Photorefractive Keratectomy and Laser-Assisted In-Situ Keratomileusis

Definition

Photorefractive keratectomy (PRK) and laserassisted in-situ keratomileusis (LASIK) are two similar surgical techniques that use an excimer laser to correct nearsightedness (myopia ) by reshaping the cornea. The cornea is the clear outer structure of the eye that lies in front of the colored part of the eye (iris). PRK and LASIK are two forms of vision-correcting (refractive) surgery. The two techniques differ in how the surface layer of the cornea is treated. As of mid 1998, two eximer lasers (Summit and Visx) had been approved for laser vision correction (refractive surgery using a laser) in the PRK procedure. Since then, Visx, Summit, and other lasers have received approval by the Food and Drug Administration (FDA) for use in LASIK procedures.

Purpose

The purpose of both LASIK and PRK is to correct nearsightedness in persons who don't want to, or can't, wear eye glasses or contact lenses. Most patients are able to see well enough to pass a driver's license exam without glasses or contact lenses after the operation. After approximately age 40, the lens in the eye stiffens making it harder to focus up close. Because laser vision correction only affects the cornea, the procedures do not eliminate the need for reading glasses. Patients should be wary of any ads that "guarantee" 20/20 vision. Patients should also make sure that the laser being used is approved by the FDA.

Precautions

Patients should be over 18 years of age, have healthy corneas, and have vision that has been stable for the past year. People who may not be good candidates for these procedures are pregnant women or women who are breastfeeding (vision may not be stable); people with scarred corneas or macular disease; people with autoimmune diseases (i.e., systemic lupus erythematosus or rheumatoid arthritis ); or people with diabetes. Patients with glaucoma should not have LASIK because the intraocular pressure (IOP) of the eye is raised during the procedure. A patient with persistent lid infections (i.e., blepharitis) may not be a good candidate because of an increased risk of infection. An ophthalmologist who specializes in laser vision correction can determine who would be likely to benefit from the operation and suggest which of the two operations might be more appropriate for any given patient.

If a patient is thinking of having cataract surgery, they should discuss it with the doctor. During cataract surgery an intracocular lens (IOL) will be inserted and that alone may correct distance vision.

Description

PRK and LASIK are both performed with an excimer laser, which uses a cold beam of ultraviolet light to sculpt or reshape the cornea so that light will focus properly on the retina. The cornea is the major focusing structure of the eye. The retina sends the image focused on it to the brain. In myopia, the cornea is either too steep or the eye is too long for a clear image to be focused on the retina. PRK and LASIK flatten out the cornea so that the image will focus more precisely on the retina.

In PRK, the surface of the cornea is removed by the laser. In LASIK, the outer layer of the cornea is sliced, lifted, moved aside while the cornea is reshaped with the laser, then replaced to speed healing. Both procedures cause the cornea to become flatter, which corrects the nearsighted vision.

At least one laser has been approved to treat mild astigmatism as of 2000. Correcting farsightedness (hyperopia ) may be possible in the future.

These laser vision-correcting procedures are rapidly replacing radial keratotomy (RK), an earlier form of refractive surgery that involved cutting the cornea with a scalpel in a pattern of radiating spokes. RK has declined in popularity since the approval of the excimer laser in 1995, falling from a high of 250,000 procedures performed per year in 1994 to 50,000 in 1997.

For both LASIK and PRK, the patient's eye is numbed with anesthetic drops. No injections are necessary. The patient is awake and relaxed during the procedure.

LASIK is sometimes referred to as a "flap and zap" procedure because a thin flap of tissue is temporarily removed from the surface of the cornea and the underlying cornea is then "zapped" with a laser. Prior to the surgery, the surface of the cornea is marked with a dye marker so that the flap of cornea can be precisely aligned when it is replaced. The doctor places a suction ring on the eye to hold it steady. During this part of the operation, which lasts only a few seconds, the patient is not able to see. A surgical instrument called a microkeratome is passed over the cornea to create a very thin flap of tissue. The IOP is increased at this time which is why it is contraindicated in patients with glaucoma. This thin tissue layer is folded back. The cornea is reshaped with the laser beam and the cell layer is replaced. Because the cell layer is not permanently removed, patients have a faster recovery time and experience far less discomfort than with PRK. An antibiotic drop is put in and the eye is patched until the following day's checkup.

In PRK, a small area of the surface layer of the cornea is vaporized. It takes about three days for the surface cells to grow back and vision will be blurred. Some patients describe it as "looking through Vaseline." PRK is generally recommended for patient's with mild to moderate myopia (usually under -5.00 diopters).

With both PRK and LASIK, there is a loud tapping sound from the laser and a burning smell as the cornea is reshaped. The surgery itself is painless and takes only a minute or two. Patients are usually able to return home immediately after surgery. Most patients wait (up to six months) before they have the second one done. This allows the first eye to heal and to see if there were complications from the surgery.

The cost of these procedures can vary with geographic area and the doctor. In general, the procedure costs $1,350-$2,500 per eye for PRK and about $500 more per eye for LASIK. PRK and LASIK are generally not covered by insurance. However, insurance may cover these procedures for people in certain occupations, such as police officers and firefighters.

Preparation

If a patient wears contact lenses, they should not be worn for a few weeks prior to surgery. It also is important to discontinue contact lens wear prior to the visual exams to make sure vision is stable. The doctor should be advised of contact lens wear.

Upon arrival at the doctor's office on the day of surgery, patients are given some eye drops and a sedative, such as Valium, to relax them. Their vision is tested. They rest while waiting for the sedative to take effect. Immediately before the surgery, patients are given local anesthetic eye drops.

Aftercare

After surgery, antibiotic drops are placed in the eye and the eye may be patched. The patient returns for a follow-up visit the next day. The patient is usually given a prescription for eyedrops (usually antibiotic and anti-inflammatory). Patients who have had PRK usually feel mild discomfort for one to three days after the procedure. They may need a bandage contact lens. Patients who have had LASIK generally have less, or even no discomfort after the surgery. After LASIK, antibiotic and anti-inflammatory drops are generally necessary for one week. After PRK, steroidal eye drops may be necessary for months. Because steroids may increase the possibility of glaucoma or cataracts, it is a big drawback to the procedure. The patient should speak with the doctor to see how long follow-up medications will be necessary.

Most patients return to work within one to three days after the procedure, although visual recovery from PRK may take as long as four weeks. An eye shield may be used for about one week at night and patients may be sensitive to bright light for a few days. Patients may be asked by their doctor to keep water out of their eye for a week and to avoid mascara or eyeliner during this period.

Risks

There is a risk of under- or over-correction with either of these procedures. If vision is under-corrected, a second procedure can be performed to achieve results that may be closer to 20/20 vision. About 5-10% of PRK patients return for an adjustment, as do 10-25% of LASIK patients. People with higher degrees of myopia have vision that is harder to correct and usually have LASIK surgery rather than PRK. This may account for the higher incidence of adjustments for LASIK patients. Patients with very high myopia (over -15.00 diopters) may experience improvement after LASIK, but they are not likely to achieve 20/40 vision without glasses. However, their glasses will not need to be as thick or heavy after the surgery. However, most patients, especially those with less extreme myopia, do not need glasses after the surgery.

Haze is another possible side effect. Although hazy vision is unlikely, it is more likely to occur after PRK than after LASIK. This haze usually clears up. Corneal scarring, halos, or glare at night, or an irritating bump on the cornea are other possible side effects. As with any eye surgery, infection is possible, but rare. Loss of vision is possible with these procedures, but this complication is extremely rare.

Most complications from LASIK are related to the creation and realignment of the flap. The microkeratome must be in good-working order and sharp. LASIK requires a great deal of skill on the part of the surgeon and the complication rate is related to the experience level of the surgeon. In one study, the rate of LASIK complications declined from 3% for surgeons during their first three months using this technique, to 1% after a year's experience in the technique, to 0% after 18 months experience.

KEY TERMS

Blepharitits— An inflammation of the eyelid.

Cataract— A condition in which the lens of the eye turns cloudy and interferes with vision.

Cornea— The clear, curved tissue layer in front of the eye. It lies in front of the colored part of the eye (iris) and the black hole in the center of the iris (pupil).

Diopter (D)— A unit of measure of the power or strength of a lens.

Excimer laser— An instrument that is used to vaporize tissue with a cold, coherent beam of light with a single wavelength in the ultraviolet range.

Intraocular lens (IOL) implant— A small, plastic device (IOL) that is usually implanted in the lens capsule of the eye to correct vision after the lens of the eye is removed. This is the implant is used in cataract surgery.

Macular degeneration— A condition usually associated with age in which the area of the retina called the macula is impaired due to hardening of the arteries (arteriosclerosis). This condition interferes with vision.

Microkeratome— A precision surgical instrument that can slice an extremely thin layer of tissue from the surface of the cornea.

Myopia— A vision problem in which distant objects appear blurry. Myopia results when the cornea is too steep or the eye is too long and the light doesn't focus properly on the retina. People who are myopic or nearsighted can usually see near objects clearly, but not far objects.

Refractive surgery— A surgical procedure that corrects visual defects.

Retina— The sensory tissue in the back of the eye that is responsible for collecting visual images and sending them to the brain.

Normal results

Most patients experience improvement in their vision immediately after the operation and about half of LASIK patients are able to see 20/30 within one day of the surgery. Vision tends to become sharper over the next few days and then stabilizes; however, it is possible to have shifts in myopia for the next few months. Vision clears and stabilizes faster after LASIK than after PRK. Final vision is achieved within three to six months with LASIK and six to eight months with PRK. The vast majority of patients (95% for people with low to moderate myopia and 75% for people with high levels of myopia) are able to see 20/40 after either of these procedures and are able to pass a driver's license test without glasses or contact lenses.

LASIK is more complicated than PRK because of the addition of the microkeratome procedure. However, LASIK generally has faster recovery time, less pain, and less chance of halos and scarring than PRK. LASIK can treat higher degrees of myopia (-5.00-25.00 diopters). LASIK also requires less use of steroids. Patients need to speak with qualified, experienced eye surgeons to help in choosing the procedure that is right for them.

Resources

ORGANIZATIONS

American Academy of Ophthalmology. 655 Beach Street, P.O. Box 7424, San Francisco, CA 94120-7424. 〈http://www.eyenet.org〉.

American Society of Cataract and Refractive Surgery. 4000 Legato Road, Suite 850, Fairfax, VA 22033-4055. (703) 591-2220. 〈http://www.ascrs.org〉.