Eyeworld

EW NEWS & OPINION 42 April 2016 by Mitchell Gossman, MD –3 9% –4 21% –5 9% –6 0% Some higher cutoff 0% Perhaps many do not use mitomy- cin-C for lower ablations because of the low incidence of haze and the unknown long-term consequences of exposure to mitomycin-C. The seventh question was, "What do you routinely use for pain control after PRK? Multiple respons- es allowed." Percentages indicate how many use that modality. Bandage contact lens 100% Topical NSAID 72% Chilled balanced salt solution 77% Narcotics prn 38% Gabapentin or similar class 33% Topical anesthetic postop prn 31% Migraine analgesic such as sumatriptan or rizatriptan 3% As in most cases in medicine where there are many ways to treat a prob- lem, it means that none of them is perfect because otherwise the others would wither away. Postoperative pain continues to be an issue. The eighth question was, "What is the highest PRK myopic ablation you will do?" Speed of recovery of vision after PRK is highly variable and is for most the Achilles' heel of the procedure. In my own practice, patients factor this in highly as well and most opt for LASIK. The fourth question was, "For PRK, how do you prefer to remove epithelium for a virgin cornea?" Alcohol 63% Amoils brush 25% Blade (sharp or blunt) 7% Laser scrape 5% The fifth question was, "For PRK, how do you prefer to remove epithe- lium for a prior LASIK cornea?" Alcohol 76% Blade (sharp or blunt) 8% Amoils brush 5% Laser scrape 4% Both alcohol and Amoils brush 2% The concern with Amoils brush epithelial removal when perform- ing PRK on a preexisting flap is the potential to dislodge the flap and even injure it. This is likely the rea- son many Amoils users shun its use when a flap is present. The sixth question was, "For what myopic ablation or above do you apply mitomycin?" Mitomycin for all cases 52% Never use mitomycin 5% –1 2% –2 2% The second question was, "If you prefer PRK over LASIK for such a case, give a ranking of your reasons." The following choices were offered and are listed in descending order of importance to participants: No flap complications intraop or periop such as buttonhole, striae, dislocation, epithelial ingrowth No traumatic flap complications possible Less structural weakening, thus less risk of iatrogenic ectasia DLK impossible Less dry eye symptoms Faster Ease of enhancement Better quality of vision Cheaper It is interesting and not unexpected that cost is low in this list despite a very competitive refractive surgery market. One issue to keep in mind, however, is that while cost to the office or patient may be lower than LASIK, especially femtosecond laser flaps, PRK may require considerably more office visits. The third question was, "If you prefer LASIK over PRK for such a case, give a ranking of your reasons." The following choices were offered and are in descending importance to participants: Quicker vision recovery More comfortable Concern about haze with PRK Fewer postop visits Part 1 of a 2-part series R eshaping the cornea with a laser has been performed since the 1980s but was initially performed on the stromal surface without making a flap first. The practice of creating a stromal flap, which was pioneered in the late 1980s, allows for a more rapid and comfortable re- covery because no epithelial healing is required. Not all patients are good candidates for LASIK due to inad- equate corneal thickness, concern about borderline normal topogra- phy, anterior basement membrane dystrophy, and more. There are also advantages to not making a flap, such as the impossibility of flap-re- lated complications, less structural weakening, no late flap trauma, etc. However, many ophthalmologists are concerned about postoperative haze and the delayed vision recov- ery. So how many perform PRK cur- rently, why, and in what manner? A survey was performed of 59 practicing ophthalmologists who volunteered to participate from the ranks of participants of the eyeCONNECTIONS online commu- nity and volunteers around the U.S. Responses are anonymous in order to encourage candor. Totals may not be 100% due to rounding or unus- able responses. The first question was, "For an average patient wanting laser refractive surgery who isn't overly concerned about speed of recovery, do you recommend PRK or LASIK? For the purposes of this question- naire, PRK=LASEK." The question was phrased in this manner because the patient who cannot afford to wait for vision recovery would likely be a natural LASIK patient for most surgeons. LASIK 61% PRK 39% How does PRK fit into our refractive practices and how are we performing it? Pulse of ophthalmology: Survey of clinical practices and opinion Mitchell Gossman, MD

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