Seminars in Ophthalmology 0882-0538/03/1801-002$16.
00
2003, Vol. 18, No. 1, pp. 2–10
LASIK vs LASEK vs PRK: Advantages and indications
Renato Ambrósio Jr, MD1,2 and Steven E. Wilson, MD1
1
Department of Ophthalmology, University of Washington School of Medicine, Seattle, WA, USA and
2
Department of Ophthalmology, University of São Paulo, São Paulo, Brazil
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Abstract
The advent of the excimer laser as an intrument for use in
reshaping the corneal stroma was a great step forward in
refractive surgery. Laser energy can be delivered on the
stromal surface in the photorefractive keratectomy (PRK)
procedure or deeper on the corneal stroma by the means
of a lamellar surgery in which a flap is created with the
For personal use only.
microkeratome in the laser in situ keratomileusis (LASIK)
procedure. LASIK is currently the dominant procedure in
refractive surgery. The main advantage of LASIK over PRK
is related to maintaining the central corneal epithelium. This
increases comfort during the early post-operative period,
allows for rapid visual recovery, and reduces the wound
healing response. Reduced wound healing correlates with
less regression for high corrections and a lower rate of com-
plications such as significant stromal opacity (haze). PRK,
however, remains as an excellent option for mild to moder-
ate corrections, particularly for cases associated with thin
corneas, recurrent erosions, or a predisposition for trauma
(Martial arts, military, etc.). Recently, a modification of PRK,
laser subepithelial keratomileusis (LASEK), was introduced.
In the LASEK procedure, an epithelial flap is created
and replaced after the ablation. The benefits, if any, of the
creation of an epithelial flap compared to traditional PRK
are not fully appreciated. Advocates of LASEK suggest that
there is less discomfort in the early postoperative period,
faster visual recovery, and less haze compared to standard
PRK for correction of similar levels of refractive error. Addi-
tional long-term clinical studies, along with laboratory
research, will be crucial to validate these potential advan-
tages of LASEK procedure.
Keywords: LASIK; PRK; LASEK; complications; wound
healing; visual performance
Correspondence: Steven E. Wilson, M.D., Department of Ophthalmology, University of Washington School of Medicine, Box 356485, Seattle,
WA 98195-6485, USA. Tel.: +1 206 543-5575, Fax: +1 206 543-4414, E-mail: sewilson@u.washington.edu
© Swets & Zeitlinger
Introduction
Refractive surgery has undergone a significant evolution
during the last two decades, emerging as a true ophthalmic
subspecialty. Refractive surgical procedures are among the
most commonly performed procedures in medicine.
The 193 nm argon fluoride excimer laser was introduced
by Trokel in 1983 and first used on a human subject by
McDonald in 1987.1,2 Since that time, tremendous effort has
gone into refining its use in refractive surgery. Excimer laser
procedures have gained tremendous momentum. Improve-
ments in hardware and software have paralleled the evolu-
tion of surgical techniques.
Early models of excimer lasers used a broad beam with a
diaphragm to create small optical zones in spherical or spher-
ical-cylindrical ablation patterns. More sophisticated lasers
emerged using large scanning systems or slit beams. Further
improvement in lasers occurred with the development of
smaller beam delivery systems associated with eye-trackers,
so that more sophisticated algorithms to create smoother
aspheric ablations became possible. For example, the VISX
S3 laser has variable spot scanning with beam diameters
from 6.5 to 0.65 mm. Custom corneal ablation, in which there
is a link between the excimer laser and either information
from the patient’s corneal topography or wavefront (total
eye’s aberration) analysis, is becoming a reality.
During the evolution of surgical techniques, the manner
in which excimer laser energy is applied to reshape the
cornea has undergone major changes since the introduction
of surface ablation, photorefractive keratectomy (PRK). PRK
was eclipsed by laser in situ keratomileusis (LASIK). LASIK
rapidly became the dominant refractive procedure mainly
because of the advantages of leaving the central epithelium
intact.3,4 The convenience of faster visual rehabilitation asso-
ciated with less discomfort during the early post-operative
 LASIK vs LASEK vs PRK: Advantages and indications
period made it possible for LASIK to be performed in a large
number of patients. In addition, microkeratome technology
underwent important developments, augmenting the safety of
LASIK procedure. This further increased the popularity of
LASIK. It is important to mention that PRK has always
remained as an option, particularly for low to moderate levels
of correction and for specific cases, such as thin corneas,
recurrent erosion associated with anterior basement mem-
brane (Cogan’s) dystrophy (ABMD) and personal predispo-
sition to contact injury.
Recently, laser subepithelial keratomileusis (LASEK), a
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new version of surface ablation, has been introduced inde-
pendently by Dimitri Azar5 and Massimo Camelin. (“LASEK
May Offer the Advantages of Both LASIK and PRK” Ocular
Surgery News, International Edition, March 1999). LASEK
includes the creation of an epithelial flap that is put back in
position after the refractive ablation. Early studies suggested
that patients will experience less pain, faster visual recovery
and less haze compared to standard PRK if the epithelial
flap is properly detached.5–13 However, the true benefits of
LASEK, if any, are not understood and require long term
study.
This manuscript will review the dissimilarities between
LASIK, PRK and LASEK from a clinician-scientist
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perspective, covering the clinical advantages and best
indications of each of these procedures. We will begin by
summarizing the main events of corneal wound healing
response following epithelial injury. This will facilitate the
understanding of the differences and advantages for each
procedure.
Corneal wound healing after refractive
surgery: a brief overview
Corneal wound healing contributes significantly to the
efficacy and safety of keratorefractive surgery. It is a major
factor determining under- or over-corrections with all laser
ablation procedures. Also, abnormalities associated with
wound healing are responsible for complications such as
haze and diffuse lamellar keratitis.
The emergence of refractive surgery dictated the need
for a better comprehension of corneal wound healing.
Thus, in parallel with the developments that occurred in
refractive surgery technology and instrumentation, there
has been an explosion in our knowledge of the cellular and
molecular events that occur during corneal healing
response.14–16
The majority of refractive procedures performed on the
cornea have injury to the epithelium in common. Epithelial
injury initiates a sequence of events that occur as part of a
protective system for preserving vision. For example, kera-
tocyte apoptosis, the first detectable event after any type
of epithelial injury, is associated with either mechanical
trauma,17 corneal surgical procedures18,19 or herpetic (HSV)
keratitis, where cellular suicide may provide an early fire
3
wall to viral penetration into the eye and central nervous
system.20
Animal studies demonstrated that superficial keratocytes
undergo programmed cell death mediated by cytokines
released from the injured epithelium, such as interleukin
(IL)-1 alpha, Fas/Fas-ligand, bone morphogenic protein
(BMP) 2, BMP4, and tumor necrosis factor (TNF) alpha.14–16
Redundancy is probably intended to augment the natural
defense system by making it difficult for viral pathogens to
overcome one apoptosis activation system. These cytokines
are also present in the tear film.21,22 Keratocyte apoptosis is
followed by a complex cascade of events that takes place in
the corneal epithelium and stoma. These events are regulated
by cytokine-mediated interactions between epithelial cells,
stromal cells, inflammatory cells, nerves, and lacrimal
gland.14,15
Following keratocyte death, the remaining keratocytes
surrounding the zone of depletion begin to undergo prolifer-
ation within twelve to 24 hours of epithelial injury.23 At this
point, inflammatory cells are also attracted by chemotactic
factors such as the monocyte chemotactic and activating
factor (MCAF). MCAF production is upregulated in kerato-
cytes by IL-1 alpha. IL-1 is released from the epithelium after
injury, but is also present in the tear film. It appears to be
a master modulator of many of the events involved in
this cascade.24 In recent IRB (Institutional Review Board)
approved experiments performed on eyes from patients
scheduled to undergo enucleation because of intraocular
melanoma, it was confirmed that keratocyte apoptosis and
proliferation occur in the human cornea after epithelial
scrape.25 These events occur in parallel with the closure of
the epithelial defect, which is enhanced by growth factors
produced by both the lacrimal glands and keratocytes, such
as epidermal growth factor (EGF), hepatocyte growth factor
(HGF) and keratinocyte growth factor (KGF).26
Myofibroblasts are keratocyte-derived cells that are
present in the repopulated stromata that are characterized by
the expression of alpha smooth muscle actin (SMA).27,28
These cells, along with other activated keratocytes, produce
disorganized collagen, glycosaminoglycans and growth
factors that stimulate healing of the overlying epithelium.27,28
Myofibroblasts also have altered transparency in vivo, related
to corneal crystallin expression. They are thought to be
responsible for stromal haze.29,30 Differentiation of myofi-
broblasts is induced by transforming growth factor (TGF)
beta, and reversal to fibroblast phenotype has been observed
in vitro in the presence of fibroblast growth factor (FGF).31,32
TGF-beta found in the basal layer of the epithelium during
its closure seems to controls stromal myofibroblast trans-
formation during corneal repair.31–33 In addition, basement
membrane formation seems to have an indirect effect on the
myofibroblast transformation by regulating the extent of
TGF-beta release into the corneal stroma.33
There is a return to a normal physiologic state in the
corneal stroma several months after injury. This process
is associated with eradication of myofibroblasts via pro-
 4 Renato Ambrósio Jr. and Steven E. Wilson
grammed cell death or phenotype reversal to quiescent
keratocytes.34 Remodeling of disordered collagen that was
produced by myofibroblasts or activated keratocytes during
the wound healing process is also mediated by keratocytes.35
The corneal epithelium may undergo hyperplasia following
corneal injury, as a result of the growth factors produced by
activated keratocytes and myofibroblasts.36 Stromal remodel-
ing and epithelial hyperplasia are thought to be the most
important mechanisms for regression of the refractive effect
of PRK or LASIK surgery.15,36–38
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Clinical relevance of the wound healing response
There are fundamental differences in the location and inten-
sity of the wound healing events following PRK and LASIK.
For example, after PRK, keratocyte apoptosis and the sub-
sequent events of the healing cascade occur immediately
beneath the epithelium, probably causing more influences
towards epithelial hyperplasia. This contrasts with LASIK, in
which keratocyte apoptosis takes place at the level of the flap
interface and at the site where the blade penetrated the
peripheral epithelium.14–19,39 In addition, there are large quan-
titative differences in keratocyte apoptosis, keratocyte pro-
liferation, and myofibroblast transformation, between PRK
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for low myopia and PRK for high myopia, and between PRK
for high myopia and LASIK for high myopia.34 In general,
higher PRK corrections incite more keratocyte apoptosis,
keratocyte proliferation and myofibroblast transformation
than lower PRK corrections, and these events are less intense
in LASIK, even for higher levels of correction for myopia.34
These observations at the cellular level provide us with an
explanation for the differences in clinical outcomes and com-
plications such as haze, that occur after LASIK and PRK, as
well as for different levels of correction.15
Wound healing in LASEK
In the LASEK procedure, an epithelial flap is detached after
application of a diluted alcohol solution (typically 18 to
25%). After laser ablation, the epithelial sheet is repositioned,
as the stromal flap is in the LASIK procedure. The use of
alcohol for facilitation of the epithelial removal in PRK is
not new. Additionally, some studies demonstrated that epithe-
lial removal facilitated by dilute alcohol application showed
quicker visual rehabilitation without significant adverse
effects in PRK.40,41
Viability of the epithelium is critical for determining the
benefit of leaving the sheet of epithelium as a protective layer
after laser ablation. If the concentration of alcohol used
is 20%, alcohol exposure time remains the most critical
factor.42 Other factors such as the type of alcohol, dilution
vehicle (distilled water or BSS) and temperature of the solu-
tion are also important. If the epithelial flap does not have
good vitality, the dead cells and cellular debri could provide
a mechanical barrier for epithelial healing. For example, in a
study performed in rabbits, increasing exposure time to the
20% alcohol solution to more than 1 minute resulted in sig-
nificant damage to superficial corneal epithelium and pro-
longed epithelial healing time.42 Viability of corneal epithelial
cells can be studied using culture models with trypan blue.
These studies demonstrated that epithelial viability dimin-
ished as a function of alcohol exposure time.42,43 Vinciguerra
observed that the communication with the limbal steam cells
are important for preserving the vitality of the epithelial sheet
and developed the “Butterfly” technique.12 In contrast to the
classical LASEK technique, in which the epithelium is dis-
sected in a “U” fashion after partial trephination, in “Butter-
fly” LASEK the epithelial flap is created from a paracentral
linear area that is deepitelized (Fig. 1).5–13
Alcohol weakens the adhesions of the basal epithelial
cells to the anterior stroma. Studies that used immunohisto-
chemical techniques for laminin 5, alpha6-beta4 integrin and
collagen VII found that patches of laminin 5 and alpha6-
beta4 integrin are still attached to the epithelial flap. In con-
trast, linear staining with collagen VII is observed in the
stromal bed.43 The epithelial adhesion complex is composed
by hemidesmossomes that adhere to the anchoring network
in the superficial stroma. The hemidesmossomes have an
inner and an outer plaque. The outer plaque contains alpha6-
beta4 integrin. The anchoring network is composed by
anchoring filaments (laminin 5), anchoring fibrils (collagen
VII) and anchoring plaque (collagen IV). Thus, the cleavage
plane of the epithelial flap occurs at the level of anchoring
fibrils, between the epithelium basement membrane and
anterior stroma (Bowman’s layer).43
It is also important to note that there are significant dif-
ferences in the epithelial adhesion among different patients.
For example, the contralateral eye of a patient who had total
epithelial sloughing during LASIK required much less pres-
sure for the epithelial removal during PRK than a normal
case (Ambrósio, Wilson, unpublished data 2001). These
cases with poor adhesion may represent an asymptomatic
form of anterior basement membrane (Cogan’s) dystrophy
since signs of this dystrophy can be noted in pathologic
specimens (Fig. 2).
There are no clinical tests that could determine the adhe-
siveness of the corneal epithelium to the stroma. Several ben-
efits would be possible if we could determine this variable.
For example, less alcohol would be needed in weak adhesion
Figure 1. A. Superior hinged “U” shaped epithelial flap in
classic LASEK. B. “Butterfly” LASEK. (Surgery done by Paolo
Vinciguerra, MD).
 LASIK vs LASEK vs PRK: Advantages and indications
Figure 2. Transmission Electron Microscopy of human epithelium
specimens obtained after PRK in a case with normal epithelium (A)
and from a case whose contralateral eye had epithelial slough during
LASIK (B). Note several hemidesmossomes present and a thin layer
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of basement membrane in A. In B, a multilaminated basement mem-
brane is present, which is a characteristic of Anterior Basement
Membrane (Cogan’s) Dystrophy.
Table 1. Possible Beneficial Mechanisms of the Epithelial Flap.
• less keratocyte apoptosis in the anterior stroma
– less release of cytokines from the epithelium
– protection of the anterior stroma from epithelium-derived tear
film cytokines
• less myofibroblast transformation
– less release of TGF-beta into the tear film
– less epithelial-stromal interactions due to faster epithelial
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healing and less damage to basement membrane
cases, improving epithelial cells viability. In addition, cases
with strong epithelial adhesion could be detected. LASEK
would lead to severe damage to the epithelial flap in these
eyes, obligating conversion to standard PRK.5–13 In order to
maximize epithelial flap viability, McDonald introduced Gel-
assisted LASEK (MB McDonald. Binkhorst Lecture. AAO
2001. New Orleans) Using the base of a microkeratome to
give support, a special canula is introduced under the epithe-
lium. The epithelium is then detached by injecting the gel.
Once the epithelium is detached, it is opened using delicate
scissors in a “butterfly” fashion. Early results using this
technique were promising.
If properly created, the epithelial flap in LASEK could
have a positive impact on wound healing, inciting a less
aggressive response and inciting less haze. The mechanism
through which the epithelial flap could provide protection
and improve clinical outcomes is not completely understood.
Some possible mechanisms are listed on Table 1.
Reduced keratocyte loss was observed after LASEK when
compared to PRK in a preliminary rabbit study.44 This may
occur due to a barrier effect against pro-apoptotic cytokines
that are also present in the tear film. For example, the use of
a collagen shield diminished keratocyte loss after corneal
epithelial scrape in rabbits.45 Also, lower levels of TGF-beta
were detected in the tear film during the first week after
LASEK when compared with PRK in the contralateral eye.46
In addition, a recent study pointed out the importance of the
TGF-beta liberated from the healing epithelium for myofi-
5
brobast transformation, as well as the effect of the basal
membrane as a barrier for this interaction.33 Thus, it is logical
to hypothesize that if an epithelial flap is properly created,
less myofibroblast transformation would occur, determining
less haze. However, clinical significant haze typically does
not develop in the early post-operative period of epithelium
healing after PRK.
More clinical data are needed to conclusively demonstrate
whether LASEK has significant advantages over PRK. Is
epithelial healing accelerated? Is the visual rehabilitation
faster? Is there really greater comfort with LASIK compared
to PRK augmented with oral Vioxx and a good fitting contact
lens? Is there really less clinically significant haze in LASEK
for high myopia compared to PRK for high myopia? In addi-
tion, late onset corneal haze (LOCH) in PRK, a distinguished
type of corneal scarring that appears after a period of at
least 4 months of good clinical outcome and could appear up
to 33 months after the surgery, has an incidence between
0.5% and 1.8%.47,48 Thus, studies with large numbers of
patients and follow up over 2 years in both the PRK and
LASEK group will be needed to answer the critical haze
question.
LASIK: the most popular refractive
procedure today
The concept of lamellar refractive keratoplasty was first
introduced by Prof. Joaquim I. Barraquer in Bogotá,
Colombia. Prof. Barraquer developed complex and
technically demanding lamellar procedures for correction of
refractive errors in the early 1960s.49 The combination of
the lamellar surgery with the excimer laser ablation, first
reported by Pallikaris and Burrato in the early 1990s, brought
several advantages.50,51 Independently, Gholam A. Peyman
also conceived of lamellar surgery combined with laser abla-
tion and patented this concept in the United States. The
greater accuracy and precision of the excimer laser facilitated
the lenticular resection of tissue for the refractive correction.
In addition, preservation of the central epithelium increased
patient comfort and allowed for more rapid visual recovery.
It also made bilateral surgery an attractive option for the
patient. Less damage to the epithelium results in increased
predictability of the surgery for high corrections.
Thus, LASIK has emerged as the dominant refractive
surgical procedure performed today.3,4 The most significant
advantages of LASIK are:
✓ Faster visual rehabilitation with earlier post-operative
stabilization of visual acuity
✓ Less post-operative patient discomfort
✓ Attenuated wound healing and less stromal haze
formation
✓ Possibly improved predictability, stability, and corneal
clarity in higher correction groups
✓ Shorter duration of post-operative medications use
✓ Easier enhancement procedure.
 6 Renato Ambrósio Jr. and Steven E. Wilson

Perhaps never before has an ophthalmic procedure
received so much attention in the absence of data regarding
efficacy or safety as LASIK in its early days. The most feared
complication is an imperfect flap (i.e., incomplete flap,
button hole) but important developments in microkeratome
technology minimize these complications. With the increase
in the popularity of LASIK, several new complications
emerged:
✓ LNE – LASIK induced neurotrophic epitheliopathy
✓ Diffuse lamellar keratitis (DLK)
✓ Lamellar opportunistic infections
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cytokines into the interface. Several advantages in the wound
healing can be imagined. This procedure also has the poten-
tial to virtually eliminate complications related to the cre-
ation of the flap. Additionally, a thin flap would leave more
tissue available for the refractive ablation, minimizing the
risk of keratectasia.
The case for PRK
PRK remains an option to LASIK and in some situations is
the preferred procedure. The safety of the procedure, partic-

✓ Progressive ectasia (keratectasia) ularly because of the absence of flap complications, has been
an important reason for several refractive surgeons continu-
Even though the clinical aspects and pathophysiology
ing to perform high volumes of PRK cases. Arguments in
of these complications is very different, they all have in
favor of doing PRK are listed in Table 2.
common some relation to the flap. Some of these complica-
One of the most important drawbacks of PRK is pain
tions are not completely understood and the topic of LASIK
during the first week after surgery. We have been pleased with
complications is currently one of the most important in
the pain control achieved through the use of a soft contact
refractive surgery. A significant increase in publications
lens with excellent fit (Soflens 66, Boush & Lomb) and oral
regarding the complications of LASIK has been observed in
COX-2 inhibitor Vioxx, taken 50 mg per day for the first 5
the literature.52,53
days after surgery.
The LASIK flap was demonstrated to induce biomechani-
Bilateral surgery is a commonly selected approach with
cal changes in the cornea and produce significant changes in
PRK for patients who do not need to work or drive for a week
aberrations.54 As a result, a two step approach has been pro-
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after surgery. Vision is surprisingly good in the early period

posed to use custom cornea technology to best treat higher
after PRK, with most patients seeing between 20/40 and
order aberrations.55 In addition, the flap may work as a carpet,
20/60 the first day after surgery.
smoothing out the very subtle changes in contour produced
Retreatment for undercorrection or overcorrection is
during customized treatment. Results of custom cornea
more complicated with PRK. In LASIK, we typically do the
surgery were reported to be better with surface ablation
enhancement 3 to 4 months after the first procedure. In PRK,
(PRK) than with LASIK in the early trials LASEK (MB
we typically wait until 5 to 6 months after surgery to allow
McDonald. Binkhorst Lecture. AAO 2001. New Orleans).
for stability of the refraction and resolution of haze.
These considerations make flap free surgery more appealing
Late onset corneal haze (LOCH) is a very important
if a procedure can be developed that also has many of the
complication of PRK.47,48,56–58 It is characterized by dense
advantages of LASIK.
subepithelial opacity along with regression and loss of best-
Despite these possible flap-related complications, we
corrected visual acuity (BSCVA) that characteristically
believe that LASIK remains the best option for most refrac-
begins several months after PRK.47,48 It has been associated
tive surgery patients. If proper screening and evaluation are
with irregular ablations caused by imperfect delivery systems
performed, along with the use of appropriate instrumentation
and higher corrections, but may occur with any laser in a
and technique, virtually all of these LASIK complications
small proportion of patients.59 The incidence has been
can be avoided or optimally treated. Careful and timely post-
operative evaluation by the surgeon is also important.
However, the surgeon should understand the limits of LASIK
Table 2. Advantages of cases where PRK may be a better option.
and avoid extending the procedure beyond these limits,
where the efficacy and safety of the procedure are compro- • Patients preference
mised. Serious outcomes are likely to be noted if these lim- • Predisposition for contact injury (i.e., martial arts practitioners)
itations are not appreciated. This is an evolving process based • Anterior Basement Membrane (Cogan’s) Dystrophy
on peer-reviewed publication and personal experience. For • Epithelial sloughing during LASIK in the contralateral eye
example, despite FDA approval for higher levels, we no • Thin corneas in which the stromal residual bed would be less
longer attempt corrections beyond +4 diopters of hyperopia than 250 to 300 microns
or -10 diopters of myopia corrected to the corneal plane. • Deep orbits or tight eyelid fissure causing poor exposure for the
However, in some eyes even these limits are excessive, microkeratome base
depending on the pre-operative corneal curvature or corneal • Flat corneas (<41 D) or steep corneas (>48 D)
• Previous surgery involving the conjunctiva: bleb associated with
thickness.
filtering procedure; scleral buckle for the treatment of retinal
A surgical device with properties such as the fentosecond
detachment
laser could be useful in producing a thin flap with uniform • Moderate dry eye prior to surgery
thickness with minimal introduction of epithelial debris and
 LASIK vs LASEK vs PRK: Advantages and indications
reported to be around 1%, depending on several factors, such
as smoothness of the laser ablation, level of correction and
variations in the wound healing response. In the authors
experience of over 3500 PRK procedures there has not been
a single case of late haze (Wilson, unpublished data, 2002).60
It resolves over time, but in severe cases years may be
required for full resolution. Epithelial debridement is associ-
ated with recurrence.47 Treatment with Mitomycin C may be
effective in severe cases.61,62 We hypothesize that this type
of severe haze is associated with an underlying genetic
disorder in wound healing.
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Delays in epithelial healing caused by toxicity of medica-
tions, dry eye, or other factors are also associated with haze,
but this haze is noted in the early postoperative period.
If we limit the comparison between PRK and LASIK to
mild myopia (less than -5 or -6 diopters of myopia), there
appears to be little if any longterm advantages to LASIK. In
this group, many studies have found no significant difference
in the refractive outcome after the first month between PRK
and LASIK.63–69 In addition, some studies show a tendency
for LASIK patients to experience more problems related to
quality of vision than similar PRK patients.63,64
PRK for hyperopia is associated with even longer visual
rehabilitation, but the results are also good after stabiliza-
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tion.70 This may be due to the new surface contour, which has
an elevated area in the center, making it more difficult for the
epithelium to heal. Typically we do not treat more than +3 to
+4 diopters of hyperopia with either LASIK or PRK.
Some authors consider PRK an option for early kerato-
conus, especially using custom ablation profiles based on
cornea topography.71 Since the pathophysiology of ectatic
dystrophies on the cornea may be associated with acceler-
ated programmed cell death of the keratocytes, we are
conservative in applying a procedure that itself triggers ker-
atocyte apoptosis.7,73
LASEK: Is it going to replace LASIK?
It has been suggested that LASEK combines the advantages
of LASIK and eliminates the disadvantages of PRK. This
might be the ideal, but long-term studies are necessary to
support this hypothesis. It is, however, appealing to have
a procedure free of flap complications if LASEK is truly
superior to PRK and is associated with less late haze for
higher corrections. In addition, the better results of surface
ablation for custom cornea surgery have created a great deal
of interest in using this type of procedure.
There remain several controversial issues regarding
LASEK. For example, some authors only consider LASEK
as an option for PRK and recommend it for cases in which
LASIK is not an option, or they give the patient an opportu-
nity to choose between the procedures. On the other hand,
some refractive surgeons are really believers of the advan-
tage of LASEK and have converted to this procedure for
most patients, regardless of refractive error. Thousands of
7
cases performed with the same laser will be required to deter-
mine that LASEK is associated with a lower incidence of late
haze than PRK.
The advantages of LASEK are related to a viable flap
epithelium. Nevertheless, if the flap epithelium is not viable,
it could have a negative impact on the overall wound healing
response and, consequently, result in worse outcomes than
classic PRK. It is critical to master the technique of creating
an epithelial flap if LASEK is to become a routine choice in
a surgeons practice. Ethanol is toxic to all cells. Therefore,
it will be important to determine whether there are any long-
term changes in keratocyte or endothelial cell density in eyes
that have LASEK.
There are also technical issues with LASEK. LASEK
takes longer to perform than PRK and LASIK. It also
requires more instrumentation. These factors might be asso-
ciated with problems with patient flow in a busy refractive
surgery center.
Conclusions
Customized ablations have become a reality, but there remain
significant limitations. Surface ablation may be the best
method for application of laser energy to create subtle cor-
rections to treat higher order aberrations. Further investiga-
tion will be needed to determine whether PRK, LASEK, or
LASIK is the optimal procedure for application of cus-
tomized treatments. The advent of the fentosecond laser,
which gives surgeons the ability to create thin flaps with
uniform thickness and minimal epithelial trauma may also
have advantages. This requires supplementary research as
well.
Acknowledgments
Supported in part by US Public Health Service grant
EY10056 from the National Eye Institute, National Institutes
of Health, Bethesda, Maryland, and an unrestricted grant
from Research to Prevent Blindness, New York, NY, USA.
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