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Do you believe another refractive surgery procedure will overtake PRK in terms of popularity for military members?
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LASIK, SMILE poised to overtake PRK
I believe LASIK is poised to overtake PRK as the favored procedure in Navy refractive surgery, but it will be very interesting to see what role there is for small incision lenticule extraction in the future.
The Navy tallies 10,000 to 14,000 refractive surgery procedures per year at six Navy Refractive Surgery Centers and one joint Army-Navy center at Walter Reed National Military Medical Center. In fiscal year 2017, our procedures were 57% PRK, 42% LASIK and 1% ICLs. While our overall numbers do indicate a preference for PRK, these overall numbers do not tell the entire story.
At many of our centers, LASIK is the procedure of choice because there is less postoperative pain, faster visual recovery and a faster return to duty. Navy and Marine Corps pilots led the way for this increasing preference for LASIK because they could return to the cockpit more quickly: as early as 2 weeks after LASIK compared with a mandatory 90-day “down” status with PRK. Navy SEALs were also early adopters of LASIK so they could return to training and operational deployments sooner. We often find that patients are disappointed when we tell them they can “only” have PRK because they are not medically qualified for LASIK.
So why do the overall Navy numbers favor PRK? These statistics are skewed toward PRK due to the large number of Naval Academy midshipmen treated at Walter Reed. In fact, if we did not count the Naval Academy PRK numbers, the Navy’s annual numbers of PRK and LASIK would be roughly equal. Naval Academy midshipmen are often younger than age 21, so we want to minimize our risk of post-refractive surgery ectasia. Furthermore, midshipmen do not deploy, so they have the benefit of recovering from their surgery while they continue their studies.
There will always be a role for PRK, both due to surgeon preference and patient preference. Some patients simply do not qualify for LASIK because their corneas are too thin or too scarred. There is still a subset of patients who “fear the flap.” Some are worried that they will not be able to cooperate with the additional surgical steps of making the flap, while others are concerned that they will dislocate flap in the future, despite our reassurances that this is extremely unlikely with reverse-bevel geometry of the flaps created with femtosecond lasers. SMILE may alleviate these patients’ concerns, and we are actively investigating this procedure in the Navy, along with our colleagues in the Army and Air Force. As we have for RK, PRK and LASIK in the past, we will objectively evaluate this new procedure to assess its safety and efficacy in the military setting.
Elizabeth M. Hofmeister, MD, Capt, MC, USN, is refractive surgery advisor for Navy Ophthalmology at Naval Medicine Center San Diego. Disclosure: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the U.S. government.
LASIK will be next big thing
This is an interesting question with perhaps a more interesting answer. The Army Warfighter Refractive Eye Surgery Program began in 2000 at Fort Bragg, the largest U.S. Army base with more than 53,000 troops. The program rapidly expanded to nearly a dozen other bases with large populations.
Initially, PRK and LASIK were performed at Fort Bragg; however, Special Operations Forces (SOF) were not allowed to have LASIK over the concern for LASIK flap dislocations. Although extremely rare, a LASIK flap dislocation would create significant difficulty in those in austere environments without reasonable access to eye care providers. This concern was echoed in a 1999 AAO poster from Mass. Eye and Ear Infirmary, highlighting LASIK flap dislocations and concluding PRK may be better than LASIK for military troops and policemen.
During 2000 to 2004, LASIK was done at Fort Bragg at the request of non-SOF soldiers. In 2004, all LASIK was stopped at Fort Bragg due to a review showing a flap dislocation incidence of one in 500 LASIK cases.
Although some Army locations continued with LASIK in a minority of cases, Fort Bragg surgeons only performed PRK/LASEK.
The improvements in femtosecond LASIK, particularly with a 120° inverted side cut and a temporal-based hinge, led to a reintroduction of LASIK at Fort Bragg in 2011. This has quickly become the preferred laser refractive procedure at Fort Bragg, now comprising up to 75% or more of all laser cases in 2017.
The main reasons I believe femtoLASIK could surpass PRK as the major refractive procedure are the rapid visual recovery, the rapid return to duty, and the theoretical, clinical and anecdotal confirmation of safety advantages in the way femtosecond LASIK is done at Fort Bragg over that previously done with a microkeratome in our experience.
Scott D. Barnes, MD, is Colonel, U.S. Army, Chief of Ophthalmology and Refractive Surgery at Womack Army Medical Center, Fort Bragg, N.C., and flight surgeon, diving medical officer and former deputy surgeon for the U.S. Army Special Operations Command at Fort Bragg. Disclosure: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Army, Department of Defense or the U.S. government.