can be extremely successful in freeing patients from their glasses
or contact lenses. It is important, however, that patients are realistic
in their expectations of the surgery and comfortable with the surgery
itself, the surgeon, the clinic and its staff. LASIK does have risks,
and as someone considering the procedure you should be aware of
those risks. The LASIK CONSUMER REPORT is written to help educate
you about the entire LASIK experience.
LASIK has enhanced
my life beyond description. I hope this report will help you sift
through the milieu of LASIK marketing. It is not prudent to tolerate
"corners being cut" when it comes to your eyes. Please,
insist on the highest standards.
You a Candidate For LASIK?
LASIK is a procedure
that reshapes the cornea to improve vision. Appendix A provides
more details on the LASIK procedure itself.
LASIK can treat
nearsightedness (myopia), farsightedness (hyperopia), and astigmatism.
Appendix B provides more detail on blurred vision from these conditions.
These are conditions that require the use of glasses and contact
lenses for clear vision. With some exceptions, LASIK generally treats
myopia between -0.5 and -10 diopters, hyperopia between +0.5 and
+6.0 diopters, and astigmatism between 0.5 and 6.0 diopters.
have had previous eye surgery may qualify for LASIK. LASIK can be
performed after previous radial keratotomy (RK), photorefractive
keratotomy (PRK), and cataract surgery. LASIK can be performed on
"lazy eyes" and eyes with nystagmus.
Procedures to LASIK
For lower degrees of nearsightedness (less than -3.00 diopters),
Intacs-micro precision implants placed within the cornea, which
sharpens vision by flattening the cornea-may be an option. Intacs
micro-prescription inserts are removable and exchangeable, and this
procedure avoids operating in the center of the cornea. Intacs can
be performed in patients with keratoconus as well.
For lower degrees of farsightedness (less than +2.50 diopters),
LTK (Laser Thermokeratoplasty)-a three-second, no-touch laser procedure
that uses heat spots to steepen the cornea and refocus light rays-may
be an option. LTK improves vision in patients with farsightedness
For the same range of LASIK, No-Cut LASEK is an alternative to LASIK.
The difference is that there is no flap of the stroma of the cornea.
The surface skin is loosened with a solution and moved to the side.
The top of the cornea is reshaped with the same laser used in LASIK.
The skin is replaced, thereby covering the cornea. The recovery
of vision is slower, but the end result can be predicted to be similar
to LASIK. This is an alternative for patients uncomfortable with
the flap aspect of LASIK.
glasses or contact lens prescriptions may fall within the diopter
ranges above, there are conditions that make these procedures inappropriate
until the conditions are treated or resolved. These include:
of this CONSUMER REPORT, LASIK will be emphasized as it represents
the majority of vision correction procedures performed.
to Expect From LASIK
individuals greater independence from glasses or contacts by enabling
them to have functional natural vision. LASIK has changed the lives
of thousands of people (myself included), freeing them from their
dependency on contact lenses and glasses. However, one needs to
be realistic about the limitations of the vision-correction procedure.
It is impossible
to guarantee exact results due to the unique healing factor of each
patient and potential variability of surgical technique, eye measurements,
and equipment. Excellent surgeons can largely control the latter
should not expect "perfect vision" even though surgeons
will aim for it. Although over 50% of patients can achieve 20/20
vision, it is not essential to be 20/20 to be satisfied and functional
in most, if not all, daily activities. The success rates can be
as high as 90-97% with patients achieving 20/30 vision or better
(20/25, 20/20). Such patients can function most if not all times
without their glasses or contact lenses. If the vision is less than
20/30, then an enhancement LASIK procedure, glasses or contacts
are options for additional improvement in vision.
It is important
to have realistic expectations of vision improvement to maximize
your level of satisfaction.
You should expect
the procedure to be relatively quick, usually under 15 minutes
per eye. It should be painless. Immediately after the surgery,
your vision may be fuzzy. This is normal.
takes six to eight hours to notice the initial recovery in vision,
so it is important to be patient. The day of the surgery it is important
to keep your eyes closed after surgery to allow for proper
lubrication of the eye's surface during recovery. Before you leave
the clinic to go home, your eyes should be examined again
(usually 15 minutes to an hour following the procedure) to ensure
that the flap is in good position. Valium (or an equivalent medicine)
may be given as a sleeping aid.
It is normal
to experience some stinging or foreign-body-in-the-eye sensations
after the procedure and patients should expect to use anti-inflammatory
and antibiotic drops for the first four to seven days following
the surgery. Frequent use of artificial tears (minimum of
one drop four times a day) over the first month is helpful to lubricate
the surface during the healing phase.
By the next
morning, patients should notice a dramatic improvement in vision.
Patients are often thrilled to be able to read the alarm clock and
look out the bedroom window and see trees or houses. The quick recovery
of functional vision is impressive and often described as miraculous.
have up to an 80-90% improvement in vision by the next morning after
LASIK and can return to most routine activities promptly.
It is not uncommon
for patients to experience glare and halos at night during
the first few weeks after surgery. This typically improves within
the first three months following surgery and should not interfere
nighttime activities. The glare and halo effect may be more pronounced
in those with greater degrees of myopia, hyperopia and astigmatism.
patients must wear a shield or patch while napping or sleeping
during the first week. The shield is important to protect the
eye from being accidentally touched. It is essential to avoid
rubbing or bumping the eye during the first month following
surgery so as not to displace the flap.
To monitor healing,
patients should see the doctor the day after surgery, again at 1
month, 3 months, 6 months, and one year following the surgery. If
a retreatment is required, this is typically determined after
the three-month visit, when the eye is fully stabilized. (In
some cases stabilization may require more than three months).
ASK YOURSELF: If you do not know what to expect,
you be comfortable with the procedure and recovery period?
an Excellent Surgeon
your surgeon is the most important aspect of making the decision
to undergo LASIK.
seek out surgeons who are sincere, qualified, use quality equipment
and processes. LASIK is a surgical procedure, not a product
taken off a supermarket shelf. Thus, surgeons of varying skill quality
using the same tools will achieve different outcomes. Talented baseball
players and golfers use tools to achieve results; the same holds
true for surgeons. However, having state-of-the-art equipment does
not necessarily make for a talented user of that equipment. It is
best to have confidence in your surgeon based on a face-to-face
meeting, and to receive reasonable responses to questions you ask.
A Surgeon With Sincerity
Part of being
comfortable with elective surgery is to believe the surgeon is sincere.
Patients should be given the opportunity to meet with the surgeon
to discuss their individual condition before the day of surgery.
If a patient meets the surgeon on the day of surgery, the meeting
should happen before going into the surgery room. A patient
should not be comfortable committing to surgery if he or she has
not met or spoken with the surgeon before the procedure.
the surgeon, a patient should feel the surgeon is cordial, respectful,
and caring. A surgeon who rushes in and out of the room during a
consultation conveys a different message about patient care than
the surgeon who spends time talking to the patient about his or
her condition and concerns. Ultimately, you should feel the surgeon
has your best interests at heart and really cares.
surgery such as LASIK, there should be ample time to carefully
read the informed consent document prior to surgery. The consent
form should never be signed under duress.
YOURSELF: How can quality patient care be given if the
surgeon is not sincerely interested in you and your goals?
Selecting A Surgeon Qualified In LASIK
are two ways that ophthalmologists learn LASIK:
1. A Fellowship in Refractive and Corneal Surgery
2. A LASIK course taken over one to two days
Fellowship in Refractive and Corneal Surgery entails a year of advanced
training that occurs follows the completion of a 3-year ophthalmology
training program. This training promotes better and more individually
tailored vision-correction treatments for each patient. In the Fellowship,
several principles are taught, including:
- Basic and
advanced LASIK techniques
of good candidates
- Other surgical
techniques beyond LASIK
You may hear that a doctor is a "fellow of the American Board
of Ophthalmology". This "fellow" designation does
not indicate that the surgeon completed a year fellowship in refractive
surgery. It means that the surgeon completed the general ophthalmology
exams - not a year fellowship in refractive surgery.
and corneal surgery fellowships have only existed for the past seven
years or so. Older surgeons who completed ophthalmology training
before such fellowships existed are typically trained with a one
to two day LASIK course. The course certifies the use of a specific
laser and microkeratome and allows a surgeon to treat LASIK patients
immediately after course completion.
There are excellent
LASIK surgeons trained this way, who have excellent reputations
in their communities and were performing refractive surgery prior
to the arrival of LASIK on the scene. If you are evaluating a surgeon
who has not performed a one-year refractive and corneal surgery
fellowship, it is appropriate to inquire if the surgeon has performed
earlier forms of refractive surgery such as PRK and RK, procedures
that existed prior to LASIK.
It is also advisable
to inquire whether potential surgeons are contributing to the field
through research and/or are teaching other surgeons. You may read
in their brochures that they "teach other doctors" and
"perform important research". It would be appropriate
to ask what they are teaching, to whom, and when? What are they
researching, with whom and when? Is this a surgeon who taught glaucoma
surgery at a meeting 10 years ago? Or is it a surgeon who is currently
teaching the latest refractive surgery techniques to peers? And,
is the surgeon being invited to conferences to teach about the latest
diagnostic testing and surgical technique?
are often recognized through awards and special honors. Does the
surgeon's literature list any such distinctions?
You many hear
claims about clinic experience such as: "Our center performed
more than 40,000 surgeries." If so, consider asking:
- How many
- How many
were performed by a specific surgeon?
- How long
has the surgeon been at that center?
- What are
patient satisfaction levels of that surgeon?
surgeon does your procedure, not a center.
A powerful way
to determine whether the surgeon you are considering is a leader in
the field is to search the Internet using the surgeon's last name.
For example, go to www.google.com
and type in the last name of a potential surgeon. This may identify
attributable research or teaching presentations, or if the surgeon
was featured in local or national news about refractive surgery.
Check your surgeon's
state license and any issues such as discipline or suspension at
the Association of State Medical Board Executive Directors' website
YOURSELF: How can you be comfortable with the
procedure, if you are not confident in your surgeon?
A Surgeon With Quality Equipment
The lasers used
in the United States should be approved by the Food and Drug Administration
(FDA). A key feature, which differs between FDA approved lasers,
is the range of treatment zones. At the time of this writing, the
maximum treatment zone is 8.0 mm, but not all lasers are that broad.
Large treatment diameters allow treatment of patients with large
pupils and higher degrees of nearsightedness.
should be the latest generation, which have a higher safety level
than earlier models that are over 5 years old.
equipment is only as good as the surgeon who uses it.
A Surgeon With Quality Process
1. Changing into surgical scrubs. Clothes worn outside, in
the home, and in the office are not as clean as surgical tops and
pants. It is proper surgical protocol to operate in surgical
2. Use of
Gloves. Bacteria are ubiquitous. These tiny organisms are especially
prevalent on the skin, eyelids, and even on the surface of the eye
itself. Some bacteria can cause infection, which is why using sterile
technique in LASIK is important to minimize the risk of infection
by preventing bacteria or bacterial debris from getting under the
flap. The most sterile procedure is for surgeons to use separate
sterile surgical gloves for each eye of each patient.
3. One or
Two Sets of Microkeratomes and Instruments. There are three
methods of performing LASIK on both eyes of a patient on the same
- Double Sterile:
After LASIK is performed on the first eye, a second setup of freshly
cleaned and sterilized microkeratome and equipment is used for
the second eye. Therefore, each patient has two sets of microkeratomes
- Single Sterile:
After LASIK is performed on the first eye, the just used instruments,
including the microkeratome, are again used on the second eye.
In other words, one set of microkeratome and instruments are used
on both eyes. Debris and bacteria can be transferred from one
eye to the next by use of one set of instruments and blade for
- Not Sterile:
The same set of instruments and microkeratome blade are used on
multiple patients without being cleaned and sterilized. Fortunately,
this is not common practice; unfortunately, it still exists.
Cleaning Protocol. The surgical technician is responsible for
the maintenance of the instruments. Therefore, all elements, including
use and maintenance of the autoclave that heat-sterilizes the instruments,
should be accomplished with a high level of meticulous care and
diligence. If the autoclave is not cared for properly, bacteria
can grow, which can contaminate the instruments with dead, toxic
ASK YOURSELF: How can you be confident in the safety process
if shortcuts are taken?
Now that you
have an idea of matters to be considered in selecting a surgeon,
the next step is to understand if the surgeon is properly testing
your eyes. Maximizing the chance of a successful result is dependent
on selection of appropriate patients through careful evaluation.
(I to V) must be done to determine if LASIK is appropriate:
It is normal
for patients to experience temporary dryness after LASIK.
Patients who have inadequate tears before surgery are at higher
risk of prolonged dry-eye symptoms after LASIK and should have increased
lubrication before surgery. Some patients have the feeling of dryness
while wearing contact lenses since lenses absorb tear moisture.
This does not mean that the eyes are dry when contact lenses are
not being worn.
There are different
methods to evaluate tear function: Some involve evaluation with
a special "tearscope"; some place colored agents in the
tears; another, physically measures the tears themselves. Visual
inspection of the tear film with a microscope is another technique.
ASK YOURSELF: If the tear film is not assessed, how can the
surgeon know if a patient is at high risk of developing dry eyes
II. Pupil size evaluation
some patients experience glare and halos. Often this is due
to a combination of larger pupil sizes and higher amounts of nearsightedness
or farsightedness that was not recognized as a risk factor prior
to surgery. With large pupils, light rays from the peripheral
cornea are more likely to cause symptoms of glare and halos after
can be minimized by programming a larger optical zone of the laser
for patients who have a combination of larger pupils and higher
amounts of nearsightedness. If central optical zones are custom-programmed
with lasers that have an adjustable central optical zone from 6.0
mm to 8.0 mm, even patients with large pupils and high prescriptions
can do very well and avoid troubling glare, halos, and night-driving
difficulties. To accomplish this, the surgeon must have a high level
of understanding and experience with advanced laser and corneal
optics in order to know how to program the laser based on a given
individual patient's measurements.
How are pupils measured? There are four categories of hand-held
tools for evaluation:
Infrared technology gives a digital readout of the pupil size, so
there is no need for the examiner to make estimates. Infrared
technology is the gold standard method to measure pupil size,
albeit the most expensive.
amplification. An examiner looks through one end of the device
at the pupil. Pupil diameter is measured against a tiny ruler in
card. An examiner uses a hand-held card with different sized
circles on it to match the diameter of the pupil to that of a circle
on the card.
estimation. Here the pupil size is "guestimated" by
the examiner. This is the least accurate method.
ASK YOURSELF: If the pupils are not measured, or the surgeon
did not understand how to use the measurement in programming
the laser, how can the risk of glare and halos be minimized?
III. Corneal Topography
shows the surgeon whether or not the cornea has normal astigmatism
or abnormal astigmatism. Some patients with abnormal astigmatism
have a condition called keratoconus, or "bulging
of the cornea." These corneas often are weaker than normal
corneas and thus should not be treated by LASIK.
ASK YOURSELF: If the topography test is not performed, how
will the surgeon know if the patient has keratoconus?
is the medical term for "corneal thickness." As
you already know, the LASIK procedure involves creating a flap on
the surface of the cornea and using the laser to reshape the cornea
by removing tissue. It is possible that too much tissue can be removed
by the laser. This can destabilize the cornea and lead to corneal
bulging. This condition is called ectasia and results in
the surgeon should calculate how deep the laser will penetrate
and be sure it does not penetrate beyond the safe level, which is
why measuring corneal thickness is imperative.
ASK YOURSELF: If pachymetry is not performed, or even in
conjunction with the test, if the calculation is not done, how can
the surgeon be sure that the laser is not going too deep?
V. Epithelium evaluation
the surface of the cornea there is a thin clear layer of "skin"
or epithelium. In some patients, this layer of skin may not
be firmly attached. If so, while making the flap in the LASIK procedure,
this skin layer may be brushed off by the microkeratome, leading
to a higher risk of complications. It is important to identify
beforehand with a microscopic examination of the cornea if the "loose
skin" condition exists.
ASK YOURSELF: If a careful exam is not performed, how can "loose
skin" be identified?
stands for Laser In-Situ Keratomileusis, which translates:
"using a laser to reshape the cornea from the inside."
It was first performed in 1991.
The basic elements
of the LASIK procedure involves the creation of a flap in
the outer cornea; moving the flap to the side to expose the inner
part of the cornea; using an excimer laser to reshape the cornea
based on the patient's specific measurements, and then replacing
the flap to its original position. The reshaped cornea then focuses
the previously unfocused light rays onto the retina.
At a more detailed
level, LASIK is in fact two procedures combined:
The first procedure,
keratomileusis, which was developed in the late 1950s, employs
a small surgical instrument: a microkeratome (much like a
carpenter's plane) that creates smooth flaps with a mechanically
oscillating tiny blade contained within a microkeratome metal head.
The head is used in conjunction with a suction ring that holds the
eye in position during the flap creation. (Back then, lasers were
not developed for reshaping the cornea. To do so, the microkeratome
was used a second time under the flap.) The same principles underlying
the original microkeratomes are used in the modern microkeratomes.
The long-term safety record of properly created flaps in the cornea
is excellent, and many microkeratomes are currently FDA approved.
laser was developed in the 1980s for reshaping the eye. The
precision wavelength of 193 nanometers was found to be the safest
and most accurate. Many excimer lasers are FDA approved, but not
all lasers have the same range of approvals. For example, one brand
of laser may be FDA approved only for treating myopia without astigmatism,
while another laser may be FDA approved for all five possible conditions:
myopia with and without astigmatism, hyperopia with and without
astigmatism, and mixed astigmatism.
The most advanced
lasers today are small spot (less than 2 mm) and have advanced eye-tracker
technology that follows the eye during the laser application (this
compensates for small eye movements). Such lasers have adjustable
treatment zones up to 8.0 mm to compensate for large pupil diameters.
Lasers have extremely sophisticated self-run computer diagnostics
that verify this entire system during calibration testing. The most
advanced lasers available today can correct myopia with/without
astigmatism and hyperopia with/without astigmatism.
History of Refractive Surgery
LASIK was developed
from procedures described above. The excimer laser was initially
developed to aid in a procedure called radial keratotomy (RK). In
the early 1980s, RK involved changing the corneal shape for myopia
by making tiny slits in the outer cornea with a special blade. The
excimer laser was created in an attempt to replace the blade for
the excimer laser was used instead to directly reshape the central
cornea in a procedure called photorefractive keratectomy (PRK).
of Blurred Vision
The eye functions
much like a camera. The camera's lens, located in front, focuses
the image on the film in the back of the camera. In the eye, there
are two lenses-the cornea (outer lens) and crystalline lens (inner
lens)-which focus the image on the retina, that lines the back wall
of the eye (analogous to the film of a camera).
In the eye,
the pupil acts like a camera shutter, gauging which light rays are
allowed to enter the eye through the cornea. The electrical impulses
are sent to the brain through the cable-like optic nerve. The eye
takes the picture, and the brain develops it into the image you
clarity by which some people see distance images without glasses
or contact lenses indicates that the image is being focused on the
retina. If the image is focused either in front or behind the retina,
the image is blurry.
A major factor
determining the success of the image focused on the retina is the
length of the eyeball:
that can blur vision is astigmatism, which indicates that
the cornea is misshapen (like a football). Astigmatism can occur
in combination with nearsightedness as well as with farsightedness.
The ideal corneal shape is round (like a basketball).
when the lens inside the eye can no longer focus on closer reading
material (books, menus, shopping tags, etc.), is the reason most
people over 40 must use bifocals and reading glasses. Presbyopia,
to some degree, eventually happens to everyone.
write prescriptions for glasses and contact lenses-usually a single
number or three numbers-that indicate the condition of the eye:
- A minus
sign (-) in front of the first number indicates nearsightedness
- A plus
sign (+) in front of the first number indicates farsightedness
- The number
itself indicates the degree of nearsightedness or farsightedness.
Mild to moderate
nearsightedness shows in the range of -1 to -6 diopters (the
units of measurement). Mild to moderate farsightedness generally
falls within the range of +0.75 to +4.00 diopters.
of a second or third number indicates there is no astigmatism. A
second number verifies both the presence of astigmatism and the
degree of it. Astigmatism may have either a minus sign or a plus
The third number,
called axis, indicates the direction of astigmatism: right
and left eye is designated by OD and OS, respectively.
Two sample prescriptions
for right eyes are:
- OD -4.50
- OD +2.25
-1.00 x 165
is an outline of the basic steps of a typical LASIK procedure:
- Patient is
positioned under the laser and, for practice purposes, is directed
to look at a specific light.
drops are used to numb the eye so there is little or no pain.
- Eyelids and
lashes are cleaned; they are covered and held open (with drapes
and a gentle eyelid holder) so they are out of the surgical field.
- Cornea is
marked to assist the surgeon in realigning the flap at the end
of the procedure.
- A suction
ring is placed on the eye, giving a little squeezing sensation
to hold the eye steady; lights usually disappear for a few seconds.
or "flapmaker," is used to make the flap.
- Surgeon centers
the laser (even if an eye-tracking laser is used, it is surgeon's
responsibility to properly center laser beam).
- Laser is
activated while surgeon carefully watches patient's eye to be
sure it remains in position.
- Flap is repositioned
so surface is smooth; inner surface is rinsed.
- Drapes and
eyelid holder are removed.
and anti-inflammatory drops are started.
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