Barraquer Lecture: SBK, what Barraquer would have wanted

Lamellar refractive surgery is no longer the "terrifying operation" it was when myopic keratomileusis, the first such procedure, was performed several decades ago. But the faster, safer, and more effective surgeries widely performed today will not remain state of the art any more than their predecessors, said Stephen G. Slade, MD, FACS, during the annual Barraquer Lecture.

He suggested that sub-Bowman's keratomileusis (SBK) could combine the strengths of LASIK and PRK and be an improvement over current practices.

"We need to move away from LASIK to whatever you want to call it-it's not the same procedure we did in 1991," said Dr. Slade, a LASIK surgeon in private practice in Houston.

Through manual keratomes, automated keratomes, femtosecond laser keratomes, wavefront and other developments, LASIK has evolved to become the dominant refractive procedure and was shown in a Cochrane review to be superior to PRK, he said.

"But is there a way to work on the lamellar aspects and further improve the safety and efficacy of this wonderful procedure?" Dr. Slade asked.

He and others have been working for several years on a technique to custom design flaps fashioned to a particular laser ablation, saving more of the anterior stroma and sparing more of the fibers at the periphery. This was the genesis of SBK, in which the cut is just beneath Bowman's membrane, he said. Dr. Slade performs SBK with a depth of 100 µm and flaps 8.5 mm in diameter.

Advantages of SBK include reduced potential for dry eye, less surgical time, little or no haze or pain, rapid re-enervation, and topographic and biomechanical stability, according to Dr. Slade.