I have a central corneal thickness of 470 in both eyes, (too thin for LASIK?). Do You Recommend ICL or PRK For Thin Corneas?

Question

I am 28, have a prescription of -3.0 (right) and -2.0 (left).  I have been to two separate eye clinics and one advises PRK and one ICL. The surgeon recommending ICL says they believe my corneas are too thin even for PRK and that ICL would be much safer. ICL does sound like the more pleasant option but is twice the price! Any advice?

Farzad Yaghouti, MD · Answer

Your case falls in the grey zone for PRK procedure. Even though the residual cornea after your treatment would be above 250 Micron (the lowest number which is considered to be a safe and within the standard of care), some physicians consider any cornea less than 500 micron at a higher risk for destabilization following any type of corneal thining procedure and advise against them.  ICL is an intraocular procedure that in my opinion has a much higher risk of long term serious complications than does PRK. So I would not recommend ICL.

Michael K. Tracy, MD · Answer

With corneas as thin as yours, I would be reluctant to recommend LASIK or PRK. Using the standard Randleman criteria, you would be classified as "high risk" for LASIK and "unknown risk" for PRK. If you are determined to have a procedure, in ICL may be your best option. But waiting until you are 30 to have anything done would reduce your risk into the "moderate" category for LASIK and also give us time to find safer alternatives. Until then, I prefer glasses to contact lenses. Given your low prescription, you do not even need to wear your glasses all the time if you can function without them.

Jay Bansal, MD · Answer

Your prescription is considered low in both eyes and based on the calculations alone, you might still qualify for LASIK although there are more factors to consider than just the corneal thickness and the prescription.  An irregular topography would be a red flag for potential post-LASIK problems. 

	ICL provides better vision for patients with high prescriptions but since your prescriptions are low, the vision would be very similar.  Since ICL is an intraocular surgery, it would be difficult to argue that it is safer than LASIK or PRK and would probably not be more pleasant.

	ICL is certainly more expensive, but cost should be secondary to safety, comfort, and vision quality.

	If several surgeons are recommending ICL over LASIK or PRK, I would certainly lean in favor of an ICL but make certain that you have a full understanding of why they are making that recommendation.

Christopher Starr, MD · Answer

According to my calculations you are looking at a residual stromal bed of about 360 microns in the right eye and about 380 microns in the left eye, which is well above our accepted standards for safety. That being said, your 470 micron cornea is significantly thinner than the average cornea and it is possible that one of your doctors saw other abnormalities (possibly on the topography test) that were concerning.

Christopher Coad, MD · Answer

Really depends on other factors too such as topography. In the US, the Visian ICL is only approved for -3.00 to -15.00 dioplers with less than 2.5 dioplers of astigmatism and the reduction of myopia from -15.00 to -.20.0 dioplers. Therefore Visian ICL may not be an option for your left eye.

Andrew E. Holzman, MD · Answer

There is no question that you are better off with PRK. Both are great procedures, but ICL is a bit aggressive for your low RX. Many studies show that the stability of PRK over many years may even exceed that of LASIK. It is a fantastic procedure when done properly and the healing isn't nearly as bad as some may tell you. It really does depend on your pre and post op care, and the skill and care of your surgical team/surgeon. Choose that carefully and you will do great!

Mark Golden, MD · Answer

Your two options of PRK or ICL are both reasonable. Personally, I would want PRK as you have a relatiely low prescription. I usually reserve ICL for prescriptions over -7 or so. With respect to risk, the chance of blindness from PRK is about 1 in ten million vs 1 in ten thousand for ICL. PRK is dependent on your having a completely normal cornea. Many surgeons who recommend ICL at such a low prescription do not perform PRK. If you are still concerned, seek one more opinion from someone that you know does a lot of laser vision correction. LASIK is also a possibility, depending on your LASIK surgeon's skill and technology.

Emil William Chynn, MD, FACS, MBA · Answer

i will explain the math and then the real answer will be obvious to everyone

	it is unsafe to do anything if your initial corneal thickness is below 450, because then you may have KC

	assuming your thickness is 455, to fix -3 about 35 microns of cornea would need to be lasered off

	if you chose hi-def, then you would need about 55 microns removed, so you would be left with 400

	the minimum safe thickness is 250, or else you would increase the chance of getting KC

	a LASIK flap can be as thick as 150 microns, so you can see that 400-150 = 250 which is the safe limit

	therefore, you cannot get LASIK

	PRK is an outdated procedure that i did myself but stopped doing in 1999

	LASEK is the Advanced Surface Ablation that has replaced PRK

	based on this math, it is obvious that LASEK is the choice for you, provided my assumptions are correct

	an ICL involves cutting into your eye and putting a piece of plastic in it behind the iris

	very few surgeons would recommend an ICL for your low Rx, given the risk/benefit ratio

	i think that clearly, an ASA is the safest option for you in this case

Anthony J. Kameen, MD (retired) · Answer

You describe your corneas as 470 microns thick, which is on the thinner side of the average range of corneal thickness. You do not mention any other corneal abnormalities from the computer testing, so, for the purposes of this discussion, I will assume your corneas are otherwise normal.

	PRK(Photorefractive Keratectomy), also known as Advanced Surface Ablation and, with a few minor variations in technique, LASEK, is a surface corneal procedure that does not require a corneal flap(that is LASIK). I have performed about 25,000 PRK procedures and also had it performed on my eyes in 1994(before other procedures existed). This is an extraordinarily safe and effective way to correct the refractive error you describe and is a relatively easy procedure to perform as the surgeon, and to experience from the patients perspective. Where the "work" of PRK comes in is in the aftercare and visual recovery. Since this procedure is performed on the very outer layer of the cornea, the patient is left with a surgeon induced corneal abrasion that takes about 4 days to heal. During this period, the patient wears a bandage contact lens to remain comfortable. In my experience, on average, the visual improvement with PRK is about 50% right away, then it stays that way for about 4 days until the bandage lenses are removed. Upon removal, and the normal friction occurs as one blinks thousands of times per day, visual improvement improves quite readily in most cases. I performed 15 cataract procedures 5 days after my PRK, if that helps. So, other than the up front inconveneince of PRK(vs LASIK) it is marvelous and the long term visual results and stability are at least equal to LASIK, if not just a tiny bit better. It is true that most surgeons perform many fewer PRK procedures now compared to LASIK, but that is strictly because of the faster recovery.

	The ICL or Intraocular Contact Lens procedure(seen on my website under "Phakic Implants") is a more involved procedure that involves making a surgical incision and entering the eye, then gently gliding a permanent plastic contact lens type lens into position in front of the human lens. Just as I describe it, it sounds more complex, doesn't it? It is also performed in an out patient surgical center, not in the office as PRK and LASIK are. Any time you enter a surgical center you can count on the cost of a procedure rising about two fold. In the case of the ICL procedure, my patients pay me a global fee, then from that I buy the ICL, pay the surgery center for the cost of using it and all of its supplies, pay the anesthesiologist for his or her services, then pay myself. In addition, at least in my office, we follow you for no charge for one year. From a financial perspective, I make more money seeing three patients for an annual eye exam than I do performing bilateral ICL procedures! On the other hand, and this is huge, my ICL patients are also the happiest patients I have ever seen! Seeing better than they have ever seen!

	All in all, my thought process goes like this. If a patient has a nice thick and normal cornea I perform LASIK. If a patients corneas are on the thinner side, yet normal, and their prescription is not huge(this is you), I perform PRK. If a patients corneas are thin and their prescription is huge I perform the ICL procedure. So, if I were you, I would have PRK. Good Luck!

I have a central corneal thickness of 470 in both eyes, (too thin for LASIK?). Do You Recommend ICL or PRK For Thin Corneas?

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