Lamellar procedures: the future of refractive surgery

The debate over which type of refractive procedure will prevail continues, and according to George Waring III, MD, FACS, FRCOphth, the future belongs to lamellar surgery.

His rationale is based on a number of factors. "Refractive surgery is a patient-driven enterprise, it is elective, paid for by the patient, and the number of procedures performed follows the consumer confidence index," he said during Cornea Day 2006 at the American Society of Cataract and Refractive Surgery meeting.

LASIK has greater recognition than does IOL implantation, and patients prefer a surface procedure rather than one done intraocularly.

"The perception on the part of patients is that a lamellar procedure is great," he said. Dr. Waring is the founder of InView Vision, Atlanta.

Another argument that supports his thesis is that the results of LASIK in the vast majority of patients treated to correct myopia are near emmetropia and high numbers of patients with hyperopia achieve good visual acuity levels. The selection of appropriate patients for LASIK is improving with the avoidance of thin corneas, keratoconus suspects, extremes of steep and flat corneas, and perfectionist patients.

"The use of lamellar surgery is what really makes it exciting. The reason it will survive into the future is that it covers the spectrum of patient needs: primary treatment, secondary treatment, and finally it can be used as a rescue procedure following the failure of other types of refractive procedures," Dr. Waring stated.

The number of re-treatments that can be performed is unlimited as long as the patient has a sufficiently thick stromal bed and the flap is health, he added, and attributes the ability to re-treat to the manner in which the wound heals.

In addition, surgeons have become more skilled at avoiding complication and microkeratomes cut flaps that are closer to the desired thickness.

The long-term challenges include acquiring long-term follow-up data; surgeons still need to determine if there is progressive corneal steepening over the long term. Others are developing faster lasers and even more accurate microkeratomes.