During the last 5 years, PRK has re-emerged as a common procedure among most experienced refractive surgeons. Numerous reasons for this resurgence are that (1) PRK avoids flap-related complications, (2) PRK may be safer in some eyes with regard to preventing ectasia, (3) PRK allows the treatment of some corneas that are too thin for LASIK, and (4) the introduction of mitomycin C to prevent haze has broadened the treatment range of PRK to include high myopes and deep ablations.
The drawbacks to PRK include more pain and a slower visual recovery compared with LASIK. I certainly think that LASIK is more convenient for patients and that it therefore will remain most informed patients' procedure of choice for the near future. However, I believe we are entering an era of much better pain control with PRK patients, and this change will make the procedure better accepted by patients.
For me, the biggest advance in pain control for PRK patients involves the routine use of topical anesthetics such as Tetracaine (Alcon Laboratories, Inc., Fort Worth, TX) during the first 4 days after surgery.
I have used topical Tetracaine to control pain after PRK in all of my patients during the last 2 years. In that time, I have treated 541 eyes of 293 patients without any serious complications. One of my patients experienced delayed epithelialization in both eyes (see sidebar, Case of Delayed Wound Healing, on page 86), but he sustained no visual loss and eventually recovered fully. All of the other eyes I have treated have achieved complete epithelialization within 1 week of surgery.
My postoperative regimen for PRK is as follows. Immediately after surgery, I instill a fluoroquinolone antibiotic in the patient's surgical eye and place a bandage contact lens (Bausch & Lomb, Rochester, NY). Next, I instruct patients that they may use Tetracaine q.i.d. for the first 4 days postoperatively to help control their eye pain. Because I supply them with a single, 2-mL bottle, patients who use the medication too often will run out of it before they injure themselves. I also tell patients that they may use a topical NSAID q.i.d. for the first 4 days after surgery to help control their eye pain.
For antibiotics and steroids, patients start the following regimen on the day after surgery. They use Quixin (Johnson & Johnson, New Brunswick, NJ) q.i.d. for 1 week. Starting the day after surgery, patients use Lotemax (Bausch & Lomb) q.i.d. for the first week, t.i.d. for the second week, b.i.d. for the third week, and q.d. for the fourth week. I instruct patients to use artificial tears every 1 to 2 hours for the first 2 weeks after surgery and then as needed for symptoms of dryness.
Finally, I prescribe one or more of the following oral medications as needed: Tylenol No. 3 (Johnson & Johnson); Ambien (Sanofi Aventis, Bridgewater, NJ); and/or Celebrex (Pfizer Inc., New York, NY).
Without topical anesthetics, only a minority of PRK patients' pain is well controlled on topical NSAIDs and/or oral pain medication. In contrast, an overwhelming majority of my PRK patients have reported that topical Tetracaine effectively controlled their pain. Many have said to me that, in retrospect, they would be genuinely fearful of undergoing PRK without having Tetracaine as an option to control their pain postoperatively.
I consider the use of topical anesthetics for PRK patients to be within the standard of care for refractive surgeons today. Again, I would emphasize prescribing no more than 2mL of anesthetic without refills in order to avoid the potential abuse of the medication and subsequent injury. (All of my PRK patients must read and sign an informed consent that discusses the potential for vision loss due to neurotrophic keratitis from the use of topical Tetracaine.)
Richard Maw, MD, is a board-certified ophthalmologist and refractive surgeon in Las Vegas. He states that he holds no financial interest in any company or product mentioned herein. Dr. Maw may be reached at (702) 228-4554; firstname.lastname@example.org.