LASIK Surgery: Things to Know

by | August 16, 2010 @ 01:00PM

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miopiaLaura Moss is nervous. The North Wilmington resident is about to undergo laser surgery to correct myopia, the medical term for nearsightedness. A Valium has hardly diminished the butterflies. But that won't stop her. Moss has worn glasses since fourth grade and she's tired of it. Before the procedure, Andrew Barrett, M.D., a Wilmington ophthalmologist, asks Moss to read the clock on the wall. She squints and knits her brows. At -7.5 diopters, her vision falls in the severely myopic range. The clock is blurry. She reclines on the examining table and links her hands across her stomach. The surgery starts.

Less than 10 minutes later, she correctly tells the time through vision she calls "steamy," a temporary side effect of the surgery. After 20 minutes, she's on her way home. "It wasn't nearly as bad as I thought," she says. "I was expecting it to be worse."

Leslie Holmes of Greenville has the composure of a Buddhist monk during her surgery to correct farsightedness. "So many people I knew had had the procedure and were happy with the results," she says afterward. "I felt a little pressure but no pain."

Moss and Holmes are among the more than one million Americans expected to get LASIK, or laser-assisted in situ keratomileusis, this year, reports the American Academy of Ophthalmologists. Nicknamed the "flap-and-zap" surgery, LASIK involves cutting a flap in the cornea and reshaping it with an excimer laser.

Chances are you know people who've had it. Certainly, you've seen them, if only on television. Courteney Cox Arquette, Cindy Crawford, Tiger Woods, and Brad Pitt all have undergone the outpatient procedure.

Most patients are enthusiastic advocates. Take John Warren of Hockessin, 37. Warren, who had moderate myopia, had worn corrective lenses since fifth grade. He had LASIK in November and now his vision is 20/10. "Sometimes I feel I can see through walls," he jokes.

He's not alone. By 2010, some surgeons say LASIK will offer 90 percent of patients vision that exceeds 20/20. Yet it's not for everyone. Diabetics and sufferers of autoimmune diseases, such a rheumatoid arthritis and lupus, are poor candidates. Even with multiple surgeries, there are those who may never have 20/20 vision. And like any medical procedure, there are risks.

Experts encourage patients to get the facts. "I'm a big proponent of the physician and assistant really discussing the process," says George Popel, M.D., who has a practice in Wilmington and Newark. "Where patients get into trouble is with an assembly-line doctor who doesn't see the patient before the surgery. They may not be aware of the patient's problems."

Some practices won't see patients younger than 18. Others have a 21-or-older age limit. Pregnant or nursing women, whose vision can fluctuate, are poor candidates. As are people with a history of eye disease, such as glaucoma or cataracts.

Doctors should examine patients' eyes as part of a comprehensive initial consultation, Barrett says. He maps the patient's cornea to detect abnormalities and measure corneal thickness. Thin corneas may not offer enough tissue for the laser to reshape, says Jeff Blackney, spokesperson for Gary Markowitz, M.D., an ophthalmologist with offices in Newark, Dover, and Milford.

Contact lenses, which distort the cornea's curvature, may affect eligibility, Barrett says. Wearers must shelve their lenses at least a month before the evaluation to see if the cornea pops back into shape.

Pupil size is another factor. Current laser machines sculpt an area no wider than 6.5 mm, Blackney says. After surgery, people whose pupils grow larger than the corrected area could see halos at night. But even people with normal-size pupils could see halos after surgery, though that could disappear over time.

Warren, however, has better night vision after LASIK. Waking up one night, he spotted the cat sitting in the bedroom window. He was thrilled to discern the cat's whiskers, which were gleaming in the moonlight.

Ideal candidates have healthy eyes and need little vision correction, most experts agree. Yet doctors have successfully performed LASIK on patients whose correction is as high as –15 or, in the case of farsightedness, +6.

However, even the best candidates may be denied. Celebrity spokespeople have made LASIK seem like a wonder cure, Blackney explains. Some patients want guarantees that their post-surgery vision will be perfect. But with higher corrections, that might not be possible. And 20/20 vision doesn't translate into perfection. Patients still might have problems distinguishing shades of gray, for instance.

"There are some weeks where we will wash out more patients than we'll do because their expectations are too high," Blackney says. "Ethically, it's critical to never infer that someone will have [perfect] vision."

Just ask Cynthia Morgan of Chadds Ford, who had refractive surgery in the early '90s. In those days, friends thought she was crazy. But the doctor said she'd be able to drive without glasses, and that was too good to pass up, she recalls.

On her right eye, he performed radial keratotomy, a Soviet-pioneered procedure during which doctors use scalpels to reshape the corneas of nearsighted patients. On her left eye, he did LASIK, then a new procedure. When the results weren't satisfactory, she had LASIK again.

The doctor advised a third procedure. "It wasn't prefaced that I [might] need to go three times," says Morgan. Though she knows several people who have had successful LASIK procedures, she decided twice was enough. "You wonder what it does for your eyes."

Today, her prescription is less severe, but she still needs glasses. Her astigmatism increased and her night vision waned. On a stormy night, call a cab rather than ride in her car, she jokes.

Along with poor night vision, other complications could include post-operative infections or problems stemming from improperly made cornea flaps. Imagine seeing through wrinkled plastic wrap and you get the general idea.

Barrett encourages prospective patients to watch LASIK in action. Like most LASIK surgeons, he rents the equipment. Units can cost $500,000 and more, and rapidly changing technology makes long-term investments about as savvy as sticking with a Pentium I computer.

At the First Sight Laser Center in Christiana, Barrett and his assistants wear surgical scrubs and caps. Patients also don caps. The examining table wheels under an arm attached to the laser equipment. During the procedure, the patient's face is hidden from the audience's sight. A television monitor displays the patient's eye, which fills nearly the entire screen.

While the staff is getting the laser ready, the eye often zips back and forth as though a tennis match were in progress. Easy to see why some patients accept the proffered Valium. "It puts anxiety at a level so the patient can focus without being distracted with their own fear," Blackney says.

If Warren had the surgery to do over again, he would take the drug. He kept flinching when objects neared his eye. Holmes, however, was calm without Valium.

Once the patient is settled, Barrett bathes the eye with a liquid anesthetic, which numbs it for surgery. He uses a sterile drape, which looks like clear plastic, to pull lashes away from the eye. Then he slips a speculum under the lids to prop them open.

"There's some discomfort from those paper clip-type things that keep the eye open," Warren says. "You know they're there – but there's really nothing else to focus on."

One patient struggled so much that, the procedure was aborted, Barrett recalls. With a little more Valium, she breezed through the insertion. Mosshad dreaded the speculum and Holmes had no problems.

When the eyelids are open, Barrett marks the eye with a water-soluble ink. The lines will later aid in the flap's repositioning. A suction ring holds the eye steady. The cornea is sucked up. "It feels like a low-volume vacuum cleaner sucking on the palm of a hand," Warren says. There's pressure, but no pain."

Patients fixate on a red dot while Barrett uses a device called a microkeratome to slice the cornea's outer layers. The instrument stops short, creating a hinge. Rarely, the microkeratome could cut a flap that's too thin or a partial flap. "It's the most disappointing complication," says Julianne Lin, M.D., who practices with Popel. "If that put the flap back, let it heal and then come back to redo the procedure."

A successful flap, which looks like a contact lens, is gently pulled back with forceps. Underneath, the eye has the texture of a peeled grape. During this process, vision is impaired. But patients rarely panic, Barrett says. He tells them what to expect before and during the procedure.

He uses his stocking foot to trigger the laser, which is guided by a computer program. Though you can't see the laser's progress, you can hear its short, rapid bursts. He stops if the patient's attention drifts from the red dot.

The laser removes a small amount of tissue – about a quarter the thickness of a human hair – from the underlying layers. For nearsighted patients, the laser trims tissue from the cornea's center, producing a flatter curve. For farsighted patients, the laser creates a steeper curve.

Undergoing LASIK won't negate the need for reading glasses, a condition called presbyopia. As we age, the lens in our eye grows more rigid, affecting its ability to generate extra focusing power. A solution is monovision: one eye is corrected, while the other stays the same or is under-corrected, depending on the prescription. Patients should test it with contacts first, to see if the brain can rewire, Lin says.

The laser only fires for about a minute. Barrett gently taps the flap into place, absorbing excess moisture with a lint-free tool. Some doctors let the cornea dry back into shape, which takes from two to three minutes. Others insert an extra-large contact lens, which acts like a bandage to hold the flap in place. Patients should not rub their eyes and must use antibiotic drops to prevent infection.

Immediate results vary. "Nobody should expect perfect vision right after the procedure," Blackney says. "The maximum healing time for LASIK is three months."

After surgery, Warren felt as though he'd opened his eyes in a sand storm. "It was as bad as when I first wore contacts, when I was 13," he recalls. "At 6 p.m., I was 100 percent better. I said to my wife, 'Hey, I can see the TV.' At 6:45, I could read the time on the VCR 15 feet away."

Some patients see well enough to drive the next day, Barrett reports. Still, many will experience what Blackney calls the "roller-coaster effect of healing." Vision will fluctuate for days -- even months. The reason is the flap, which like any mending tissue, can swell. "Most people don't realize it until you point it out," Lin says. "They won't see as clear in the afternoon as they do in the morning."

LASIK generally is not covered by insurance. Prices vary, but typically run about $1,700 to $1,900 an eye. Some doctors offer payment plans. The price has decreased with demand and availability.

For Warren, it's been worth every penny. "It really alters your life," he says. "Don't let cost get in the way. When you're done, you won't care." 

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