Letter from Dr. Fischer

Learn in what circumstances Dr. Fischer will use PRK, as well as his opinion on the effectiveness of the procedure.

I’m sure you know that when the excimer laser was initially approved to treat patients it was approved for PRK.  LASIK was not the intended procedure approved by the FDA, but was initiated as an “off label” use just as in medicine we use drugs or devices for other indications than what they were originally approved for.  The question of whether PRK is “effective” or not has never been an issue.  In fact every study comparing LASIK to PRK or intralase flap creation versus PRK or intralase customized LASIK versus custom PRK has shown no difference in the final result once you reach the 3 month point and beyond.  LASIK will always win the race in the first 1 to 3 months, but in the end there is no difference in the visual result. 

But why then do we do what we do and the vast majority of surgeons perform way more LASIK than PRK? 

The answer is simple.  People want results yesterday, painless, and free in America.  And the doctors have provided them with this in LASIK.  I’m as guilty of that as anyone, considering how many LASIK procedures I’ve done.  But is that really what is best for patients?  Yes they see better more quickly than the PRK patients do, but what is the downside, because we know they don’t see any better than PRK patients after the 3 month period.  In my opinion, PRK is safer on a long term basis.  The flap created with LASIK is there for the rest of your life.  Accidents happen that can damage the flap years later.  If you do enough LASIK, you start to see examples show up in your office all the time that would have been a minor corneal abrasion to an eye that did not have any prior surgery or an eye that had PRK.  Also, the long term risk of ectasia has been the prime focus of refractive surgery over the past couple of years.  How do you prevent it?  Well one way to cut down the risk is to perform PRK.  You can still have ectasia with PRK, but most likely not within the parameters most surgeons now use to set their limits on the amount of correction they will attempt and with the better pre op testing that is available (pentacam).  So the long term safety favors PRK in my opinion, by a wide margin.

Now what is better for preventing dry eye patients after lasik.  By far PRK, because it does not damage corneal nerves to the extent that LASIK does – whether a mechanical microkeratome or the intralase is used. PRK is safer in patients with very steep or flat keratometry readings.  It is better when correcting higher amounts of astigmatism, and we can treat higher without the great concern of ectasia, because there is no flap to worry about.  So the only thing that is better on the LASIK side is speed of visual recovery and that is what has won the race here in America.  In Europe PRK makes up a far greater percentage of the amount of refractive surgery performed.  So you may ask if PRK is better in all these instances when will we recommend it to our patients?  EVERYTIME.

Jeff Fischer