Deciding between LASIK or phakic IOL

Chicago-Refractive surgeons able to offer both phakic IOL implantation and LASIK can meet the needs of a broader population seeking treatment for moderate-to-high myopia. However, when a patient is a candidate for both procedures, different surgeons have different opinions on which is preferred.

Participating in a "Great Debate" session during refractive surgery subspecialty day at the annual meeting of the American Academy of Ophthalmology, Karl G. Stonecipher, MD, director of The Laser Center in Greensboro, NC, explained why he considers LASIK using a wavefront-optimized (WFO) technique the procedure of choice.

Specifically addressing patients with higher myopia (>–8 D), Jason E. Stahl, MD, in practice with Durrie Vision, Overland Park, KS, and assistant clinical professor of ophthalmology, Kansas University Medical Center, Prairie Village, KS, discussed his preference for phakic IOL implantation. He noted this technology is also an attractive method compared with an excimer laser procedure for more moderate myopia if indicated based on the clinical circumstances.

"In this situation, the phakic IOL is very appropriate and I've achieved great results," he said. "Without enhancement, one of four patients gains lines in best-corrected visual acuity (BCVA) and many achieve uncorrected visual acuity (UCVA) postoperatively that is better than their preoperative BCVA."

Safety also is an important issue, he said.

"Implanting the ICL can be challenging, and if you consider the relatively young age of these patients and their long life expectancy, the risks of phakic IOLs, including cystoid macular edema, retinal detachment, pupillary block, and nuclear sclerotic cataract formation, are a concern," Dr. Stonecipher said. "Furthermore, because there is no toric version of the ICL available now in the United States, patients with significant astigmatism must have an enhancement procedure, which also has risks."

Explaining his preference for LASIK to treat moderate-to-high myopia, Dr. Stonecipher noted that his enhancement rate postLASIK has been significantly lowered using femtosecond laser technology for flap creation and most recently has fallen below 1%. Discussing the ablation procedure itself, he offered his opinion that the device does matter, and he presented evidence supporting why he favors a WFO ablation using a certain excimer laser platform (Allegretto Wave Eye-Q, Alcon Laboratories).

"With Guy Kezirian, MD, I have analyzed my data for LASIK performed with the STAR S4 laser (Abbott Medical Optics [AMO]) and found that the predictability of the refractive outcome begins to decrease at about –7 D," Dr. Stonecipher said. "In addition, even when treating lower levels of sphere, the ablation takes twice as long using this laser compared with the 400-Hz Allegretto Wave Eye-Q. The difference may not have a clinically significant impact for eyes with up to –7 D of myopia and up to –2 or –2.5 D of cylinder, but faster speed is important for better outcomes at higher levels of cylinder and myopia."

Analyses of SurgiVision DataLink data confirm that refractive outcome predictability is excellent using the Allegretto Wave 200-Hz laser or the 400-Hz laser in a series of eyes treated for up to –12 D of myopia with up to 3 D of cylinder. Results from a recently published paper by Dr. Stonecipher and colleagues highlight the performance of the newer 400-Hz Allegretto Wave laser to treat up to –12 D of myopia and astigmatism up to –3 D [J Refract Surg. 2010;26:S819-S823].

"UCVA outcomes are also excellent whether using the older 200-Hz platform or the newer device, but there is still a difference favoring the 400-Hz device that can be primarily explained by the faster speed," he said.