PRK: Simple, Safe & Reliable

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1 OSN New York 2013 PRK: Simple, Safe & Reliable Technique & Pearls Christopher E. Starr, MD Associate Professor of Ophthalmology Director, Refractive Surgery Service Director, Ophthalmic Education Director, Cornea & Refractive Surgery Fellowship Weill Cornell Medical College New York-Presbyterian Hospital

2 Disclosures I have no direct financial interest in any of the products I will discuss Consultant, Speaker and/or Research Funding: Allergan Alcon Merck Bausch & Lomb Rapid Pathogen Screening / Nicox TearLab

3 Disclosures This 7 minute talk is not meant to be an exhaustive literature review of LASIK vs. PRK Instead, much of this talk will be based on my personal preferences, opinions and experiences Generally I embrace new techniques and technology LASIK, LASEK, Epi-LASIK are all fine procedures in the right hands but I prefer, and now exclusively perform, PRK - (and we have an Intralase in our center)

4 LASIK vs. PRK: Traditional Pros & Cons Advantages of LASIK Proverbial wow factor Faster visual recovery & return to work Painless Shorter post-op course Preservation of Bowman s? Disadvantages of LASIK Equipment much more expensive Click fee higher per case Procedure takes longer, more complex Greater patient anxiety, intraop discomfort? Higher chance of iris registration issues Possible higher risk of dry eye Possible higher risk of night vision issues Glare, halos, starbursts etc. Flap Complications!!! Striae, DLK, slippage, incomplete, free cap, buttonhole, late dislocation, epi ingrowth, etc. Higher risk of ectasia Higher risk of law suits OMIC 10 year data: 20x higher risk than PRK Advantages of PRK No Flap Complications, less ectasia, better biomechanics Modifiable refractive effect Fewer induced HOA s = better visual quality Cheaper equipment, cheaper procedure fees Easier surgery to perform Wider range of suitable candidates Less dry eye, night vision issues? Fewer Lawsuits Easier iris registration of ablation Fewer aborted surgeries Easier enhancements / retreatments May be more suitable for post-cataract surgery touch-ups Disadvantages of PRK Slower visual recovery Pain Risk of haze and other wound healing issues Increased risk of infection (2008 ASCRS White Paper) Longer post-op course: more steroid/more visits MMC long term risks? Ablation of Bowman s?

5 LASIK vs. PRK: Visual Outcomes Recent Cochrane Reviews: LASIK vs. PRK Myopia. Shortt AJ et al. January trials (1923 eyes), 9 randomized (spanning from 1980 s to 2012) overall quality of evidence to be low for most outcomes because of the risk of bias LASIK gives a faster visual recovery and is a less painful technique than PRK The two techniques appear to give similar outcomes one year after surgery Hyperopia: Settlas et al., June 2012 Planned to include only randomized controlled trials comparing PRK against LASIK for correction of hyperopia. We did not identify any studies that met the inclusion criteria for this review Instead we discussed the results of non-randomized trials and they appear to be in agreement that hyperopic-prk and hyperopic-lasik are of comparable efficacy PRK vs. LASEK vs. Epi-LASIK: highly variable study designs and techniques but essentially no significant advantages in pain, haze, visual outcomes with LASEK or Epi-LASIK vs PRK. Worldwide there is well over a 95% satisfaction rate with all surgeries

6 PRK: Technique & Pearls

7 What I Use: If < 5D + MMC: loteprednol or prednisolone for 4-6 weeks If > 5D + MMC: difluprednate or prednisolone for 8-10 weeks Post-Op Regimen 4 th generation fluoroquinolone QID for 10 days post op If health care worker or high risk for MRSA, polymyxin/trimethoprim Cyclosporin 0.05% BID for 6 months Vitamin C 2-3 grams PO x 1 week Omega-3 FA 2-3 grams PO x 1 week Pain Control Ketorolac up to QID for 1 st 3-4 days Oral OTC NSAIDs PRN Chilled PFAT s & Cold Compresses What I Don t Use: Oral steroids Oral narcotics Anti-epileptics like neurontin/lyrica etc. Comfort drops like diluted tetracaine/proparacaine

8 Visual Results 1st 10 Bilateral Consecutive Patients in Follow-Up of at least 6 months - Mean spherical equivalent: -4.25D (range to -8.00D) Mean Uncorrected Visual Acuity Both Eyes Immediately After Procedure: 20/23 (range 20/15- to 20/30) - most patients exhibited a wow moment POD 1: mean 20/20 (range 20/15- to 20/30) - 90% 20/20 or better OU POD 4: 20/28.5 (range 20/20 to 20/40) - vast majority back at work POM 1: 20/16 OU (range 20/15 to 20/25 OU) - one eye was 20/40, one eye was 20/15 but complaint of afterimage POM 6: 100% 20/15 in each eye individually

9 Results: Pain & Complications Pain Scale (0-5) First Night: mean 1.3 (range 0-3) POD 1: mean 1.2 (range 0-3) - 60% had scores of 1 or less - 40% had no pain on day 1 - No one reported pain after POD3 Complications (last 6 years): Delayed Epithelial Healing: 0-100% healed by POD4, all BCLs removed Infection/Infiltrate: 0 Haze: 0 Enhancements: 0 (first one upcoming though) Refractory Dry Eye: 0 Lasting Night Vision Disturbance: 0 MMC or Steroid Induced Complications: 0 Ectasia (Flap Complications): 0

10 Modern PRK (aka ASA) - Safe Conclusion: - eliminates flap complications - MMC is safe and has virtually eliminated haze - ectasia is extremely rare - Long-term visual outcomes comparable to LASIK - Short-term visual outcomes much closer to LASIK - Significantly less pain than in past and only for 3 days - Easier, cheaper, quicker to perform than LASIK - High patient satisfaction and definite wow factor

11 Thank You

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