by George W. Rozakis, MD

here is a growing belief that laser in-situ keratomileusis (LASIK) is the future of refractive surgery. The problems of photorefractive keratectomy (PRK) include corneal haze, late regression or shift, pain and confusion regarding re-treatment. Although LASIK supporters highlight lack of pain and rapid restoration of visual acuity, there are other differences between PRK and LASIK that need to be considered especially with regard to postop management.

The key difference between PRK and LASIK lies within the postoperative management of each procedure. Without question, the management of a PRK eye is medical, and for LASIK, surgical.

Epithelium in the interface

For example, post-LASIK, it is not uncommon for the epithelium to present itself in the interface. This problem is best managed by surgically elevating and repositioning the corneal flap as soon as possible. Irregular astigmatism post-LASIK is also quite responsive to flap repositioning.

In addition, post-LASIK, the corneal flap could dislodge and warrant repositioning. Loss of a corneal cap is a frightening possibility that would require reconstruction of the anterior segment of the eye.

In view of these potential problems, we must rethink co-management protocols with LASIK. It is my opinion that co-management is acceptable by a referring ophthalmologist who is equipped to handle surgical complications that may occur post-LASIK. However, I am concerned with co-management by surgeons outside of the United States and optometry. A patient referred to a “center” for LASIK runs a significant risk should a complication develop due to the distances and potential delays the patient may experience should there be a complication.

Access to training, technology

While there is undoubtedly a need in our country for access to excimer laser technology and training with regard to the keratome, efforts by outside ophthalmologists to commercialize LASIK in the United States are inappropriate. It is fascinating to me that an ophthalmologist and supporting manufacturer can work through United States optometric programs and commercialize their device on traveling patients who stand to be left in the cold should a problem develop. Let's hope the Food and Drug Administration will free up technology and techniques so patients and optometry will keep patients home near the care they deserve. There are many unanswered questions surrounding refractive surgery. For example, when does one switch from RK to automated lamellar keratoplasty, PRK, or LASIK? Does one enhance an RK with LASIK or vice versa? How does one enhance a PRK? How is a central island and other “optical-zone anomalies” most effectively managed? We have a lot of work to do in a professional, non-commercial environment with these new techniques. Free access to all excimer laser technology as well as curtailment of commercial efforts by industry from other countries would be a step in the right direction to getting the right answers.