Factors determining the refractive effects of intrastromal photorefractive keratectomy with the picosecond laser

Purpose: To determine the relationship between laser parameters and tissue removal with picosecond laser intrastromal photorefractive keratectomy (ISPRK) and to assess the effect of the parameters on the healing process and the long-term refractive changes. Setting: Medical Laser Center Lubeck, Germany. Methods: A modified Intelligent Surgical Lasers (ISL) 2001 system with a cone angle of 30 degrees was used for in vitro investigations of the laser effects in water and on the porcine cornea. Photographic methods were used to determine the plasma volume and to investigate the thickness of the intrastromal bubble layer as a function of the laser pulse energy, the number of layers in which the pulses were applied, and the layer separation. The data were used to calculate the amount of tissue removal. Histologic evaluation was done by polarization microscopy after Sirius-red staining. Results: The laser pulses produced a sponge-like appearance of the stroma in a layer extending through about one third the corneal thickness, accompanied by mechanical distortions of the stromal lamellae. Thermal changes were weak. Tissue removal was impaired by the cavitation bubbles from preceding laser pulses: The amount of evaporated tissue depended only weakly on laser pulse energy and number of layers in which the pulses were applied. The maximum amount of tissue that could be evaporated without damaging the outer corneal layers was a 10.0 mu m thick layer. With a 6.0 mm optical zone, the tissue removal produced an immediate refractive effect of only 0.85 diopter. Conclusions: Intrastromal PRK does not work as originally envisioned because the amount of evaporated tissue is very small. The greater long-term refractive changes observed in animal experiments and clinical studies must therefore be due to the healing response of the cornea. Because the refractive effects are strongly influenced by the healing response of the cornea, they are poorly predictable.