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LASIK, LASEK, PRK: The choice is yours
Three surgeons discussed which is best. There are advantages to each technique, they said.
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Ease of surgical performance, high patient satisfaction, minimal complications and surgeon comfort — These are the leading reasons that LASIK, photorefractive keratectomy and laser epithelial keratomileusis are all viable options for the correction of many refractive errors, according to a panel of experts.
The focus of the symposium at the European Society of Cataract and Refractive Surgeons meeting was to discuss reasons for choosing each procedure over the others.
Moderator Daniel Epstein, MD, asked Michael Knorz, MD, Niels Ehlers, MD, and Daniel S. Durrie, MD, to address whether LASIK deserves the popularity it has achieved, why surgeons should still consider photorefractive keratectomy (PRK) as a refractive procedure and whether laser epithelial keratomileusis (LASEK) is a “flash in the pan.”
Favoring LASIK
Dr. Knorz said LASIK is popular because it is relatively painless surgery offering rapid recovery of vision. Patients are comfortable and have their sight improved by the next day, he said.
“LASIK is far more comfortable for the patient because there is instant visual recovery and no postoperative pain,” Dr. Knorz told Ocular Surgery News in an interview. However, he said, there is not a great difference in long-term visual outcomes among the three procedures.
“Some clinical data suggests that LASEK will be more predictable with wavefront-guided ablations. The possible reason for this is the more complex biomechanical response in LASIK. We measure before the cut but treat after the lamellar cut, assuming that the ocular aberrations remain the same. However, this assumption may be wrong. LASEK causes more epithelial healing, which may also negate any effects of wavefront-guided ablations. More data are needed to answer the question of which procedure is best when using wavefront-guided ablations,” Dr. Knorz said.
In the past 3 years, Dr. Knorz said, has seen the number of LASIK procedures more than triple at the FreeVis laser centers where he practices in Mannheim, Germany.
Dr. Knorz evaluated 9,656 LASIK cases performed at his laser centers. In both myopic and hyperopic correction, visual acuity was within ±2 D of prediction in 99% of the cases, he said.
PRK still OK
Dr. Ehlers described a study he performed comparing LASIK and PRK. He found that optical aberrations after PRK or LASIK for myopia were about the same at 1 year.
Dr. Ehlers compared the results of LASIK and PRK performed with the same Asclepion-Meditec MEL-70 G-scan flying spot excimer laser. He conducted Orbscan (Bausch & Lomb) optical analysis and topography preoperatively and at 1, 3, 6 and 12 months postoperatively.
“There is no real difference between the two techniques in terms of optical aberrations,” he said. The sum of aberrations was more variable after PRK, but the difference between the procedures was not statistically significant after 1 year. Coma was greater and more variable after PRK, which remained true at 1 year. There was more spherical aberration in the LASIK group initially, and that held at the 1-year follow-up as well. Defocus was more variable after PRK but higher after LASIK at 1 year, he said.
“Corneal and ocular aberrations after PRK and LASIK for myopia are about the same,” Dr. Ehlers said. “There’s no clear winner between these two techniques. There’s more pain and a longer recovery for patients who undergo PRK, but there are potential flap complications with LASIK.”
He advised surgeons to use the technique they are most comfortable performing.
LASEK’s potential
There are reasons LASEK may be the preferred technique, Dr. Durrie said. He considers it a safer procedure than LASIK because it involves no flap creation. With no flap there is no cutting of corneal sensory nerves and therefore less risk of dry eye symptoms, he said. LASEK also may be more amenable to the emerging wavefront-guided technology, he said.
“It’s easier for both the patient and the doctor. There are no flap complications and no cut across the nerves, so no dry eye. There may also be less induced higher-order aberrations,” Dr. Durrie said.
Dr. Durrie advised using LASEK in patients with thin corneas or symptomatic dry eye, in young, active patients with less than 6 D of myopia and as an enhancement procedure in patients in whom a LASIK flap is contraindicated.
He described results in more than 500 cases of LASEK performed in his practice. Using conventional, non-customized-ablation lasers by Bausch & Lomb and Alcon, he said patients achieved “better uncorrected visual acuity with LASEK than I can get with LASIK.”
In his study, 90% had UCVA of 20/20 or better, 92% had 20/25 or better, 98% had 20/30 or better and 100% had 20/40 or better, he said.
Dr. Knorz said more study is needed to see which will be the preferred procedure.
“Regarding PRK, it is essentially the same as LASEK,” he said. “Using modern technologies developed for LASEK (trephination of the epithelium and alcohol to loosen the epithelium), epithelial healing is actually faster after PRK than after LASEK,” he said.
For Your Information:
- Daniel S. Durrie, MD, can be reached at the Hunkeler Eye Centers, 5520 College Blvd., Overland Park, KS 66211; (913) 491-3737; fax: (913) 491-9650; e-mail: ddurrie@hunkeler.com.
- Niels Ehlers, MD, can be reached at the Dept. of Ophthalmology, Århus University Hospital, Nerrebrogade 44, DK-8000 Århus C; (45) 8949-3222; fax: (45) 8612-1653.
- Michael C. Knorz, MD, can be reached at the Dept. of Ophthalmology, Klinikum Mannheim, Mannheim 68135 Germany; (49) 62-13-83-34-10; fax: (49) 62-13-83-38-03; e-mail: knorz@eyes.de.