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Sources of medical error in refractive surgery
Majid Moshirfar1, Rachel G Simpson, Sonal B Dave
1University of Utah, Salt Lake City, Utah 84132, USA. majid.moshirfar@hsc.utah.edu
Summary
Laser programming errors in refractive surgery compromise vision, with 27% losing corrected distance visual acuity (CDVA). Surgical revision improved outcomes, highlighting the need for strict verification protocols to prevent these avoidable errors.
Area of Science:
- Ophthalmology
- Refractive Surgery
- Surgical Technology
Background:
- Laser refractive surgery relies on precise programming for optimal outcomes.
- Errors in laser programming can lead to significant visual deficits and necessitate corrective procedures.
Observation:
- A multicenter retrospective review analyzed 22 eyes with refractive laser programming errors.
- Identified error sources include cylinder conversion, data entry, and patient identification mistakes.
Findings:
- All patients experienced compromised uncorrected visual acuity.
- 32% lost at least one line of corrected distance visual acuity (CDVA).
- 59% required follow-up treatment (surgical or contact lenses), with 27% still showing CDVA loss post-treatment.
Implications:
- Preventive measures, including strict patient verification and parameter rechecking, are crucial to avoid programming errors.
- Surgical revision offers better outcomes for patients with visual deficits due to programming errors.
- Addressing these errors is vital for patient safety and satisfaction in refractive surgery.
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