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Refractive Surgery Update
In this episode, W. Allan Steigleman, MD, discusses the latest updates in refractive surgery. He compares and contrasts the most widely used corneal refractive procedures, describes common contraindications for refractive surgery and discusses alternative refractive surgery options when corneal refractive surgery may not be appropriate.
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Learn more about W. Allan Steigleman, MD
W. Allan Steigleman, MD
W. Allan Steigleman, MD is an Associate Professor in the Department of Ophthalmology at University of Florida College of Medicine.Learn more about W. Allan Steigleman, MD
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we offer a refractive surgery update on laser surgery for refractive errors of vision. Joining me is Dr. W. Allan Steigleman. He's an Associate Professor in the Department of Ophthalmology at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital.
Dr. Steigleman, it's a pleasure to have you join us today. As we get into this topic, let's set the table as it were. Can you tell us a little bit about refractive errors of the eye in patients? What have we been seeing in the trends? Is this becoming more common? Tell us a little bit about what we're talking about today.
Dr Allan Steigleman: Yeah. Sure. Well, thank you for having me. I appreciate the opportunity. So refractive errors, we categorize them as nearsightedness, farsightedness, and astigmatism. Most patients who have nearsightedness or farsightedness have some degree of astigmatism that goes along with that. It's pretty uncommon to have astigmatism by itself.
We have been seeing an increase worldwide inn the prevalence of myopia or nearsightedness in patients most notably in Southeast Asia and in China. There's been some interesting papers that have come out now since the pandemic, that it seems that more near work and near tasks, you know, folks on their laptops and doing things in indoors, has led to perhaps an increase in the degree of myopia in children more so than in adults. And so that's definitely an area to watch as we move forward.
Melanie Cole (Host): That makes a lot of sense, considering even in these COVID times, but before that certainly with kids. Now, can you tell us a little bit about the role of surgery and how that has evolved for these refractive errors?
Dr Allan Steigleman: Absolutely. So we've been doing corneal refractive surgery. The cornea is the clear window and the front of the eye. We've been doing corneal refractive surgery for over 25 years now with laser-based technologies, including PRK and LASIK. The most recent changes or advances in laser refractive surgery involve using a procedure that's called SMILE. So there's quite an alphabet soup out there of these different laser procedures. But basically what each of them do is to change the shape of the cornea so that it basically mimics the shape of the glasses that someone needs to wear in order to correct the refractive error. So for those of you who have nearsightedness and you take your glasses off and you look at them, you'll see they're a little bit thicker on the edge and a little bit skinnier in the middle. And so what we do with each of these laser technologies is we try to reproduce that same shape. So for nearsightedness, we'll remove tissue in the center of the cornea, so we make it a little bit thinner. And then by default, the periphery gets thicker and that's what helps to create the refractive change to neutralize the glasses that the patient would need.
Melanie Cole (Host): So then can you compare and contrast the most widely used refractive procedures for other providers? Tell them what you're doing at UF Health Shands Hospital that they may not know about. Compare and contrast these for us.
Dr Allan Steigleman: Sure. Well, this is an exciting time in refractive surgery. We have a lot of great options available to us. This technology is, I guess, similar to cell phones. Each year or two, there's new technology, a new capability that comes out. And right now, we're blessed with some of the latest and most modern techniques with excellent outcomes.
A number of papers have been published recently that demonstrate that refractive outcomes in patients with many of these different laser procedures have 20/20 rates greater than 95%, which is just fabulous. The differences between each of these laser technologies, the most commonly being LASIK, PRK, or SMILE now, are actually quite subtle. The majority of the outcomes from each of these laser technologies is a lot more alike than it is different. However, there have been some reports that have been able to tease apart some of these nuances.
For instance, a paper that was just published this past month in one of our leading journals, the Journal of Cataract and Refractive Surgery, demonstrated that when compared in the same patient, so one eye was treated with one laser technology and the other eye in the same patient was treated with a different laser technology, LASIK seemed to be slightly better in certain visual parameters than SMILE was. And this was attributed maybe to some subtle details in how the procedures are centered on the cornea. There's more obviously studies that need to be done in the future to kind of tease some of these out. There's other studies that have been done in the past that compare one laser platform to another. And again, those differences seem to be very subtle. I joke with patients and I say, "Well, the differences between the lasers is essentially the difference between a BMW or Mercedes. They're both excellent, but there are some folks that are entrenched in one camp versus the other."
We do know that there are differences in the healing rates of each of these procedures. So for instance, for LASIK, that seems to be the fastest visual results and the least associated patient discomfort. PRK seems to have the slowest visual recovery and the greatest discomfort. And then, SMILE seems to be somewhere in the middle in most of the report has studies.
Melanie Cole (Host): What a comprehensive explanation. Thank you so much, Dr. Steigleman. Where does physician experience come into play here? Do you have any technical considerations that you would like to offer other providers?
Dr Allan Steigleman: Absolutely. I think the crux of the issue for refractive surgery these days is in patient selection. And that's where I think experience can really matter because it's difficult to know who to treat and who not to treat sometimes. And there are some medical contraindications. Folks who've had a history of other eye pathology. For instance, herpetic eye disease, including herpes simplex or herpes zoster associated with shingles is a reason not to do laser surgery on someone. We used to think that other contraindications were HIV status, diabetes, even certain immune disorders, including collagen vascular disease like lupus, rheumatoid arthritis. Many of us still will not treat patients with concerns for delayed healing or difficulty healing after refractive surgery. However, there's some mounting evidence that patients with comorbidities like HIV or diabetes, as long as they're well controlled and well managed could be suitable candidates for refractive surgery.
There are other eye parameters that may indicate whether a patient is a good candidate or not. That technology is advancing as well. We're able to use imaging technology now to evaluate the cornea preoperatively to decide who may or may not be a good candidate. And we have some exciting technologies that have come along now that allow us not only to look at the front of the cornea, but also the back surface of the cornea. And we can now actually use technology to determine the exact contributions to the thickness of the cornea by each of the separate five layers. And that allows us again to determine who's a good candidate and who may be a poor candidate.
I would also like to mention that I'm very excited about the fact that we recently incorporated some brand new technology in our LASIK practice. We have been able to get the iDesign system from Johnson & Johnson that communicates with our laser. We have the 2.0 software. We're able to use 1,257 little beams of lights actually go inside of an eye, gets reflected off the retina and those little beams of light are then captured, so it creates a customized, essentially a fingerprint for the eye. So instead of the old days of deciding which are better, number one or number two, which many of us are confused when we try to get our new glasses prescription, this is completely customized and passive for the patient. So they just put their face up into a scanner. The scanner evaluates the eye and comes up with this fingerprint-like treatment in order to give the best possible outcomes for the patient. The outcomes using this technology are just fabulous. There are several studies that have published the absolute best visions available with laser technology today, with many of the reports with 20/20 rates more than 98%. What I think is also fabulous about this technology are those patients who are better than 20/20.
So we can now take fully one-third of patients and we can make them able to see better without glasses after LASIK than they could ever see before in their best glasses or contacts. That's just a remarkable position for us to be in now. Really exciting times.
Melanie Cole (Host): Well, you got to my technology question even before I asked it. So that was excellent to cover some of the advancements that have been made that have augmented your diagnostic and therapeutic capabilities. Dr. Steigleman, can you tell us about alternative refractive surgical options when these procedures you've described maybe contraindicated or may not be appropriate?
Dr Allan Steigleman: Yeah, that's a great question. Because given our referral pattern here, we end up actually seeing a number of patients who have been told they're not suitable laser candidates at other laser centers. And so we would agree with that assessment, but we do have a lot of other capabilities available for these patients. We offer an intraocular collamer lens or an ICL. What this is is it's kind of like a small contact lens-related device that we can actually insert into the eye. It's a different type of procedure and involves a trip to the operating room. The lens doesn't come out to clean it. It just stays in the eye. And it can give just astounding refractive results for folks with incredibly thick glasses who are not suitable laser candidates. Now, it takes definitely some extra scrutiny for patient selection and for post-operative care, but the ICL results are just really quite remarkable.
We also can offer refractive lens exchange technologies. And so this is something that's commonly practiced throughout the country and throughout the world. What this is is instead of a patient needing to have essentially cataract surgery, we can do the same sort of technique for someone who's not yet developed a cataract. And our lens technologies these days are quite fantastic. There are a number of lenses available that can behave kind of like bifocals or even trifocal lenses, so that patients can see to read their computer and they can actually see to drive with no glasses these days. So the technology throughout our field is quite remarkable.
Melanie Cole (Host): Well, it certainly is. And as you said at the beginning, what an exciting time to be in your field. Dr. Steigleman, do you have any final thoughts you'd like to leave other providers with? An update or anything that's changed, research studies, your best advice. Wrap it up for us.
Dr Allan Steigleman: Sure. We could spend all day talking about some of the latest studies. Our journals are replete with these comparisons. I think the bottom line is we have great options these days to treat just about every patient who comes in the door. If there's a patient that you're concerned about, or you don't feel comfortable that you can help, I think that we have the capability to help most every patient here. So please send them our way.
Melanie Cole (Host): Thank you so much, Dr. Steigleman, for sharing your expertise with us today. And to refer your patient or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we offer a refractive surgery update on laser surgery for refractive errors of vision. Joining me is Dr. W. Allan Steigleman. He's an Associate Professor in the Department of Ophthalmology at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital.
Dr. Steigleman, it's a pleasure to have you join us today. As we get into this topic, let's set the table as it were. Can you tell us a little bit about refractive errors of the eye in patients? What have we been seeing in the trends? Is this becoming more common? Tell us a little bit about what we're talking about today.
Dr Allan Steigleman: Yeah. Sure. Well, thank you for having me. I appreciate the opportunity. So refractive errors, we categorize them as nearsightedness, farsightedness, and astigmatism. Most patients who have nearsightedness or farsightedness have some degree of astigmatism that goes along with that. It's pretty uncommon to have astigmatism by itself.
We have been seeing an increase worldwide inn the prevalence of myopia or nearsightedness in patients most notably in Southeast Asia and in China. There's been some interesting papers that have come out now since the pandemic, that it seems that more near work and near tasks, you know, folks on their laptops and doing things in indoors, has led to perhaps an increase in the degree of myopia in children more so than in adults. And so that's definitely an area to watch as we move forward.
Melanie Cole (Host): That makes a lot of sense, considering even in these COVID times, but before that certainly with kids. Now, can you tell us a little bit about the role of surgery and how that has evolved for these refractive errors?
Dr Allan Steigleman: Absolutely. So we've been doing corneal refractive surgery. The cornea is the clear window and the front of the eye. We've been doing corneal refractive surgery for over 25 years now with laser-based technologies, including PRK and LASIK. The most recent changes or advances in laser refractive surgery involve using a procedure that's called SMILE. So there's quite an alphabet soup out there of these different laser procedures. But basically what each of them do is to change the shape of the cornea so that it basically mimics the shape of the glasses that someone needs to wear in order to correct the refractive error. So for those of you who have nearsightedness and you take your glasses off and you look at them, you'll see they're a little bit thicker on the edge and a little bit skinnier in the middle. And so what we do with each of these laser technologies is we try to reproduce that same shape. So for nearsightedness, we'll remove tissue in the center of the cornea, so we make it a little bit thinner. And then by default, the periphery gets thicker and that's what helps to create the refractive change to neutralize the glasses that the patient would need.
Melanie Cole (Host): So then can you compare and contrast the most widely used refractive procedures for other providers? Tell them what you're doing at UF Health Shands Hospital that they may not know about. Compare and contrast these for us.
Dr Allan Steigleman: Sure. Well, this is an exciting time in refractive surgery. We have a lot of great options available to us. This technology is, I guess, similar to cell phones. Each year or two, there's new technology, a new capability that comes out. And right now, we're blessed with some of the latest and most modern techniques with excellent outcomes.
A number of papers have been published recently that demonstrate that refractive outcomes in patients with many of these different laser procedures have 20/20 rates greater than 95%, which is just fabulous. The differences between each of these laser technologies, the most commonly being LASIK, PRK, or SMILE now, are actually quite subtle. The majority of the outcomes from each of these laser technologies is a lot more alike than it is different. However, there have been some reports that have been able to tease apart some of these nuances.
For instance, a paper that was just published this past month in one of our leading journals, the Journal of Cataract and Refractive Surgery, demonstrated that when compared in the same patient, so one eye was treated with one laser technology and the other eye in the same patient was treated with a different laser technology, LASIK seemed to be slightly better in certain visual parameters than SMILE was. And this was attributed maybe to some subtle details in how the procedures are centered on the cornea. There's more obviously studies that need to be done in the future to kind of tease some of these out. There's other studies that have been done in the past that compare one laser platform to another. And again, those differences seem to be very subtle. I joke with patients and I say, "Well, the differences between the lasers is essentially the difference between a BMW or Mercedes. They're both excellent, but there are some folks that are entrenched in one camp versus the other."
We do know that there are differences in the healing rates of each of these procedures. So for instance, for LASIK, that seems to be the fastest visual results and the least associated patient discomfort. PRK seems to have the slowest visual recovery and the greatest discomfort. And then, SMILE seems to be somewhere in the middle in most of the report has studies.
Melanie Cole (Host): What a comprehensive explanation. Thank you so much, Dr. Steigleman. Where does physician experience come into play here? Do you have any technical considerations that you would like to offer other providers?
Dr Allan Steigleman: Absolutely. I think the crux of the issue for refractive surgery these days is in patient selection. And that's where I think experience can really matter because it's difficult to know who to treat and who not to treat sometimes. And there are some medical contraindications. Folks who've had a history of other eye pathology. For instance, herpetic eye disease, including herpes simplex or herpes zoster associated with shingles is a reason not to do laser surgery on someone. We used to think that other contraindications were HIV status, diabetes, even certain immune disorders, including collagen vascular disease like lupus, rheumatoid arthritis. Many of us still will not treat patients with concerns for delayed healing or difficulty healing after refractive surgery. However, there's some mounting evidence that patients with comorbidities like HIV or diabetes, as long as they're well controlled and well managed could be suitable candidates for refractive surgery.
There are other eye parameters that may indicate whether a patient is a good candidate or not. That technology is advancing as well. We're able to use imaging technology now to evaluate the cornea preoperatively to decide who may or may not be a good candidate. And we have some exciting technologies that have come along now that allow us not only to look at the front of the cornea, but also the back surface of the cornea. And we can now actually use technology to determine the exact contributions to the thickness of the cornea by each of the separate five layers. And that allows us again to determine who's a good candidate and who may be a poor candidate.
I would also like to mention that I'm very excited about the fact that we recently incorporated some brand new technology in our LASIK practice. We have been able to get the iDesign system from Johnson & Johnson that communicates with our laser. We have the 2.0 software. We're able to use 1,257 little beams of lights actually go inside of an eye, gets reflected off the retina and those little beams of light are then captured, so it creates a customized, essentially a fingerprint for the eye. So instead of the old days of deciding which are better, number one or number two, which many of us are confused when we try to get our new glasses prescription, this is completely customized and passive for the patient. So they just put their face up into a scanner. The scanner evaluates the eye and comes up with this fingerprint-like treatment in order to give the best possible outcomes for the patient. The outcomes using this technology are just fabulous. There are several studies that have published the absolute best visions available with laser technology today, with many of the reports with 20/20 rates more than 98%. What I think is also fabulous about this technology are those patients who are better than 20/20.
So we can now take fully one-third of patients and we can make them able to see better without glasses after LASIK than they could ever see before in their best glasses or contacts. That's just a remarkable position for us to be in now. Really exciting times.
Melanie Cole (Host): Well, you got to my technology question even before I asked it. So that was excellent to cover some of the advancements that have been made that have augmented your diagnostic and therapeutic capabilities. Dr. Steigleman, can you tell us about alternative refractive surgical options when these procedures you've described maybe contraindicated or may not be appropriate?
Dr Allan Steigleman: Yeah, that's a great question. Because given our referral pattern here, we end up actually seeing a number of patients who have been told they're not suitable laser candidates at other laser centers. And so we would agree with that assessment, but we do have a lot of other capabilities available for these patients. We offer an intraocular collamer lens or an ICL. What this is is it's kind of like a small contact lens-related device that we can actually insert into the eye. It's a different type of procedure and involves a trip to the operating room. The lens doesn't come out to clean it. It just stays in the eye. And it can give just astounding refractive results for folks with incredibly thick glasses who are not suitable laser candidates. Now, it takes definitely some extra scrutiny for patient selection and for post-operative care, but the ICL results are just really quite remarkable.
We also can offer refractive lens exchange technologies. And so this is something that's commonly practiced throughout the country and throughout the world. What this is is instead of a patient needing to have essentially cataract surgery, we can do the same sort of technique for someone who's not yet developed a cataract. And our lens technologies these days are quite fantastic. There are a number of lenses available that can behave kind of like bifocals or even trifocal lenses, so that patients can see to read their computer and they can actually see to drive with no glasses these days. So the technology throughout our field is quite remarkable.
Melanie Cole (Host): Well, it certainly is. And as you said at the beginning, what an exciting time to be in your field. Dr. Steigleman, do you have any final thoughts you'd like to leave other providers with? An update or anything that's changed, research studies, your best advice. Wrap it up for us.
Dr Allan Steigleman: Sure. We could spend all day talking about some of the latest studies. Our journals are replete with these comparisons. I think the bottom line is we have great options these days to treat just about every patient who comes in the door. If there's a patient that you're concerned about, or you don't feel comfortable that you can help, I think that we have the capability to help most every patient here. So please send them our way.
Melanie Cole (Host): Thank you so much, Dr. Steigleman, for sharing your expertise with us today. And to refer your patient or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.