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Use of surface ablation increasing; experts debate its future
Improved equipment, better pain regimens and greater concern over LASIK complications spur procedure’s popularity, surgeons say.
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The popularity of surface ablation for refractive surgery in on the rise. This year, surface ablation procedures made up an estimated 15% of all refractive surgical procedures, compared with 11% last year, according to the industry analyst publication Market Scope.
Recovery times and patient pain ratings have been reduced from earlier versions of surface ablation procedures and, as a result, the number of procedures has risen each year in recent years, experts said.
“We have better lasers. They give smoother ablations. They give better outcomes, and we have better pain regimens. So, it’s time to consider doing at least some of your cases as surface,” Marguerite B. McDonald, MD, FACS, told Ocular Surgery News. “It’s definitely on the rise.”
Increasing use
Dr. McDonald presented statistics from Market Scope at the American Academy of Ophthalmology meeting, showing a steady increase in surface ablation procedures over the past 3 years.
“I think it’s everything all at once,” Dr. McDonald said. “As spectacular as wavefront-based LASIK is, wavefront-based surface ablation is even better – by a little, but it definitely is – and nobody can contest the safety. You don’t have flap complications if you don’t have a flap.”
She and other surgeons agreed that the increase is due to a combination of reasons, ranging from improved equipment and greater concern over LASIK complications to new medications and more extensive pain regimens.
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Image: Donnenfeld ED |
Eric D. Donnenfeld, MD, cited the increased recognition and fear of ectasia after LASIK and the need for performing deeper ablations for customized surgery as key reasons for the rise in surface ablation.
“All these different contributing forces are leaving us with more surface ablation and, with more surface ablation, we need to maximize patient comfort,” he said.
The need for deeper ablations, particularly in patients who have previously undergone refractive surgery, is the reason Daniel S. Durrie, MD, said his percentage of surface ablation procedures is higher than the norm, at 25%.
Dr. Durrie noted, however, that he mainly performs surface ablation on patients who are not good candidates for flap creation with the Intralase FS laser, and those numbers are dwindling. In the future, he said, surface ablation may not be the answer.
William B. Trattler, MD, whose practice has been 100% surface ablation for almost 5 years, said he thinks the trend toward more surface ablation will continue due to improved results.
“Some doctors are still doing a lot of LASIK, but they’re realizing that surface ablation works really well for patients who may not be the best for LASIK,” he said.”
Dr. McDonald said postoperative treatment regimens, such as her extensive regimen to control pain, are allowing a less painful and quicker recovery.
“What really puts people off from surface ablation, and doctors too, is the pain,” she said. “Now, we have some good regimens to make people comfortable. It has been gratifying to see how comfortable the patients are and how well they do.”
Physics of ablation
William J. Dupps, Jr., MD, PhD, discussed the favorable biomechanics of surface ablation compared to the more complex biomechanical insult of LASIK at the AAO meeting. The advantage lies with surface ablation, he said, because it induces less biomechanical variability.
Dr. Dupps pointed out that LASIK causes a greater depth of lamellar disruption, altering the balance of forces in the cornea by weakening of the corneal cap. He added that the flap itself can induce hyperopia, astigmatism and higher-order aberrations, depending on the hinge position.
Alternatives and additives
The future of refractive procedures may lie in alternatives and additives to traditional LASIK and surface ablation, surgeons said.
In Europe, Dr. Durrie said, some surgeons are applying a phototherapeutic keratotomy compound to smooth the corneal surface after ablation. This compound is then polished with the phototherapeutic keratotomy mode on the laser, he said. This application is not yet approved in the United States.
“I think it’s a shame we don’t have companies pursuing that here in the U.S. With this increasing number of surface ablations being done, it would be great to have all the technology to get the best results,” Dr. Durrie said.
Although that compound is still out of reach, Drs. Durrie and Trattler said new thin-flap procedures, such as sub-Bowman’s keratomileusis, are beginning to appear in an attempt to combine the advantages of LASIK and surface ablation.
“If they can show that the risk of ectasia, for example, is now made much less with [sub-Bowman’s keratomileusis], then I think you may see a return to Intralase-driven LASIK,” Dr. Trattler said.
Dr. Durrie agreed, predicting that the debate over LASIK vs. surface ablation could disappear if that balance is struck by thin-flap procedures.
“The thin, computer-controlled flap procedures that are starting to develop are scientifically showing that when we cut less tissue, we cause less trauma,” Dr. Durrie said.
Even Dr. McDonald, who told the AAO audience that she has “hung up her microkeratome” for surface ablation, expressed an interest in thin-flap procedures.
“I’m not married to this regimen, nor am I married to surface ablation. I’m just looking for the best results and the safest results,” she said.
The future
As the number of surface ablation procedures increases, surgeons are looking ahead to further improve PRK.
“If we can come up with a good regimen that minimizes pain and maximizes visual recovery, I think patients will be more comfortable and more satisfied with their procedure,” Dr. Donnenfeld said.
Dr. McDonald said she is always looking to improve her pain regimen and is open to new procedures if they prove to be as safe and effective.
“I’m always looking for a better drop, a better bandage lens. That’s why the first-day pain scores are as low as they are,” she said.
New treatments such as Neurontin (gabapentin, Pfizer) and cytochrome C peroxidase are options that may be considered for the future.
“The Italians are working the cytochrome C peroxidase, which almost doubles the speed of re-oxidation, and we all know that the faster you heal, the better your outcome,” she said.
For more information:
- Marguerite B. McDonald, MD, FACS, can be reached at OCLI, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; e-mail: margueritemcdmd@aol.com. Dr. McDonald is a consultant for AMO-VISX and Allergan.
- Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Alcon and Allergan.
- Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 200, Overland Park, KS 66211; 913-491-3737; fax: 913-491-9650; e-mail: ddurrie@durrievision.com. Dr. Durrie is a paid consultant for Alcon.
- William B. Trattler, MD, can be reached at Center for Excellence in Eye Care, 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@earthlink.net. Dr. Trattler is an Allergan consultant and conducts research for Allergan and Ista.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.