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Minimal clinical difference seen in pain scores for flap-off epi-LASIK, automated PRK brush removal
After the first 12 hours, the difference in overall pain scores over the next 4 days was marginal.
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A study of postoperative discomfort and epithelial healing time found a statistically significant difference but no clinically significant advantage between epi-LASIK with flap amputation and automated brush PRK to remove epithelium.
“Advanced surface ablation has been the procedure of choice in the active-duty military war-fighter population since the inception of our program over 12 years ago,” study co-author Joseph F. Pasternak, MD, a staff physician and medical director of Refractive Surgery Service at Walter Reed National Military Medical Center in Bethesda, Md., said.
The prospective study comparing the two surgical techniques involved 60 patients from active-duty refractive surgery consults. All patients were treated bilaterally without mitomycin C, with one eye randomly receiving flap-off epi-LASIK and the other eye brush removal PRK.
Although patients experienced statistically significantly less pain in the flap-off epi-LASIK eye, the average difference in pain scores between the two groups over 4 days postop was only 0.33 on a scale of 0 to 6. However, the flap-off group reported significantly less pain in the first 12 hours after surgery. Over the first 96 hours, the median reported use of tetracaine was five drops in the flap-off group compared with seven drops in the brush group.
Joseph F. Pasternak
“Our preference for surface treatment has been in large part due to safety considerations in a young, highly physical, active patient population who may be at increased risk for traumatic complications in the post-LASIK setting,” Pasternak said.
Pasternak said the safety advantage of surface ablation has its trade-offs: “In addition to delayed visual recovery, postoperative ocular discomfort remains a significant postop challenge. A large number of patients have to contend with perioperative pain that can be quite severe.”
Limiting pain
Over the years, Pasternak and colleagues have undertaken numerous clinical investigations, with the goal of limiting perioperative pain. They embarked on their current study of pain control in response to anecdotal reports that patients had diminished discomfort after advanced surface ablation using flap-off epi-LASIK, he said.
Patients kept a pain log and recorded the use of pain-control medications as part of the study, which was published in the Journal of Refractive Surgery. Pasternak speculated that the flap-off group may have had less pain because of the cleaner edges made by the mechanical keratome and a more homogenous epithelial defect.
“The brush can create very controlled epithelial defects, but there is quite a bit more variability to the epithelial removal than there is with epi-LASIK,” he said. “I did not expect there to be a statistically significant difference in the pain experienced by patients in each arm of the study, as the epithelial defects were similarly sized, so our findings were a bit unexpected.”
Beyond pain
Pasternak said that, despite decreased pain scores with the flap-off technique, other factors, such as cost, intraoperative pain and length of the procedure, need to be considered in deciding between the techniques.
“When factoring all of these considerations, we are continuing to perform epithelium removal with the mechanical brush, in spite of the less favorable pain scores,” he said.
Regarding intraoperative discomfort, Pasternak said, “Our study did not specifically address intraoperative discomfort, but it came as no surprise that patients anecdotally reported increased intraoperative discomfort with epi-LASIK, due to [use of] the suction ring.”
At his practice, Pasternak and colleagues manage postop pain with a combination of a bandage contact lens, oral pain medication and sparing, judicious use of topical anesthetic, he said.
There was no meaningful difference in epithelial healing time: 3.8 days for flap-off eyes and 4.1 days for brush eyes.
For practices that still use a microkeratome, performing epi-LASIK on patients undergoing advanced surface ablation may be a consideration, Pasternak said. – by Bob Kronemyer
Editor’s note: The views expressed in this article are those of Pasternak and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense or the U.S. government.