Resurgence of PRK

PRK and LASEK offer effective visual correction without LASIK’s pitfalls.

BY JOHNNY GAYTON, MD

Early in 2001, with demand for LASIK going strong nationwide, I took a step many considered counterintuitive and began performing exclusively LASIK’s out-of-fashion cousin — surface treatment — for refractive error.

My biggest reason for the switch was my practice’s patient base. I celebrate 30 years in the same location this year. Now, you don’t stay 30 years in one area messing people up. And one of the things I saw with LASIK is that the procedure had a higher complication rate than I wanted to deal with: dry eyes, higher-order aberrations, slipped flap, keractasia, etc.

I would not have found a high complication rate acceptable with my cataract surgery, so why would I have found it acceptable in patients who just wanted to have an improvement in vision? As surface treatments, PRK and LASEK effectively corrected refractive error while offering none of the complications that could come back to haunt my patients — and myself — later on. I’ll lay out my case for going surface-only. Maybe you will be persuaded to give it a try.

New and Improved

Much of what drove patients from PRK to LASIK, of course, were the reduced pain and the much faster visual recovery the laser procedure offered. These days, though, the playing field between the two procedures is more level.

No patient wants to hear about pain, but the pain associated with surface treatments is more manageable because of the different medications we now have available.

At my practice, if someone is having a difficult time with re-epithelialization, we use drops made from the patient’s serum to promote epithelialization (Figure 1). We use it on cataract patients, injury patients, PRK patients — anyone who has delayed epithelialization. Recently, I had a 3-year-old child come in with a chemical burn. His left epithelium was completely gone. We put him on the serum drops, and within three days, the child’s vision was completely normal. So the serum certainly promotes epithelialization.

As for visual recovery, though recovery for surface treatments is still not as speedy as that for LASIK, it has definitely improved. I tell my patients that they will be able to drive during daylight hours in five to seven days; it may, however, require a couple of weeks before they feel comfortable driving after dark. As for optimal vision, patients will achieve excellent vision in about four weeks, and maximum vision at six months.

While patients still see this slower recovery as a disadvantage, the real strength of surface treatments such as PRK and LASEK lies in the problems they allow the surgeon and his patients to avoid. It is up to the surgeon to make sure patients know about this.

Educate Them About the Flap

Despite all the publicity for LASIK, I’ve been able to persuade many of my patients to opt for surface treatment of their refractive errors because my practice has been consistent in teaching them about its benefits. Chiefly, this means educating patients about the potential complications that flow from the creation of the corneal flap in LASIK (Figures 2, 3).

We particularly stress that surface treatments are less likely to lead to dry eye than LASIK, where it shows up in a disturbingly large percentage of patients — 95% of patients report some dry eye symptoms immediately after LASIK, with as many as 60% of patients reporting symptoms one month after LASIK.^1,2 But because surface treatments don’t involve cutting a flap or excimer laser ablation of the cornea, with concomitant iatrogenic corneal nerve damage, nor are goblet cells damaged in flap creation, patients who choose this procedure can avoid troublesome dry eye.

Directions for Serum Drops
1. Have blood drawn at : Doctor’s Laboratory of Macon - (478) 474-8808 3200 Riverside Drive, Suite 300-A Macon, GA 31210 (Behind Arby’s) 2. Take the serum to: Graves Pharmacy - (478) 745-0476 770 Pine Street Macon, Georgia 31201 3. Take serum prescription home and freeze all but one bottle. Start using the unfrozen bottle: One drop in ___________ eye ____________ times a day KEEP THE BOTTLE YOU ARE USING IN THE REFRIGERATOR. 4. After one week discard the bottle of serum you have been using, even if there is some left in the bottle. DO NOT USE A BOTTLE LONGER ONE WEEK. 5. Unfreeze another bottle of serum. Start using the new bottle following the above directions. After one week throw the bottle away. DO NOT USE A BOTTLE LONGER THAN ONE WEEK. 6. Keep repeating each week until all the bottles have been used or until the doctor tells you to stop.
How to write the prescriptions for serum drops

Figure 1: I have found this serum to be very effective for promoting re-epilthialzation

The absence of flap creation means also that there is no danger of a slipped flap after surface treatments. I realized slipped flaps are fairly uncommon, but they do occur. For instance, last fall, a woman came to me years after an Intralase LASIK flap done elsewhere. She and her boyfriend were horsing around and pulled the flap loose. With surface treatments, flaps coming loose are simply not possible.

Figures 2 and 3: Debris beneath the LASIK flap.

Not having to cut a flap also means achieving better vision than LASIK offers. I explain to patients that as far as quality of vision goes, the trouble in LASIK begins when it’s time to put the flap back down, after the laser has ablated the cornea. Let’s be honest: The flap is not going to go back down in the same size hole it came up from. There are little microscopic wrinkles in the flap, which degrade the quality of vision. You can see those any time and every time you do a surface treatment over somebody who’s had LASIK. It’s amazing how many wrinkles are in that flap. Again, I can tell my patients that because no flap is cut in surface treatments, they don’t have to worry about reduced visual quality.

To help my patients understand the difference between surface treatments and LASIK, I remind them of the fable of the tortoise and the hare: The LASIK procedure is certainly much faster as far as getting your vision back and the discomfort, but ultimately you have a stronger eye anatomically and physiologically — and in many studies, better vision — with surface treatment.

While many refractive surgeons tell me their patients want the faster visual recovery of LASIK, I believe that if they educated their patients more carefully, they could lead them to a procedure that offers ultimately better outcomes.

In Anticipation of Cataract Surgery

Here’s another plus for PRK: We are doing a lot of premium cataract surgery now, and PRK is a beautiful way to fine-tune those people. A lot of those patients already have a dry eye. You certainly don’t want to make it worse by making a LASIK flap, so we use surface treatments to enhance the vision of our premium IOL patients, including our femtosecond cataract patients.

Mine is one of only two practices in the country that have the Catalys femtosecond laser platform (OptiMedica, Sunnyvale, Calif.). We have done nearly 600 femto cataract procedures with it. We finetune our patient’s vision with PRK, because we don’t have to enhance the eyes of many people, when we do enhance them, we’ve been confident that we’re not going to make their eyes worse. With cataract patients, frequently you can get them close to the vision they want, but if they want to be even closer, you can do a surface treatment to get them precisely the vision they expect.

The Enhancement Issue

Regarding enhancements, another plus for surface treatments is that should you need to improve them later on, you don’t have to worry about epithelial ingrowth. That certainly isn’t the case with LASIK.

But I find fewer patients want enhancements following surface procedures anyway. The longer recovery time involved means that they realize it is real surgery. Those patients who might want an enhancement for the sake of obtaining a tiny degree of improved vision think twice.

I switched to doing exclusively surface treatments because of LASIK’s drawbacks. To my mind, if I stuck with a safer, more predictable procedure I could sleep better at night. And so that’s what I’ve been doing now for 12 years. Fewer headaches — and lower costs. Needless to say, I’m very, very happy with my choice. OM

References

1. Yu EY, Leung A, Rao S, Lam DS. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000;107:2131–2135.

2. Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J Cataract Refract Surg. 2001;27:577–584.

Johnny Gayton, MD, is in private group practice at Eyesight Associates in Warner Robins, Ga. Disclosures: Dr. Gayton disclosed that he is a consultant to Optimedica and Bausch + Lomb, and is a speaker for Optimedica..