The decision to perform refractive surgery in patients at risk for glaucoma should be made carefully. The inability to accurately measure IOP after LASIK and potential optic nerve damage from steroid-induced elevated IOP are factors that need to be considered. Likewise, refractive surgeons who offer phakic intraocular lens implantation should carefully examine their patients for signs of pigment dispersion, including gonioscopy, to rule out heavy pigmentation of the trabecular meshwork. Regardless of the type of refractive procedure chosen, patients with glaucoma risk factors should be informed of the special issues concerning their follow-up and potential complications. Though opinions vary, patients with known glaucomatous damage should not undergo LASIK for 2 reasons. It will be difficult to establish a target IOP for these patients post-LASIK because of inaccurate tonometry measurements. Also, patients with glaucoma are more likely to develop steroid-induced elevated IOP, which could lead to further optic nerve damage. Refractive surgery has its place in special circumstance patients such as those who are glaucoma suspects, but buyer beware! Both the surgeon and patient should be aware of the caveats that exist.
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