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Hoopes, Phillip C.

Moshirfar, Majid

Shah, Tirth J.

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Safety of the Excimer Laser in LASIK and PRK for Patients with Implantable Cardiac Devices: Our Clinical Experience in the Past Two Decades

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LetterSafety of the Excimer Laser in LASIK and PRK forPatients with Implantable Cardiac Devices: Our ClinicalExperience in the Past Two DecadesTirth J. Shah1,2, MD; Majid Moshirfar3,4,5, MD, FACS; Phillip C. Hoopes, Sr3,4, MD1College of Medicine, University of Arizona, Phoenix, Arizona, USA2Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa3John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, SaltLake City, UT, USA4HDR Research Center, Hoopes Vision, Draper, UT, USA5Utah Lions Eye Bank, Murray, UT, USAORCID:Tirth J. Shah: https://orcid.org/0000-0001-7924-8444J Ophthalmic Vis Res 2019; 14 (4): 530–531Sir,Continued high prevalence in cardiac morbidity inthe US has led to more refractive surgical candi-dates with cardiac implantable electronic devices(CIED), although the Food and Drug Adminis-tration (FDA) studies have consistently excludedsuch populations during laser-assisted in situ ker-atomileusis (LASIK) or photorefractive keratectomy(PRK) evaluations. Major manufacturers have dis-couraged laser eye surgery in patients with CIEDsuntil recently when Medtronic and St. Jude, the twolargest manufacturers of such devices, approvedLASIK surgery with recommendations to shieldingthe CIED with a magnet and closely monitoring theheart rate during the surgery.[1] We aim to share ourinsights and experiences over the years, hopefullymitigating some of the concerns in clinical practice.The excimer laser can electromagnetically inter-fere with the CIEDs and cause changes in asurgical setting[2] with potential adverse effectsincluding cardiac stimulation inducing ventriculartachycardia or ventricular fibrillation, unexpectedmovement of the body, and interference with theability of the CIEDs to adequately monitor forpotential arrhythmias.[3] The factors affecting elec-tromagnetic interference depend on the frequencyof the emitting device, the distance betweenthe devices, and the amount of shielding of theaffected device.[2] Particularly, with excimer use,L’Esperance et al[4] demonstrated that nearly allof the 193 nm energy is absorbed by the corneaindicating that the frequency of light emitted bythe ablation process may not cause significantinterference with the CIEDs. Furthermore, a recentstudy by Sher et al[5] demonstrated that in-vitrooperation with the three most commonly usedophthalmic lasers (VISX Star S4 Excimer Laser,Lumenis Selecta II Glaucoma Laser, and LaserexUltra Q Photodisruptor) did not lead to oversens-ing, inappropriate therapy, or change in the pro-gramming of the Atlas II+ implantable cardioverterdefibrillators (ICDs) or the St. Jude Medical Victorypacemaker.We retrospectively analyzed data from 1997 to2014, and found at least 13 patients documentedwith a CIED, although we expect more patientswith such a device who did not disclose thisinformation to us, necessitating the surgeon to askthis important question to all refractive surgerycandidates. The average age of patients under-going LASIK/PRK correction in our center wasapproximately 35 years (range: 23–60), and inthis cohort was 52 years (range: 27–77) with amale predominance (69%) – a consistent findingin individuals with arrhythmia or heart disease.The indications of CIED were primarily for atrialfibrillation (46%), although one male patient aged27 years had the device for Wolf-Parkinson-Whitesyndrome. The other small subset of patientshad the device for either ventricular tachycar-dia, atrioventricular block of unknown degree, oran unspecified arrhythmia. Out of 13 patients,one patient developed ventricular tachycardia two530 © 2019 J  O  V R | P  KNOWLEDGE ELetter; Shah et alweeks postoperatively. However, the consultingcardiologist felt the etiology was due to her uncon-trolled underlying condition, rather than any elec-tromagnetic interference from the femtosecondand excimer laser that may have offset the devicesettings. From our records, none of the otherpatients experienced any CIED-related complica-tions during the surgery. There was no clinicallydetectable change in the heart rate or rhythm, andpostoperatively, the programmed parameters ofthe pacemakers and/or ICDs remained unchanged.Due to the older age, LASIK enhancement wasusually used to achieve emmetropia following thecataract surgery. Thus, we believe this informationmay be particularly helpful to those clinicians whotend to perform LASIK on the elderly population intheir practice.Each laser and CIED has a unique design andmay interfere with one another differently. Thecurrent body of evidence and our concomitantexperiences illustrate a low risk of complicationsin patients with CIED during refractive surgery. Webelieve it is safest to inactivate any anti-tachycardiafunctions if electrocautery is used during surgery[3]and to follow manufacturer recommendations atall times. With the recent paradigm shift in theadvancements to leadless pacemakers, some ofthese newer devices are immune to electromag-netic interference up to a very high threshold.[5]These remarkable technological advancementswill only make ophthalmic lasers safer for patientswith CIEDs in the future.Financial Support and SponsorshipThis study was funded by an unrestricted Grantfrom the Research to Prevent Blindness (RPB), 360Lexington Avenue, 22nd Floor New York, NY 10017.No support was received for the publication of thisarticle.Conflicts of InterestThere is no conflict of interest.REFERENCES1. Medtronic. Medical and dental procedures [cited 2018Jun 6]. Available from: http://www.medtronic.com/us-en/patients/electromagnetic-guide/medical-dental.html2. L’Esperance FA Jr, Labuda EF, Johnson AM. Photocoag-ulation delivery systems for continuous-wave lasers. Br JOphthalmol 1969;53:310–322.3. Lakshmanadoss U, Chinnachamy P, Daubert PJ. Elec-tromagnetic interference of pacemakers. In: Das MM,editor. Modern pacemakers-present and future. Norder-stedt, Germany: BoD – Books on Demand.-1591682083-1591682083.4. Sher AN, Golben MP, Kresge K, Selznick L, Adabag S.An in vitro evaluation of electromagnetic interferencebetween implantable cardiac devices and ophthalmiclaser systems. Europace 2011;13:583–588.5. Audoubert M, Ostiguy G, Nguyen D, Plante M, DubucM, Guerra P, et al. Resistance of the medtronic Micraleadless pacemaker to 60 Hz electric fields. Can J Cardiol2017;33:S155.This is an open access journal, and articles are distributed under the terms ofthe Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, whichallows others to remix, tweak, and build upon the work non-commercially, aslong as appropriate credit is given and the new creations are licensed under theidentical terms.Correspondence to:Majid Moshirfar, MD, FACS. HDR Research Center ¨CHoopes Vision 11820 S. State St., Suite #200 Draper, UT84020.Email: cornea2020@me.comReceived: 07-01-2019 Accepted: 29-04-2019Access this article onlineWebsite:https://knepublishing.com/index.php/JOVRDOI:10.18502/jovr.v14i4.5473How to cite this article: Shah TJ, Moshirfar M, Hoopes PC. Safety of ExcimerLasers with Cardiac Devices. J Ophthalmic Vis Res 2019;14:530–531.J  O  V R Volume 14, Issue 4, October-December 2019 531

Shah, T. J. (Tirth)

Moshirfar, M. (Majid)

Hoopes, P. C. (Phillip)

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Safety of the Excimer Laser in LASIK and PRK for Patients with Implantable Cardiac Devices: Our Clinical Experience in the Past Two Decades

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