LaZrPlastique: The non–cutting edge over LASIK

LaZrPlastique is an excimer laser procedure that corrects corneal ametropia and abnormalities by refractivity sculpting rather than by cutting the cornea. (Image Credit: Adobe Stock/mikhail_b_azarov)

Where is the pain? Where is the haze? Eureka, we got it!

More than 3 decades ago when I performed my surface refractive surgeries on regular and irregular corneas, I was pleasantly surprised that no patient complained of pain, nobody had regression, and there was no scarring or haziness, which are the Achilles’ heel of photorefractive keratoplasty (PRK) surgery.

With experienced refractive surgeons visiting my practice in Jacksonville, Florida, I allowed them to question every patient of mine about the presence of pain intraoperatively, day 1 postoperatively, day 5 postoperatively (when I removed their bandage contact lenses), or years later—and none complained of pain despite being a population of patients who were extremely intelligent, very demanding, and most often skeptical, having had past surgical experiences elsewhere.

This made me think about what I was doing differently. Analysis of my technique showed that the difference may be in the way I removed the surface epithelium (MASSTER technique) and the avoidance of the use of toxic materials such as alcohol or hypertonic fluids. I did use mitomycin C for every patient.

Most patients received a hydrocodone tablet for the night of surgery because many were from out of state or out of country and I wanted to ensure they did not go out partying but were resting and sleeping in a hotel.

This also started my video recording of patients (because of the exceedingly high accountability I placed on my shoulders) intraoperatively, immediate postoperatively, 1 day postoperatively, and during long-term follow-up to share with colleagues my own amazement about how patients were not only being corrected despite having high and irregular refractive errors, including corneal scars and previous corneal surgeries, but also their level of comfort and gratified reactions to flawless-looking eyes. All these patients were fully paying and very intelligent and hence had no reason to be on video or say anything nice about their surgical experience.

I first performed laser in situ keratomileusis (LASIK) surgery more than 3 decades ago, much before FDA approval, and I was enamored by my results with zero enhancement and zero complication rates, which I attribute to always refracting each and every patient personally. Due to my experience and range of refractive, corneal, and lenticular surgeries, I was uniquely becoming a practice that was seeing patients for second opinions and LASIK complications from around the world and had already designed my Gulani LASIK Complication Correction instrument set (Bausch + Lomb) for this super specialty that would eventually give birth to my concepts of Corneoplastique.

As I studied these referred patients from around the world, based on my refraction even more than the topographic and wavefront data, I realized the direct correlation between refraction and every corneal refractive component (regular or irregular) and decided that surface laser surgery would indeed be the future; there would be no corneal cutting or any anatomically destabilizing impact.

Keratoconus after the LaZrPlastique technique.

With my confirmed concept and decades of experience with patients from all parts of the planet of different cultures and complexity levels, I created what I feel is a universally applicable, safe, and consistent corneal refractive surgery. Additionally, since I do not like hype or advertising, I did not give it the prefix of LASIK but chose the name LaZrPlastique, which is in line with my plastique thought process and work because it is a term that surgeons can use (rather than an advertised hype or lure for patients).

LaZrPlastique is an excimer laser procedure that corrects corneal ametropia and abnormalities by refractivity sculpting (ie, manipulating the optics) rather than by cutting the cornea. In contrast to LASIK, LaZrPlastique does not require flap creation.

I developed LaZrPlastique, a corneal surface technique, as a solution for and superior choice to correct the potential problems associated with LASIK, PRK, and small incision lenticule extraction (SMILE) performed by referring refractive surgeons, and what started as a quest for a safe and universally applicable corneal refractive technique with all the positives of LASIK and PRK without their negative aspects was applied to normal myopic, hyperopic,
and astigmatic cases to achieve excellent and consistent vision.

“Any cut that is made in the cornea will ultimately cause some instability in the near or far future that might be undiagnosable at the time of the procedure while also resulting in a physiologic imbalance, including dry eyes,” he commented.

Wide applicability of LaZrPlastique

I now regularly perform LaZrPlastique to correct a wide spectrum of conditions besides normal refractive errors, such as against-the-rule astigmatism; corneal scars; complications associated with LASIK, collagen cross-linking, SMILE, PRK, radial keratotomy, and cataract surgery; and adverse effects associated with implantation of premium intraocular lenses (IOLs). The procedure also can be used to treat refractive errors in patients with thin corneas and relatively dry eyes (which can be corrected first if needed).

(Images courtesy of Arun Gulani, MD, MS)

In addition, LaZrPlastique can be per- formed in combination with other procedures, such as cataract surgery, which I refer to as “inside out” and “outside in” techniques. In an example of the latter in which a patient with a corneal scar also has a cataract, the scar is corrected first, which makes the cornea measurable to obtain the appropriate IOL power, and then the cataract is extracted. For an inside-out technique, the optics can be manipulated with an IOL to obtain a desirable refractive error that then lends itself to correction of both the refractive error and the associated corneal pathology—and it’s straight to emmetropia.

This concept allows me to correct a large number of unhappy premium cataract surgery patients and make them “20/20” happy. The applications are unlimited.

Visual results after treating a series of corneal scars and irregular corneas

A series of patients with corneal scars treated with LaZrPlastique was reported at the recent World Cornea Congress in Chicago, Illinois. A total of 64 eyes (53 patients) were followed for from 1 month to 15 years. All patients who were treated using LaZr- Plastique had improved postoperative vision compared with the preoperative level but none losing any line of best corrected vision.

The top left image shows radial keratotomy scars. Images at lower left and right show corneeall scars. (Images courtesy of Arun Gulani, MD, MS)

The corneal scars in these patients were the results of LASIK, PRK, corneal dystrophy, contact lens infections, including scarring from Acanthamoeba, and herpes simplex virus.

The mean preoperative unaided vision improved from 20/165.26 (±136.47) to 20/50.00 (±26.49) day 1 after undergoing LaZrPlastique, with a mean improvement in unaided vision to 20/23.55 (±7.05) at an average of 53.70 (±52.50) months postoperatively.

LaZrPlastique provides good levels of vision to patients who might not have been considered candidates for a refractive procedure. The level of vision that they achieve can be life changing.

In my hands, after 3 decades of performing LaZrPlastique, this procedure is safe, consistent, and stable and is highly applicable to a wide range of ophthalmic scenarios, including regular and irregular ametropia, and can be performed alone or in combination with other procedures.

Arun Gulani, MD, MS
E: gulanivision@gulanivision.com

LaZrPlastique is a registered trademark.