Refractive surgery complications (LASIK, PRK, SMILE) — AU general practice guide

Post-refractive surgery: what GPs need to know

Approximately 250,000 refractive procedures are performed in Australia each year, according to RANZCO. Most are uneventful — over 95% of LASIK patients achieve uncorrected vision of 6/12 or better. But a subset of patients develops complications, and they often present first to their GP rather than the surgeon who operated: the operating clinic may be geographically distant, appointment waits may be long, or the patient may not recognise their symptoms as surgery-related.

The GP’s role does not require slit-lamp proficiency. It requires: recognising the presenting syndromes, knowing which presentations are ophthalmological emergencies, providing first-line dry-eye management, screening for depression in chronic post-operative pain, and ensuring the operating surgeon or an independent corneal specialist receives a competent referral.

This article covers LASIK (laser in-situ keratomileusis), PRK (photorefractive keratectomy), and SMILE (small-incision lenticule extraction) — the three most common procedures — and the ICL (implantable Collamer lens) and RLE (refractive lens exchange) briefly.

A. Core clinical — the AU general practice framework

Procedure overview

Procedure	Mechanism	Key difference for GPs
LASIK	Corneal flap (femtosecond laser) + excimer stromal ablation + flap repositioned	Most common; flap dislocation risk is lifelong; worst dry-eye profile
PRK	No flap; epithelium removed, anterior stroma ablated	Slower visual recovery; more haze; better dry-eye profile; preferred for contact sport, police, military
SMILE	No flap; intrastromal lenticule extracted through 2 mm incision	Best dry-eye + neuropathic pain profile; fewer nerve-severing; learning curve
ICL	Phakic IOL implanted behind iris	For high myopia or thin corneas; endothelial cell monitoring required
RLE	Clear-lens cataract surgery with IOL	High retinal detachment risk in high myopes; dysphotopsias; posterior capsule opacification

History to take

• Which procedure, when, and where; pre-operative prescription; current refraction.
• Pre-operative risk factors that were present: pre-existing dry eye, autoimmune disease (Sjögren, rheumatoid arthritis, lupus), high refractive error, thin cornea, asymmetric topography.
• Symptom onset timeline: symptoms in the first month (recovery-phase) vs symptoms persisting beyond 6–12 months (complication).
• Specific symptoms: dryness / burning / foreign-body sensation; halos / glare / starbursts (especially night driving); fluctuating vision; eye pain (quality, constancy, response to rest).
• Trauma to operated eye: rugby, ball sport, baby finger, animal — any impact can displace the LASIK flap years post-operatively.
• Mental health screen: PHQ-9 and GAD-7; ask specifically about suicidal ideation in patients with chronic post-operative pain or severe dry eye.
• Occupational implications: pilot, professional driver, military — visual standard requirements; contact-sport occupations.

Examination (GP-feasible)

• Visual acuity: uncorrected and best corrected — a drop in corrected acuity warrants referral.
• Outer eye inspection: blink rate, lid closure, blepharitis.
• Meniscus inspection: any obvious tear deficiency or excessive tearing.
• Basic slit-lamp assessment if available: fluorescein staining for superficial keratopathy patterns.

More detailed assessment — corneal topography (Pentacam), OCT cornea, Schirmer tests — is ophthalmology and optometry territory.

Red flags requiring urgent same-day referral

The following presentations warrant same-day urgent ophthalmology:

• Acute pain + photophobia + blurring in a previously stable post-operative eye: flap dislocation (LASIK — can occur with any eye impact, even minor, decades post-operatively) or infectious keratitis.
• Sudden unexplained vision loss post-procedure.
• Suppurative corneal infiltrate with pain and photophobia: infectious keratitis — sight-threatening.
• Posterior symptoms in an RLE patient (floaters, flashing lights, curtain in vision): retinal detachment — emergency.

B. Dry eye — the dominant complication

Epidemiology and mechanism

Dry eye after LASIK affects approximately 50% of patients at 6 months and around 30% at 12 months, per Toda (Cornea 2018). The mechanism is direct nerve damage: the LASIK flap creation severs the anterior stromal nerve plexus across the full corneal circumference. Corneal nerve density falls dramatically post-LASIK, impairing both reflex tearing (corneal sensation triggers lacrimal gland secretion) and neurotrophic support of the corneal epithelium. Regeneration occurs over 12–24 months but may never fully recover in some patients.

SMILE performs significantly better because the small incision (2 mm) severs far fewer anterior nerves than the full LASIK flap. PRK avoids the flap entirely, so nerve anatomy is also better preserved, though surface ablation causes its own early nerve injury that resolves faster.

First-line dry-eye management (GP-appropriate)

Per eTG — Eye: dry eye and AMH:

• Preservative-free artificial tears (carmellose, sodium hyaluronate, hypromellose): the cornerstone of management; use QID or as needed; preservative-containing drops (BAK) should be avoided — BAK is toxic to already-compromised corneal epithelium and worsens dry eye with frequent use.
• Lipid-based artificial tears (Systane Complete, Cationorm): for meibomian gland dysfunction component, common in older adults.
• Lid hygiene + warm compresses: addresses concurrent blepharitis driving evaporative dry eye.
• Omega-3 supplementation: the DREAM trial (NEJM 2018) found no significant benefit over placebo for severe dry eye; modest effects may exist in milder presentations. Reasonable low-harm adjunct.
• Environmental modification: humidifier, reduce screen time (or implement 20-20-20 rule), avoid air-conditioning drafts, adequate hydration, smoke avoidance.

If symptoms persist beyond 8 weeks of consistent preservative-free artificial tear use:

• Punctal plugs: temporary (collagen, dissolves in 1–2 weeks) then semi-permanent (silicone) if effective — ophthalmology or optometry procedure.
• Topical anti-inflammatory agents:
  • Cyclosporine 0.05% (Restasis) — BD; PBS Authority Required for severe dry eye.
  • Lifitegrast 5% (Xiidra) — BD; PBS Authority Required.
• Autologous serum tears: for refractory severe dry eye; specialist / immunology preparation; not PBS-listed.

Pitfalls to avoid

• Continuing preserved drops in someone with post-LASIK dry eye — worsens symptoms.
• Reassuring a patient their persistent post-LASIK symptoms are “normal” without formal dry-eye assessment.
• Overlooking blepharitis as a contributing factor.

C. Halos, glare, and regression

Halos and glare

Common in the first 3–6 months post-procedure; usually improve by 12 months as neural adaptation occurs and corneal oedema settles. Persistent halos and glare beyond 12 months suggest:

• Optical zone smaller than mesopic pupil diameter: the ablation zone did not fully cover the pupil in dim light. Wavefront-guided enhancement by the operating surgeon may help.
• Residual higher-order aberrations: trefoil, coma — wavefront analysis by ophthalmology.
• Regression: myopia returning — correctable by enhancement if residual stromal bed allows.

Driving at night requires careful discussion — patients with significant halos or glare should not drive at night until symptoms resolve or are managed.

Regression

Gradual return of myopic prescription over months to years — more common in high myopes and in PRK (haze can cause regression). Enhancement laser procedure may be appropriate if residual stromal bed is adequate. Refer to the operating surgeon.

D. Post-LASIK ectasia

Ectasia is the most serious sight-threatening complication unique to corneal refractive surgery. The residual corneal stromal bed after ablation must be at least 250–300 µm to withstand intraocular pressure. When this threshold is breached — through high myopic correction, thin cornea, or unidentified pre-operative keratoconus — the cornea progressively bulges, thins, and develops irregular astigmatism.

Incidence: approximately 0.04–0.6% with modern topographic screening; was higher in earlier LASIK cohorts. Salomão et al. (Ophthalmology 2017) comprehensively reviewed corneal cross-linking for ectasia management.

Presentation: typically 6–18 months post-operatively; new astigmatism, increasing myopic shift, frequent prescription changes, monocular diplopia, decreased corrected acuity.

GP action: any post-LASIK patient with deteriorating corrected vision or new astigmatism — refer for serial corneal topography (Pentacam / Scheimpflug imaging). Early ectasia detected before significant thinning has occurred can be arrested with corneal cross-linking (CXL) — an outpatient procedure using riboflavin drops and UV-A light. Late ectasia requires scleral lenses or keratoplasty.

E. Neuropathic eye pain and the mental health dimension

The under-recognised complication

Persistent neuropathic eye pain is a chronic pain syndrome following refractive surgery where patients experience severe burning, electric, or aching eye pain despite a clinically healed cornea with normal slit-lamp and topographic appearance. Prevalence is 1–8% depending on definition, per Galor et al. (Survey of Ophthalmology 2018). The mechanism is analogous to phantom limb pain: peripheral nerve injury (corneal denervation) triggers central sensitisation that maintains pain without a peripheral stimulus.

The proparacaine challenge test: if a topical anaesthetic drop produces complete pain relief, the source is peripheral (ocular surface — dry eye, epithelial breakdown). If pain is not relieved or only partially relieved, the source is central (neuropathic) — topical drops alone will not manage this.

Systemic neuropathic agents

Per AMH and specialist pain medicine guidance:

• Pregabalin 75–150 mg twice daily — first-line neuropathic agent; PBS-listed for neuropathic pain.
• Duloxetine 30–60 mg daily — SNRI with neuropathic indication.
• Amitriptyline 10–25 mg nocte — low-dose tricyclic; evidence in corneal neuropathic pain.

These agents are managed as a GP–pain specialist collaboration for this indication.

Depression and suicidality

The FDA 2020 Patient Labeling Draft Guidance acknowledged a signal — described as small but real — of severe depression, suicidality, and completed suicide in post-refractive surgery patients with chronic dry eye and neuropathic pain. The GP managing a patient with chronic post-LASIK pain should routinely screen with PHQ-9 and ask specifically about suicidal ideation. Referral for psychological support alongside pain management is appropriate.

When to escalate

Same-day ophthalmology:

• Acute pain + photophobia + blurring.
• Flap trauma (LASIK) — any time post-operatively.
• Sudden vision loss.
• Suppurative corneal infiltrate.

Urgent but not same-day:

• Suspected ectasia (deteriorating corrected vision, new astigmatism) — within 1 week for topography.
• Persistent neuropathic eye pain — corneal specialist + pain management.

Routine referral:

• Dry eye not responding to 8 weeks of preservative-free drops.
• Halos / glare >12 months without improvement.
• Regression requiring enhancement assessment.
• Chronic post-operative symptoms with depression or suicidality requiring multidisciplinary input.

What this article is and is not

This is general health information drawn from current Australian ophthalmology guidelines — RANZCO, eTG, AMH — and the post-refractive surgery complications literature. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about refractive surgery, management of complications, and referral pathways are made with the individual’s own GP and treating clinicians.

For consumer-friendly Australian sources: HealthDirect — Eye care, RANZCO.

For acute mental health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

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Sources cited

1. RANZCO — Refractive surgery position statement
2. eTG — Eye: dry eye
3. Toda I — Dry eye after LASIK (Cornea 2018)
4. Galor A et al. — Neuropathic eye pain post-refractive surgery (Survey of Ophthalmology 2018)
5. Salomão MQ et al. — CXL for ectasia (Ophthalmology 2017)
6. FDA — LASIK Patient Labeling Draft Guidance 2020
7. Asbell PA et al. — DREAM trial (NEJM 2018)
8. AMH
9. RACGP
10. HealthDirect — Eye care