EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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32 32 EW REFRACTIVE SURGERY August 2012 Focusing on LASEK over LASIK by Vanessa Caceres EyeWorld Contributing Writer the option to choose which one they wanted. Although he would tout the quicker recovery with LASIK, he emphasized the safety benefits of LASEK. "One patient challenged me and said, if it's safer, why am I giving the option? I thought he had a point," said Dr. Chynn, noting that a similar sce- nario would probably never occur for heart valve surgery. "It's only because of the self-pay aspect that we're letting patients choose." The move to all LASEK 5 years Emil W. Chynn, M.D. Surgeon discusses his switch L aser-assisted subepithelial keratectomy (LASEK) is the most reliable surgical ap- proach to avoid epithelial ingrowth and iatrogenic keratoconus, believes Emil W. Chynn, M.D., New York. Dr. Chynn believes so strongly in the power of LASEK that he has named his practice accordingly— Park Avenue LASEK—and switched to all LASEK about 5 years ago. Dr. Chynn contacted EyeWorld in response to the March article, "Stomping out post-LASIK epithelial ingrowth." Although Dr. Chynn is not against LASIK—he himself had the procedure done in 1999—he was concerned that the article (and similar ones within ophthalmology) did not mention LASEK's benefits as they relate to zero epithelial in- growth. Here's more on what Dr. Chynn had to say—and why he switched to all LASEK. From LASIK to LASEK For a number of years, Dr. Chynn performed both LASIK and surface ablation procedures, giving patients ago was a difficult one. "In the be- ginning it was rough, as patients would compare their recovery time with friends," Dr. Chynn said. "Over the last 5 years, we have refined and honed our technique to try to make the procedure as close to LASIK as possible." This has included the use of oral steroids to reduce inflamma- tion, selecting eye drops that are the least epithelial-toxic, and using mitomycin-C (MMC) judiciously. "Mitomycin-C has been a total game-changer," he said, noting the value of increased MMC use within ophthalmic surgery over the past 10 years. Dr. Chynn sees a number of pa- tients who come to his practice for enhancements after previous LASIK surgery. Sometimes these patients are upset with their initial procedure results and don't want to return to the original surgeon. Sometimes they will not even give Dr. Chynn the original surgeon's name. "Customers are so savvy now with the internet. On the minus side, we have to pay the price for patients being overeducated or thinking that they are. On the posi- tive side, at least for enhancements, they've done some research, and they're not excited to have the flap lifted up again," he said. In addition to avoiding epithe- lial ingrowth, Dr. Chynn said he is EyeWorld @EWNews Are you a fan of EyeWorld? Like us on Facebook at Find us on social media facebook.com/EyeWorldMagazine Follow EyeWorld on Twitter at twitter.com/EWNews Dr. Chynn believes LASEK is the most reliable surgical approach to avoid epithelial ingrowth (pictured here) Source: Edward J. Holland, M.D. eliminating the risk for iatrogenic keratoconus with the use of LASEK or what Dr. Chynn terms epi-LASEK. "Many enhancement patients are getting closer to the limits," where they are at greater risk for ectasia or keratoconus, Dr. Chynn said. Ultimately, Dr. Chynn tells patients that the risks eliminated by performing LASEK outweigh the slightly longer recovery time. Dr. Chynn widely publicizes his approach, including with the use of an OR that can be seen through glass windows from the New York City street his office sits on. "You see people eating lunch there and watching surgery. I don't think I could do that if I were cutting flaps," he said. Weighing in Knowing that surface ablation is always a hot topic but that LASIK is still strongly advocated by many, EyeWorld contacted two of the physi- cians interviewed for the original "Stomping out post-LASIK epithelial ingrowth" article to ask if or when they use surface ablation. "The rapid healing and immedi- ate 'wow factor' of LASIK continue to hold a strong attraction for me," said Mark Packer, M.D., clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, "I do PRK as indicated by suspect topogra- phy, dry eye, and occasional multi- focal IOL enhancements, but if there is no reason not to do LASIK, I prefer the instantaneous achievement of corrected vision to the ongoing documentary of re-epithelializa- tion." Steven E. Wilson, M.D., profes- sor of ophthalmology, Cole Eye Institute, Cleveland Clinic, Cleveland, does a fair amount of surface ablation. "About 15% of my primary cases are PRK, and all original PRKs are enhanced with PRK if needed. Some of my primary LASIK cases are enhanced with PRK with MMC, if the flap cannot be safely lifted," he said. "The results of both PRK en- hancement and LASIK enhancement are excellent, if performed properly. The incidence of epithelial ingrowth after LASIK enhancement should approach zero, or the method being used is inadequate." Ultimately, surgeons should use what's comfortable for them but also assess each patient's individualities, Dr. Wilson said. "My opinion is no surgeon should be wedded to the notion that one particular enhance- ment method is the best. In some patients, LASIK enhancement is bet- ter, and in some patients, PRK with mitomycin-C enhancement is better. It is up to the surgeon to decide which is best for a particular patient," he said. EW Editors' note: Dr. Packer has financial interests with Abbott Medical Optics (Santa Ana, Calif.) and Bausch + Lomb (Rochester, N.Y.). Drs. Chynn and Wilson have no financial interests related to this article. Contact information Chynn: 212-741-8628, toplasikdoc@gmail.com Packer: 541-687-2110, mpacker@finemd.com Wilson: 216-444-5887, wilsons4@ccf.org