EyeWorld India December 2018 Issue

60 EWAP REFRACTIVE December 2018 is older or the refraction is more than +5 D,” he said. His preferred method of enhancement is LASIK with LASIK flap lift within 3 years. PRK is the enhancement technique of choice for PRK. If it has been more than 3 years since the primary LASIK procedure, he recommends enhancement using PRK. Dr. Gatinel recommends LASIK for a –2 D correction, a –6 D correction, and hyperopia correction. “As far as enhance- ment, lifting the LASIK flap can be performed even 20 years after the initial procedure. It warrants time/refraction evolution cus- tomization. Enhancement can be indicated not only in the case of refractive regression, but also when the visual needs are chang- ing, such as presbyopia. The fact that enhancements are easy and safe gives LASIK a great advan- tage over PRK (pain and regres- sion) and SMILE, which can be enhanced with PRK but with an increased risk of haze,” he ex- plained. Safety Dr. Slade said that all three pro- cedures are safe, but he prefers LASIK and SMILE to avoid the open cornea that is required with PRK. “Both SMILE and LASIK avoid the wound healing. As far as which is safer between LASIK and SMILE, safety is something that you can give an opinion on, but to prove safety, you must do thousands of eyes to be statisti- cally significant,” he added. Dr. Cummings said that PRK and SMILE provide the least chance of flap dislocation, while LASIK has the least chance of haze. “Overall, all three are very safe,” he noted. Dr. Gatinel said that safety in refractive surgery depends mostly on the quality of the indication and patients’ education. “All procedures are safe, as long as they are performed adequately on a patient who is a good candidate and who will comply with the postoperative guidelines and regi- men,” he said. He added that the main risk factor for PRK is regression of the refractive effect (epithelial regres- sion), sometimes accompanied by haze. “The main risk in LASIK is persisting dry eye over the first year, which can cause discomfort and visual quality reduction. To me, the main risk in SMILE is incomplete lenticule extraction, which can cause definitive ir- regular astigmatism. With proper patient selection and education on the dangers of postoperative eye rubbing, the risk of ectasia is virtually null with these three techniques,” Dr. Gatinel said. Future Dr. Slade thinks that surgeons will be performing more SMILE procedures in 10 years. “However, I do not see LASIK going away; it’s too good of a procedure. I think we will be doing more lens-based surgery. IOLs are getting better, so I think that’s becoming more of an option. Maybe someday, we will be doing one-third SMILE, one-third LASIK, one-third lens-based procedures, and a few PRKs,” he said. Dr. Cummings said that it will be difficult for any procedure to beat the popularity of LASIK. “Centration is exquisite and high- ly controllable, precision is in the 0.25 µm order, and customization is possible with topography-guid- ed and wavefront-guided LASIK. In the next 12 months, customi- zation will be possible with ray tracing-guided ablation profiles. There is the fast recovery, too. SMILE will advance, however, and as the technology improves with increased precision and greater ability to customize, it will grow in popularity. I don’t think that it will surpass LASIK in 10 years un- less there are significant advances on the technology front,” he said. Dr. Gatinel agreed. “LASIK has maintained its supremacy over PRK for the past 20 years, and it has still prevailed over SMILE during the past decade. If there are no significant advances in SMILE in the next 10 years, I would not doubt that we will still have LASIK as our predominant corneal refractive technique,” he said. EWAP Editors’ note: Drs. Cummings has financial interests with Alcon (Fort Worth, Texas). Dr. Gatinel has financial interests with Alcon, Nidek (Gamagori, Japan), PhysIOL (Liege, Belgium), and Carl Zeiss Meditec (Jena, Germany). Dr. Slade has fi- nancial interests with Alcon and Carl Zeiss Meditec. Contact information Cummings: abc@wellingtoneyeclinic.com Gatinel: gatinel@gmail.com Slade: sgs@visiontexas.com User feedback – from page 59