report

Ophthalmologist comments on citizen petition to ban LASIK


Effect of the Euphoria Period

When first liberated from glasses and/or contact lenses, patients are understandably astonished and euphoric over their ability to navigate through life without optical correction. Many of the superlatives applied by patients are garnered during this early post-operative period. Poor contrast sensitivity, night vision difficulties, and pain from dry eye symptoms are dismissed as expected, short term issues which do not (yet) detract from satisfaction with the final outcome. Refractive surgeons who perform their final patient examination less than 6 months after surgery have no experience with long-term patient satisfaction or the frequency of permanent vision difficulties which interfere with daily function. Sporadic reports from co-managing optometrists are not sufficient to create a detailed professional understanding of these issues. Therefore, the personal anecdotal experience of typical high volume refractive surgeons is suspect, since most do not follow their patients long-term.

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LASIK Surgeon, Stephen S. Lane, Personal Account of LASIK

From the article: Roughly 7 or 8 years ago, I decided to undergo LASIK... I am 100% satisfied with both my decision to undergo LASIK and my postoperative results... My contrast sensitivity is worse since undergoing LASIK. On sunny days, I see very well, but I notice a distinct decrease in my contrast sensitivity when the skies are overcast. I have minimal halos and glare, and my decrease in contrast does not affect my ability to perform surgery. I experience mild dry eye periodically, but I do not consider the problem bothersome enough to merit regular treatment. This dry condition has not changed significantly from the third month postoperatively. I keep artificial tears handy at all times, especially when I travel on an airplane. On average, I use artificial tears a couple of times a day, three or four times a week. Occasionally, I wake in the morning with symptoms of dry eye. The problem also occurs when I work late. If necessary, I will use a topical steroid to make my eyes more comfortable when they are feeling particularly dry... I would undergo the procedure again without hesitation.

Link to article

Eye (Lond). 2011 Jul 1.
Visual and non-visual factors associated with patient satisfaction and quality of life in LASIK.
Lazon de la Jara P, Erickson D, Erickson P, Stapleton F.

From the article: Some dissonance has been found between high levels of satisfaction and the presence of visual disturbances, especially night vision symptoms with refractive surgery, as in one study, a third of patients experienced night vision symptoms yet almost all subjects responded that they would recommend laser in situ keratomileusis (LASIK) to a friend...

The Cognitive Dissonance Theory refers to a psychological process that creates a change in attitudes and behaviour to maintain a cognitive consistency towards their beliefs. This effect will be more pronounced when patients pay a fee for the operation, and the surgery is irreversible, although, if the surgery involves new technology, the placebo effect will increase.

Note: In the following case report, the patient developed ectasia, a devastating complication which may require corneal transplantation. This is a perplexing example of patient satisfaction in spite of a serious, sight-threatening complication.

Journal of Cataract & Refractive Surgery
Analysis of ectasia after laser in situ keratomileusis: Risk factors
Volume 33, Issue 9, Pages 1530-1538 (September 2007)
Perry S. Binder

From the article:
Two contralateral eyes developed ectasia 2 years after LASIK (Figure 1). This patient was still satisfied with the surgery as the least involved eye has 20/30 uncorrected visual acuity.

J Refract Surg. 2002 Jul-Aug;18(4):454-9.
An informal satisfaction survey of 200 patients after laser in situ keratomileusis.
Hill JC.

PURPOSE: Patient satisfaction following laser in situ keratomileusis (LASIK) is commonly reported as high. This paper reviews the outcome of LASIK both in terms of visual results and satisfaction.

METHODS: Two-hundred patients were surveyed telephonically to establish their degree of satisfaction with LASIK and to enquire about postoperative use of glasses, and symptoms of light sensitivity and of night vision problems. Patient anonymity was assured.

RESULTS: The majority of patients (95%) never wore distance glasses after LASIK. Reading glasses were used by 49 (24.5%), related to age and presbyopia. Light sensitivity was not a problem or was unchanged from baseline in 73% of patients; 27% said they were worse; a few (5.5%) said their symptoms were better. Night vision was not a problem or was unchanged from baseline in 76% of patients; 24% said they were worse; 17% said their symptoms were better. One hundred ninety-five patients (97.5%) were extremely happy with their results and 197 (98.5%) would have the procedure again.

CONCLUSION: After LASIK, 95% of 200 patients wore no distance optical correction; 99% would have the procedure again; and light sensitivity and night vision problems bothered a significant number of patients.

From the full text:

The third patient was a 56-year-old male with anisometropia who had one eye corrected. His refraction before LASIK was OD plano with visual acuity of 20/20, OS -4.50 -6.00 x 25, BSCVA 20/50. After LASIK, the eye had 20/60 unaided. BSCVA was 20/50. He still wore distance and reading glasses occasionally, he was moderately light sensitive but not more than before LASIK. He had severe night problems that were considerably worse than before, nevertheless he was extremely happy (4+) with the outcome despite stating he would not have it again.

J Cataract Refract Surg. 2007 Feb;33(2):191-6.
Eleven-year follow-up of laser in situ keratomileusis.
Kymionis GD, Tsiklis NS, Astyrakakis N, Pallikaris AI, Panagopoulou SI, Pallikaris IG.
Department of Ophthalmology, and Institute of Vision and Optics, University of Crete, Crete, Greece.

PURPOSE: To report the long-term (11-year) outcomes (stability and complications) of laser in situ keratomileusis (LASIK) in patients with high myopia. SETTING: University refractive surgery center.

METHODS: Seven patients (4 with bilateral treatment and 3 with unilateral treatment) who had myopic LASIK and completed 11 years of follow-up were included in the study.

RESULTS: The mean age of the 2 men and 5 women was 41.7 years +/- 6.5 (SD) (range 34 to 50 years). The mean follow-up was 140.18 +/- 6.70 months (range 132 to 150 months). At 11 years, the spherical equivalent error was statistically significantly reduced, from a mean of -12.96 +/- 3.17 diopters (D) (range -19.00 to -10.00 D) before LASIK to a mean of -1.14 +/- 1.67 D (range -4.25 to 1.00 D) after (P<.001). Predictability of postoperative refraction 6 months and 11 years after LASIK showed that 6 eyes (55%) were within +/-1.00 D of intended correction. No late postoperative complications occurred. Five patients (8 eyes, 73%) were satisfied with the final outcome.

CONCLUSIONS: Laser in situ keratomileusis was moderately predictable in the correction of high degrees of myopia. After the sixth postoperative month, refractive and topographic stability were obtained. No long-term sight-threatening complications occurred during the follow-up period.

From the full text:

Unexpectedly, 5 patients, representing 73% of eyes, reported being satisfied with the final outcomes despite the increased incidence (82%) of night-vision problems and the moderate predictability.

Results similar to ours have been reported in published long-term follow-up studies of LASIK. Six years after LASIK, Sekundo et al.6 reported an increase in patients' satisfaction score (75%) despite the high incidence of cut failures (15%) and night-vision problems (75%) and the low predictability of attempted corrections.

CLAO J. 2001 Apr;27(2):84-8.
Patient satisfaction after LASIK for myopia.
Miller AE, McCulley JP, Bowman RW, Cavanagh HD, Wang XH.
University of Texas Southwestern Medical Center at Dallas, USA.

PURPOSE: To determine satisfaction among patients treated with laser-in-situkeratomileusis (LASIK) for various degrees of myopia (-0.75 D to -16.00 D) and myopic astigmatism (+0.50 D to +4.50 D) and assess factors which may affect satisfaction.

METHODS: One-hundred seventy-four consecutive patients treated with LASIK between November 1, 1997 and October 31, 1998 were surveyed. Charts were reviewed to collect refractive data.

RESULTS: Eighty-three patients (163 eyes) returned surveys for a response rate of 53%. Of the responders, 55% were female, the average age was 39.6 years (range 21-59), the mean preoperative sphere was -6.36 +/- 0.23 D, cylinder +0.94 +/- 0.07 D, and spherical equivalent-5.89 +/- 0.23 D. Ninety-six percent of eyes enjoyed freedom from corrective lenses following LASIK. Twenty-nine percent reported reduced night vision clarity following LASIK and 27% noted more eye dryness following LASIK. Overall, 84.8% were at least "very pleased" with the results of the procedure and 97% indicated that they would decide again to have LASIK. Uncorrected visual acuity and lower preoperative cylinder correlated positively with satisfaction, while increased postoperative dry eyes correlated negatively with satisfaction.

CONCLUSIONS: This study demonstrates a very high level of patient satisfaction following excimer laser treatment for myopia and myopic astigmatism. A great deal of literature has evaluated objective outcomes of LASIK, but this is one of few studies to examine patient satisfaction.

Note: The patient in this case report has considerable compound myopic astigmatism after LASIK. The surgical goal of reduced dependency on glasses or contact lenses was not achieved. This patient's outcome does not meet the definition of a "successful" LASIK by anyone's standards, yet the patient claims to be satisfied.

J Refract Surg. 2007 Nov;23(9):937-40
Fifteen-year follow-up after LASIK: case report.
Kymionis GD, Tsiklis N, Pallikaris AI, Bouzoukis DI, Pallikaris IG.

PURPOSE: To present 15-year follow-up of one of the first LASIK-treated patients.

METHODS: A 40-year-old woman underwent LASIK in the left eye for myopia in July 1991.

RESULTS: Fifteen years after LASIK, spherical equivalent error was statistically significantly reduced from preoperative -8.75 -3.75 x 025 degrees to postoperative -4.25 -2.75 x 010 degrees. Six months postoperatively, refractive and topographic stability was obtained and remained stable during follow-up with no significant changes between interval mean time (-3.75 -3.00 x 020 degrees 6 months postoperatively to -4.25 -2.75 x 010 degrees 15 years postoperatively). No early or late postoperative complications were observed, and confocal microscopy revealed a regenerated nerve plexus and normal cornea. However, increased scattering and presence of debris were observed at the flap interface even after 15 years. Despite moderate predictability (residual refractive error) and small optical zone, the patient was satisfied with final outcome.

CONCLUSIONS: One of the first LASIK-treated patients was presented 15 years after surgery. LASIK in this patient had low predictability, although refractive and topographic stability occurred after the sixth postoperative month. No long-term, sight-threatening complications were identified during follow-up.

From the full text: "Unexpectedly, the patient was satisfied with the final outcome despite considerable residual compound myopic astigmatism."

J Cataract Refract Surg. 2005 Oct;31(10):1943-51.
Functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia.
Tahzib NG, Bootsma SJ, Eggink FA, Nabar VA, Nuijts RM.

From the article:
" A total of 92.2% of patients were satisfied or very satisfied with their surgery, 93.6% considered their main goal of surgery achieved, and 92.3% would choose to have LASIK surgery again. Satisfaction with uncorrected vision was 3.03 +/- 0.71. The mean score for glare was 3.0 +/- 0.9. At night, glare from lights was believed to be more important than before surgery by 47.2%. Glare from oncoming car headlights after surgery was reported by 58.4% and was believed to be more bothersome for night driving than before surgery by 52.8%. Night driving was rated more difficult than before surgery by 39.4%, whereas 59.3% had less difficulty driving at night."

J Cataract Refract Surg. 2005 Dec;31(12):2313-8.
Sensitivity of the National Eye Institute Refractive Error Quality of Life instrument to refractive surgery outcomes.
Nichols JJ, Twa MD, Mitchell GL.

From the article:
"One might also predict these 2 groups to report a significant difference in glare. However, the design of the clinical trial for these LASIK patients limited enrollment to those who were unlikely to experience this problem (ie, low to moderate myopia and pupil sizes less than 7.5 mm)."

Cesk Slov Oftalmol. 2006 May;62(3):206-17.
Effect of lasik on objective and subjective visual functions in patients with myopia
Hejcmanova M, Horackova M.
Ocni klinika, LF MU, FN Brno-Bohunice.

PURPOSE: To determine the effect of laser in situ keratomileusis (LASIK) on visual functions: visual acuity (VA) and contrast sensitivity (CS) and to evaluate functional complaints.

PATIENTS AND METHODS: Prospective study includes results of VA and CS preoperatively and 1, 3, 6 and 12 months after the surgery in patients with middle and high myopia. 105 eyes of 53 patients (37 females, 16 males) were divided according to spherical equivalent into 2 groups: group A (more than -5D, 51 eyes) and group B (less than -5D, 54 eyes). Mean patients'
age was 28,2 years. Visual acuity was measured on log MAR charts. Contrast sensitivity at spatial frequency of 3, 6, 12 and 18 c/deg was tested using CSV 1000 Contrast sensitivity Unit. Influence of glare on CS was determined by BAT (Brightness Acuity Tester). Functional complaints were evaluated using a wide-ranging questionnaire focusing on 4 main topics.

RESULTS: Visual acuity preoperatively in both groups was significantly decreased in comparison to controls. A considerable decrease can be detected at 1 month postoperatively but later (1 year after the surgery) it reaches the values of 1.02. Postoperatively, a significant decrease of CS can also be detected, above all at intermediate spatial frequencies. During postoperative period, values of CS slowly increase in both groups. However, only in group B (with less than -5D), the preoperative values have been reached. Further, glare has decreased CS at spatial frequency of 6 c/deg, i.e. the most sensitive spatial frequency for human eye. The satisfaction with final outcome has reached 91%. However, some patients (14%) reported reduced vision under dim illumination and at night and also difficulty with night time driving.

CONCLUSIONS: Our study suggests that both used methods (VA and CS) are very sensitive to evaluation of visual functions after refractive surgery. Changes of contrast sensitivity can reveal even slightly changed optic factors of cornea that can
cause subjective complaints of patients.

LARRY JOACHIM Sugar Land, Texas:

"My eyesight before LASIK was about 20/900--which amounts to being legally blind. Three weeks after LASIK, I am at 20/50. I'm using artificial tears pretty regularly, but I am thrilled that I can see what I could not before. Was I expecting better? Sure! Am I satisfied? You bet!"


OSN SuperSite Breaking News 9/18/2006
At 5 years, LASIK patients remain happy with results

From the article:
Of those who responded to the questionnaire, 6.2% indicated they had worse vision now than before LASIK, and 21% said their night vision was worse than it was before. "But when you ask people if they would do laser again, everyone, bar none, said they would do it again, and 100% said they would refer a friend," Dr. Cummings said.

J Cataract Refract Surg. 2004 Sep;30(9):1861-6.
Reasons patients recommend laser in situ keratomileusis.
Bailey MD, Mitchell GL, Dhaliwal DK, Wachler BS, Olson MD, Shovlin JP, Pascucci SE, Zadnik K.
Ohio State University College of Optometry, Columbus, OH 43210, USA.

PURPOSE: To evaluate the reasons patients who have had laser in situ keratomileusis (LASIK) recommend it to others and examine the disparity between high levels of satisfaction and patient reports of night-vision symptoms and/or dry eye after LASIK.

SETTING: Northeastern Eye Institute, Scranton, and the University of Pittsburgh, Pittsburgh, Pennsylvania, and the University of California at Los Angeles, Los Angeles, California, USA.

METHODS: Questionnaires assessing symptoms and satisfaction after LASIK were mailed to 2,100 patients. The questionnaires included items about nightvision symptoms and satisfaction and an open-ended question for patients to give their reasons for recommending LASIK to others. The open-ended responses were categorized and tabulated.

RESULTS: Four hundred thirty-four patients provided reasons for recommending LASIK to others. Sixteen categories of reasons were identified. "No more spectacles/contact lenses" was listed by 180 patients (42%), followed by "better vision" (21%) and "convenience" (15%). Women were significantly more likely to cite "better comfort" (27 women versus 3 men; chi square = 8.99, P =.003) and "better quality of life" (41 women versus 9 men; chi square = 7.36, P =.007) as a reason for recommending LASIK. Of the 35 patients who reported dissatisfaction with post-LASIK vision, 20 (57%) would recommend LASIK to a friend because "LASIK helps others."

CONCLUSIONS: Categories of reasons for recommending LASIK to others were similar to reasons given by patients for seeking LASIK. Some patients who reported dissatisfaction with their vision said they would recommend LASIK, suggesting that recommendation of LASIK to others is not necessarily a measurement of the quality of a patient's vision after LASIK.

From the full text:

Previous investigations have characterized patient satisfaction and complaints, such as night-vision symptoms and dry eye, after laser in situ keratomileusis (LASIK).1, 2, 3, 4, 5, 6 Although night-vision symptoms have been reported in 12% to 57% of patients3, 4, 5, 6, 7, 8, 9 and dry-eye symptoms have been reported in 4% to 9%,2, 10 post-LASIK satisfaction remains very high. For example, Hill6 reported that 15 (7.5%) of 200 patients considered their night-vision symptoms to be “considerably worse” than before LASIK. Yet, 195 of them (97.5%) reported they were “extremely happy” and only 1 reported being “slightly unhappy.” Similar disparities have been reported after photorefractive keratectomy (PRK). Brunette et al.11 found that 31.7% of PRK patients reported a decrease in night vision; nevertheless, 91.8% were satisfied or very satisfied with their surgery. In a previous study,9 we characterized the factors associated with nightvision symptoms and decreased satisfaction following LASIK. We also found a disparity between the relatively frequent report of postoperative night-vision symptoms and high patient satisfaction. Ninety-seven percent of patients in our sample of LASIK patients would recommend LASIK to a friend.9 When asked to rate satisfaction with their vision, patients reported a median score of 100% of the maximum value on the visual analogue scale (mean 87.2%). Yet, 30.0% reported halos, 27.2% reported glare, and 24.5% reported starbursts when asked about these symptoms in a questionnaire. While this disparity can be explained by assuming that the symptoms were not severe enough to adversely affect satisfaction reports, there may be other explanations.

The purpose of this study was to further investigate explanations for this disparity by examining and categorizing the reasons post-LASIK patients say they would recommend LASIK to a friend. We also looked for associations between categories of reasons for recommending LASIK and factors known to be associated with an increase in postoperative night-vision symptoms and decreased satisfaction after LASIK. There is more than 1 plausible explanation for the disparity between the relatively common frequency of postoperative complaints and the high levels of satisfaction after LASIK. The first is that the night-vision symptoms and symptoms of dryness after LASIK are mild relative to the benefits of LASIK, so patient satisfaction remains high. There are, however, other explanations.

The discrepancy between symptoms and satisfaction has also been reported after PRK. Brunette et al.11 conclude, “[Patients'] self-conditioning to the belief in the success of this expensive and irreversible surgery was not assessed in the present study. However, if such a psychological process prevailed, one would expect patients to deny the secondary effects such as glare and night vision problems. This was not the case here. Patients may simply adapt to their new condition.” The idea that patients may adapt to their new condition is a second explanation for the disparity between symptoms and satisfaction. The third explanation for this disparity is one that is dismissed by Brunette et al. Although a specific “psychological process” is not mentioned in their report, they may be referring to a process called cognitive dissonance. The theory of cognitive dissonance suggests that individuals need to have consistency among their attitudes or beliefs.15 The theory can apply to many types of decisions, ie, purchases and surgical procedures, and the effects of cognitive dissonance have been investigated in nonocular surgical procedures.16, 17 Certain criteria are required for dissonance to be induced following a decision.18 First, the decision must be important and the consumer/patient must have invested substantial money or psychological cost. Second, the consumer/patient must freely choose to make the purchase or have the surgical procedure. Finally, the commitment must be irreversible. It is evident that the LASIK procedure meets all 3 criteria for inducing cognitive dissonance in patients who have post-LASIK complications/side effects. Homer and coauthors17 predict that cognitive dissonance might have less effect on specific questions about symptoms and a greater effect on questions about the overall success of the surgical procedure, such as whether the patient would have the procedure again or recommend the procedure to others. This prediction is supported by our previous study in LASIK patients and by Brunette et al.9, 11 Cognitive dissonance should be explored in future studies as an explanation for the disparity between the relatively frequent occurrence of postoperative symptoms and the high levels of satisfaction.

J Cataract Refract Surg. 2003 Jun;29(6):1152-8.
Six-year follow-up of laser in situ keratomileusis for moderate and extreme myopia using a first-generation excimer laser and microkeratome.
Sekundo W, Bönicke K, Mattausch P, Wiegand W.
Department of Ophthalmology, Philipps-University Marburg, Germany.

PURPOSE: To evaluate objectively and subjectively the long-term outcome of laser in situ keratomileusis (LASIK) in patients with high and very high myopia.

SETTING: Department of Ophthalmology, Philipps University, Marburg, Germany.

METHODS: Thirty-three eyes of 19 patients were followed for a mean of 76 months (range 50 to 84 months) after primary LASIK using the Keratom I excimer laser (Schwind) and the ALK microkeratome (Chiron). Refraction, glare, pachymetry, corneal topography, and tear-film secretion and stability were measured. At the last examination, patients also answered a 14-item questionnaire.

RESULTS: Preoperatively, the mean spherical equivalent was -13.65 diopters (D). At 1 year, it was -0.25 D and after 6 years, -0.88 D. Fifteen percent of eyes lost > or =2 lines of best spectacle-corrected visual acuity (BSCVA), and 9% gained > or =2 Snellen lines. At the end of the study, 46% of eyes were within +/-1.0 D of the attempted corrected and 88% were within +/-3.0 D. There were 5 microkeratome-associated complications; 3 resulted in loss of BSCVA. The latest pachymetry showed a mean corneal thickness of 498.5 microm (range 396 to 552 microm). There were no cases of keratectasia. Seventy-five percent of patients noted an increase in their quality of life. Seventy-one percent were satisfied with their postoperative visual acuity; however, 75% noticed glare and halos at night.

CONCLUSIONS: Laser in situ keratomileusis correction of very high myopia did not cause keratectasia in the long term provided the corneal thickness was respected. A flap thickness setting of 130 microm with a first-generation microkeratome resulted in a high number of cut failures. Most patients were happy with the results despite a modest level of accuracy and glare.

From the full text:
"On a scale of 0 to 10 for current satisfaction with one’s visual acuity, the mean score was 5.7. Scores from 0 to 4 were considered “being unhappy”; 29% of patients were not happy with their UCVA. This percentage was smaller than that immediately after surgery, 35%. Eighty-one percent noticed an improvement in their UCVA after surgery as opposed to the time before LASIK. Twenty-eight percent of patients described their BSCVA as “worse than before surgery and 72%, as better or unchanged. The preoperative refraction of patients who were dissatisfied with their BSCVA was –12.0 D."

"There were no microkeratome-associated complications in this group; however, 2 eyes of the same patient developed severe
dry-eye disease and peripheral epithelial ingrowths and 2 eyes had decentrations of 1.5 mm and 2.0 mm. After almost 7 years, 75% continued to complain of ghosting images and/or halos. Patients who graded their halos between 8 and 10 also felt a decline in their BSCVA (see above) and had irregular flaps due to cut failures or a preoperative refraction greater than –15.0 D. However, 81% of all patients questioned said they would recommend the surgery to friends and would have the surgery again."

"Our study highlights the problems of quality of vision. Often, Snellen acuity, particularly after enhancements, is given as a measure of success.11, 12 Nevertheless, 75% of our patients have glare at night, with the worst symptoms in patients who had decentrations, cut problems, or treatments over –15.0 D with subsequent flat corneas down to 32.5 D in 1 extreme case. Our decentration rate of >0.5 mm was 15%. This relatively high number can be the result of using retrobulbar anesthesia and pilocarpine in contrast to patient self-fixation supported by the eye-tracker technology of modern lasers. Objectively, virtually all patients in this study had poor mesopic vision. Moreover, our study leaves no doubts that this problem continues to persist in the long term and possibly forever."

"A question still to be answered is why 81% of patients appeared to be quite happy with the overall results when all of them had poor night vision."

"Nearly a quarter to a third of patients that underwent LASIK surgery reported problems seeing at night, a new study suggests. Even so, 97 percent of the subjects said they would recommend LASIK to a friend."

"The researchers sent questionnaires to 605 patients, asking if they were satisfied with the surgery or if they had nighttime vision problems. They also examined the patients' medical charts. All subjects in the study had at least six months of recovery time."

"Ninety-seven percent of the patients in the study said they would recommend LASIK to a friend, in spite of the side effects. Of the patients that would make the recommendation, on average, one out of four experienced some nighttime vision problems, compared to an average of two out of three patients who would not recommend the surgery."

J Cataract Refract Surg. 2005 Aug;31(8):1537-43.
Changes in quality of life after laser in situ keratomileusis for myopia.
Garamendi E, Pesudovs K, Elliott DB.
Department of Optometry, University of Bradford, Richmond Road, Bradford, West Yorkshire, United Kingdom.

PURPOSE: To measure quality of life (QoL) outcome in prepresbyopic myopic patients having laser in situ keratomileusis (LASIK) refractive surgery using the Quality of Life Impact of Refractive Correction (QIRC) questionnaire and to compare the QoL of preoperative patients with a sample of spectacle and contact lens wearers not considering refractive surgery.

SETTING: Department of Optometry, University of Bradford, Bradford, and Ultralase, Leeds, West Yorkshire, United Kingdom.

METHODS: The validated QIRC questionnaire was prospectively completed by 66 patients before and 3 months after LASIK. Patients had myopia greater than 0.50 diopters (D) (range --0.75 to --10.50 D) and were aged 16 to 39 years. Patients were also directly asked to evaluate their QoL after surgery.

RESULTS: Overall QIRC scores improved after LASIK from a mean of 40.07+/- 4.30 (SD) to 53.09+/- 5.25 (F(1,130)=172.65, P<.001). Greater improvements occurred in women (53.83+/- 5.46) than in men (49.39+/- 5.94; F(1,64)=9.37, P<.005). Overall, 15 of the 20 questions (especially convenience, health concerns, and well-being questions) showed significantly improved scores (P<.05). Patients who "strongly agreed" (53.96+/- 4.91, n=33) or"agreed" (51.78+/- 6.19, n=23) had improved QoL and had significantly higher QIRC scores than those who "neither agreed nor disagreed" (44.36+/- 4.97, n=5) or "strongly disagreed" (42.82, n=1) (F(1,60)=11.24, P<.001). The matched group not contemplating LASIK scored 42.41 +/- 3.89 on QIRC overall.

CONCLUSIONS: Large improvements in QIRC QoL scores were found after LASIK for myopia in the majority of patients, with greater improvements in women. Asmall number of patients (4.5%) had decreased QIRC QoL scores, and these were associated with complications. People presenting for LASIK scored measurably poorer than matched patients not contemplating refractive surgery.

From the full-text:
"McDonnell et al.8 assessed refractive-error-related QoL in patients following refractive surgery with the NEI-RQL; a 42-item questionnaire that included subscales related to clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limitations, glare scale, symptoms, dependence on correction, worry, suboptimal correction, appearance, and satisfaction with correction. Improved QoL was mostly correlated with expectations, near and far vision, diurnal fluctuations, activity limitations, symptoms, dependence on correction, worry, perceptions about having suboptimal correction, appearance, and satisfaction with correction. However, symptoms of glare were significantly worse after refractive surgery and clarity of vision showed no significant change. Schein and coauthors7 used the RSVP, a 42-item questionnaire to measure vision-related health status in patients with refractive error including domains such as concern, driving, expectations, physical and social functioning, symptoms, optical problems, glare, and problems with corrective lenses. Patients reported significantly improved QoL after refractive surgery in subscales related to expectations, physical and social functioning, and problems with corrective lenses. However, driving, symptoms, optical problems, and glare showed significantly worse scores after surgery."

"A small number of patients (n=3; 4.5%) had overall lower QIRC QoL scores after surgery. One former high myope was very disappointed with her quality of vision, and 2 former moderate myopes reported having better vision with their contact lenses prior to surgery than postoperatively. Their QIRC scores showed a worsening in items related to visual function, symptoms, concerns, and wellbeing. One patient (high myope), who had a significantly lower score postoperatively (preoperative QIRC score 50.57; postoperative QIRC score 42.82), “strongly disagreed” that her QoL improved after refractive surgery. This patient reported some common complications of laser refractive surgery such as having better vision with contact lenses prior to surgery, eyes sensitive to bright light, and misty and unclear vision, especially when driving at night."

"the optical zone was at least 6.0 mm, increased to 0.5 mm greater than the scotopic pupil for pupils over 5.5 mm".

"... other factors, such as the Hawthorne effect and cognitive dissonance, should be considered. Participating in a clinical trial or study can make patients report a significant positive effect of the surgery due to the added attention being made toward them (the Hawthorne effect)."

"Cognitive dissonance states that a change in attitude or belief occurs in an attempt to be consistent with the choice taken. Patients who have chosen to have surgery could justify this choice by indicating that the outcome was successful".