Surface ablation has traditionally involved more postoperative pain,
slower visual recovery and more postoperative haze than LASIK. However,
advanced surface ablation techniques have optimized visual outcomes and raised
safety profiles, surgeons say.
Advanced surface ablation encompasses PRK, epi-LASIK and LASEK, but
advanced PRK has moved to the forefront because epi-LASIK and LASEK entail
slower epithelial healing, a significantly greater risk of infection and slower
visual recovery, OSN Refractive Surgery Board Member Kerry D. Solomon, MD,
“We found absolutely no benefit to a LASEK technique, which is why
in my practice we’ve moved entirely to PRK, or what we call ‘advanced
surface ablation,’” Dr. Solomon said.
In addition, wavefront-driven profiles markedly enhance visual outcomes
in advanced surface ablation, Dr. Solomon said.
“The military has certainly shown that to be a more precise and
more effective way to treat vision,” he said. “The profile is such
that they are designed to reduce night vision symptoms and to provide an
overall better quality of vision. This is probably due to the lower amount of
higher-order aberrations that are induced by the treatments themselves.”
Ronald K. Krueger, MD, also prefers PRK over other techniques.
“In my opinion, LASEK has declined some and epi-LASIK is performed
by a handful,” Dr. Krueger said. “Personally, I have made PRK the
surface procedure of choice and perform all my surface cases this way.”
William B. Trattler
Dr. Krueger said PRK profiles can yield even better visual outcomes than
“My 20/20 rates with optimized PRK are even better than my 20/20
rates with optimized IntraLASIK,” he said.
Advanced surface ablation is a viable surgical alternative for patients
who are not good candidates for LASIK, such as those with corneal pathology and
suspect topography, William B. Trattler, MD, OSN SuperSite Board Member, said.
“I’m choosing surface ablation for patients that are not
eligible for LASIK but want refractive surgery and where we can do PRK,”
Dr. Trattler said. “For me, [indications are] going to be corneal
opacities, irregular forme fruste keratoconus or any suspicious corneas.”
Managing postop pain
Ethyl alcohol is commonly used to remove the epithelium before surface
ablation is performed.
“I don’t know why, but in my own experience and others’,
if you use alcohol to remove the epithelium as opposed to just manual
debridement, patients seem to have and notice less pain,” Dr. Solomon
Nonsteroidal drugs, bandage contact lenses, analgesics and chilled
balanced salt solution are also used to minimize postoperative pain, he said.
Acuvail (preservative-free ketorolac tromethamine ophthalmic solution
0.45%, Allergan), a new preservative-free formulation of ketorolac indicated
for the treatment of pain after cataract surgery, is particularly effective,
Dr. Solomon said.
“It’s gentle to the epithelium yet it penetrates much more
potently into the cornea and into the eye,” he said. “And
there’s twice daily dosing. It’s well-tolerated by the patients with
no burning or stinging. It’s more effective in terms of reducing
Vistakon’s Acuvue and other bandage contact lenses are also
beneficial, he said.
Preservative-free topical Alcaine (proparacaine hydrochloride, Alcon)
has also proven effective in minimizing pain. Patients are typically directed
to use the agent four to six times daily or as needed.
“It’s rare that patients use it that often, but it has
tremendously helped with discomfort,” Dr. Solomon said. “In fact,
patients really don’t have pain. It’s been interesting that after 24
hours, patients rarely need to use it anywhere.”
Dr. Trattler said he uses either Acuvail or Xibrom (bromfenac ophthalmic
solution 0.09%, Ista Pharmaceuticals) twice daily, and also provides topical
anesthetics (dilute tetracaine and/or proparacaine hydrochloride) for use by
patients only if they experience significant discomfort.
|Some surgeons recommend applying ice-cold balanced salt
solution immediately after laser treatment to reduce postoperative pain after
advanced surface ablation. |
|A sponge soaked with mitomycin C 0.02% is applied to the cornea
for 12 seconds during advanced surface ablation to prevent late-onset
Images: Trattler WB
Chilled balanced saline solution is also effective in reducing pain, Dr.
Trattler said. The frozen solution is typically applied to the eye for 30
seconds immediately following the ablation.
Dr. Trattler said the use of Restasis (cyclosporine ophthalmic emulsion,
Allergan) and/or punctal plugs helps to optimize the ocular surface
“We want to make sure we do everything we can to have a very
healthy tear film, which is critical for speeding epithelium healing,” Dr.
Dr. Krueger said he uses properly fitted contact lenses, Acular
(ketorolac tromethamine ophthalmic solution 0.5%), oral Percocet (oxycodone and
acetaminophen, Endo Pharmaceuticals), and slightly chilled, not ice-cold,
balanced salt solution to mitigate postoperative pain.
Pain is frequently not an issue with advanced surface ablation, Dr.
“I think postop pain is a variable thing. I tell my patients to
expect some pain and, surprisingly, less than half of them really say they
notice much of anything, and I’m not doing anything special,” Dr.
Mitomycin C is currently the gold standard for minimizing postoperative
haze, Dr. Solomon said.
“I think mitomycin C has become pretty much standard of care,”
he said. “The goal of the mitomycin C is to prevent any visually
significant corneal haze that can occur.”
Formerly, MMC was applied for 2 minutes but is currently applied for 15
to 30 seconds, Dr. Solomon said.
MMC is effective in preventing late-onset postoperative haze, which
typically occurs 1 or 2 months postoperatively, Dr. Trattler said.
“If your patient experiences a delay in epithelial healing and
develops early haze, the best treatment appears to be topical steroids. The use
of intraoperative mitomycin does not appear to prevent early haze from
developing,” Dr. Trattler said. “MMC only prevents the late-onset
haze, which appears to be related to UV exposure. MMC helps prevent the
activation of collagen fibers in the cells, which leads to haze.”
Dr. Krueger prefers using MMC in cases that involve more than 3 D of
“As far as preventing problems, haze is the biggest-volume type of
concern that can happen,” Dr. Krueger said. “That can happen
sometimes with delayed epithelialization. But also with higher corrections,
where the surface sometimes gets rougher, you can get haze. That’s where
mitomycin comes in. The ideal concentration is 0.02%. We have tried using a
tenfold lower percent concentration, 0.002%, but the incidence of haze was
statistically higher, so we went back to the standard dosage.” –
by Matt Hasson
- Blake CR, Cervantes-Castañeda RA, Macias-Rodríguez Y,
Anzoulatous G, et al. Comparison of postoperative pain in patients following
photorefractive keratectomy versus advanced surface ablation. J Cataract
Refract Surg. 2005;31(7):1314-1319.
- Randleman JB, Loft ES, Banning CS, Lynn MJ, et al. Outcomes of
wavefront-optimized surface ablation. Ophthalmology.
- Thornton IL, Xu M, Krueger RR. Comparison of standard (0.02%) and
low dose (0.002%) mitomycin C in the prevention of corneal haze following
surface ablation for myopia. J Refract Surg. 2008;24(1):S68-S76.
- Trattler WB, Barnes SD. Current trends in advanced surface
ablation. Curr Opin Ophthalmol. 2008;19(4):330-334.
- Ronald K. Krueger, MD, can be reached at the Cleveland Clinic
Foundation, 9500 Euclid Ave., Room i32, Cleveland, OH 44195; 216-444-8158; fax:
216-445-8475; e-mail: Krueger@ccf.org.
- Kerry D. Solomon, MD, can be reached at Carolina Eyecare
Physicians, 1280 Johnnie Dodds Blvd., Suite 100, Mt. Pleasant, SC 29464;
843-881-3937 or 888-849-3937; fax: 843-884-8587; e-mail:
- William B. Trattler, MD, can be reached at 8940 N. Kendall Drive,
#400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail:
firstname.lastname@example.org. Dr. Trattler is a
paid consultant for Allergan and ISTA Pharmaceuticals.