Recommending Surface Ablation

Bennett Walton, MD; Christopher Starr, MD; and Lewis Groden, MD, join Marguerite McDonald, MD, FACS, to discuss modern surface ablation. How is epi-Bowman keratectomy changing the conversation with patients?

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: Welcome. This is the Informed Consent: Getting to Yes podcast, where I discuss with leading ophthalmologists and eye surgeons the exact, fair and balanced language they use with patients to get them to say, “Yes,” to premium services or the recommended treatment. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York. Today’s topic is surface ablation, particularly epi-Bowman keratectomy or EBK.

BENNETT: Anything that we can do to shorten that time of healing and to shorten that time of discomfort is something that really helps build a practice better and also helps patients get through the difficultly of struggling through poor vision for a few days and maybe discomfort.

MARGUERITE: That’s Dr. Bennett Walton. He is a refractive cataract and cornea surgeon at Slade & Baker Vision in Houston, Texas.

CHRIS: Promoting surface ablation and devoting my practice to surface ablations in no way belittles LASIK or says it's unsafe or unfit for anyone. It's just that that is my preference, in my practice, my comfort zone, and I've had really good results with surface ablation.

MARGUERITE: That’s Dr. Chris Starr, who is associate professor of ophthalmology at Weill Cornell Medicine and also director of refractive surgery at Weill Cornell in New York City. And this is Dr. Lou Groden, the Medical Director of LasikPlus and the Director of Refractive Surgery at the University of South Florida in Tampa.

LOU: As I got more concerned about ectasia and wanting to do refractive surgery as safely as possible, doing what's best for the patient, surface treatment began to become more of my practice. Currently I do about 15% PRK. The way I do PRK has really changed in the last couple of years. I now do a variation of PRK, if you will, called EBK. EBK stands for epi-Bowman keratectomy. It's really a misnomer in many ways. We don't remove Bowman's with the device, but it's a mechanical device to remove epithelium. It's very simple, and instead of using alcohol or the Amoils brush, I find the results are better, and the patients are much more comfortable. So that's now what I do, and it's really changed the way I practice PRK.

MARGUERITE: I couldn't agree with you more. I've been doing EBK for a while as well, a long time. And the great advantage of this deceptively simple device, it's no moving parts, disposable, and it's got this polymer tip with two "blades," if you will, soft, round, and bits of polymer that scoop up the epithelium. So, there's no question. I agree with you. Better, safer, faster, less pain, better clinical outcomes, less enhancements, closer to 20/20 without correction.

BENNETT: I actually had not heard about EBK until you presented the data, I believe at the Advanced Refractive Congress a couple of years ago. The data are compelling. The speed of the defect healing is statistically significantly faster. The comfort was statistically significantly better. And so that's what made me interested in trying it.

CHRIS: The Epi Clear device is really pretty nifty, for lack of a better word, because it basically allows the surgeon to remove, layer by layer, the epithelium in very rapid movements along the ocular surface. So, you're not taking the whole epithelium off all at once. You're going layer by layer, which provides a sort of sloped interface between Bowman's and the not ablated area. So, you have this sort of sloped epithelial ridge rather than a clear demarcation, which we usually get with a well, and alcohol and scoring the epithelium with an 8- or 9-mm well, depending on what one uses. And you have epithelium and then no epithelium in a rigid interface.

Whereas with the EBK, you get a nice sloped interface, and that, apparently, helps to speed up at the epithelial recovery. Whereas with traditional PRK with alcohol and a well, I find that the epithelium is usually healed within 4 to 5 days in most cases. But with the EBK device, we're seeing it healed as early as 24, 48 hours in some cases. But almost everybody is healed within 2 to 3 days. And that's a big advantage. And a lot of that has to do with the demarcation and the sloped epithelial edge that you get with this device.

MARGUERITE: So, Bennett, I'm going to ask you to pretend I'm Mrs. Smith. You've decided that I need surface ablation, and I want you to just tell me what you say to people when you've decided they're a good candidate.

BENNETT: I think the classic scenario where someone comes in wanting, say, LASIK or SMILE and I recommend surface ablation is that of a thin cornea within an otherwise normal topography and I feel just a little more comfortable. I would say, "Mrs. Smith, you have a healthy-looking cornea. As you know we're going to remove some tissue with the laser no matter which way we do it. I think what would make me feel comfortable in the long run is if we saved just a little bit of extra thickness that can help for structural integrity. Because if you look these maps," and, of course, then I would show you the maps and show you the pachymetry.

LOU: What I would say, what I do say, is, “We do two procedures, LASIK and PRK. Same laser applied in LASIK under a flap, but for you, treating on the surface is a better option. Now you may have read about PRK, and if you have, you probably have heard it's more painful than LASIK, it takes longer to heal, and that's why LASIK is so much more popular. But given your eyes and that exam you just went through, it is better to treat on the surface. The results are the same.

The way I am currently doing PRK using the device called EBK, the healing time's much faster than with the traditional PRK, much less pain, and instead of taking maybe a week or 2 before you can drive, most patients are driving in the first few days. For pain, I no longer give a prescription for pain pills—will recommend you take Aleve or Motrin just before the procedure, starting the day before the procedure, and continue it for several days. You'll also be using drops, an antibiotic steroid drop, four times a day starting the day after the procedure, and you'll use it for about 1 week.

That's the same as you would do if you were having LASIK. You will have a contact lens on the eye afterwards. It's a very thin lens with essentially no power, and it's there to help people be more comfortable during that initial healing. The procedure itself in many ways is much simpler for you than LASIK would be.”

CHRIS: I usually give patients the pros and cons between having a flap in LASIK versus no flap and the pain and the slower recovery associated with laser with surface ablation versus the speedier recovery but maybe higher risk with flaps and the longer surgery with flaps, etc. So, I usually go through that messaging. But a lot of patients, quite frankly, are better candidates for surface ablation and, in my mind, not even good candidates at all for LASIK due to various corneal thickness, corneal shape, any remote irregular astigmatism, or issues of ectasia or potential risk of ectasia, etc.

“So, in your case, I've reviewed all of your data, and you are definitely a good candidate for laser vision correction. I would recommend to you to do what's called advanced surface ablation, which, in my hands, is a safer procedure. It doesn't involve cutting of the cornea or creating flaps, which could be problematic in the short or long term. That being said, the surface ablation procedure does involve more discomfort and slightly slower visual recovery with the traditional means of doing it called PRK.

We do have a newer technique called EBK now, which is similar but different in some key ways. It doesn't involve alcohol, which has potential effects of delaying recovery and increasing discomfort after the surgery. And so, that step is eliminated, which has led to faster recovery times, less pain, and less risk for inflammation and haze. And this is the procedure that I think you would do best with.”

BENNETT: One of the things I find can be really helpful if someone comes in and they're a better candidate for surface ablation is telling them, "For the rest of your life, you'll have an extra 50 or so microns of stroma, which means an extra 50 or so microns of strength." And if someone comes in with a thinner cornea than average, that 50 microns is a big boost, and that's something that can give them confidence long-term as well as the fact that you tell them, you know, there's a 0% chance of a flap complication.

Now, thankfully, flap complications are rare, but telling someone there's a 0% chance of a negative thing happening can be compelling reassurance if someone has come in expecting, perhaps, to have one procedure but they find for whatever personalized reason that they're a better candidate for another.

LOU: What I find is, most patients have Googled or in other ways researched LASIK and PRK, and if they've read about PRK, what they're concerned about is pain and time off from work. Those are the two barriers. So, I address that even before they ask about it. Because I know it's in there. They're thinking about it, and that can be an issue as to when they schedule or if they even schedule. Telling them that, with EBK, they'll be able to return to work much more quickly, heal faster, and not use drops for a month as I used to do with my traditional PRK patients, really makes it easy for them.

BENNETT: And I would say, "I expect your vision, the accuracy, and the quality of the vision to get to exactly where we want it to get. I do think you will be a little bit less comfortable for a few days, but it's important to me that you like me and you appreciate the work we've done together for many years, even if it's just a little slower to get there.” I have yet to have a patient really push back hard once they realize, you know what? That's a small price to pay: a couple days of delay of epithelial healing and then maybe a little more fluctuation in those first few weeks. I find it easy for patients to understand. You know what? That makes sense. We’re going to conserve more tissue.

MARGUERITE: I agree, and I never put down LASIK. I've done LASIK for years, but I do say, "There is no cutting involved. You will not have a flap, and, rare as they are, you can't have a flap complication if you don't have a flap.” That's just a slightly different way to approach it. When they listen to your talk, are there any concerns or questions that they give you at that point?

BENNETT: I think the number one question or pushback is how much is it going to hurt and when can I get back to work or back to taking care of my family? They want to get back to their lives just like we all do.

So, those are the times in which I tell them it's a little bit variable in terms of who has how much discomfort but it's a lot better than it used to be. It's a bit of a segue, but rather than make, say, a big 9-mm epithelial defect for everyone, I think critically about the specific ablation pattern needed. So, for a wavefront-optimized ablation on, say, a 6-mm optical zone from myopia, the amount of ablation beyond 6 mm is effectively zero. Even with a diopter of astigmatism, there are only about 5-6 somewhere microns of depth of ablation that extend an additional half-millimeter or so. So, I routinely use a 7-mm epithelial removal diameter unless I have a hyperope or a high astigmat or a recent … and I think that's just another way to significantly reduce the exposed surface area. A 7-mm defect versus a 9-mm defect is 40% in reduction in surface area. So that can speed the healing, and letting patients know that it's again a customized approach to their eye and to exactly what they need. That can help with that.

LOU: The other thing they will ask is how many visits do they have to have? Because very often, they know people who have had LASIK, who come in the day after, and then they come for one more visit, and they're done. And a lot of patients don't want to take time off from work or otherwise have to come into the office if they're doing well. With EBK, my postop schedule is very similar to that of LASIK. The first visit is between 3 and 5 days. We take off the contact lens. Most of them are completely healed and seeing well. They stop the drops after a week, 5 to 7 days. Therefore, I don't have to worry about is their pressure going to go up in 3 to 4 weeks.

So, I don't bring them back until a month or 2, assuming they're seeing well. Of course, they're all told, if they feel there's a problem, or they're not seeing well, call, and they'll be seen immediately.

MARGUERITE: So, your first postop visit is similar to your first LASIK postop at 3 to 5 days?

LOU: Correct. Although I prefer seeing LASIK patients day 1, because I don't want to worry about a flap’s dislocating, something that, of course, is not a problem with EBK. So I'm comfortable seeing them in 3 to 5 days. The other thing I looked at when we studied the series of patients, in PRK, if you see them day 1, they may feel fine, but day 2 or 3, they're in agony. With EBK, they don't get that spike in pain. They're comfortable, controlled with Aleve or Motrin, from the get-go. It doesn't become uncomfortable. So, they come in, they're seeing well, and we take the lens off. And if they continue to see well, I see them anywhere from 1 to 2 months, mainly because I want to see how well they're doing and get a refraction to keep my nomogram up to date.

MARGUERITE: So, for our listeners, would you recommend they consider EBK when they're doing surface ablation or removing epithelium?

BENNETT: I would absolutely consider at least trying the EBK device. The data are far more compelling than I expected them to be when I first saw them. Anything that can help patient comfort can help patient trust, because they feel like you haven't hurt them. Anything that helps speed of recovery certainly helps the whole situation, and at the end of day, that's what we want. We want the patients to be happy. We want the vision to have healed in a predictable way with fewer touch-ups. We would like to have the cleanest-looking eye we can get so that they're as happy as they can be.

CHRIS: I don't see any good reason to go back to traditional PRK when EBK is so good and it doesn't have any of those kinds of complications of some of these other advanced surface ablation techniques that have come and went. I don't really see any reason why EBK would ever go.

MARGUERITE: I definitely agree.

Well, that wraps up another Informed Consent: Getting to Yes podcast. I’d like to thank my guests, Dr. Bennett Walton, Dr. Chris Starr, and Dr. Lou Groden, for their valuable perspectives. I’m Dr. Marguerite McDonald, and I’d also like to thank you for listening and invite you to come back for next month’s edition.

Speaker 1: Informed Consent: Getting to Yes is editorially independent content supported with advertising by Alcon.