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Fine-Tuning
the epi-LASIK Procedure
Surgeons make it a more
patient-friendly experience.
By Jerry Helzner, Senior Editor,
Ophthalmology Management, September 2006
Thanks to a group of dedicated refractive
surgeons who have devoted a great deal of their time to improving Epi-LASIK,
patients who choose this procedure are finding that they can now expect less
pain, faster healing and quick visual recovery.
This article will explore the primary
reasons why the work of these surgeons is making epi-LASIK a more
patient-friendly experience, enabling it to close the gap with LASIK as a
procedure of c
A Growth Trend
The epi-LASIK procedure, which was no
more than a blip on the refractive surgery radar screen only 2 years ago,
does not yet pose a major challenge to LASIK, but it is expected to account
for approximately 5% of all U.S. laser vision correction procedures in 2006,
up from an estimated 1.5% last year. Even more telling is the fact that a
number of the country's refractive surgery thought leaders, including H.L.
"Rick" Milne, M.D., Marguerite McDonald, M.D., Eric Donnenfeld, M.D., Barrie
Soloway, M.D., Thomas Claringbold, D.O. and Dimitri Azar, M.D., are now
choosing to perform epi-LASIK on an increasing percentage of their patients.
The growth in epi-LASIK also coincides with renewed interest in the overall
range of surface ablation procedures. Though the industry newsletter
MarketScope reports that LASIK currently accounts for approximately 89% of
all laser refractive procedures performed in the United States, there is
evidence of a slow but steady growth trend back toward surface procedures.
This trend has been confirmed by the results of two recent surgeon surveys,
one conducted by MarketScope and the other the annual Duffey/Leaming survey
of trends in refractive surgery.
Although LASIK has been an extremely successful procedure, industry analysts
agree that the penetration of the potential refractive surgery patient
population is still relatively low.
A large number of candidates have chosen to remain on the sidelines, often
because of a stated reluctance to undergo blade-created flap creation as
part of the procedure. Most industry observers believe that the recent
introduction of femtosecond laser technology, which eliminates the
blade-created flap from the LASIK procedure, has helped ease the fear factor
that had previously existed among many potential patients. Still, advocates
of surface ablation say that many of today's refractive surgery candidates
are a little less enamored with the "WOW" factor of LASIK — and more
safety-minded — and thus more inclined to opt for surface ablation. In
addition, many surface ablation advocates believe that wavefront surface
ablation produces better visual outcomes than wavefront LASIK.
Surface
Treatment of Choice
Dr. Claringbold, of the Mid-Michigan Physicians Group in Clare, Mich., who
has long been a champion of surface ablation, now performs epi-LASIK on
approximately 80% of his refractive patients.
"I still do LASEK for some patients, such as those who are post-cataract,
but I find epi-LASIK a better procedure because you eliminate the alcohol
that you have to use in performing LASEK," he says.
"With epi-LASIK, we are now closing the gap on LASIK in terms of improving
the patient experience. I found that LASEK requires about a week of recovery
time," Dr. Claringbold continues. "My epi-LASIK patients are much more
functional during the first week postop and some are quite functional after
1 day."
Dr. Claringbold envisions a time when epi-LASIK accounts for the majority of
all laser vision correction procedures in the United States, as it currently
does in Europe.
"Surface ablation has always been popular in Europe because the European
culture does not put as high a priority on instant gratification as our
culture does," Dr. Claringbold notes. "They have a slower lifestyle and tend
to choose the safer surface procedure even if it means a little longer
recovery time."
Some
Surgeons Use it More Selectively
While Drs. Claringbold, Milne and McDonald have moved almost exclusively to
epi-LASIK and surface ablation, Drs. Donnenfeld, Soloway and Azar still
perform LASIK on a majority of their patients.
"I'm still a big believer in LASIK," says Dr. Donnenfeld of Ophthalmic
Consultants of Long Island. "I'm currently performing epi-LASIK on about 10%
of my refractive patients but I expect that to increase to approximately
20%. I favor epi-LASIK for patients with irregular topographies who would be
at risk for ectasia with LASIK. I also favor epi-LASIK for patients who have
a history of dry eye."
Dr. Donnenfeld believes that the development of multi-faceted pain-reduction
regimens over the past few years has removed one obstacle to patients'
acceptance of epi-LASIK.
"Pain is no longer the issue with epi-LASIK," he says. "What surgeons are
focusing on now is achieving faster visual recovery and healing."
Dr. Soloway, director of vision correction at the New York Eye and Ear
Infirmary, is currently performing surface treatments on about one-third of
his refractive patients, with epi-LASIK his procedure of choice.
"I prefer to perform a surface treatment if a patient has a pachymetry
issue, a history of dry eye, or simply if the patient prefers what I
consider a safer procedure," says Dr. Soloway. "I think with epi-LASIK we
are closing the gap on the pain issue compared to LASIK, but I don't think
we are quite there yet. I will say that with my epi-LASIK patients, after 24
hours the pain is pretty much gone."
The Flap Issue
Though all of the surgeons interviewed for this article generally agree on
such epi-LASIK issues as appropriate patient selection and effective
pain-reduction regimens, one area of minor disagreement on how epi-LASIK
should best be performed is still being studied. That is the question of
whether the intact epithelial flap should be used as a natural bandage or be
discarded. The issue is of such interest that Drs. Donnenfeld, Soloway,
Milne and Azar all have conducted their own studies on just this point.
One of the more ambitious studies was conducted by Dr. Milne of the Eye
Center in Columbia, S.C., who performed 50 epi-LASIK procedures in which he
left the intact epithelial flap on as a natural bandage and then 50 more
procedures in which he discarded the flap.
"My study convinced me that there are definite advantages in discarding the
flap," says Dr. Milne. "The biggest advantages are in terms of faster visual
recovery and healing, which are of major importance to patients. When I
discard the flap, 95% of my patients can drive and get back to work within
three-and-a-half days, which means that they can have the surgery on a
Thursday after work and be back at work with no pain and fully functional
vision by Monday morning. Compare that to PRK which takes about a week to
heal."
Dr. Milne says that when he left the epithelial flap on, a small percentage
of his epi-LASIK patients experienced delayed visual recovery.
"My belief is that when you leave the flap on, new epithelium grows over the
old epithelium and you get a "skin-on-skin" effect that can delay visual
recovery," he says.
Advocates of leaving the epithelial flap on as a natural bandage after epi-LASIK
assert that the presence of the flap diminishes pain and reduces the chances
of the patient developing haze.
The Haze Issue
Dimitri Azar,, M.D., field chair of ophthalmic research and head of
Ophthalmology and Visual Research at the University of Illinois at Chicago,
has conducted an animal study on the haze issue. He found that retaining the
flap is the best way to prevent haze from developing after epi-LASIK.
"If the epithelial flap is intact and it adheres, I will put it back over
the eye," says Dr. Azar. "If the epithelial sheet is torn, which happens
very rarely, I will convert the procedure to PRK or possibly LASEK. I'm
open-minded and would like to see further studies on this issue, but as of
now I see no reason for throwing a viable epithelial flap away."
"If the flap is healthy and intact, I prefer to leave it on," adds Dr.
Soloway.
"We conducted a contralateral study with epi-LASIK patients in which we left
the flap on one eye and discarded the flap from the other eye," Dr. Soloway
continues. "The differences were not huge, but patients reported slightly
less pain in the eye with the flap and we found a slightly smaller chance of
developing haze when the flap is retained. Visual recovery may be a bit
quicker if the flap is discarded, but we place a higher priority on patient
comfort and pain reduction."
Dr. Milne is aware of the widespread perception that discarding the flap
creates a greater chance of the patient developing haze, but he believes
that he has effectively negated the haze issue by using mitomycin C (MMC) 15
to 20 seconds after the surgery is completed for all patients who have an
ablation depth of more than 75 microns.
"I have not seen a single case of haze in any of these patients," says Dr.
Milne.
No one disputes Dr. Milne's findings, but some surgeons, including Dr.
Soloway, prefer not to use MMC for their refractive patients because they
believe that in isolated cases it can slow the healing process.
Dr. Donnenfeld comes down on the side of discarding the epithelial flap. He
calls this variation of epi-LASIK lamellar epithelial debridement.
"We have found that, with lamellar epithelial debridement, both vision
recovery and healing are faster," says Dr. Donnenfeld. "But whether you
retain the flap or discard it makes no difference in long-term visual
outcomes."
Small
Disagreements, but a Single Goal
One thing to remember is that even though these surgeons may disagree on
specific points, they are all advocates of epi-LASIK and are working to make
the procedure as safe, effective and patient-friendly as possible.
"Epi-LASIK is meeting with growing acceptance and continues to become a more
appealing option," concludes Dr. Azar. "When it is done well, it can be an
elegant and predictable procedure."
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