June 2017




Rebirth of laser vision correction
How to start performing refractive surgery

by Ellen Stodola EyeWorld Senior Staff Writer


LASIK procedure just after the flap is lifted, immediately preceding excimer laser ablation; in this example, the flap is centered upon the visual axis created by the VisuMax femtosecond laser, which is the same laser used to perform ReLEx SMILE.
Source: Gregory Parkhurst, MD

LASIK procedure at the conclusion of closing the flap
Source: Gregory Parkhurst, MD

Physicians discuss expanding the practice of the comprehensive ophthalmologist to include more procedures

In this changing ophthalmic environment, with new technologies and innovations, many ophthalmologists are beginning to incorporate a wide variety of procedures into their practice scope. Comprehensive ophthalmologists are doing more than just cataract surgery and are learning refractive and corneal refractive procedures, including PRK and LASIK. Elizabeth Yeu, MD, Virginia Eye Consultants, Norfolk, Virginia; Kathryn Hatch, MD, Massachusetts Eye and Ear, Waltham, Massachusetts; and Gregory Parkhurst, MD, Parkhurst NuVision, San Antonio, Texas, commented on why it could be valuable for ophthalmologists to offer more procedure options, tips for learning to perform these refractive surgeries, and how to incorporate them into practice.

Why perform corneal refractive surgery?

With the increasing popularity of refractive cataract surgery, patient expectations run high, Dr. Hatch said. Sometimes even with surgical planning and newly available technologies, patients don’t end up on refractive target, so laser vision correction is a handy tool.
Corneal refractive surgery is proven to deliver high quality uncorrected vision, with a very low side effect profile, Dr. Yeu said. “If nothing else, refractive cataract surgeons will have a skill set and option to help correct surprises from refractive errors after cataract surgery.”
Before even getting into the topic, Dr. Parkhurst thinks it’s important to define what refractive surgery is. “The field is expanding with a lot of innovations and several recent [Food and Drug Administration] approvals,” he said.
In the past, Dr. Parkhurst said, refractive surgery was limited in definition to procedures like LASIK and PRK, but now encompasses additional procedures, some of which are applicable to the three milestones of human vision development. The first milestone, he said, is ocular maturity. This means that a child has completed physical growth, and the eye has stopped changing. This usually occurs between ages 18 and 20. Once that milestone has been reached, you can use a number of procedures, he said, like small incision lenticule extraction (SMILE, Carl Zeiss Meditec, Jena, Germany), LASIK, PRK, crosslinking, and phakic IOL implantation to treat the distance vision in a permanent way. The second milestone, Dr. Parkhurst said, is presbyopia, and the third is cataracts.
“Refractive surgery is expanding and becoming a subspecialty,” he said. “While we think that every ophthalmologist should involve themselves in refractive surgery in some way, there are various ways to participate.” He added that what’s happening in refractive surgery is similar to other subspecialties, with expanding ways to perform surgery.

Best ways to learn

A skills transfer course could be helpful for surgeons wanting to learn the new technical skills needed for corneal refractive surgery, Dr. Yeu said. She recommended attending a thorough didactic course and supplementing it with other didactic courses to understand some of the nuances involved with these surgeries and how to manage potential complications. Surface ablation
procedures are technically easier than LASIK, she added.
With regard to learning this, Dr. Hatch thinks that a cornea and refractive fellowship is ideal. Learning laser vision correction is relatively straightforward for the anterior segment surgeon, she said, but finding good candidates, treating the ocular surface, and having the ability to manage problems are key.
“I think it’s great if someone can start with a training program,” she said. However, for those who have been out of training for many years and who are not necessarily going to do a corneal fellowship before doing laser vision correction, Dr. Hatch suggested taking a course and investing time with an experienced surgeon to learn as much as possible.
The best way to gain expertise is first to find a mentor, Dr. Parkhurst said. He suggested visiting practices where a physician is willing to sit by your side and provide direct instruction on how to perform various procedures and select the correct procedure for each patent. “Getting access to that kind of training goes beyond what you can access at a weekend training course or hear at a lecture,” he said. It involves a hands-on, deep dive into the procedure.
Dr. Parkhurst said there are a number of advanced training programs available, but he noted that there are only a handful of refractive surgery fellowships available in the U.S. today. Additionally, he said that many corneal fellowships are heavy in training for corneal pathology, transplants, and other corneal procedures, so refractive surgery training may need to be specifically sought out by the individual. A well-trained anterior segment surgeon has the skill set for some refractive procedures and would be well served by understanding all the options that are available.
PRK and LASIK are two options for procedures that surgeons may want to become well versed in. When it comes to choosing between PRK and LASIK, Dr. Yeu said that PRK has less of a chance for ectasia. It’s also technically easier to perform, she said.
Although PRK is a simpler procedure to master technically, Dr. Hatch thinks it’s an advantage to be able to offer both procedures to patients. “A lot of people are good candidates for LASIK, and you don’t want to restrict them to PRK,” she said.
Many refractive procedures may look easy, particularly when they go well, Dr. Parkhurst said. However, they are no different from other surgical procedures when there is any risk of complications. “Surgeons performing [these procedures] need to know how to avoid complications and manage complications and how to select the right procedure for the right individual,” he said. For someone starting in refractive surgery, Dr. Parkhurst said that determining good candidates for a procedure is the first step.

Incorporating corneal refractive surgery into a practice

To incorporate corneal refractive surgery into a practice, Dr. Yeu advised surgeons look at how other surgeons, particularly in a practice size similar to theirs, incorporate it. She said to question if there is a need in the market. Are you planning to use it as a primary surgery or only to correct refractive errors after cataract surgery? “Certain marketing can be helpful, but start with internal marketing with established patients,” she said. It’s also important to educate staff and consider having a counselor.
“We learn in medical school that any time we’re consulting patients for any health condition, our job is to discuss the risks, benefits, and alternatives of every option,” Dr. Parkhurst said. This is important when evaluating all options for patients.
Dr. Hatch said incorporating corneal refractive surgery into a practice involves advertising that you’re doing it. “You have to make it available and make it known that you’re doing it.” This could be done through patient education materials. She also said the staff needs to support what the surgeon is doing and should be educated when talking to the patients about these procedures.

Tips for LASIK or PRK after phaco

Dr. Yeu recommended waiting at least 6 weeks to allow full healing of any limbal relaxing incisions or cataract wounds. Perform YAG posterior capsulotomy before performing corneal refractive surgery, she added.
Dr. Hatch stressed the importance of waiting until the patient is well healed from the cataract procedure. She also recommended managing dry eye issues and optimizing the ocular surface. Dr. Hatch likes to perform a YAG capsulotomy before a laser vision correction procedure.
All ophthalmologists who perform anterior segment surgery are participating in refractive surgery whether they think of it in that way or not, Dr. Parkhurst said. The first step is to start really looking at refractive outcomes in cataract surgery, he said, because you can’t improve until you measure it.

Editors’ note: Dr. Parkhurst has financial interests with Carl Zeiss Meditec. Drs. Hatch and Yeu have no financial interests related to their comments.

Contact information

: kathryn_hatch@meei.harvard.edu
Parkhurst: gparkhurst@sanantonio-lasik.com
Yeu: eyeulin@gmail.com

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