Did this patient with blurry vision, normal visual acuity (20/20), dry ocular surface, and mild optic nerve head hyperemia undergo LASIK (Laser-Assisted In Situ Keratomileusis) or refractive surgery?

Clinical Presentation Highly Suggestive of Prior Refractive Surgery

This patient almost certainly underwent LASIK or another form of refractive surgery, as the constellation of findings—20/20 visual acuity with persistent subjective blur, dry ocular surface, and mild optic nerve head hyperemia with obliterated cup—is characteristic of post-refractive surgery complications rather than naturally occurring pathology.

Key Clinical Features Supporting Prior Refractive Surgery

Discordance Between Objective and Subjective Vision

• The hallmark finding is 20/20 visual acuity with persistent patient dissatisfaction about clarity, which is extensively documented in post-LASIK patients 1
• The American Academy of Ophthalmology specifically notes that "the most frequent complaints of patients dissatisfied with refractive surgery are blurred distance or near vision, glare, dry eyes, and night-vision problems. In many cases, dissatisfied patients had relatively good UCVA" 1
• This dissociation between objective measurements and subjective visual function is a well-recognized phenomenon after refractive surgery 1

Dry Ocular Surface

• Development or exacerbation of dry eye symptoms is one of the most common complications of both LASIK and PRK, occurring in nearly half of patients 1, 2
• Post-LASIK dry eye results from corneal denervation caused by flap creation, which disrupts the corneal-lacrimal gland reflex and reduces tear secretion 2, 3
• The dry eye typically manifests within the first month but can persist for over a year in some patients 2
• This patient's presentation at 3 months post-symptom onset fits the typical timeline for persistent post-refractive surgery dry eye 2, 4

Artifactual IOP Measurements

• The IOP readings of 18/17 mmHg may be artificially low due to corneal thinning from refractive surgery 1
• The American Academy of Ophthalmology explicitly warns that both LASIK and PRK cause "artifactual reduction of IOP measured by applanation tonometry" due to altered corneal biomechanics 1
• This is particularly relevant given the finding of mild optic nerve head hyperemia with obliterated cup, which could represent true elevated IOP masked by post-surgical corneal changes 1

Optic Nerve Findings

• The mild optic nerve head hyperemia with obliterated cup is concerning and may indicate true glaucomatous damage that is being underestimated due to artificially low IOP readings post-refractive surgery 1
• This patient requires true IOP assessment using methods that account for corneal biomechanical changes (such as dynamic contour tonometry or pneumatonometry) rather than standard applanation 1

Additional Considerations for Post-Refractive Surgery Complications

Corneal Neuralgia vs. Dry Eye

• If symptoms persist beyond typical dry eye patterns, consider corneal neuralgia, a distinct entity from dry eye that can occur after LASIK 1, 5
• Corneal neuralgia presents with pain and visual symptoms out of proportion to clinical signs, requiring multimodal treatment including systemic agents for neuropathic pain 5

Visual Quality Issues

• Smaller treatment zones in refractive surgery increase the likelihood of visually disturbing halos and reduced quality of vision under low-light conditions 1, 6
• The patient's subjective blur despite 20/20 acuity may represent irregular astigmatism from the surgical procedure 1

Diagnostic Approach

Obtain a detailed surgical history immediately, specifically asking about:

• Any prior LASIK, PRK, SMILE, or other corneal refractive procedures 1
• Timeline of procedures relative to symptom onset 6
• Pre-surgical refractive error and treatment parameters 1

Perform corneal topography/tomography to evaluate for:

• Evidence of prior ablation patterns 1
• Irregular astigmatism 1
• Corneal ectasia (progressive steepening) 1

Reassess true IOP using:

• Alternative tonometry methods that account for altered corneal biomechanics 1
• Consider the optic nerve findings may represent true glaucomatous damage 1