LASIK remains the most popular refractive procedure, but concern about potential ectasia in patients with unusual corneal topographies or borderline corneal thicknesses, however, is changing the way many surgeons approach surgical candidates.

This month's National Panel Report addressed refractive surgery issues. Thirty surgeons, or 6 percent of our 500-surgeon sample, responded. Here's what they had to say.

 


LASIK Spotlight


LASIK continues to be the most popular surgical option among our panelists, with 83 percent of the respondents who perform refractive surgery saying they do conventional and/or custom LASIK. Their preferred procedure for the majority of their cases is custom LASIK for 73 percent of the panel; 17 percent like PRK and 10 percent choose conventional LASIK. Among surgeons who perform surface ablation procedures, 77 percent use the antifibrotic agent mitomycin-C prophylactically to stave off haze and regression.


On average, most of the respondents (86 percent) say they perform between five and 20 LASIK cases each month. Seven percent perform 51 to 75 cases and another 7 percent do 76 to 100 cases. They charge an average of $2,454 per eye for LASIK, and have to deal with an average facility fee of $795. If they offer custom LASIK, they usually increase the price an average of $109 over conventional LASIK.


When it comes to making their LASIK flaps, 43 percent say they use the IntraLase femtosecond laser. The average flap thickness of all the LASIK surgeons is 130 µm.

"I like the IntraLase," says a surgeon from Los Angeles. Harvey Rosenblum, MD, of New York City concurs, saying, "The IntraLase gives better, smoother, thinner flaps."

"The IntraLase gives excellent, smooth flaps," says Roseland, N.J., surgeon Edward Decker.

 


Ectasia Concerns


Eighty-three percent of the respondents say the threat of ectasia has affected the way they approach LASIK candidates, raising their index of suspicion. "If the corneal thickness is less than a certain level, I won't make a flap," avers Dr. Decker. "I'll advise the patient to have surface ablation."




A doctor from Washington, D.C., says she now uses the Pentacam to image every patient for fear of ectasia. "I'm also counseling every LASIK patient about ectasia," she says.


"I'm going to PRK more readily for patients with funny topography," says a surgeon from Missouri.


An Arizona surgeon has changed in several ways when faced with LASIK candidates. "I use thinner flaps with the IntraLase, perform more surface ablation and implant more ICLs," he says. Says Dr. Rosenblum, "I make sure to look for inferior corneal steepening."




Preferred Procedures


Surgeons were also asked how they would approach patients with certain refractive errors. Here's how they responded for the various patient presentations:


 • -3 D myope. As one might expect, custom LASIK was the most popular choice for this type of patient, and was chosen by 70 percent of the respondents. Thirteen percent chose conventional LASIK and 13 percent preferred PRK. "Custom LASIK is low risk for this patient," says a surgeon from Washington, D.C.


Douglas Liva, MD, of Paramus, N.J., agrees, saying, "Custom LASIK gives excellent results." A surgeon from Arkansas, however, would do PRK. "It's safer," he says. "Avoiding the flap equals predictability." A surgeon from Texas feels similarly, saying, "PRK yields fewer complications."


A Los Angeles surgeon who prefers conventional LASIK in this patient says it gives him "consistent results."


 • -6 D myope. For this level of correction, both custom LASIK and surface ablation become a little more popular. Almost three-quarters of the surgeons say they'd choose custom LASIK, 17 percent like PRK and 7 percent would stick with conventional LASIK.

"I believe custom's results are excellent," says Dr. Liva.


 • -11 D myope. Once the error gets this high, 77 percent of the surgeons say the best procedure is probably a phakic intraocular lens. Thirteen percent think clear-lens extraction/IOL implantation is the way to go, and 10 percent think LASIK is an option.


"A phakic intraocular lens would induce less optical aberration," says a surgeon from California.


A surgeon from Washington agrees. "A phakic lens gives the patient better quality of vision," she says.


New Jersey's Dr. Liva, however, doesn't like any option. "I wouldn't recommend any surgery," he says. "There's too much tissue removal with laser, and CLE puts the patient at risk for retinal detachment. And phakic IOL also has a risk of cataract formation that puts a high myope at risk for retinal detachment after the cataract surgery."


 • +2 D hyperope. For this patient, 83 percent say that LASIK would be the best procedure if the patient were young (younger than around 50), while 6 percent think PRK could do it for a younger patient, and 10 percent fall on the side of a clear lens extraction procedure, especially if the patient were older than 50. "It definitely depends on age," says a physician from Washington, D.C.


 • 45-year-old myopic presbyope. For this patient, 30 percent of the respondents who answered the question think bifocals are best, 30 percent prefer LASIK monovision, 20 percent like contact-lens monovision, 10 percent say conductive keratoplasty is useful and 10 percent think the Crystalens is best.


"I offer contact-lens monovision, bifocals and multifocal contact lenses," says Dr. Liva. "I don't feel the results of any of the presbyopic IOLs are good enough to offer them for CLE/IOL."


A Texas surgeon feels bifocals would be best, saying, "This patient isn't symptomatic enough for surgical presbyopic correction."



"Multifocal IOLs cannot compete with the clarity of a clear crystalline lens," says a surgeon from Washington, D.C., who thinks contact-lens monovision would be the best option. A surgeon from Arkansas agrees, saying, "Contact-lens monovision is safe, cost-effective and has no downside or surgical risk."


 • 45-year-old hyperopic presbyope. For this particular patient presentation, 20 percent of respondents prefer contact-lens monovision, 20 percent like CLE/implantation of a monovision IOL, 20 percent think CLE/ReSTOR lens implantation is best, a fifth think LASIK monovision would be preferable, 10 percent say multifocal contact lenses are the best option and 10 percent like CLE/Crystalens implantation.


"For +1 D to +2.5 D, I'd prefer LASIK," says an Arizona surgeon. "Over 2.5 D and I think the best option is CLE/ReSTOR."


"In the absence of cataract, I have difficulty offering multifocal lenses to a patient," says a Washington, D.C., surgeon.