Reprinted by permission from the May 16,1999 issue of

THE SUNDAY NEWSPAPER MAGAZINE

For two decades, a quiet revolution in surgical vision-correction has been helping millions to see clearly without glasses or contact lenses.

Is Laser Eye Surgery For You?  By Dr. Isadore Rosenfeld

     AN OLD FRIEND came to dinner one night, and as he stepped out of his car and walked toward me, I was seized with panic. This man is so nearsighted, he can't see a thing without his Coke-bottle glasses. Yet here he was, walking briskly toward me in the dim light with no glasses at all! As I rushed to help him, he sensed my anxiety.

     "Relax," he said. "I can see perfectly." "Contacts?" I asked.

     "No, LASIK-laser in situ keratomil-eusis," he replied, proudly enunciating this tongue-twister. "If you don't know what it is, you'd better learn pretty soon, because your patients are going to be calling you in droves to find out about it. It's the most fantastic thing that's ever happened to me. It took no more than a few minutes for the doctor to fix my eyes so that I could see without any glasses the very next morning!"

     I had heard of laser correction of vision but had no first­hand experience with it. After my friend's rave review, I decided to look into it. I learned that, if you have to wear glasses or contacts to correct for impaired vision, LASIK – which corrects the eye itself – ­can free you from the need for lenses. Some 2 million people world­wide have already received this treatment.

     To understand the procedure, you need to know a little about the mechanism of vision:

 
 

Dr. Sandra Belmont performs LASIK surgery on Melinda Anderson at Laser Vision Correction Center In New York City.
 
 

 

 


     Think of your eye as a camera. Light rays pass through the cornea (the transparent covering of the eyeball), through the lens and end up focused on the retina, which is covered with light-sensitive receptors, at the back of the eyeball. The resulting image is transmitted by the optic nerve to the brain, where it is interpreted.

 

     Vision can be affected by trouble anywhere from the cornea up front to the optic nerve at the back and even in the brain itself. For vision to be normal, the light rays reaching the retina must be properly focused. There are three common conditions in which that doesn't happen: nearsightedness (myopia), far­sightedness (hyperopia) and astigmatism (see box, opposite page).

     Millions of people have one or more of these problems (as much as 40% of the world's population), and most of them need either eyeglasses or contact lenses.

     At the end of the last century, doctors became aware that they could correct abnormal vision by cutting into the cornea and changing its shape. However, the technology to do so did not become available for nearly 100 years. In 1978, doctors performed the first such refrac­tive surgery, called "radial keratotomy" (RK), in this country. Using a scalpel, the surgeon made six to eight radial slits in the cornea, like the spokes of a wheel. Although the results were often satisfac­tory, especially in mild cases of nearsightedness, there were too many complications. For example, the inci­sions sometimes didn't heal or weakened the cornea so that its shape fluctuated, and vision was unpredictable.

     The early RK procedure has been superseded by more sophisticated and effective techniques. The first of these is "photorefractive keratectomy" (PRK). The surgeon scrapes away the outer surface of the cornea and then reshapes its underlying tissues with a cool ultravi­olet beam that removes anywhere from 5% to 30% of its thickness (depending on the severity of the nearsightedness). This procedure does not weaken the cornea, because it is not being cut.

     About 98% of patients treated with PRK end up with 20/40 vision unaided (sufficient to drive legally without glasses), and many enjoy 20!20 vision. But improvement may not be apparent

for several days after the surgery. One of the potential problems with PRK is that scraping the cornea may cause scar formation and hazy vision later on.

     Some doctors continue to perform PRK for mild nearsightedness. However, more and more are using the newer LASIK technique, which is less painful and whose benefits are apparent almost immediately. The main difference between PRK and LASIK is that, instead of scraping the surface of the cornea, the LASIK surgeon creates a hinged flap in the cornea using a motorized blade called a microkeratome. The flap is lifted up, and  the  ultra-

 
 

 

violet laser beam reshapes the exposed underlying cornea, after which the flap is replaced-and you can now see without glasses!

     It takes experience to use the micro-keratome, and whatever rare visual complications there are with LASIK surgery occur when the flap does not fall back properly into place.

     Before you have any kind of refractive corrective eye surgery, you will need a careful eye exam. If you normally wear contacts, you will have to remove them for several days.

     The LASIK operation is an outpatient procedure. Some surgeons prefer to do one eye at a time; others will fix both at one sitting in view of the rarity of complications. You remain awake, but your eye is anesthetized with drops.

     The entire procedure takes only a few minutes, and you usually can go home within an hour or two after it's done. You may feel, as some patients do, a sensation like having an eyelash in your eye for a few hours. Chances are you'll be able to read your newspaper in the morning. Some doctors ask you to stay home for a few days; others permit you t return to work the next day. Avoid eye makeup for about a week, and for several weeks eschew strenuous activities such as contact sports and swimming, and also stay away from saunas and hot tubs.

     Many doctors advise you to wear clear shields for a few weeks after surgery to cover the eyes while you sleep. This prevents you from inadvertently rubbing them and damaging the corneal flap. Some patients experience glare from lights at night after surgery, but this usually clears up in a few months. Your doctor will give you a schedule of follow-up visits for the first six months, just to make sure everything is okay.

Questions To Ask the Doctor

 

Eye surgery is a personal choice. It's serious business, the stakes are high, and it should be done only after all your concerns have been addressed. Here are some Important questions to ask the doctor:

·          What is your success rate for achieved visual acuity (that is, 20/40 or better)?

·          How many operations have you personally performed?

·          May I speak with any of the patients on whom you've done this procedure?

·          How many of them have required second operations? (it should be under 10%.)

·          What is the best correction I can expect?

·          How much will the operation cost me?

·          What are the chances that I may not see as well after the operation?

·          Do you operate on both eyes the same day?

·          What are the possible complica­tions?

·          What anesthesia will I receive during the operation?

·          How long will the procedure take?

·          What Is the recovery period?

·          When will I be able to return to work?

·          If the operation fails to correct my vision, will I be able to go back to contact lenses?

·          What If, years from now, I develop cataracts? Will this operation prohibit or Interfere with later cataract surgery?

·          What are the long-term risks of this surgery?

·          What other questions should I have asked you?

 

 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


     What can you expect after the LASIK procedure? As with PRK, as many as 9896 of patients end up with at least 20/40 vision, and 80% or more have perfect 20/0 sight. There's very little downside when a skilled doctor does the operation. Some eye doctors tell me that changing the shape of the cornea reduces the accuracy of diagnosing glaucoma (increased pressure within the eye). However, there are ways to compensate for this change.

     Getting rid of your glasses is great, but don't expect LASIK to give you signifi­cantly better vision than glasses or contacts do (unless you have severe astigmatism, which is hard to correct perfectly with lenses).


However, LASIK is much more convenient for many people, although some may still need to wear glasses when driving at night. If you're over 40, you may also require them for reading.

     (Recently, the FDA approved an alter­nate method of treating mild nearsightedness that does not require PRK or LASIK. Two tiny, transparent polymer rings about the thickness of a contact lens are implanted around the edge of the cornea and flatten it without destroying any tissue. Called Intacs, the rings cost between $2000 and $2500 per eye. In premarketing trials, the implants resulted in 20/20 vision in 74% of patients. If you're planning to get rid of your glasses or contacts, you may want to discuss this new development as well with your doctor.)

     Anyone between 18 and 70 can gener­ally have PRK or LASIK surgery, but there's really no upper limit if you're in good health. The procedure is not done before puberty, when the lens attains its final shape. If you're pregnant, wait until you've had your baby.

You're not a candidate for these proce­dures if you have any disorder that might affect healing of the cornea, serious vascular disease, any autoimmune disor­der such as lupus or rheumatoid arthritis, or diseases of the cornea or retina.

 

     PRK and LASIK are "elective" proce­dures, so most insurance companies will not pay for them. The cost varies, but you can count on spending in the vicinity of $2,500 per eye, depending on where you have it done.

     If you're considering laser vision correction, choose your doctor carefully. The more experienced he or she is, the better the results. Find out how many of these operations the doctor has done and with what results. It takes time and train­ing to learn how to use the laser equipment-it's not a skill a surgeon can pick up from textbooks and mere obser­vation.

     When you've finally decided by whom and where you want the operation done, take with you the questions listed on page 2. Don't be shy or embarrassed about asking them. Nothing that you want or

need to know is silly, trivial or inappro­priate.

     Most eye doctors predict that laser vision correction will one day be a common alternative to eyeglasses and contacts, now worn by 50% of the popu­lation. If you decide to have PRK or LASIK, do so with your eyes wide open.

 

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