EyeWorld Asia-Pacific December 2011 Issue

December 2011 9 EW FEATURE Managing haze, pain, and scarring in PRK and LASEK I f recent surveys are any indication, there’s a back- to-the-surface movement happening among refractive surgeons. According to the 2010 Practice Styles and Preferences of US ASCRS Members report by David Leaming, MD, Palm Springs, Calif., USA, 4.6% of those polled were not currently performing surface ablation but planned to start. Results were similar in 2009, with 3% and 4% prepping to take on PRK and LASEK, respectively. “When I talk to people and say I’m surface, 5 years ago the response was, ‘Are you kidding? How do you deal with the pain and scarring?’” said Emil Chynn, MD , founder, Park Avenue LASEK, New York, NY, USA. “Now when I say that, they say, ‘I’ve been thinking of doing that in general, and I am doing that on select cases like the high prescriptions.’” It’s true that surface ablation has some negatives such as slower visual recovery, occasional discomfort during healing, and haze with the potential of scarring. There’s also less of a “wow factor” in comparison to LASIK; patients don’t go to work the day after surface ablation. But PRK and LASEK enable surgeons to expand their patient pool to those with a higher refractive error—such as the –22 Dr. Chynn recently treated—as well as patients with thin corneas, previous flap complications, and corneal scars. There are also strategies to minimize—if not eradicate—pain, haze, and scarring. “There are things you can do before surgery, in surgery, and right afterward that make a big difference,” said Daniel S. Durrie, MD , clinical professor of ophthalmology, University of Kansas, Overland Park, Kan., USA. For instance, resolve any blepharitis, dry eye, red eye, or meibomian gland disease before surgery to avoid operating in a hostile environment. Those patients are eligible for treatment, but only after they’re on an established routine of cleaning their eyelids, using Restasis (cyclosporine, Allergan, Irvine, Calif., USA), and whatever else needed to create a healthy surgical setting. Dr. Chynn likes to pre-dose all patients with oral and topical steroids the morning of surgery in order to immunosuppress them and relies on mitomycin C intraoperatively to avoid scarring. “If you don’t use mitomycin, the patient is going to scar,” he said. “We’re using mitomycin based on laser time. If the patient is a myope, we’re doing the same time as laser time. If the patient is a hyperope, we’re doing the laser time divided by two. It reduces scarring to Successful LASEKs of primary granular corneal dystrophy Source: Emil Chynn, MD Surface ablation for the refractive surgeon by Faith A. Hayden EyeWorld Staff Writer AT A GLANCE • Surface ablation gives surgeons a larger patient pool to treat • To avoid haze, make sure the epithelial defect closes as quickly as possible • If haze develops, it will clear up with a tapered steroid regimen. No other intervention is needed • If a patient scars, perform a transepithelial removal of the epithelium using a laser with PTK mode almost zero.” Dr. Durrie has a different approach to mitomycin usage and doesn’t believe it should be used for everyone having surface ablation. “It’s a toxic chemical that I don’t want to use unless it’s necessary,” he said. He recommended using it for high myopic corrections above six diopters and in young patients under 30. “Younger patients are more likely to have haze, and people who have high corrections are more likely to have haze,” Dr. Durrie said. “I also use it on anyone who has had previous surgery, like a corneal transplant, and those with very active corneas.” For those patients, Dr. Durrie recommended using mitomycin at 0.02% for 12 seconds. He also believes surgeons are removing more epithelium than they need to and suggested reducing the size of the epithelial defect from 9 mm to 7.5 mm. “Using a 7.5 mm epithelial defect is one of those big things you can do,” he said. “There are no problems with it optically, and it’s been scientifically proven that that’s the best way to do it. [Patients] epithelialize at least 24 hours earlier, have faster vision recovery, less pain, and less chance of chronic epithelial defects, which can form late haze.” Both Drs. Chynn and Durrie use chilled balanced salt solution during surgery, but Dr. Durrie uses a premade frozen Popsicle of sorts for 10 seconds on the eye before removing the epithelium and after lasering the patient. “Everyone who has tried that has found it makes patients more comfortable, and it also controls the wound healing,” he said. In terms of a post-op regimen, Jason E. Stahl, MD, Durrie Vision, Overland Park, recommended putting the patient on an antibiotic and steroid four times a day for a week. “There are some surface ablation gurus who have a very lengthy and complex list of medications that they use afterward, but we keep it pretty simple and similar to our LASIK patients,” he said. “Patients can use a nonsteroidal for pain as needed for a couple of days. We encourage cold compresses and chilled artificial tears, which help with discomfort. We recommend taking ibuprofen and then using acetaminophen and hydrocodone for any breakthrough discomfort.” Dr. Chynn puts all of his patients with high refractive errors on Pred Forte (prednisolone, Allergan) over a months-long taper, i.e., four times daily for a month, three times daily for a month, two times daily for a month, and so on. Dr. Chynn also stressed the importance of having the patient wear UV protection diligently for a few months after surgery. “If you don’t give them continued on page 10