Is refractive surgery safe in patients with autoimmune disease (Autoimmune Disorder)?

From the Guidelines

Refractive surgery is generally not recommended for patients with active autoimmune diseases due to increased risks of complications, but patients with well-controlled autoimmune conditions may be considered for refractive procedures on a case-by-case basis after a thorough evaluation by both their rheumatologist and ophthalmologist. The most recent evidence from 2024 suggests that dry eye syndrome, which is common in patients with autoimmune diseases, can compromise the results of refractive surgery and worsen dry eye symptoms after surgery 1. Common autoimmune diseases that raise concerns include rheumatoid arthritis, lupus, Sjögren's syndrome, and multiple sclerosis, which can affect wound healing, increase inflammation, and potentially lead to complications such as severe dry eye, corneal melting, or persistent epithelial defects following surgery.

Some key considerations for patients with autoimmune diseases who are considering refractive surgery include:

• The autoimmune disease should be in remission or well-controlled for at least 6-12 months prior to the procedure, and patients should continue their immunosuppressive medications as prescribed
• Preoperative evaluation should include comprehensive dry eye testing, as many autoimmune patients already have compromised ocular surface health
• Postoperatively, these patients require more intensive monitoring and may need more aggressive anti-inflammatory therapy, including topical steroids like prednisolone acetate 1% or loteprednol 0.5% for a longer duration than typical patients, along with preservative-free artificial tears and possibly punctal plugs for dry eye management
• Surface ablation procedures like PRK may be preferred over LASIK in some cases to reduce the risk of flap-related complications. According to the most recent study on dry eye syndrome preferred practice pattern, patients with dry eye syndrome considering keratorefractive and lens-based surgery should be cautioned that the dry eye symptoms could become worse after surgery 2.

The American Academy of Ophthalmology's preferred practice pattern for refractive surgery also highlights the importance of careful patient selection and preoperative evaluation to minimize the risk of complications 3. Overall, the decision to undergo refractive surgery should be made on a case-by-case basis, taking into account the individual patient's unique circumstances and medical history.

From the Research

Refractive Surgery in Patients with Autoimmune Disease

• Refractive surgery, such as laser refractive surgery (LRS), can be a viable option for patients with well-controlled autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, and seronegative spondyloarthropathy 4.
• However, patients with uncontrolled systemic disease or ocular involvement of the disease should not undergo LRS, as it may pose significant risks 5.
• The US Food and Drug Administration's guideline considers autoimmune and immune-mediated diseases as contraindications for laser refractive surgeries, but recent studies suggest that LRS can be safe and effective in patients with well-controlled autoimmune diseases 4, 5.
• Patients with primary Sjogren's syndrome may not be good candidates for LRS due to the potential for severe ocular complications 4.

Considerations for Refractive Surgery

• Patients with autoimmune diseases should be carefully evaluated and managed before undergoing refractive surgery, with consideration of their disease status, ocular involvement, and potential surgical complications 4, 5.
• More multicenter and larger prospective studies are needed to compare the refractive outcomes and surgical complications in patients with and without autoimmune diseases, to provide better informed medical decisions 4.
• Physical exercise has been shown to have anti-inflammatory effects and improve quality of life in patients with autoimmune diseases, but its impact on refractive surgery outcomes is not well established 6, 7, 8.

Patient Selection and Management

• Patients with autoimmune diseases should be made aware of the potential surgical complications and informed of the currently available data on refractive surgery outcomes in this population 4.
• A thorough evaluation of the patient's disease status, ocular involvement, and potential surgical complications is necessary to determine their suitability for refractive surgery 5.
• Patients with well-controlled autoimmune diseases and minimal ophthalmic manifestation may be good candidates for LRS, but should be closely monitored and managed to minimize the risk of complications 4.