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Medline Abstract for Reference 16

of 'Laser refractive surgery'
16
PubMed
TI
Ten years after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) for moderate to high myopia
(control-matched study).
AU
AliJL, Ortiz D, Muftuoglu O, Garcia MJ
SO
Br J Ophthalmol. 2009;93(10):1313.
OBJECTIVE: To compare the long-term outcomes of photorefractive keratectomy (PRK) and laser in situ keratomilesis
(LASIK) for myopia between -6 and -10 D.
METHODS: A retrospective, control-matched study including 68 eyes, 34 which underwent PRK and 34 LASIK, with myopia
between -6 and -10 D, operated using the VISX 20/20 excimer laser, was performed. Optical zones of 5.5 to 6 mm were
used. All PRK-treated eyes were matched with LASIK-treated eyes of the same age, spherical equivalent within +/-1.25 D,
sphere within +/-1.5 D and cylinder within +/-2.5 D. All patients were evaluated 3 months, 1 year, 2 years, 5 years and 10
years after surgery. The main outcomes measures were refractive predictability and stability, safety, efficacy and retreatment rate.
RESULTS: At 10 years, 20 (71%) and 23 (88%) were within +/-1.00 D after PRK and LASIK respectively. The retreatment rate was 35% and 18% respectively. No eye lost more than two lines of BSCVA in both groups. The
efficacy was 0.90 for PRK and 0.95 for LASIK.
CONCLUSIONS: Both PRK and LASIK were safe for moderate myopia. LASIK demonstrated slightly better efficacy,
predictability, and less rate of re-treatment after 10 years. The technical improvements should be taken into account
when comparing these results with those obtained more recently.
AD
Instituto Oftalmolgico de Alicante, Vissum (Department of Refractive Surgery) and Division of Ophthalmology, Miguel
Hernandez University, Medical School, Alicante, Spain. jlalio@vissum.com
PMID
18292203

Lasik has better (than PRK) efficacy, predictability, and less retreatment at 10 years. At 10 years, PRK is 71%
and Lasix is 23% +/- 1.00D.

17
PubMed
TI
Wavefront-guided excimer laser ablation using photorefractive keratectomy and sub-Bowman's keratomileusis: a
contralateral eye study.
AU
Durrie DS, Slade SG, Marshall J
SO
J Refract Surg. 2008;24(1):S77.
PURPOSE: To explain the basic science and clinical evidence that has led to the development of a new technique in corneal
refractive surgery--sub-Bowman's keratomileusis (SBK).
METHODS: A comprehensive review of the literature and report of a contralateral eye study of 50 patients (100 eyes)
enrolled at 2 sites (25 patients per site) and randomized according to the dominant eye was conducted. All eyes underwent
a wavefront-guided refractive correction using the Alcon LADARVision4000 System. In one eye, an 8.5-mm, ETOH-assisted
photorefractive keratectomy (PRK) was performed. In the second eye, an 8.5-mm, 100-microm flap was attempted using a
60 kHz IntraLase FS femtosecond laser. Pre- and postoperative tests included best spectacle-corrected visual acuity,
uncorrected visual acuity, corneal topography, wavefront aberrometry, retinal image quality, contrast sensitivity, and
biomechanical response of the cornea. Patients completed subjective questionnaires at each follow-up.
RESULTS: Clinical results demonstrate that SBK provides quicker visual recovery, although the data suggest that
the 3- and 6-months results are similar in terms ofvisual outcomes. Reichert Ocular Response Analyzer results
demonstrate that its impact on the cornea is similar to PRK.
CONCLUSIONS: This study indicates that SBK provides the visual recovery of a LASIK procedure with the Optical
Response Analyzer results similar to PRK.
AD
Durrie Vision, Overland Park, KS 66211, USA. ddurrie@durrievision.com

SBK vs PRK similar visual outcomes.

18
PubMed
TI
A prospective, contralateral eye study comparing thin-flap LASIK (sub-Bowman keratomileusis) with photorefractive
keratectomy.
AU
Slade SG, Durrie DS, Binder PS
SO
Ophthalmology. 2009;116(6):1075.
PURPOSE: To determine the differences in the visual results, pain response, biomechanical effect, quality of vision, and
higher-order aberrations, among other parameters, in eyes undergoing either photorefractive keratectomy (PRK) or thin-flap
LASIK/sub-Bowman keratomileusis (SBK; intended flap thickness of +/-100 microm and 8.5-mm diameter) at 1, 3, and 6
months after surgery.
DESIGN: A contralateral eye pilot study.
PARTICIPANTS: Fifty patients (100 eyes) were enrolled at 2 sites.
METHODS: The mean preoperative spherical refraction was -3.66 diopters (D) and the mean cylinder was -0.66 D for all
eyes. Eyes in the PRK group underwent 8.5-mm ethanol-assisted PRK, whereas in eyes in the SBK group, an 8.5-mm,
(intended) 100-microm flap was created with a 60-kHz IntraLase femtosecond laser (Advanced Medical Optics, Santa Ana,
CA). All eyes underwent a customized laser ablation using an Alcon LADARVision 4000 CustomCornea excimer laser (Alcon
Laboratories, Fort Worth, TX).
MAIN OUTCOME MEASURES: Preoperative and postoperative tests included best spectacle-corrected visual acuity,
uncorrected visual acuity (UCVA), corneal topography, wavefront aberrometry, retinal image quality, and contrast sensitivity.
Patients completed subjective questionnaires at each visit.
RESULTS: One- and 3-month UCVA results showed a statistically significant difference: SBK, 88% 20/20 or better vs. 48%
20/20 or better for PRK. At 6 months, UCVA was 94% 20/20 or better for PRK and 92% for SBK. At 1 and 3 months, the SBK
group had lower higher-order aberrations (coma and spherical aberration; P<or=0.05); at 1, 3, and 6 months, there was no
statistically significant difference in spherical aberration and vertical and horizontal coma between the 2 groups.
CONCLUSIONS: At the 1-month follow-up, the thin-flap/SBK group demonstrated clinically and statistically significant better
visual acuity than the PRK group. By 3 months, the vision in the 2 groups had begun to equalize, although the SBK eyes
continued to have better vision. At 6 months, there were no statistical differences between the 2 groups.
FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Basically, SBK has quicker recovery than PRK at 1month. Afterwards about the
same at 6m for vision.

20
PubMed
TI
Biomechanical and wound healing characteristics of corneas after excimer laser keratorefractive surgery: is there a
difference between advanced surface ablation and sub-Bowman's keratomileusis?
AU
Dawson DG, Grossniklaus HE, McCarey BE, Edelhauser HF
SO
J Refract Surg. 2008;24(1):S90.
PURPOSE: To describe the biomechanical and wound healing characteristics of corneas after excimer laser keratorefractive
surgery.
METHODS: Histologic, ultrastructural, and cohesive tensile strength evaluations were performed on 25 normal human
corneal specimens, 206 uncomplicated LASIK specimens, 17 uncomplicated sub-Bowman's keratomileusis (SBK)
specimens, 4 uncomplicated photorefractive keratectomy (PRK) specimens, 2 uncomplicated advanced surface ablation
(ASA) specimens, 5 keratoconus specimens, 12 postoperative LASIK ectasia specimens, and 1 postoperative PRK ectasia
specimen and compared to previously published studies.
RESULTS: Histologic and ultrastructural studies of normal corneas showed significant differences in the direction of collagen
fibrils and/or the degree of lamellar interweaving in Bowman's layer, the anterior third of the corneal stroma, the posterior
two-thirds of the corneal stroma, and Descemet's membrane. Cohesive tensile strength testing directly supported these
morphologic findings as the stronger, more rigid regions of the corneawere located anteriorly and peripherally. This suggests
that PRK and ASA, and secondarily SBK, should be biomechanically safer than conventional LASIK with regard to risk for
causing keratectasia after surgery. Because adult human corneal stromal wounds heal slowly and incompletely, all excimer
laser keratorefractive surgical techniques still have some distinct disadvantages due to inadequate reparative wound
healing. Despite reducing some of the risk for corneal haze compared to conventional PRK, ASA cases still can develop
corneal haze or breakthrough haze from the hypercellular fibrotic stromal scarring. In contrast, similar to conventional
LASIK, SBK still has the short- and long-term potential for interface wound complications from the hypocellular primitive
stromal scar.
CONCLUSIONS: Ophthalmic pathology and basic science research show that SBK and ASA are improvements in excimer
laser keratorefractive surgery compared to conventional LASIK or PRK, particularly with regard to maintaining corneal
biomechanics and perhaps moderately reducing the risk of corneal haze. However, most of the disadvantages caused by
wound healing issues remain.

SBK has better corneal biomechanics and maybe decrease risk of corneal haze vs
LASIK/PRK. Other wound healing issues remain.

J Cataract Refract Surg. 2010 Oct;36(10):1709-17. doi: 10.1016/j.jcrs.2010.04.041.

Long-term refractive outcomes and stability after excimer laser

surgery for myopia.
Dirani M1, Couper T, Yau J, Ang EK, Islam FM, Snibson GR, Vajpayee RB, Baird PN.
Author information
Abstract
PURPOSE:
To evaluate the long-term refractive outcomes of photorefractive keratectomy (PRK) and laser in situ
keratomileusis (LASIK) for myopia.
SETTING:
Centre for Eye Research Australia, Melbourne, Australia.
DESIGN:
Comparative case series.
METHODS:
Preoperative baseline refractions in eyes having PRK, LASIK, or both at 1 multisurgeon center were
analyzed from patient databases. Two- to 13-year follow-up data were analyzed and compared with 1month postoperative visual outcomes.
RESULTS:
The study evaluated 389 eyes (229 patients). In the PRK group, the mean preoperative spherical
equivalent (SE) was -4.05 diopters (D) 1.17 (SD) in eyes with low to moderate myopia and -7.97 2.00
D in eyes with high myopia (P = .009) and in the LASIK group, -3.98 1.27 D and -7.64 1.66 D,
respectively (P = .008). At the last visit, the mean SE in the PRK group was -0.64 0.83 D in eyes with
low to moderate myopia and -1.06 1.74 D in eyes with high myopia (P = .73) and in the LASIK group,
-0.33 0.59 D and -0.63 0.90 D, respectively (P = .68). At the end of the study, 45.9% of eyes with low
to moderate myopia and 25.0% with high myopia in the PRK group and 64.8% and 37.3%, respectively, in
the LASIK group were within 0.50 D of the attempted correction.
CONCLUSIONS:
Laser refractive surgery effectively treated all levels of myopia. Refractive stability was achieved
within 1 year postoperatively, with LASIK showing better stability than PRK for up to 6 to 9 years.
Crown Copyright 2010. Published by Elsevier Inc. All rights reserved.

PMID:20870117

***Lasik is more stable for my high myopia prescriptions after 6-9 years (37.3% stable) than PRK (25.0%) long term.

Uptodate
Short-term visual outcomes Patients can reasonably expect to have a 90 to 99 percent chance of
achieving 20/40 or better uncorrected visual acuity (UCVA) [48,75]; 57 to 79 percent achieve 20/20 or
better UCVA [6,50,72,76]. The results of every study are based upon each patient's refractive error and
the amount of astigmatism. Approximately 85 percent of patients see 20/25 or better UCVA, which
enables them to perform the majority of activities without corrective lenses.
Outcome in a second eye treated with LASIK may be correlated with the results in the first eye [77]. As an
example, one study found a relatively high correlation between the outcomes in the two eyes of patients
who had same-session bilateral LASIK and, after controlling for baseline visual acuity, calculated an
approximately 20-fold increase in the risk of uncorrected visual acuity of 20/40 or worse in an eye treated
with LASIK if such a result occurred in the other eye [78].
The patient factors that affect refractive outcome include low versus high myopia, myopia versus
hyperopia, and astigmatism. Patients with low myopia without astigmatism have the best results, whereas
high hyperopes with astigmatism have the least predictable results [6-11,24,79].
Additional factors that may affect the surgical outcome include the type of procedure, the surgeons skill
level and experience, and the center's equipment, quality control, and maintenance. The laser
characteristics also determine refractive outcomes. The newer generation small flying spot laser beams
(less than 100 microns) with eye tracking systems theoretically offer better predictability than the older
generation wide beam (4 to 5 mm) without eye tracking systems [5]. However, large randomized
controlled trials comparing different lasers have not been published.
A systematic review included six randomized trials (417 eyes) comparing outcomes with PRK and LASIK
for myopia [80]. Visual recovery was faster with LASIK, but refractive accuracy was similar. At six months,
a nonstatistically significant greater number of eyes treated with LASIK achieved a visual acuity
of 20/20 or better (odds ratio 1.62, 95% CI 0.75-3.50). In addition to the wide confidence intervals around
results, there was significant heterogeneity across studies for some outcomes. No randomized trials were
available to compare LASIK with PRK for hyperopia [81]. It remains uncertain whether long-term visual
outcomes differ between PRK and LASIK.
Long term outcomes Long-term outcome studies for PRK and LASIK are difficult to accomplish
because the patient population is largely young, mobile, and generally doing well, resulting in loss to
follow-up. Additionally, outcomes related to new technological advances are not reflected in studies of
procedures done ten years earlier.
However, ten year outcome studies have been published for PRK and LASIK in patients with mild and
more severe myopia [82-85]. These studies, involving a combined total of 785 eyes, demonstrate stability
for refraction and best spectacle-corrected visual acuity and overall excellent safety. Myopic regression
was more likely to occur in the first two years following surgery, with slower rates thereafter.
Retreatment was performed in 20 to 45 percent of patients, commonly beyond two years from the
initial treatment, and was well tolerated. In another series of 779 eyes in 402 patients followed for five
years following LASIK procedure, best corrected visual acuity remained unchanged, compared to one
month post-operative, in 98 percent of patients; 17.5 percent of patients had undergone additional surgery

at a mean of 2.5 years after the initial procedure [86]. A case series of 42 eyes followed for 20 years after
PRK procedure found there were small (0.5 diopters) increases in myopic refractive error with no longterm sight-threatening complications [87].
83
PubMed
TI
Ten-year follow-up of laser in situ keratomileusis for myopia of up to -10 diopters.
AU
AliJL, Muftuoglu O, Ortiz D, Prez-Santonja JJ, Artola A, Ayala MJ, Garcia MJ, de Luna GC
SO
Am J Ophthalmol. 2008;145(1):46.
PURPOSE: To evaluate the long-term outcomes of laser in situ keratomileusis (LASIK) for myopia of up to -10 diopters (D).
DESIGN: A long-term (10-year) follow-up retrospective, interventional case series.
METHODS: The study included 97 eyes of 70 patients with a preoperative spherical equivalent (SE) of up to -10 D treated
with myopic LASIK at the Instituto Oftalmolgico de Alicante, Alicante, Spain, using the VISX 20/20 excimer laser (Santa
Clara, California, USA) and the Automated Corneal Shaper microkeratome (Chiron Vision, Irvine, California, USA). All
patients were evaluated three months, one year, two years, five years, and 10 years after surgery. The main outcome
measures were refractive predictability and stability, mean corneal keratometry, topographical cylinder, safety, efficacy,
stability of visual acuity, and postoperative complications.
RESULTS: At 10 years, 71 (73%) of 97 eyes were within +/- 1.00 D and 89 (92%) were within +/- 2.00 D. Twenty eyes
(20.8%) underwent retreatments because of overcorrection, undercorrection, regression, or both. The mean SE slightly
decreased (myopic regression) over 10 years, with a mean myopic regression of -0.12 +/- 0.16 D per year. Fifty-four (54.6%)
of 97 eyes demonstrated an increase in best spectacle-corrected visual acuity (BSCVA) after 10 years. No eye developed
corneal ectasia in the long-term, and only three eyes lost more than two lines of BSCVA because of complications that were
not attributable to the LASIK procedure.
CONCLUSIONS: LASIK for myopia of up to -10 D is a safe and effective procedure with slight myopic regression that slows
down with time and a high rate of BSCVA increase in the long-term.
AD
Vissum Department of Refractive Surgery and Division of Ophthalmology, Instituto Oftalmolgico de Alicante, Miguel
Hernandez University, Medical School, Alicante, Spain. jlalio@oftalio.om
PMID
18154754
84
PubMed
TI
Ten-year follow-up of photorefractive keratectomy for myopia of more than -6 diopters.
AU
AliJL, Muftuoglu O, Ortiz D, Artola A, Prez-Santonja JJ, de Luna GC, Abu-Mustafa SK, Garcia MJ
SO
Am J Ophthalmol. 2008;145(1):37.
PURPOSE: To evaluate the long-term outcomes of excimer laser myopic photorefractive keratectomy (PRK) for myopia
higher than -6 diopters (D).
DESIGN: A long-term (10-year) follow-up retrospective, interventional case series.
METHODS: The study included 267 eyes of 191 patients with myopia with spherical equivalent (SE) of more than -6 D
treated with myopic PRK at the Instituto Oftalmolgico de Alicante, Alicante, Spain, using the VISX 20/20 excimer laser
(Santa Clara, California, USA). All patients were evaluated three months, one year, two years, five years, and 10 years after
surgery. The main outcome measures were refractive predictability and stability, mean corneal keratometry, topographical
cylinder, safety, efficacy, stability of visual acuity, and postoperative complications.
RESULTS: At 10 years, 156 (58%) of 267 eyes were within +/- 1.00 D and 209 (78%) were within +/- 2.00 D. One hundred
and twenty-four eyes (46.4%) underwent retreatments because of overcorrection, regression, or both. The mean SE
decreased (myopic regression) in eyes that did not undergo retreatment, with a mean magnitude of -1.33 +/- 2.0 D over 10
years (-1.13 +/- 0.20 D per year). One hundred and twenty-one (48.3%) of 267 eyes demonstrated increase in best
spectacle-corrected visual acuity, and only eight eyes lost lines of vision because of cataract and posterior segment-related
complications. The mean corneal haze score decreased gradually from 0.48 +/- 0.69 at three months to 0.09 +/- 0.33 at 10
years.

CONCLUSIONS: PRK for myopia of more than -6 D is a safe and effective procedure in the long-term.
Vissum Department of Refractive Surgery and Division of Ophthalmology, Instituto Oftalmolgico de Alicante, Miguel
Hernandez University, Medical School, Alicante, Spain. jlalio@oftalio.com
REGRESSION APPEARS MUCH WORSE IN PRK, THAN IN LASIK (58% VS 73% WITHIN +/- 1.00D). NOTE
POPULATIONS MAY NOT BE COMPARABLE. (PRK WAS GREATER THAN -6, LASIKS IS 0-10)
18154753
85
PubMed
TI
Ten-year follow-up of laser in situ keratomileusis for high myopia.
AU
AliJL, Muftuoglu O, Ortiz D, Prez-Santonja JJ, Artola A, Ayala MJ, Garcia MJ, de Luna GC
SO
Am J Ophthalmol. 2008;145(1):55.
PURPOSE: To evaluate the long-term outcomes of laser in situ keratomileusis (LASIK) for high myopia.
DESIGN: A long-term (10 years) follow-up retrospective interventional case series study.
METHODS: The study included 196 myopic eyes of 118 patients with a mean preoperative spherical equivalent of -13.95 +/2.79 diopter (D) treated with myopic LASIK at the Instituto Oftalmolgico de Alicante, Spain using the VISX 20/20 excimer
laser (VISX Inc, Santa Monica, California, USA) and the Automated Corneal Shaper microkeratome (Chiron Vision, Irvine,
California, USA). All patients were evaluated three months, one year, two years, five years, and 10 years postoperatively.
The main outcome measures were refractive predictability and stability, mean corneal keratometry, topographical cylinder,
safety, efficacy, stability of visual acuity, and postoperative complications.
RESULTS: At 10 years, 82 (42%) of 196eyes were within +/-1.00 D and 119 (61%) were within +/-2.00 D. Fifty-four (27.5%)
eyes underwent retreatments attributable to under correction and/or regression. The myopic regression decreases with time
in eyes that did not undergo retreatment with a mean rate of -0.25 +/- 0.18 D per year. Eleven eyes (5%) lost more than 2
lines of best spectacle-corrected visual acuity (BSCVA) and 78 eyes (40%) showed a postoperatively uncorrected visual
acuity of 20/40 or better. Two eyes (1%) with more than 15 D myopic correction developed corneal ectasia.
CONCLUSIONS: LASIK for myopia over -10 D is a safe procedure with myopic regression that slows down with time and a
high rate of BSCVA increase in the long-term.
AD
Vissum-Instituto Oftalmolgico de Alicante and Division of Ophthalmology, Miguel Hernandez University, Medical School,
Alicante, Spain. jlalio@oftalio.com
PMID
17996210