About Lasik Eye Surgery Treatments

Who would have thought that so many people would be so willing to have a doctor shoot a laser beam at their eye so they won't have to wear glasses or contact lenses? What's more, to pay for it out of their own pockets?

Yet millions of Americans have had LASIK laser eye surgery since it was introduced in the United States about six years ago. The procedure involves cutting a flap in the cornea, using a laser to reshape the tissue underneath, and then putting the flap back. It became popular because it doesn't hurt and works for most people--and the buoyant economy of the mid-1990s certainly helped. Nearsighted people can end up with 20/20 or 20/40 vision without glasses or contact lenses.

But LASIK is highly commercialized. For better or worse, this is a realm where the patient is a customer, so better to be a tough one. Bear in mind, too, that while the complication rate is low, it isn't zero.
Complications

Firm complication rate statistics are hard to come by. Some experts say it ranges from less than 2% to 15%, depending on the doctor and eye center. The problems include halo-or starburst-like images around bright lights for several months. People with large pupils are more likely to have this problem. Some people can't see as well in dim light after LASIK because they've suffered a loss in contrast sensitivity. In about 1 in every 1,000 cases, the flap wrinkles, which may cause lasting dryness or glare. In about 1 in 40,000 cases, blindness or serious infection occurs. Eye color can change if the infection causes scarring.

If your vision is changing a great deal, LASIK probably isn't a good idea. The structure of your eye is in too much flux. The procedure can make a dry eye problem worse. And for people with "steep" or very thin corneas or an inherited condition known as anterior basement membrane dystrophy, an older procedure, called photorefractive keratectomy, is recommended.

People in certain occupations may want to avoid LASIK. For example, a photographer might be seriously hampered by the halos. Any visual problem can jeopardize a pilot's career. Still, some professional athletes have had LASIK with good results.
For presbyopia

Most people have LASIK surgery to correct nearsightedness and farsightedness. LASIK surgery for presbyopia (see story below) involves correcting one eye so it can see far away and the other so it can see up close. In medical parlance, this is called monovision. Contact lenses have been used to create monovision. Some people can adjust to having the focus of their eyes set differently, but others can't. For that reason, the FDA advises anyone considering LASIK for monovision to first try it with contact lenses. You can always take out the lenses. LASIK is not so easily undone.
Shop around

LASIK costs anywhere from $1,000 per eye at discount eye centers or in Canada or Mexico, to $2,000 or more at university hospitals. Many eye centers tout money-back guarantees and the like.  No agency or government rates LASIK centers. The best approach is to ask questions: How many procedures have you done? How often? What is your complication rate?

In the end, you should trust your own comfort level with a doctor or facility. It may be quick. The risk of problems may be relatively low. But LASIK is surgery and with it comes the risk of infection, surgical error, and outcomes that require follow-up. The break you get on price from some discount centers may mean that you see the doctor only briefly for the procedure with the rest of care delegated to support staff.
Fixing the Aging Eye.

LASIK was ideally suited to the New Economy 90s--eye surgery for the young and affluent. But the Baby Boom generation isn't getting any younger. Wouldn't they like a reliable repair of presbyopia (pronounced prez-be-OH-pee-ah), the lens-related farsightedness that besets nearly everyone starting at about age 40? One possibility is replacing natural lenses with adjustable plastic replacements. LASIK and similar procedures can be used to give people monovision. (See story above.) Meanwhile, Ronald Schachar, a controversial Texas ophthalmologist, is promoting a procedure called scleral expansion. But the FDA hasn't approved scleral expansion, and many ophthalmologists doubt it will work.
The aging lens

Farsightedness, nearsightedness, and astigmatism are caused by problems with the cornea, the clear, dome-shaped piece of tissue that covers your pupil and iris. The overall shape of the eye is a factor, too. Farsightedness is caused by the eye being too short from front to back, nearsightedness by the eye being too long in that dimension. Presbyopia has the same consequence for vision as farsightedness --you can't see objects up close clearly. But it's a problem with the lens of the eye, which is behind the pupil and the iris. Most experts believe that as we age, the lens stiffens. Without some give in the lens, the eye is like an autofocus camera stuck in one position. The tiny ciliary muscles within the eye can't change the shape of a stiff lens, so it can't adjust to objects being near and far.
A different theory

Schachar has a different theory about the aging lens. The lens is living tissue and expands as we grow older. As it does, it edges out toward the ciliary muscles. According to Schachar, the lens ends up cramping the ciliary muscles, which makes it impossible for them to adjust the shape of the lens and thus its focus. He has argued, therefore, that presbyopia could be cured if the ciliary muscles were, in effect, stretched out.

Other experts agree with Schachar about the lens getting bigger; that's conventional wisdom. But they don't believe that the bigger lens interferes with the functioning of the ciliary muscles in the way he describes.
What the procedure involves

Scleral expansion involves putting tiny pieces of special plastic into the sclera to stretch it out. The sclera is like a tough but flexible outer peel encasing the watery innards of the eye; we see it as the white of the eyeball. It's Schachar's theory that pulling the sclera out with the inserts, often called bands, will cure presbyopia by creating more space between the lens and the ciliary muscles, thereby stretching the muscles.

Schachar's initial design involved ring-shaped inserts to expand the sclera, but they caused bleeding in the eye. Now surgeons are using four pieces of plastic about the size of a piece of rice, spaced evenly around the lens.
Results

Schachar founded Presby Corp. in Dallas, Texas, to market scleral expansion devices and is president of the company. Presby officials say eye surgeons in Europe and elsewhere are already doing scleral expansions. The company hopes to win FDA approval with the results of a 300-400 patient study announced late last year. It's also investigating using scleral expansion for glaucoma. The surgeons participating in the early Presby trials have been upbeat about the results. But as a Wall Street Journal article last year pointed out, many of them own stock in Presby and so may have a financial incentive to put a positive spin on the trials.

Little independent testing has been done, which isn't surprising; after all, drug companies keep a tight leash on the trials of their new experimental agents. Still, it is notable that a French eye surgeon with no ties to Presby reported largely negative results in the December 2001 issue of Ophthalmology, the journal published by the American Academy of Ophthalmology. François J. Malecaze said he used Schachar's techniques on eight eyes: one eye of four patients and both eyes of two patients. He reported that in five of the eyes near vision didn't improve.
What's wrong with glasses?

Many people with good eyesight deal with presbyopia just by buying a pair of inexpensive reading glasses, which are basically just weak magnifying glasses set in a frame. You can buy a pair at a drugstore for about $20.

People who are nearsighted and then become presbyopic will often try to cope by taking off their regular glasses when they need near vision. Then there are those of us who have two pairs of glasses, one for nearsightedness, another for reading, and we fumble back and forth.

Bifocals help end the fumbling. But many people think that little square in the bottom of the lens makes them look old. Progressive-lens glasses are supposed to solve that problem. They have a gradual and therefore invisible change in correction. Progressive lenses take some getting used to -- you have to "aim" your eyes a little bit, and walking up and down stairs can be a visual adventure for a while. But most people end up liking them. They're about $100 more expensive than bifocals.

Contact lenses can also be made to accommodate both near and far vision correction. They can be hard to get used to. Some people complain they make vision blurry.
POINTERS FROM THE FDA

• You may need multiple treatments. For some, the results after the first treatment won't be so good, and because of the shape of their eyes, additional treatments aren't possible.

• Results are usually not as good for people with very small amounts of astigmatism. People with very bad vision, either nearsighted or farsighted, don't fare well either.

• Improved vision may wear off, especially if you are farsighted or have presbyopia. Farsighted patients should be screened with special exams (cycloplegic and manifest refraction tests) to gauge whether LASIK will truly benefit them.

• Patients with low contrast sensitivity should not have LASIK because it seems to degrade the ability to see subtle differences in light and dark. Some LASIK centers screen patients for contrast sensitivity.

Last updated Jan 4/07