Refractive surgery in Europe: not just LASIK any more

New alternatives and customized ablation pave the way for a future with surgical options encompassing the cornea, the lens and beyond.

LASIK is the principal form of refractive surgery throughout Europe, and its popularity increases every day among both patients and surgeons. But other surgical options such as phakic IOLs and LASEK, and new diagnostic techniques like wavefront analysis, promise to broaden refractive surgery into a spectrum of correction strategies, more versatile and customizable than at present.

In a series of interviews, members of the editorial board of Ocular Surgery News Europe-Asia/Pacific Edition spoke about the current state of refractive surgery in Europe and in their own countries. The surgeons’ observations and opinions echo and amplify data from the European Society of Cataract and Refractive Surgeons (ESCRS) Survey of 2000.

Data from that survey, an initiative of David Leaming, MD, and his corporation, Analeyz Inc., show LASIK to be the most frequently used and most widely preferred surgical refractive technique for both myopia and hyperopia.

But the data also show a growing interest in phakic IOLs and other procedures. Our board members agree that these emerging technologies and techniques will give surgeons a range of approaches to correction of the human optical system, from the corneal surface back to the lens.

LASIK by a landslide

Almost half of surgeons who participated in the ESCRS survey are currently using LASIK, while 40% plan to start practicing it in the future. For the time being, photorefractive keratectomy (PRK) and phakic IOLs are LASIK alternatives, while laser epithelial keratomileusis (LASEK) continues to draw interest.

Information accumulated from nearly 700 refractive surgeons throughout Europe in 2000 — the most recent survey data available to us at press time — showed that nearly half of them perform LASIK at least once a month. Almost 18% perform it more frequently, 16 times a month or more.

“The current trend is to use LASIK almost exclusively,” said Michael Knorz, MD, a professor at the University of Mannheim in Germany. “The volume is increasing every year.”

In the survey, LASIK was preferred for myopia ranging from 3 D to 12 D. For a patient with 7 D myopia, 79% of those surveyed agreed that LASIK would be the best procedure.

For treatment of hyperopia, LASIK was also the preferred treatment for 1 D to 5 D, with 42% of surgeons choosing the procedure for a patient with 3 D of hyperopia.

Of survey participants currently using LASIK, 35% said they plan to increase their number of procedures per month. According to the survey, 40% of surgeons not currently performing LASIK also plan to start using the treatment in the future.

PRK

When LASIK is contraindicated, PRK is often the next choice, according to the survey. Nearly 37% of surgeons recommended PRK, particularly for low myopia.

“PRK is an excellent technique for low myopia,” said Maurizio Zanini, MD, of Bologna, Italy. “I prefer PRK for low myopia up to –3 D. However, some of my colleagues are performing LASIK in myopia as low as –0.5 D, and others perform PRK as the first choice in myopia as high as –12 D. I think the indications I choose are currently followed throughout my country.”

Dr. Zanini said many factors should go into choosing a treatment for myopia. He analyzes corneal thickness, ablation depth and the optical zone of his patient to decide which procedure is best.

“In the U.K., most surgeons do PRK 10% of the time, LASIK about 90%,” said Julian Stevens, FRCOphth, of Moorfields Eye Hospital in London.

Jorge L. Alió, MD, of the Instituto Oftalmologico de Alicante in Spain, agreed that LASIK is the dominant form of refractive surgery, but added that intrastromal corneal rings, conductive keratoplasty and phakic IOLs as viable alternatives. “PRK has virtually been abandoned in my clinic,” he said.

Phakic IOLs

Thomas Kohnen, MD, a private practitioner in Frankfurt, Germany, said he uses phakic IOLs in 10% of his refractive surgery procedures. He is not alone in his interest. According to the ESCRS survey, 29% of participants are using or have interest in phakic IOLs. In addition, 27% of surgeons are showing interest for the future, and 20% are planning to use them more frequently in the future.

“In my clinic, phakic IOLs are becoming increasingly popular, but we perform LASEK selectively,” Dr. Alió said.

LASEK

LASEK, developed by Massimo Camellin, MD, is a technique in which a flap is made in the epithelium rather than the stroma, thereby eliminating complications associated with deep corneal stromal flaps in LASIK.

“Since I am not a big fan of PRK, I am currently investigating LASEK,” Dr. Kohnen said. “I would like to see how it works and how I can increase the options for people who have keratoconus and a thinner cornea.”

However, controversy exists with LASEK, as with many new procedures.

“We think LASEK is too risky,” said Julian Buratto, MD, son of Lucio Buratto, MD, an Italian pioneer of refractive surgery who was an early proponent of LASIK. “The technique is not really good yet. The materials used for LASEK don’t give us much comfort. We think it still needs to be tested.”

Dr. Lucio Buratto added, “I have never performed LASEK because I don’t think if offers any advantage with respect to PRK and LASIK.”

In Germany, Dr. Knorz agreed: “LASEK is just another name for PRK, for me. We should continue to evaluate the benefits of LASEK, but I don’t believe it will gain popularity.”

There has been similar speculation in the United Kingdom, according to Dr. Stevens: “To me, LASEK is a very good form of PRK. It’s just a different way of taking off the epithelium. Where we have really seen enormous growth is in LASIK.”

LASIK on the rise

“In the next year, I would expect LASIK to increase dramatically in terms of numbers here in the U.K. It’s already increased dramatically in the last year, as elsewhere,” Dr. Stevens said.

Dr. Lucio Buratto has noticed the trend as well. “There has been a significant increase in LASIK in my country, as in others, as patients see LASIK as a painless and fast-recovery surgery.”

In terms of numbers, refractive procedures are very popular in Spain and Italy, he said. “We are probably doing 40% to 50% of (the number of) surgeries that America is doing.”

Drs. Lucio Buratto and Stevens believe refractive surgery is performed most aggressively in specialty centers. Surgical centers devoted to refractive procedures are generating high volumes, Dr. Stevens said.

“We currently have seven new clinics opening up in London. They’re cropping up all over,” he said. He added that referrals are no longer required in the United Kingdom, so patients may easily go where they please.

Dr. Knorz has also noticed the highest number of refractive procedures performed in refractive centers in his country. “Specialty centers can quickly expedite LASIK procedures and advertise publicly, unlike hospitals and some private practices,” he said.

Amid all this growth, however, Dr. Lucio Buratto said business in Europe overall has developed more slowly than he expected. Those interviewed speculated that lack of publicity in many countries has led to an uninformed populace. In nations where cosmetic surgery is popular, LASIK gets a lot of attention, but in countries where advertising surgical procedures is prohibited or not yet common, numbers are low.

“In the last year, about 60,000 LASIK procedures were performed in Germany, out of 80 million people,” he said.

Cutting costs and increasing sales

The questions of safety and quality arise any time a surgical procedure becomes a consumer issue, Dr. Alió said. Because refractive surgery is in most cases for cosmetic or functional reasons, health care and government support is not offered to patients, he said.

Patients with little means who desire to be spectacle-free often resort to refractive centers that offer inexpensive LASIK. But according to Dr. Alió, the results can be vision-threatening.

“Low prices means low-cost equipment, low-cost maintenance and quality that is not good. This brings a lack of prestige to the technique,” he said.

José L. Güell, MD, of the Instituto de Microcirugia Ocular in Barcelona, Spain, agreed.

“When refractive surgery becomes more or less a business situation, it diminishes the consideration of most refractive surgeons and corneal surgeons. I would like to see a change in that, where patients and doctors will become more educated about what is necessary for safety and proper indication,” he said.

Catching the wave

More treatment guidance may be obtained through wavefront technology, Dr. Güell said. Wavefront technology is a tool that helps surgeons measure the minute aberrations and idiosyncratic refractive errors of the cornea. Linking this information to a laser may help improve the accuracy of ablation.

“I am using wavefront to analyze all my patients preoperatively. It’s useful to evaluate some of the problems,” he said.

However, he stressed he is not relying on wavefront data to perform ablation.

“We don’t know the true importance of wavefront and how to use that information just yet,” he said.

Like Dr. Güell, other surgeons have been cautious in adopting the technology. Drs. Lucio and Julian Buratto use wavefront technology only for preoperative testing; however, they are excited about the possibilities this new technology will offer.

“I see it as one of the most interesting technologies for the future of refractive surgery,” Dr. Lucio Buratto said.

Dr. Zanini noted that interest in wavefront-guided ablation has increased in Italy in the past 2 years. “I too am interested in it, but I have not incorporated it into my practice just yet,” he said.

A number of editorial board members who have incorporated wavefront technology into their practice reported using the Technolas 217 Excimer Laser System (Bausch & Lomb) in conjunction with the Zyoptix (Bausch & Lomb) system for customized ablation.

Dr. Knorz, a user of Zyoptix, said, “In higher myopia, I’ve found it to reduce the amount of spherical aberration induced by laser ablation. It enlarges the optical zone, and less tissue is ablated.”

At his center, Dr. Alió has been using Zyoptix on a select group of patients for almost 3 years. The results have been good to moderate, he said.

“By using Zyoptix we now have a better indication for myopia,” he said.

In larger amounts of myopia, greater than –2 D, Dr. Alió has performed Zyoptix-guided ablation as a secondary procedure.

“We think of it as a refinement procedure. We call it ZAR: Zyoptix ablation refinement.” Dr. Alió and colleagues believe wavefront-oriented ablation should be used only for refinement purposes, not for primary ablation.

Looking ahead

Dr. Alió sees a future for refractive surgery that will encompass all aspects of the visual system.

“I see refractive surgery changing from a purely laser surgery to a multi-procedural surgery,” he said.

In order for this to happen, education for refractive surgeons must be more thorough, he said.

“Training should become universally certified. The education of the refractive surgeon will have to become more complete. Surgeons will work from the lens to the cornea, with IOLs and intracorneal devices,” he said.

According to Dr. Güell, “Customized ablations will increase. There will be more lenses, more options for treatment to the cornea.” He believes refractive surgery will become more complex, with more surgical options.

“I believe LASIK and PRK will continue to play a role, but wavefront technology and the application of new techniques, with IOLs, will enlarge the indications to a safe and effective treatment for higher degrees of ametropia,” Dr. Zanini said.

With the refinement of the practice and the addition of new treatments, refractive surgery will move from a subspecialty to a cornerstone of ocular surgery, Dr. Alió said.

For Your Information:

• Jorge L. Alió, MD, PhD, can be reached at Instituto Oftalmológico de Alicante, Adva, Dénia 111, 03015 Alicante, Spain; +(34) 96-515-4062; fax: +(34) 96-515-1501; e-mail: jlAlió@oftAlió.com.
• Julian Buratto, MD, can be reached at Piazza della Republica 21, 20124 Milan, Italy; +(39) 02-636-1191; fax: +(39) 02-659-8875; e-mail: office@buratto.com.
• Lucio Buratto, MD, can be reached at Piazza della Republica 21, 20124 Milan, Italy; +(39) 02-636-1191; fax: +(39) 02-659-8875; e-mail: office@buratto.com.
• Massimo Camellin, MD, can be reached at Via Fiume 8, 45100 Rovigo, Italy; phone/fax: +(39) 042-541-1357; e-mail: cammas@tin.it.
• José L. Güell, MD, can be reached at Instituto de Microcirugia Ocular, Munner 10 Barcelona 08022, Spain; +(34) 93-253-1500; fax: +(34) 93-417-1301; e-mail: Güell@imo.es.
• Michael Knorz, MD, can be reached at 14 Leibniz St., 68165 Mannheim, Germany; +(49) 621-383-3410; fax: +(49) 621-418-3135; e-mail: knorz@eyes.de.
• Thomas Kohnen, MD, can be reached at Johann Wolfgang Goethe University, Theodor Stern kai 7, Frankfurt am Mein, 60590, Germany; +(49) 696-301-6739; fax: +(49) 696-301-3893; e-mail: kohnen@em.uni-frankfurt.de.
• Julian Stevens, MD, can be reached at Moorfields Eye Hospital, London, EC1V 2PD, England; +(44) 207-251-4835; fax: +(44) 207-431-8622; e-mail: julianstevens@compuserve.com.
• Maurizio Zanini, MD, can be reached at Centro Salus, Via Saffi 4/h, 40131 Bologna, Italy; +(39) 51-558-657; fax: +(39) 51-524-486; e-mail: mzanini@eyeproject.com.

• Bausch & Lomb can be reached at Hamilton House/ Regent Park, Kingston Road, Leatherhead, UK KT22 7PQ; +(44) 1372-22-4030; fax: +(44) 1372-22-5040.