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for 20 seconds. He then removes the epithelium mechanically, and lases away the refractive error. For patients with quality of vision issues—determined by asking if the patient experiences night symptoms, glare, or halos—Dr. Stonecipher will perform custom treatment. In almost all of his patients, Dr. Stonecipher still uses MMC—"it's kind of ingrained in my nomogram," he said. After surgery, he said, "the contact lens matters." Putting bandage contact lenses on after surgery allows the patient to "go out the front door happy," with great quality of vision. The postoperative drop regimen, he said, varies from surgeon to surgeon. Most use a corticosteroid for at least a month with a three-month taper, an antibiotic such as moxifloxacin or gatifloxacin for 1-2 weeks, and a topical NSAID, either ketorolac or bromfenac as needed. "Find your regimen, stick to it, and you don't need to change it too often," he said. Complications can occur. Dr. Stonecipher estimates about 1 in 100 patients need enhancements for low level refractive errors, 1 in 1,000 develop dry eye disease (although, he noted, if a patient has dry eye before surgery, the patient will have it after), 1 in 1,250 have glare, halos, or starburst. Very rarely, a pa- tient might have recurrent corneal erosion and—albeit not in Dr. Stonecipher's own experience, fortunately—infections, which have been documented in literature to occur at a rate of about 1 in 5,000 cases. How to obtain access to laser vision correction in your practice PRK is a simple procedure, simple enough that just about any surgeon who has performed it can teach another surgeon, according to Richard L. Lindstrom, MD, adjunct professor emeritus, University of Minnesota; founder and attending surgeon, Minnesota Eye Consultants; and associate director, Minnesota Lions Eye Bank, Min- neapolis. However, that so many cataract surgeons are unable to perform keratore- fractive enhancement surgery remains a significant problem. Part of the reason, Dr. Lindstrom said, is that somewhere around 6,000 of the 9,000 cataract surgeons in the U.S. simply do not have access to performing even a simple PRK. Dr. Lindstrom said he has spent a sig- nificant amount of time looking at various options to provide surgeons that access. "I've worked hard to try to help people get access to that technology, working with a company called Sightpath Medical [Minneapolis]," he said. "I like the idea of a mobile laser brought to you, your hospital, and your office." Dr. Hoffman has had experience with a similar model. "For the last 15 years, we've had a very unique situation," he said. "We've had an independent busi- nessman who owned a laser go to about 10 different sites in the Pacific Northwest, and it worked out great." The model frees the surgeon from the burden of the initial investment. "The advantage of having a roll-on, roll-off is you do not have to invest in the technology," said Dr. Hoffman. Even the responsibility of maintenance and constantly upgrading the technology, he said, falls on the owner of the laser. "It's an excellent choice for low- volume surgeons who don't have the volume of cases to justify the initial cost of such an investment." "Another model that we have in Minneapolis [is] an institute called Phillips Eye Institute," said Dr. Lindstrom. "It's an open-access facility with 150 ophthalmolo- gists on the staff." In addition to the Phillips Eye Institute, TLC Laser Eye Centers and the San Diego Eye Bank are examples of open-access facilities that provide surgeons with lasers for performing PRK. "You can also pick a friend and go with him over to his center and very occasion- ally surgeons will simply have someone else do the procedure for them," said Dr. Lindstrom. "But there's no reason to have someone else do a PRK for you—your patients want you to have those skills, and you can access a center with a laser pretty easily." Some academic centers will also per- form PRK on patients. Surgeons can refer patients to these centers for PRK and then have the patients sent back to them after the procedure. Perhaps more importantly, according to Sonia H. Yoo, MD, professor of ophthalmology, Miller School of Medicine, University of Miami, these academic centers have programs set up so that the "infrequent laser vision surgeon" can get training. "We do training sessions usually once or twice a year for those community doc- tors who are interested in learning," said Dr. Yoo. "We also offer proctoring for those doctors who want to bring their cases to the laser center." Learning the technique presents one "minimal barrier" to incorporating PRK into practice, said John A. Vukich, MD, assistant clinical professor, University of Wisconsin-Madison Medical School, Madison, Wis.; however, as Dr. Yoo pointed out, there are options. Since the technique itself is fairly straightforward and easy to learn, a more significant barrier may be the need for certification. A center can provide local certification, "which means basically that you've had someone with you who has done the procedure before for the first few cases," said Dr. Vukich. "That's actually very reas- suring to surgeons, and quite frankly we're all happy to do that." In addition, the various laser platforms do require a "minimum level of education," Dr. Vukich said. This can be obtained from online courses provided by the manufac- turers of all the commercially available platforms or through certification courses made available during scientific meetings. 7 "There's no reason to have someone else do a PRK for you— your patients want you to have those skills, and you can access a center with a laser pretty easily." Richard L. Lindstrom, MD

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