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BOOK EXCERPT
LASIK Complications: Trends and Techniques 3E
Howard V. Gimbel, MD, MPH, FRCSC, FACS, Diplomate ABO, AOE, CABES; Ellen E. Anderson Penno, MD, MS, Diplomate ABO, FRCSC

CHAPTER FOUR
Laser-Assisted Subepithelial Keratomileusis

INTRODUCTION

LASEK has been developed as a modification of PRK and LASIK in an effort to reduce risks associated with LASIK while attempting to avoid the postoperative pain, blurred vision, and haze formation following PRK. Thus far, LASEK has been primarily used for low to moderate myopia in patients with thin corneas or in patients who may participate in activities or work that may pose a risk for flap trauma. Several modifications to the standard LASEK technique have been used in order to optimize recovery following surgery (Table 4-1).1 This new technique shows promising results; however, it is not yet clear whether LASEK will offer benefits beyond those of LASIK or PRK.

Table 4-1

LASEK TECHNIQUES

Standard LASEK

Dr. Massimo Camellin is credited with describing the original LASEK technique. (Camellin M, Vinciguerra P, Nizzola GM. LASIK: laser epithelial keratomileusis. A new technique for improving healing and decreasing postoperative pain. Presented at the ASCRS meeting 1999, Los Angeles, CA). Topical anesthetic is given prior to surgery. The eye is prepped and draped in a standard fashion and additional topical anesthetic is instilled. A trephine is used with downward pressure to create a 270-degree incision with a hinge. If necessary, a slight rotation can be used to facilitate the epithelial cut. A holding well that is 0.5 mm larger than the trephine is placed onto the cornea to encircle the epithelial incision and filled with 20% ethyl alcohol for approximately 30 seconds. The alcohol is absorbed with a sponge, the cornea is rinsed with balanced salt solution (BSS), and the surface is dried with a second sponge. An epithelial microhoe is used to start the epithelial flap. If necessary, alcohol may be reapplied for an additional 15 seconds to loosen the flap. A spatula is used to lift the flap to the 12-o'clock hinge position, then laser energy is delivered. Chilled BSS is applied to flood the cornea for 5 to 10 seconds and then the flap is repositioned with a blunt spatula. A soft bandage contact lens is applied and left in place for approximately 3 days.

Butterfly LASEK

Vinciguerra and Camesasca have described a modified LASEK technique whereby 2 flaps are created from a single paracentral line.2 To allow separation of the flaps, 20% alcohol plus BSS was used for 5 to 30 seconds. A specially designed spatula was used to lift the epithelium from Bowman's layer and a specially designed retractor to move the epithelial flaps to the periphery. Laser ablation was applied after the surface was dried. Smoothing with a masking solution was performed prior to flap replacement. The rationale behind butterfly LASEK is to improve epithelial viability by preserving limbal epithelial connections.

Cruciform LASEK

Amolis has described a cruciform LASEK technique in which a rotating microbrush is used to cut a cross into the epithelium.1 The remainder of the technique is similar in that diluted alcohol is applied for 30 seconds prior to flap dissection. A bandage contact lens is applied after flap repositioning and left in place for 3 days. This technique is designed to retain epithelial limbal connections to enhance recovery.

Gel-Assisted LASEK

Viscous hydroxypropyl cellulose 0.3% has been used to facilitate separation of epithelial flaps and prevent dehydration.1 This technique avoids the use of alcohol. A few drops of 5% sodium chloride are applied to stiffen the epithelial cells and then it is removed. An instrument is slipped through a small hole in the epithelium and used to lift the epithelium as a sheet. Gel is placed under the epithelium, and Vannas scissors are used to cut down the middle. The flap is pushed to the periphery on the gel cushion. The gel is removed from Bowman's layer prior to laser ablation. After epithelial repositioning, compressed air is used to enhance adhesion of the epithelial sheet. A bandage contact lens is applied at the end of the case.

LASEK RESULTS

Safety and Efficacy

Safety and efficacy of LASEK for low and moderate myopia are reported to be similar to that of LASIK or PRK (Table 4-2).2-10 There are also reports of good results for high myopia from -11.25 D to -14.75 D (Table 4-3).9,11-13 LASEK series reported in the literature range from 6 eyes to 773 eyes with the majority of reports comprised of a series of 50 or more eyes. All but 3 of these papers reported no loss of best-corrected visual acuity (BCVA), with 1 reporting loss of 1 line of vision and the remaining 2 reporting no loss of 2 or more lines of BCVA.9,11-12

Table 4-2

Table 4-3

Haze After LASEK

Overall reports indicate that the incidence of haze is low following LASEK. Visually significant haze was reported in only one series, affecting 4 of 58 eyes.12 This series included eyes treated for high myopia. Transient minimal haze was reported by McDonald following gel-assisted LASEK in 39 eyes.1 Some surgeons feel that because LASEK is a form of surface ablation, it may be no better than PRK with respect to the risk of haze, especially in high myopia.14 Based on the relatively large numbers of eyes reported in the literature that received LASEK for low and moderate myopia, it is likely that the risk of visually significant haze is low in this group just as it is for PRK in this range of myopia. High myopes may be at risk for visually significant haze following LASEK; however, the numbers of LASEK cases reported for the treatment of high myopia are few. For high myopes who are not candidates for LASIK, phakic IOL may be a better alternative than either PRK or LASEK.

LASEK Versus PRK

Prospective comparative studies were performed by 2 groups. Litwak et al compared 50 eyes of 25 patients who received LASEK on 1 eye and PRK in the fellow eye and found refractive results between the 2 procedures, although the LASEK eyes had a more difficult postoperative course.4 Lee et al performed a similar study in 27 patients and found that 63% of patients preferred LASEK.7

LASEK Versus LASIK

There is 1 prospective comparative study reported by Scerrati in which 30 eyes of 15 patients received LASIK using a Hansatome microkeratome and Nidek (Japan) EC-5000 excimer laser and 30 eyes of 15 patients underwent LASEK using the Nidek EC-5000 excimer laser.6 Both groups were followed for 6 months with comparison of corneal topography, BCVA, contrast sensitivity, and refraction. Scerrati concluded that objective data showed that LASEK was superior than LASIK in this series of eyes.6

There are theoretic advantages to LASEK as compared to LASIK for wavefront-guided custom ablation. Theoretically, the LASIK flap may induce more higher order aberrations than a more superficial ablation might (flap-induced higher order aberrations are discussed in Chapter 3). It is possible that some of the higher order aberrations induced by LASIK may diminish over time, and it is also possible that LASEK may induce higher order aberrations at least in the early postoperative period.14 More evidence with respect to comparative outcomes for LASEK versus LASIK as well as refinements in wavefront-guided custom ablation will be needed to determine which procedure will optimize results.

Postoperative Recovery Following LASEK

LASEK patients experience some degree of discomfort and blurred vision postoperatively. The speed of recovery does not match LASIK, although theoretically LASEK may be safer for some patients. LASEK patients may take up to a week to recover functional vision, which is similar to PRK.

For those patients already considering PRK or those who are not LASIK candidates due to corneal thickness, some surgeons believe that LASEK offers more rapid recovery and less discomfort than PRK. However, as noted above, the results of comparative studies are variable.4 Surgeons who perform LASEK report that their clinical impression is that LASEK is associated with less pain as compared to PRK.14 It is likely that individual patient factors and surgeon techniques will affect postoperative recovery of vision and levels of postoperative pain following LASEK.

SUMMARY

From multiple reports in the literature, LASEK appears to be safe and effective for the treatment of low to moderate myopia. It remains to be demonstrated that LASEK offers clear advantages with respect to safety as compared to LASIK or recovery as compared to PRK; however, it is theoretically possible that LASEK may afford these advantages as techniques are refined.

LASEK RESULTS
  1. What is LASEK?

    LASEK is a relatively new approach to surface ablation with the excimer laser. Most experts consider it an iteration of PRK. LASEK is defined as surface ablation wherein an attempt is made to harvest and save the corneal epithelium in a sheet or sheets, to be reposited on the cornea after the ablation in an attempt to decrease postoperative pain and speed the return of vision.

  2. Who invented or first described LASEK?

    Dr. Massimo Camellin of Italy first described LASEK in the mid-90s, after which LASEK gained popularity around the world.

  3. Advantages

    a. Even safer than LASIK (no stromal flap therefore no chance of a free flap, a too thick or too thin or irregular flap, a buttonholed flap, DLK, epithelial ingrowth, striae; much decreased chance of ectasia).

    b. Easier technically, so that even the occasional refractive surgeon can do an excellent job.

    c. There is early evidence to suggest that wavefront-based clinical outcomes are even better with LASEK than with LASIK.

  4. Disadvantages

    a. Mild to moderate discomfort for 3 to 4 days, though discomfort is much decreased by "comfort drops" (a 1/20th dilution of tetracaine, made by a compounding pharmacist using unpreserved artificial tears as a diluent).

    b. Still somewhat slower recovery of vision, though faster than with surface ablation in the 80s and early 90s (most likely due to modern bandage soft contact lenses, smoother ablations, and possibly nonsteroidal anti-inflammatory drugs [NSAIDs] and "comfort" drops); though most patients are able to drive legally without glasses on the first day postoperative, it still requires 4 to 5 days for most patients to see well, and the quality continues to improve for at least 2 weeks.

    Figure 1A
    Figure 1A. The dull plastic separator moves across the cornea in epi-LASIK, passing just above Bowman's layer.

    Figure 1B
    Figure 1B. This micrograph is from a sheet of human corneal epithelium removed 24 hours postoperatively from an epi-LASIK patient.

  5. Are there different techniques for performing LASEK?

    Yes, there are 3 ways:

    a. The original Camellin technique, wherein the central epithelium is exposed to a dilute alcohol solution (usually 20%) for 20 to 35 seconds; the solution is contained within a well or a circular sponge soaked in the solution is placed on the central epithelium. Next, the cornea is irrigated thoroughly and the loosened and/or denatured and/or dead epithelium is removed in a sheet, using a small "hoe-like" instrument to roll it up and out of the way, so that the ablation can take place. The epithelium is then reposited and a bandage soft contact lens is placed on the eye.

    Another iteration of the classic Camellin technique is the butterfly technique of Vinciguerra, wherein the loosened sheet of epithelium is separated over the central cornea and gently pushed to the periphery during the ablation. This approach provides the central epithelium with an uninterrupted supply of limbal stem cells, which are otherwise temporarily "cut off" when the sheet is circular in shape with a hinge.

    b. The gel-assisted technique, first described by Marguerite McDonald of New Orleans, is intended to spare the cornea the toxic effects of alcohol. A small linear abrasion is made in the far periphery of the cornea, after which the entire cornea is exposed to 10 seconds worth of a 5% sodium hydrochloride drop (such as Muro 128) to stiffen, but not kill, the epithelium. Next, a microkeratome suction ring is placed on the eye, and while the suction is applied, a LASIK spatula is slipped through the abrasion and used to strip off the epithelium in a sheet or sheets. The sheets of epithelium, which are not denatured by alcohol and therefore very delicate, are reflected out of the way on a cloud of hydroxypropylcellulose gel; the gel is then irrigated away so that the ablation can take place. The sheets are then reposited and a bandage soft contact lens is placed on the eye. A recent prospective, randomized study comparing gel- versus alcohol-assisted LASEK in myopic patients (presented by McDonald and coworkers at the ASCRS meeting in 2002; unpublished) indicated that safety and efficacy were equal in both groups, though there were strong nonstatistically significant trends in several of the outcome parameters for gel-assisted to be superior. This technique is still in evolution, however, as new instruments are being made to make the stripping of the sheet easier and more consistent.

    c. The epi-LASIK technique, first described by Dr. Ioannis Pallikaris of Crete (Figures 1A and 1B). An automated microkeratome-like device passes an epithelial separator over the corneal surface while suction is applied (Figures 2A and 2B). The result is a hinged sheet of epithelium that is at least partially viable (Figure 3); it is reflected out of the way so that the ablation can take place. Next, the sheet is reposited and a bandage soft contact lens is placed on the eye. The first cases outside of Greece were performed in September 2003.

    Figure 2A
    Figure 2A. The epikeratome handpiece.

    Figure 2B
    Figure 2B. The epikeratome device, complete with the console, the handpiece, and the surgeon's control pedals.

    Figure 3
    Figure 3. As seen in this rabbit specimen taken 24 hours postoperatively, epi-LASIK leaves the anterior corneal stroma intact, with living keratocytes that stain normally (top photo). In alcohol assisted LASEK (bottom photo), the alcohol has killed the keratcytes in the anterior cornea, and altered the staining characteristics of the anterior stroma as well.

  6. Is there any evidence that LASEK is clearly superior to PRK (or even LASIK) in terms of postoperative pain and clinical outcomes?

    LASEK is clearly not as comfortable for the patients as LASIK, though modern bandage soft contact lenses, NSAID drops, small quantities of "comfort drops" (non-preserved tetraparacaine drops, diluted to 1/20th normal strength with saline, made by a compounding pharmacist, used hourly as needed for the first three days postoperative; must be kept chilled after opening), and the use of narcotics such as Mepergan Fortis (Wyeth, Madison, NJ) (meperidine and promethazine) have improved matters greatly for surface ablation patients.

    There are several reports in the peer-reviewed literature that differ significantly in their conclusions regarding which type of surface ablation provides less early postoperative discomfort—PRK or LASEK.

    Epi-LASIK is so new that it is not yet known whether postoperative pain is less for these patients than for PRK patients, though very preliminary and unpublished results from the psychometric testing of the Greek patients indicate that it may be less (Figure 4).

    Figure 4
    Figure 4.Slit lamp photos from Dr. Pallikaris of 2 post-LASIK eyes, taken 24 hours postoperatively.

    There is nearly complete agreement among experts that the final clinical outcomes are similar in PRK and LASEK. Early, unpublished evidence from the FDA clinical trials indicates that the clinical outcomes of wavefront-based surgery—as excellent as they are for LASIK—are actually superior for surface ablation because the unpredictable biomechanical changes that occur when making the flap—and their subsequent effects on the wavefront—are eliminated.

    No one contests the superior safety of surface ablation because of the lack of flap-related complications and decreased risk of ectasia.

BIBLIOGRAPHY

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  3. Lee JB, Seong GJ, Lee JH, Seo KY, Lee YG, Kim EK. Comparison of laser epithelial keratomileusis and photorefractive keratectomy for low to moderate myopia. J Cataract Refract Surg. 2001;27(4):565-570.
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REFERENCES

  1. Samalonis LB. LASEK techniques. EyeWorld. 2002;7(9):31-32.
  2. Vinciguerra P, Camesasca FI. Butterfly laser epithelial keratomileusis for myopia. J Refract Surg. 2002;18(3 Suppl):S371-S373.
  3. Anderson NJ, Beran RF, Schneider TL. Epi-LASEK for the correction of myopia and myopic astigmatism. J Cataract Refract Surg. 2002;28(8):1343-1347.
  4. Litwak S, Zadok D, Garcia-de Quevedo V, Robledo N, Chayet AS. Laser-assisted subepithelial keratectomy versus photorefractive keratectomy for the correction of myopia. A prospective comparative study. J Cataract Refract Surg. 2002;28(8):1330-1333.
  5. Lee JB, Choe CM, Seong GJ, Gong HY, Kim EK. Laser subepithelial keratomileusis for low to moderate myopia: 6-month follow-up. Jpn J Ophthalmol. 2002;46(3):299-304.
  6. Scerrati E. Laser in situ keratomileusis vs. laser epithelial keratomileusis (LASIK vs. LASEK). J Refract Surg. 2001;17(2 Suppl):S219-S221.
  7. Lee JB, Seong GJ, Lee JH, Seo KY, Lee YG, Kim EK. Comparison of laser epithelial keratomileusis and photorefractive keratectomy for low to moderate myopia. J Cataract Refract Surg. 2001;27(4):565-570.
  8. Vinciguerra P, Munoz MIT, Camesasca FI. Reduction of spherical aberration: experimental model of photoablation. J Refract Surg. 2002;18(3 Suppl):S366-S370.
  9. Vinciguerra P, Camesasca FI, Randazzo A. One-year results of butterfly laser epithelial keratomileusis. J Refract Surg. 2003;19(2 Suppl):S223-S226.
  10. Kornilovsky IM. Clinical results after subepithelial photorefractive keratectomy (LASEK). J Refract Surg. 2001;17(2 Suppl):S222-S223.
  11. Shahinian L Jr. Laser-assisted subepithelial keratectomy for low to high myopia and astigmatism. J Cataract Refract Surg. 2002;28(8):1334-1342.
  12. Rouweyha RM, Chuang AZ, Mitra S, Phillips CB, Yee RW. Laser epithelial keratomileusis for myopia with the autonomous laser. J Refract Surg. 2002;18(3):217-224.
  13. Claringbold TV II. Laser-assisted subepithelial keratectomy for the correction of myopia. J Cataract Refract Surg. 2002;28(1):18-22.
  14. Guttman C. LASEK may only play support on refractive stage. Eurotimes. 2002;11-16.
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