An optical system like glasses is much closer to perfect compared to an eye because it can be ground and shaped in a laboratory. The eye, on the other hand, is made of human tissue and it is naturally imperfect, so we expect a certain amount of lumps, bumps, and warping to be present. These human imperfections of the eye are as unique to the individual as their fingerprints. Modern Lasik technology is capable of registering these little imperfections and accounting for them in the laser treatment. Because of the sensitivity of this equipment, it is particularly important that the corneal surface is allowed to reach its most relaxed, natural optical state. Modern lasers usually incorporate a wave scan system which allows the computer to measure optical refractions and aberrations in an ultra-sensitive manner. In simplest terms, a wave scan system sends light into your eye and is very accurately able to measure the light that reflects back to it. By mathematically analyzing this returning light, the computer can derive an incredible amount of optical information about your eye. This optical information can in turn be used by the laser during a Lasik treatment to render very accurate treatments. With these systems, optical aberrations that may be unique to your eye can be analyzed and treated in ways that older laser technology could not.

Contact lenses sit directly on the outer corneal surface of the eye. They are a relatively firm “plastic” material and essentially a foreign body to the eye itself. So although they improve your vision while you wear them, they are directly rubbing on the outer eye surface and have been shown to create significant surface changes when they are worn. These surfaces changes are generally not permanent so when the contact is discontinued the eye returns to it native state. The outer corneal surface is composed of a very rapidly growing and renewing cell layer called the corneal epithelium. This cell layer rapidly regrows and rejuvenates so over time the surface returns to its normal physical and optical condition. In years past, we allowed patients to be out of their contacts for just 3 days prior to their Lasik evaluations and we felt this time was adequate for the measurements that we required. However, when the more advanced technologies were developed, particularly the highly sensitive wave scan analyzers, it became important that even very subtle corneal surface changes be allowed to resolve over a greater length of time. Currently a minimum of 2 weeks is considered standard for patients that wear soft contact lenses. Longer periods of over a month or more may be needed for patients who wear hard or gas permeable lenses.

Soft lenses probably only alter the outer corneal epithelium by direct contact or perhaps by affecting the amount of oxygen available to the cells. These effects can definitely create measurable warping that can be detected on corneal mapping (topography) and could alter the wave scan measurements as well. In a small number of cases, changes in the epithelium could create topographical changes in the cornea that mimic pathological problems in the eye such as keratoconus, a potentially progressive weakening and warping of the cornea. Only by stopping contact lens wear and observing the measurements after an adequate recovery period can we be sure if the cornea is healthy and stable.

Hard or gas permeable (GP) contact lenses can alter the epithelium similarly. However, these lenses are known to also flatten or compress the entire body (stroma) of the cornea in a way that may change the exact amount of nearsightedness of the patient. In this case, wearing the hard or GP contact can actually change the apparent amount of nearsightedness of the patient to a falsely lower level. If the patient discontinues the contact for several weeks, the cornea will relax and resume its natural curvature and the patient’s full nearsightedness will reveal itself. Because of the falsely lower nearsightedness readings for hard and GP contact wearers, proceeding with Lasik without an extended period out of the contact can lead to a higher chance of under correction and subsequent need for additional treatment at a later date.

In summary, contact lens patients considering Lasik should discontinue wearing their contacts for at least 2 weeks (longer for hard and GP contacts) prior to their preoperative exam and surgery. This precaution will allow for the most accurate measurement of the patient’s prescription as well as higher order optical aberrations. Getting the most stable measurements which are free of contact related distortions allows for the most accurate Lasik treatments, the best potential visual outcomes, and the lowest chance of requiring a second Lasik treatment.

There are a couple of instances where lasers may be some benefit following cataract surgery. The most common is the development of a posterior capsular opacity (PCO) which is a thin, hazy film which can grow across the remnant lens structures behind the IOL. This hazy PCO can partially block the path of light through the IOL and obscure the patient’s vision causing blurred haziness or glare. PCO is actually the most common complication after routine cataract surgery. If it becomes significant enough to limit a patient’s functional vision, then it is generally treated using an instrument called an Nd:YAG laser. This type of laser has been available for several decades and is extremely accurate and successful in clearing a PCO with little to no discomfort and with minimal recovery time. The Nd:YAG laser can be very carefully aimed behind the IOL to cut away an area of the PCO creating a new clear path for light to pass through. The procedure usually takes less than five minutes. From the patient’s perspective it is actually quite easy. The doctor places a plastic “contact lens” onto your eye which holds your eye open and also allows him to focus the laser beam. He then carefully aims the laser so that it cuts a small clear circular area in the PCO. Although there are bright lights involved, the patient typically feels little to nothing. The Nd:YAG procedure has a very high rate of success for restoring vision to a high level.

Another situation that can arise is the occurrence of residual refractive error (glasses prescription) even after cataract surgery with IOL implantation. In the case of a cataract patient, the IOL can be selected to match the characteristics of the eye thus minimizing the patient’s glasses. If there is any residual refractive error, the patient may choose to wear glasses or it may also be possible to use the Excimer laser to correct it. For these cataract surgery patients, there are a number of things to consider.

First, they should understand that the standard IOL cannot change its focus so it is always set to either far or near distance only, but not both. Because of that fact, standard IOL patients require reading glasses if their distance vision is made perfect or they require distance glasses if their up close vision is good. These patients should consider carefully what distances are most important to them in their daily function before undergoing any Lasik vision correction. Also, there are now newer advanced technology IOLs (AT-IOLs) which are able to restore some ability of the eye to focus at different distances. These AT-IOLs are capable of reducing the need for glasses or bifocals to a greater degree than their older standard IOL predecessors. Prior to having cataract surgery, patients should ask their surgeons if they might benefit from the implantation of an AT-IOL.

Second, there are a couple of different ways to use the excimer Laser to correct a refractive error and surgeons have different approaches and philosophies. The two basic methods are called PRK and Lasik. Lasik is the most common vision correction procedure in younger patients that have not had cataract surgery, but many surgeons favor PRK for their cataract surgery patients. I personally prefer Lasik using blade-free Lasik technology. The major difference between PRK and Lasik is the creation of a corneal flap off the front of the eye in Lasik. You can visualize the corneal “flap” as a wall calendar where one page can be flipped up to reveal the underlying page. Similarly, the hinged flap is created on the cornea and lifted up to reveal the underlying corneal tissue. The advantage of Lasik over PRK is the significantly faster healing and visual recovery. Some surgeons prefer the ease of PRK in post-cataract surgery patients because it avoids the need to surgically create the flap. However, the most advanced blade-free Lasik technology can very easily create the flap on post cataract surgery patients. These newer instruments place much less pressure on the eye than the older bladed flap-makers and can cut a corneal flap with far greater precision and accuracy as well. So the quick healing of Lasik can easily be applied to post cataract surgery patients and avoid the slow visual recoveries that can occur in PRK.

Modern cataract surgery is a very highly successful surgery whether laser surgery is required afterward or not and, in fact, the majority of cataract surgery patients never need laser treatment of any kind. Nevertheless, patients should be aware of the possibility that they may benefit in some cases from Nd:YAG or excimer laser (PRK, Lasik). Typically, these lasers will give added visual benefit after cataract surgery but are not absolute necessities. Your surgeon should explain the reasons and potential benefits as well as risks prior to having these additional laser procedures.

In addition to being the major site of ocular herpetic infection, the cornea is the part of the eye where Lasik surgery is performed. It’s believed that surgery involving laser treatment to the corneal surface may act as a stimulus to activate the dormant herpes virus in an otherwise quiet eye. Theoretically, this stimulus could initiate chronic, recurrent herpes corneal infections and lead to potential scarring of the eye. Also, it has been shown that topical steroid eye drop use in patients with active herpes infections can lead to prolonged problems. After Lasik surgery, patients typically use steroid eye drops for several days to a week. However, steroids act by suppressing the immune system, so they are generally avoided whenever possible in the eyes of patients known to be affected by the herpes virus. Patients with ocular herpes can become “steroid dependent” and cannot be taken off of the steroid drops without significant inflammation recurring. As we noted earlier, the herpes virus usually remains dormant in the nerves of the eye and is kept quiescent by our normal immune system. So the immunosuppressive effect of a steroid can lead to an imbalance allowing the chronic reactivation of the herpes virus in that individual. The combined risk of the stress of laser treatment in conjunction with steroid use makes patients with ocular herpes very poor Lasik surgery candidates.

It should be stressed that there is no way to know if Lasik surgery will cause a herpes reactivation in the eye. Nobody has ever conducted a study of known patients that have a history of herpes eye infections to determine if Lasik does in fact significantly increase the rate of recurrent infection and inflammation. Because of the possibility of chronic inflammation and scarring, we avoid Lasik in any patient that has a history of herpetic infections of the eye so nobody has ever intentionally designed a study that might put those individuals at risk. Certainly, some patients have undergone eye surgery or other traumatic stresses to the eye without a herpes reactivation. But because of the elective nature of Lasik, generally ophthalmologists agree that the risk is not warranted for the potential benefit. Theoretically, significant scarring could lead to significantly diminished vision which is the opposite of the goal of the Lasik surgery itself.

Medications do exist which can help to control herpes eye infections when they do occur. Many of the newer medications have increased effectiveness compared to older therapies and hopefully further developments will make significant visual loss from this disorder more unlikely. However, to date, there is no complete cure so the risk for reactivation remains. I have had patients ask whether they could use those medications as a preventative and still go forward with Lasik surgery. At this point, my answer to those people is no, it is still not a good idea. We just don’t know enough about the potential risk under these circumstances. Perhaps in the future, a therapy or cure which reduces that risk adequately will be found, but until that day, patients with a history of herpetic eye infections should avoid Lasik eye surgery.

For further information on herpetic eye infections, I recommend the American Academy of Ophthalmology’s website. http://www.geteyesmart.org/eyesmart/diseases/herpes-keratitis.cfm

First, it is always important to establish the total medical and structural health of the eye prior to proceeding with any kind of eye surgery. Pregnant women are known to be at risk for the development or worsening of diabetes and can develop significant blood pressure problems such as preeclampsia. These blood pressure or diabetes related problems can manifest in the eye, and therefore a complete dilated exam of the eye, to look for any changes or pathology in the retinal blood vessels, is extremely important. Patients can potentially present with bleeding or leaking blood vessels which can cause distortion of vision. Any changes of these kinds need to be handled very carefully to prevent long term damage to the eyes. These conditions can lead to an acute medical or surgical situation and the patient would definitely be precluded from having Lasik eye surgery. Other rare pregnancy related eye disorders can occur that induce swelling of the optic nerve or retina and can also be detected with a complete eye exam by an ophthalmologist.

But not all eye changes during pregnancy are necessarily pathologic. In some otherwise healthy women, it has been observed that their glasses prescription actually changes during pregnancy. Similar changes can also occur after the baby is delivered while the woman is breast-feeding her child. In some cases, these changes may be temporary but in others they can be permanent. Unfortunately there is no way to distinguish which cases are temporary. Actually, the majority of women never have these prescription changes during pregnancy at all. The exact mechanism of action is unknown although it has been shown that changes in the corneal thickness and curvature occur, possibly due to swelling. Some have postulated that the same hormonal changes which allow for bodily changes to accommodate for growth of the baby within the woman’s body also allow for growth of the eye as well. Usually, growth changes of the eye leading to near-sightedness come to a conclusion when a person stops growing in their late teens or early twenties, but perhaps the hormonal changes of pregnancy allow for some of these changes to re-occur later in life.

Of course, when this situation arises, the woman’s glasses prescription and near-sightedness are no longer stable and predictable. Performing Lasik on someone like this is unwise because the exact final prescription cannot be known. It’s like shooting at a moving target. It is a general rule that a patient should have a stable glasses prescription for about one year prior to having Lasik eye surgery. If my patients go through pregnancy and experience no changes, then I feel it is okay for them to proceed at any point thereafter when they feel ready. However, if changes in their prescription have occurred, I do advise them to wait on Lasik surgery until we have observed that it does not change any further. This waiting period applies to the postpartum breast-feeding time as well.

I also talk to many of my patients that are young women who are not planning on pregnancy in the near future but feel they may have children in the distant future. In these people, there is no way to predict if a future pregnancy will change their glasses prescription. I advise these people that most women have little or no change during pregnancy so it is reasonable to proceed with Lasik as they have no immediate plans for having children. They should be aware of the small possibility of developing regression of their near-sightedness in the future in the event they do become pregnant. In those cases, it is possible to do additional treatment after pregnancy is completed and once their prescription is stable. However, if the visual changes are small, many women feel that their vision is adequate and may not need additional treatment or might choose to wear glasses only under certain conditions, eg night driving. Those are personal decisions that each individual must make for themselves.

The bottom line is to make sure that any health issues of the patient which can be related to pregnancy are stable and that the overall glasses prescription is stable and predictable prior to proceeding with Lasik eye surgery. Once all of these things are stable and the pregnancy is complete, that is the best time to proceed with the procedure. Although performing Lasik just prior or during pregnancy is technically possible, there remains the small chance of a prescription change induced by the pregnancy which might require additional treatment later. To avoid multiple procedures, I recommend waiting until after the baby is delivered and breast-feeding is completed.

Consider the demands for astronauts in the zero-G environment of outer space. For these people, even wearing glasses or contact lenses becomes extremely difficult. Glasses usually rely on the weight of gravity to stay in place but without it, the glasses will tend to float up and away from your face. Contact lenses will stay in place better, but taking care of them is extremely difficult in space. Since fluids will not fall downward with gravity, contact lens solution simply forms floating balls of liquid that float through the air. Of course you might ask why doesn’t NASA simply select only people that don’t need glasses? The paradox is that they wish to select the best-of-the-best of individuals for the very specialized tasks required of their astronauts and often those people do not have perfect vision.

With regard to Naval aviators in the past, many individuals who had hopes of becoming jet pilots were rejected because of their vision. It was only because of laser refractive surgery and studies conducted by Dr. Schallhorn that these individuals eventually had the opportunity to obtain these coveted positions. He talked specifically of the Retention and Accessioning studies which looked at PRK outcomes in pilots. These studies looked at a large number of pilots that were able to upgrade their qualifications and attrition rates among pilots in training. The positive outcomes for these pilots profoundly altered the Department of Defense’s vision standards for aviators allowing a wider pool of potential candidates.

Interestingly, these studies used the older PRK technology rather than Lasik. The major difference between PRK and Lasik is that Lasik uses technology to create a “flap” of surface tissue which allows for much faster recovery. The military actually required a 3 month minimum downtown for aviators having PRK. Dr. Schallhorn commented on the incredible cost in time, money, and training time lost when their pilots are out that long. As an example, fighter jet pilots are only able to maintain qualification for landing on an aircraft carrier at night if they have performed a landing within one week! Any longer than that and they are required to go through a requalification process. Despite all this, the data with older style Lasik involving conventional lasers and bladed instruments (microkeratomes) was never used because the data revealed that visual outcomes were not good enough. In particular, he stated that there is a slight loss of contrast and night vision with these older Lasik technologies which would be unacceptable for military pilots.

As time passed Lasik technology advanced as well. Eventually, Dr. Schallhorn and his associates took interest in studying the advanced wavefront guided Laser systems and Femtosecond Laser (FSL) technology which allowed for customized optical treatments and high precision blade-free Lasik. Studies comparing commonly used conventional bladed microkeratomes vs. the FSL technology demonstrated significantly faster visual recovery and potentially improved contrast vision. These are extremely critical outcomes for all military aviation personnel and also for civilians that wish to undergo vision correction surgery. He cited additional studies that showed that a combination of wavefront-guided Lasik and the FSL technology demonstrated a gain in night driving ability compared to conventional Lasik which showed a loss of night driving capability.

The combination of wavefront guided Lasers with FSL technology formed the basis of what would eventually be called the iLasik system which is made by Abbot Medical Optics. By 2007, the iLasik technology was approved by both the US military for their aviators as well as NASA for astronauts. Today, this advanced Lasik procedure is fast becoming the standard of care for Lasik in the US and offers the best chance for rapid recovery as well as potential visual improvement in areas of contrast vision and night driving tasks for all patients.

First of all, it is normal to feel a bit excited and even nervous as the time approaches to have the surgery. Even as an experienced Lasik surgeon, I found myself becoming nervous as I waited in the prep area before surgery. In our Lasik center, we ask patients to arrive 30 to 45 minutes early in order to receive a number of medications before the procedure. One is an antibiotic eye drop and the other is a topical anesthetic drop. I recall the anesthetic drop stinging a bit initially and causing my eyes to water up. I received a couple of sets of these drops while I waited and I was happy to see that the additional sets of eye drops did not sting at all. That’s usually what our staff tells patients to expect. The initial drop stings but since it also numbs the eye, the second drop will not sting at all. That just means that the drops are doing their job properly.

Also, while in the prep area, we give patients a pill (valium) to help them relax further. As I said earlier, it is normal to feel nervous prior to any kind of surgical procedure and I was certainly no exception. The pill helps to take the edge off your nervousness and makes you less fidgety. I’ve had a number of people try to shrug it off and avoid taking the valium, but I insist that they do. Some people see it as an option and that taking it is a sign of weakness or that they aren’t tough enough. Actually, the pills make the procedure go much more smoothly for the surgeon as well as the patient. They actually decrease the hypersensitive reactions and subconscious, automatic eye movements that a person has. So with the valium, a patient’s hyper tendency to blink or squeeze their eyes shut in reaction to the eye lid holders or to the microscope lights is significantly reduced which makes access to the cornea easier for the surgeon and makes for a smoother procedure. Also the valium helps to suppress the normal involuntary movements of your eye and can make for an easier treatment by helping you stay locked on target.

From the prep area, I was taken to the laser room itself. Here the surgeon usually makes a number of marks on your cornea with a sterile felt tip pen. Again, because of the eye drops, you can’t really feel any of it. Then you lie down on the surgical table and are looking up into the microscope lights. In our system, you’d be looking up into a circular ring shaped white light and in the middle of the circle of light there is a blinking red lighted dot. The blinking red light is the fixation light that you will need to look at during the treatment. One of the staff will usually take this time to use a sterilizing solution to clean the area around your eyes. That’s done to reduce the amount of bacteria and lower the incidence of infections.

At this point, the surgeon is ready to create the Lasik flap on your cornea. So you will feel him hold your eyelids open and place a suction ring over the front of your eye. There is a little pressure associated with the suction ring but usually no pain. The one exception is that if you have a small, tight eye socket or a prominent eye brow bone, you may feel some pain if the ring is pressing up against the bone. Obviously, the surgeon will work hard to avoid any unnecessary pain but depending on your bone anatomy, it may be impossible to avoid any contact in that area.

Once the suction ring is in place, everything goes dark in that eye. I actually remember seeing just sparkles and not complete blackness. But you should not be able to see the lights or anything else clearly at all. That is actually a good sign and means that the suction ring is properly attached to your eye. I use the blade-free Intralase technology, so the next step is to attach the Laser mechanism to the suction ring and activate it. At that point, it requires about 20 seconds to create a complete Lasik flap. Afterward, the suction ring is removed and your vision returns although it usually seems somewhat fuzzy. That’s normal so you shouldn’t worry about it. The Intralase creates bubbles when it does its work so your vision should seem fogged. I usually proceed to create the second Lasik flap on your other eye at that point so you will experience the exact same things on the other side. Now we usually take about a 2 minute break. That waiting time allows most of the bubbles to absorb so that the view will be clearer during the treatment phase of the Lasik.

During the treatment phase of the Lasik, the surgeon uses the excimer laser to actually reshape your cornea. A small eyelid holder is put in place so that you cannot squeeze your eyes shut for this part. It’s okay to close the other eye and, in fact, I usually put a shield over it to block everything out so that you don’t visually have any distractions to the other side. Additional, numbing anesthetic drops are put onto the eye and additional marks are made on the cornea for orientation purposes. Again, you feel very little at this point except for some pressure. If you feel anything at all, it is typically from pressure on the lids or eyebrow bone. You will be asked to looked directly at the blinking red fixation light as much as possible. The surgeon will initially be getting the computer to lock onto your eye so that the treatment will be properly oriented.

After the computer has done its lock-on, the surgeon will carefully free up the Lasik flap and lift it out of the way. During this phase, the blinking red fixation light may seem to dance and move around so it may be somewhat difficult to hold steady. But after the flap is lifted, visually things return to a stable position. With the flap out of the way, the laser will be activated and the reshaping of the cornea starts. From the patient perspective, you may visually notice some change in the lights and they may even seem to come into focus a bit better. You also will hear a very loud banging or clicking sound which the excimer laser makes while it works. In some cases, there will be an odor of burning or fumes as the laser vaporizes the tissue. The laser doesn’t actually “burn” tissue because there is no significant temperature rise. The eye never gets hot, but remains a normal temperature as the excimer laser very precisely vaporizes and reshapes tissue. This part of the surgery usually requires less than a minute depending on the amount of your prescription. I usually let my patients know verbally how they are doing and how far along they are. Because you tend to be nervous as the patient, time seems to flow at a very different rate so it’s nice to have somebody letting you know when you only have 10 seconds or so to go.

After the laser is finished, the surgeon will need to rinse the cornea and replace the flap. During the rinsing phase, you’ll feel a lot of water flowing over the surface of your eye and some may flow down onto the side of your face a bit. After the flap is put back into position and aligned, the surgeon will wait about a minute or two to let it settle. At that point, we do a blink test. The eyelid holders are removed and you are asked to blink rapidly to make sure that the flap has taken hold. Actually, for several days to weeks, the surgeon will ask you not to rub your eyes in order to let the flap fully heal into position.

After the procedure is complete in both eyes, we have the patient sit up. Typically, we expect to have the patient see significantly better almost right away so we have them look at a clock on the wall and tell us what they can see. Most patients can tell the time by that point although it may seem a bit fogged up. I tell patients that it may seem like they have Vaseline on their vision or as though they were wearing glasses and came in from the cold so their lenses are fogged. That’s very normal because there is in fact still some water in and under the flap which takes some time to absorb. By the next day, that vision will usually improve to the point that the patient could drive.

And that marks the completion of the Lasik procedure itself. After you go home, the anesthetic drops will begin to wear off and you will begin to feel some minor irritation. For me, it felt like I had an eyelash in my eye but some people have more tearing and light sensitivity. In most cases, this discomfort only lasts in the first 6 to 8 hours after surgery. For that reason, we provide sleeping pills and pain pills for the patients. We try to get our patients to go home and take a nap because if they can sleep through those first few hours, when they wake up, they will feel almost nothing and their vision will be improving even further.

Hopefully, this insiders’ view of Lasik surgery from the patient perspective of a surgeon is helpful. Armed with an understanding of the process, you can go forward with much less anxiety. As I said, it is normal for anybody (even a surgeon) to feel nervous when they undergo a procedure. But knowledge takes away the unexpected and when there are few or no surprises, you will find yourself focusing more on the exciting outcome of great vision that you will achieve.

Lasik uses a very particular type of laser called an excimer laser. This laser produces light of a specific wavelength which has very unique properties when it contacts human tissue. Essentially, it causes the tissue to vaporize in a very precise mannerr with very little thermal effect. In other words, it can very accurately remove tissue without causing any burning so there is no collateral tissue damage. By using a controlled, computerized optical system, this laser light can be direct to the surface of the cornea to reshape it with incredible precision.

Lasik requires that some amount of cornea tissue be removed in order to change its shape. Over the years, eye surgeons have developed generally accepted principles as to reliable safety margins for how much tissue can be removed and how much must remain. It is generally believed that if too much tissue is removed from the cornea that its structural integrity can be compromised and it will be weakened. Any weakness of the cornea can lead to distortions of its shape which are unpredictable and irregular. The weakness may also be progressive causing something called ectasia where a part of the cornea pushes outward.

Everyone’s corneal thickness is different and it is an essential part of the preoperative Lasik evaluation to measure it. The most common way to measure the corneal thickness is by ultrasound but there are also a number of newer optical instruments that can make similar measurements. An average corneal thickness is usually in the neighborhood of 550 microns but there is a relatively wide variation with some being thicker and some thinner. In some cases, an unusually thin cornea may be an indication of weakness or something called keratoconus. These people should be screened out prior to having Lasik because their corneas are already inherently weak. This diagnosis is made using measures of corneal thickness, corneal shape or topography, and other clinical signs which can often be seen by a trained ophthalmologist at the microscope. Anybody determined by their eye surgeon to have keratoconus should be excluded from having Lasik surgery based on this information alone.

When performing Lasik, the surgeon can only remove tissue to a certain depth. Most surgeons will want to leave a base of at least 250 to 300 microns of untouched cornea for safety. Lasik requires a certain amount of tissue be used to create a surface flap which is lifted out of the way before the excimer laser removes tissue and reshapes the cornea optically. The thickness of the Lasik flap is critical because the thinner the flap, the more Lasik treatment can be performed before reaching the minimum untouched base requirement of 250 to 300 microns. Again, the feeling is that if the depth of treatment goes significantly beyond that point, the structural integrity of the cornea may be compromised.

With older technology, a bladed instrument called a microkeratome is used to create the Lasik flap. A typical flap thickness using this instrumentation would be approximately 160 microns. So for a patient with a 550 micron cornea, after creation of the flap, the remaining tissue would be 550-160 or 390 microns in thickness. If the surgeon wishes to leave an untouched base of 300 microns, that would leave 90 microns of tissue to be removed and reshaped for the optical effect. Generally, for each diopter of nearsightedness, it requires the removal of approximately 12-15 microns of tissue. So treatment may only be possible for up to -6 to -8 diopters in this patient.

New Lasik technology is completely blade-free and uses another laser (a femtosecond laser) to create the flap instead of a bladed microkeratome. These femtosecond lasers can accurately make Lasik flaps that are much thinner, around 100 microns in thickness rather than 160 microns. This additional 60 microns leaves more tissue for the optical treatment allowing 5 or 6 diopters of additional possible treatment in an average person. So when using the femtosecond laser systems, higher Lasik treatments can often be performed even in patients with somewhat thinner corneas. It’s this important corneal thickness measure as an indicator of risk for corneal weakness which helped to make these blade-free Lasik systems so popular. Because the femtosecond laser can create significantly thinner flaps with such precision, Lasik surgeons have a much greater sense of safety with regard to treating more nearsighted individuals.

In general, I believe that all Lasik patients should be seen for regular eye check ups at least every one to two years. Partly, these exams are for standard purposes in terms of glaucoma, cataracts, and general health of the eyes. In addition, because they have had Lasik surgery, I think that these patients should be watched for specific additional reasons:

1) To monitor for any future corneal or refractive changes
2) To monitor for retinal changes
3) To keep track of Lasik surgery parameters for future cataract surgery purposes

The first reason is that patients should be monitored for any future corneal or refractive changes. In a small percentage of people, there may be some late onset regression and return of nearsightedness. This change is usually small but possibly can be treated with additional Lasik. If these changes occur, the surgeon should watch them over a period of time and decide if they remain stable. In discussion with the patient, a decision should be made if additional Lasik is warranted. If the change is small, it may be adequate to simply observe or possibly use a small glasses prescription in certain conditions, i.e. night driving, and in other cases the limit for Lasik surgery may already have been reached.

In some rare patients, especially those that have had retreatments, epithelial ingrowth may occur. Epithelium is the outer surface “skin” that normally covers the cornea. In epithelial ingrowth, this tissue layer may grow beneath the lasik flap. If it is significant, it may need to be removed. If your surgeon notes evidence of this phenomenon at any time, he may wish to see you at periodic intervals to make sure it remains stable and to determine if any intervention is required.

The second reason is the need to monitor for retinal changes. Patients that are highly nearsighted are known to have a predisposition for retinal tears and detachments because of a tendency to have thinner peripheral retinas. Although they are not technically “nearsighted” after having had Lasik on their cornea, the structure of their eye is otherwise unchanged and this includes the retina. In other words, the retina still has a tendency to be thinner and should be monitored into the future for any development of retinal tears or detachments.

The last reason refers to changes that occur in all people when we get much older. When most of us get into our 70s and 80s, the lenses in our eyes become cloudy, a phenomenon known as cataracts. When these elderly individuals reach a certain stage, their vision will deteriorate and they will require removal of the cataracts and placement of intraocular lenses. For patients that have previously undergone Lasik surgery, it is extremely helpful to have the Lasik treatment parameters available when doing calculations for the intraocular lens implants used for the cataract surgery.

For this 3rd reason, it is very important to make sure that the Lasik surgery records remain available for future reference. It can be invaluable in choosing a Lasik surgeon to find out if they also perform cataract surgery and other general eye care. If so, all of the follow up and future cataract surgery could be done at one center and all records would be available for future use. Having a board certified ophthalmologist that performs cataract surgery and general eye care as your Lasik surgeon can allow for better, long-term, comprehensive care into your elder years.

1) Ability
2) Availability
3) Accountability
4) Affability

Ability- The most obvious trait that we look for when seeking medical care is the doctor’s ability. What is the level of skill, knowledge, and training? Some of that can be discerned by reputation in the community and word of mouth. But more specific things to look for are level of certification and schooling. Not only is it important to know that your surgeon graduated from an excellent medical school and ophthalmology residency training program, but you may want to know if they are board certified in ophthalmology as well. Are they members in good standing within the medical community and licensing boards of your state? The level of training of the support staff is just as important. In some centers, your surgeon may not be the one performing all preoperative and postoperative tests and exams. If these tasks are delegated to an optometrist by your surgeon, then you should also feel comfortable with their level of certification.
Ability also refers to the technology and equipment used by your surgeon. There is actually a wide variance in technology used from premium versus discount laser centers. Make sure that you understand the technologies available and that you are comfortable with the systems used by your surgeon. A cheaper center may mean the use of blades in your Lasik surgery whereas the current most advanced Lasik uses entirely laser systems. Whatever technology that your surgeon uses, make sure that you fully research the options and that you are satisfied with your choice.

Availability- Lasik is eye surgery and requires careful follow-up at specific intervals. The surgeon should be present for those exams but, just as importantly, they need to be available in the case of an emergency. Some centers, in an effort to cut costs, are not actually open during many usual business days and hours. In these cases, a discount center may only be open a couple of days during the week and nobody may be available if you experience unexpected pain, loss of vision, or an unforeseen complication. I have personally been called in a number of cases to see patients that had recent Lasik eye surgery and experienced an unexpected emergency but their surgeon was not available to see them for several days. In fact, in one case, the center was closed Monday through Wednesday morning and wasn’t even answering the phone. Although most Lasik surgery proceeds smoothly, the nature of emergencies is that they cannot be predicted. So every reputable eye surgery clinic and center should make reasonable accommodations for contact or emergency call coverage in the event that the primary surgeon is unavailable. Simply closing the doors for 2 or 3 days a week and having an answering machine refer patients to an Emergency Room is irresponsible. Another often overlooked point is that many discount Lasik chains in the last few years have filed for bankruptcy and may not be available to take care of your needs in the months or years to come. If possible, it would be important to look into the financial status of your prospective Lasik center with an internet search.

Accountability- Medical device manufacturers and surgical practices are accountable to a number of federal and state agencies. A number of sources can be researched to look for irregularities in a clinic or Lasik center’s practices. The internet and Google are great tools for researching the background of your Lasik surgeon and the Laser center. These government agencies exist to regulate medical practices and equipment and to keep you safe and informed. Their websites can be searched directly. Agencies that are important yet often overlooked are the Federal Trade Commission (FTC) and the Food and Drug Administration (FDA). The FTC website can be searched to see if your laser center has any history of false advertising, irregular business practices, or unrealistic promises. The FDA regulates medical equipment like lasers and their use to assure proper standards. Any warning letters on the FDA website should be researched and problems fully explained and resolved to your satisfaction before considering a Laser center.

Affability- Lastly, your surgeon’s personality and attitude toward you and your concerns is critical. Meet with your surgeon for an evaluation and make sure that you are comfortable with their attitude, manner, and demeanor. Not only should they have an attitude of excellence, but also remember that their personality should mesh with yours in a way that you can feel relaxed and at ease during the Lasik procedure. You’d be surprised that at many centers you are not even allowed to meet the surgeon prior to the Lasik procedure. In general, if your surgeon can help you feel at ease and relaxed as much as possible, it will be a better experience for you and the technical aspects of the surgery will go more smoothly too.

Because Lasik surgery in general is a very effective procedure, every surgeon has many happy patients so it’s not hard to find satisfied people that will give you a word of mouth referral. But it is important to extend your search beyond what a friend or family member says. The 4 A’s are a great starting point to begin your evaluation of potential Lasik surgeons. Use them to cut through the confusion and focus your internet search. If your surgery center passes the test on the first 3 A’s, then you can take it to the final level. The final A (Affability) is a reminder to go beyond the impersonal internet and actually talk with your surgeon. Most reputable clinics will offer a free evaluation so that you have no commitment and can make your choice freely. With these guidelines, you can make a clear and educated decision about your Lasik surgeon and center.

Why are there such significant price differences?

Many of the “discounters” are able to advertise a low fee for their services by using an ala Carte pricing structure. The Lasik surgery itself may be $699.00/eye, but this fee will not include all prescriptions, from mild to severe, nor the necessary preoperative exams and the postoperative follow-up visits that are necessary. And often the latest technologies available, such as bladeless “All Laser LASIK”, are not an option with this pricing structure.

By contrast, a typical Premium Surgery Clinic price structure might include the following:

• Comprehensive Pre-op Examination
Determines if one is a good candidate for LASIK and also determines overall health of the patient’s eyes
• Surgeon’s fee
• All follow up visits
• Laser Center/Technology fee
• Cost of any enhancements (re-treatments) for a specified period.

The “discounters” thrive on a lower technology, high volume business. They generally rely on a less demanding group of patients where the biggest perceived difference by some consumers is price. In other words, the focus at many of these centers is on price and profitability, not on the patient, technology, and potential complications.

What are typical problems to look for and avoid?

Unreliable Evaluation and Follow-up: In many low cost centers the Surgeon does NOT perform the pre and post –op exams and care. A Surgeon is only involved in your care on the day of the surgery and only during the laser treatment. Often a patient will not meet their surgeon until the day the treatment is being performed. Additionally, some LASIK providers even charge extra to see the surgeon before or after your surgery. Occasionally, even in the case of emergency, a surgeon may not be available to see the patient as some discount providers do not maintain regular business hours. Typically, the “discounters” charge additional fees for enhancements as well. These additional costs have a tendency to add up quickly.

Lower Technology and Quality Control: Premium Laser Surgery Clinics typically use the latest technology such as blade free “all-laser” Lasik systems. On the other hand, most Discount Centers use bladed systems (microkeratomes) and, in the past, many even used poor quality “knock off brand” blades in the microkeratome since the best blades are very expensive. There are actually a number of different bladed microkeratomes on the market and they are of varying quality and precision in their function. Extreme care must be used to maintain these instruments and the blades (which are disposable) should not be reused. The blades become dull with use and can develop scratches or nicks which could damage the cornea. Also, reuse of blades can potentially spread certain types of infections including, but not limited to, HIV, Hepatitis B etc. The lasers also are very sensitive and may need adjustments in order to provide the safest most accurate treatment for the patient. An attitude of excellence and attention to detail must be maintained without question by the surgeon and the entire staff with regard to the care of all of these instruments. All of these steps require attention, time, and some cost.

Trained Personnel: Some discount providers may inadequately train their staff in all aspects of the LASIK procedure as compared to staff at a Premium Lasik Clinic. Although your surgeon is the primary individual performing your Lasik, he is really the central part of a highly trained team of people that must work together for your successful Lasik surgery. Surgeons often make an analogy between eye surgery and flying an airplane. Each surgery requires a clear, consistent, precise checklist to “take-off” for a smooth and successful Lasik. The team of technicians that supports the surgeon and maintains the equipment in top working condition is every bit as important as the surgeon himself. Although, a “discount” surgeon may be credited with tens of thousands of cases based on their high volume business model, the training, skills, and attitude of excellence of all members of the team and the entire surgical facility is just as important.

Restrictions May Apply: Generally, the best of current technology is not used when discussing “Super Low Price” surgery and it may only apply to the lowest, or mildest, of prescriptions. Many centers will use a “bait-and-switch” tactic to draw people in, and then use up-selling price techniques for stronger prescriptions and the use of newer technology. Patients often find the final cost to be several times more than what was expected initially. However, with high volume as a priority, some centers are willing to negotiate to virtually any price. Their philosophy is that maintaining as high of a surgical volume as possible will ensure profitability….quantity over quality.

Whatever Lasik center you choose, whether it is a Premium or a Discount Center, make sure that you research it fully. In the end, you should be fully satisfied that they properly utilize a technology that you, as a patient, are comfortable with. Be confident, as well, that they will be available 24/7 for routine follow-up as well as in the case of an emergency. Use the Internet and Google to research the backgrounds of the laser centers that you are considering as well.

Verify for yourself, that they have the kind of commitment and attitude of excellence that is required for this very important and delicate eye surgery.