Letter to Editor Suicide and Laser Refractive Surgery Ali Salimi, MD, MS1; Edsel Ing, MD, FRCSC, MPH, MIAD2; Nicholas Nianiaris, MD, FRCSC2 1Department of Ophthalmology, McGill University, Montreal, Canada 2Department of Ophthalmology, University of Toronto, Toronto, Canada ORCID: Ali Salimi: https://orcid.org/0000-0003-0016-3478 Edsel Ing: https://orcid.org/0000-0003-0623-0934 J Ophthalmic Vis Res 2020; 15 (3): 432–434 Dear Editor, Laser refractive surgery (LRS) is one of the most frequently performed and successful operations in medicine with 96% postoperative patient satisfaction.[1] The possible sequelae of LRS include dry eye syndrome, blurred vision, glare, and night vision disturbance that are usually transient, but sometimes persist.[1] Psychiatric complications such as psychosis, depression, suicidal ideation, attempted suicide or completed suicide (PDS) following LRS are rare,[2] but generate marked media attention.[3, 4] Given the tragedy of suicide after LRS, we reviewed the PubMed, Embase, PsycINFO, and Google Scholar databases from inception to October 2019 using keywords and MeSH terms “laser refractive surgery” and “suicide”. We found the details of six patients, mainly young men, who completed suicide after LRS (Table 1).[2, 4–7] The patient-support website lasikcomplications.com[8] lists approximately 34 patients with PDS following LRS. From 2007 to 2018, approximately 8,230,000 LASIK procedures Correspondence to: Edsel Ing, MD, FRCSC, MPH, MIAD. Michael Garron Hospital, 650 Sammon Ave., K306, Toronto, ON. M4C 5M5, Canada. E-mail: edingLidStrab@gmail.com Received: 10-11-2019 Accepted: 21-03-2020 Access this article online Website: https://knepublishing.com/index.php/JOVR DOI: 10.18502/jovr.v15i3.7464 were performed in the United States.[9] Given that, the incidence rate of completed suicide and PDS in the US is estimated to be 7 per 100,000,000 individuals and 4 per 10,000,000 individuals undergoing LRS per annum, respectively. In the US, the age-adjusted suicide rate has increased by 33% over the last two decades, with 13.9 suicides per 100,000 individuals reported in 2018.[10] The proportion of patients with either completed suicide or PDS after LRS is markedly lower than the proportion of suicide in the general population (P < 0.001). A thorough informed consent before LRS may help to exclude inappropriate surgical candidates. Although it is impossible to list every possible outcome after LRS, and postoperative suicide is extremely rare, under a patient-centered standard of informed consent, the mandate to disclose the possibility of PDS after LRS merits consideration. In addition, impaired vision and chronic pain were two of the five most common adverse outcomes resulting in legal disputes over duties to disclose treatment risks in a 2012 study from Australia.[11] Dry eye syndrome was associated with suicidal ideation at an odds ratio of 1.24 and LRS can exacerbate dry eye. Psychologic and This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. How to cite this article: Salimi A, Ing E, Nianiaris N. Suicide and Laser Refractive Surgery. J Ophthalmic Vis Res 2020;15:432–434. 432 © 2020 JOURNAL OF OPHTHALMIC AND VISION RESEARCH | PUBLISHED BY PUBLISHED BY KNOWLEDGE E http://crossmark.crossref.org/dialog/?doi=10.18502/jovr.v15i3.7464&domain=pdf&date_stamp=2019-07-17 https://knepublishing.com/index.php/JOVR Suicide & LASIK; Salimi et al Table 1. Patients with completed suicide after LRS Author, Year Age Sex Post-op eye pain Blurred vision Procedure Latency between LRS and suicide Clinical factors Favaro, 2018[7] 54 M Yes No PRK 20 years Reindl, 2018[4] 35 F Yes Yes SMILE 8 weeks FDA, 2016 27 M Yes Yes PRK enhancement 1 year Veteran. Post-traumatic stress disorder and depression van Setten, 2015[2] 33 M No Subjective LASIK 8 weeks Pre-existing psychologic instability. Saw psychiatrist numerous times. LASIKComplications.com, 2011[8] 54 M Yes Yes LASIK 1 year Puglionesi, 2007[5] 28 M No Yes LASIK 6.5 years Pre-operative dry eyes, mydriasis and depressive symptoms. M, male; F, female; LASIK, laser-assisted in situ keratomileusis; LRS, laser refractive surgery; SMILE, small incision lenticule extraction; PRK, photorefractive keratectomy; FDA, U.S. Food & Drug Administration. MAUDE Adverse Event Report: LASIK 2016 https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=5434049 Eye pain, postoperative dry eye pain. pharmacologic predispositions to post-LRS dissatisfaction include preoperative depression, the use of retinoic acid and antidepressants, antipsychotics or hypnotics with anticholinergic activity that may compound dry eye symptoms in patients with LRS.[12, 13] Patients suffering from refractory pain after LASIK can be referred to clinics specializing in dry eye syndrome, scleral contact lenses, or chronic pain. Emergency psychiatric resources in addition to the hospital emergency room include psychiatry and suicide prevention hotlines. In conclusion, suicide following LRS is exceedingly rare. Suicide is a complex mental health issue with a myriad of contributing factors, and to ascribe blame to LRS is a single cause fallacy. Various publications have reported that: (i) patients with compensated pre-existing psychiatric disorders showed no increased incidence of PDS postoperatively, (ii) mental health-related quality of life has been shown not to decrease after LRS, and (iii) LRS can improve psychological well-being.[14] Acknowledgements None Financial Support and Sponsorship Nil. Conflicts of Interest There are no conflicts of interest. Keywords: Depression; Laser Refractive Surgery; LASIK; Suicide JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 15, ISSUE 3, JULY-SEPTEMBER 2020 433 https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=5434049 Suicide & LASIK; Salimi et al REFERENCES 1. Eydelman M, Hilmantel G, Tarver M, Hofmeister E, May J, Hammel K, et al. Symptoms and satisfaction of patients in the patient-reported outcomes with laser in situ keratomileusis (PROWL) studies. JAMA Ophthalmol 2017;135:13–22. 2. van Setten G. 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