Viewpoint

PRK: Back to the Future

The eye never has enough of seeing, nor the ear its fill of hearing. What has been will be again, what has been done will be done again; there is nothing new under the sun.”

— Ecclesiastes 1:8-9 (NIV)

FROM THE CHIEF MEDICAL EDITOR Larry E. Patterson, MD

I’ve been involved in corneal refractive surgery since 1991, which was around the time I had RK on my own eyes. RK reigned until PRK, and then LASIK replaced PRK, due to faster visual return and a relative lack of pain. But there’s a slow resurgence in PRK.

At last year’s AAO meeting and this year’s ASCRS meeting I spoke with a number of doctors now using PRK more frequently. Several have gone back to PRK exclusively — leaving microkeratomes and femtosecond lasers to gather dust. (See “Resurgence of PRK” by Dr. Johnny Gayton on Page 34.)

After years of performing mostly LASIK and occasionally PRK, my practice switched last summer to mostly PRK and only occasionally LASIK. Why the switch? Here are some reasons:

• PRK is less expensive. And PRK is certainly “bladeless.”

• No more DLK, or its nasty toxic interface cousin. I’ve had only one of the toxic cases, but it took him two years to recover to near normal vision.

• No more micro- or macro-striae.

• No more epithelial ingrowth. More importantly, no more flap lifts to treat it, or the above mentioned striae.

• No more dislocated flaps. I don’t have a high refractive volume, but I’ve had four dislocated flaps ranging from one to eight months post-op. In addition, a recent case report detailed a traumatic dislocated flap fourteen years after surgery. Fourteen years! These flaps never heal!

• Reduced ectasia. I’ve had two of these cases. In hindsight, both cases had normal pre-operative topography, pachymetry, and stable refractive error with no risk factors for keratoectasia (according to Randleman’s criteria). As luck would have it, one of the patients was my refractive surgery coordinator, many years after her original operation.

• Results are as good or better than LASIK; it just takes several more weeks to get there.

With advances in contact lenses, NSAIDs, anesthesia drops, and other healing modulators, our patients complain much less than they did in the late 1990’s. The small spot lasers along with mitomycin C have dramatically reduced haze. The military approved LASIK, but the continued preference favors PRK.

If you give a true and complete informed consent of the two options, you might be surprised at how many of your patients will choose PRK — short-term discomfort and blurred vision versus long-term safety. When I needed an enhancement on my own eyes, I chose PRK. Why would I insist my patients have anything less?