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Seeing Clearly
The Latest on Laser Surgery, Trifocals, and Other Advances. Plus--Advice on Choosing Good Sunglasses and Keeping Your Vision Sharp for Years By Ellen Ryan
Comments () | Published September 1, 2002

Contemplating laser eye surgery? Looking into bifocals? Wondering how to protect your eyes as they age?

Lasik may be the biggest eye-care news in recent years, but it's not the only surgical development for treating less-than-perfect vision. And there are interesting advances for the 150 million Americans wearing glasses and contacts.

Here's a look at the latest in eye care--from trifocal contacts to vision-correction surgery to how diet and sunglasses can keep your vision sharp for years.

BEYOND BIFOCALS

remember when you could sit on the beach, read a novel, then glance up and focus on a boat going by? If this is a distant memory, you may need bifocals.

Newer progressive lenses--bi- or trifocals without the lines--provide, in theory, a smooth transition from near vision to far and in between. The idea works well in glasses; it's been a challenge to force the same technology into contacts.

But the tide is turning. "You get much better acuity in the optics now," says Dr. Peter Ellis, a Falls Church optometrist.

"The quality has improved dramatically" in glasses, too, says Butch Mann of Olney Opticians. "They're more like your natural eye." Progressive glasses are about double the price of bifocals, he says.

Progressive contacts can be more versatile than monovision, for which a doctor uses regular contacts or laser correction to make one eye focused farther, the other focused nearer. With progressives, you gain the addition of midrange vision, according to Cindy Elkin, spokeswoman for the Vision Council of America and owner of Point of View Eyewear in Falls Church.

Though progressive contacts work well for some people--Elkin wears them herself--they're difficult to fit, and visual quality can be poor; you may see farther than usual but with a blurry or distorted view. Also, it's typical for patient and doctor to try several brands before finding a good match. The contacts are unlikely to work for people with high astigmatism or who need strong bifocal correction. For first-time contacts users, all this on top of adjusting to contacts makes progressives a poor prospect.

"The success rate is 50-50, and it's hard to predict who they'll work for," says Dr. Jay Lustbader, associate professor of ophthalmology at Georgetown University School of Medicine. Progressive glasses, by contrast, have fewer comfort and fit problems.

The good news, if you're patient and set on progressive contacts: Most companies let doctors order trial lenses, so you can experiment for free. Ellis says that Acuvue and Additions are particularly good brands.

LENSES BRIGHT AND DARK

Remember those glasses that were a little too dark indoors, then changed in sunlight to not dark enough?

Photochromic glasses work a lot better now, and contacts are available, too. They're almost perfectly clear indoors--the lens has just the slightest gray tint--and quickly turn almost as dark as sunglasses outdoors. "The convenience is great, and the cosmetics are very good," says Elkin, whose own contacts are also photochromic. "Golfers love them because the tint adapts to different light levels on the course."

One drawback: Because windshields cut much of the incoming ultraviolet light, photochromic glasses don't change as much in a car as you might like. Says Elkin, "You might have to fill in the gap with sunglasses on a bright day."

Photochromics are not the same as colored contacts, though those have improved a lot, too. The tints, which change the appearance of your iris, are more realistic. And with dozens of manufacturers now, choices are greater in water content, prescription ranges, and materials. So, yes, you can have violet disposable astigmatic lenses.

THE MYSTERY OF DRY EYES

maybe you've worn contacts for years, but lately they're uncomfortable; maybe you've had to switch back to glasses. Is it the contacts?

No. At some point, generally in the forties, lubricating tears naturally decrease in both quantity and quality. "There's no real symptom you'll notice unless you wear contacts," Lustbader says.

If this is a problem for you, ask your eye doctor about changing to lenses with a higher water content. Replace soft lenses regularly; if you use hard ones, have them polished at least once a year to discourage protein buildup, Ellis suggests. And whether you wear contacts, glasses, or neither--particularly if you've had lasik, which can dry the eyes--consider using artificial tears. A drop or two per eye works for hours to ease discomfort and improve vision.

Another option: filling one of each eye's two tear-drainage ducts with a tiny silicon plug. Tears then don't drain off the eye as quickly, so the surface stays lubricated longer. Placing these is a painless, five-minute office procedure, says Dr. John Mitchell of Whitten Laser Eye Associates, that insurance generally covers. Plugs last 3 to 18 months; if they solve your problem, a doctor can seal the ducts permanently.

LATEST IN LASERS

still haven't gotten around to or been tempted by laser vision correction? You're not alone. After just under 1H million procedures a year in the past few years, demand has dipped. One theory is that people who wanted the surgery have already had it. But some--including those who aren't good candidates--are waiting to see if the procedure will get even better.

Lasik prices around Washington vary: Our research turned up fees of anywhere from $800 to $2,750 an eye, though $1,300 to $2,250 is typical. The price is affected by your prescription, insurance coverage, and the care you buy; most, but not all, packages include a year of follow-up visits and lifetime enhancements if needed. "Always ask what's included--it's like buying a car," says Dr. Marwa Adi of Washington Eye Physicians & Surgeons in Chevy Chase.

Lasik involves cutting a shallow flap in the surface of the eye, vaporizing a bit of cornea underneath to achieve the right prescription, then dropping back the flap, which quickly reseals. For the newest screening guidelines, including tests any surgeon should give to see if lasik is right for you, go to www.eyesurgeryeducation.com/LASIK_Screening_Guidelines.html.

Because lasik works for the most people and has the fewest drawbacks, it's the most widely available type of laser correction. But it's not the only one.

Other procedures, some already FDA-approved, are promising for certain needs, and prices are comparable, Mitchell says. But in most cases, because of low demand and uneven results, relatively few doctors offer them. Still, if you'd like lasik but aren't a good candidate, ask your doctor about the following possibilities:

* Lasek, a procedure similar to lasik, preserves about 100 more microns of tissue. Lasek is an off-label use of the FDA-approved excimer laser, used in ophthalmic surgery for two decades.

Who might benefit: People whose corneas are too thin for lasik.

Pros: Reported results have been similar to those of lasik.

Cons: Lasek hasn't been tested as well or as long as lasik has.

* PRK, or photorefractive keratectomy, uses an excimer laser to reshape the cornea. It was most patients' best option until lasik came along.

Pros: A proven alternative for those with corneal problems, says Dr. Salim Butrus, chief of corneal service at Washington Hospital Center. Also an option for some people with dry eyes, whose eyes can get more uncomfortable after lasik.

Cons: PRK involves more pain and a longer recovery than lasik. It's also less predictable and exposes the cornea more, says Dr. Maxwell Helfgott, chief of ophthalmology at Georgetown University Hospital and Washington Hospital Center.

* CK, or conductive keratoplasty, uses radio waves, not a laser. The surgeon applies heat to the eye's surface in a circular pattern; in minutes, the cornea shrinks slightly and changes shape. Its new, steeper angle allows a clearer image of faraway objects.

Who might benefit: Mildly and moderately farsighted people over age 40 whose vision has been stable for at least a year.

Pros: CK is noninvasive, newly FDA-approved, and an alternative for those ineligible for lasik because of use of certain prescription drugs or not wanting to have surgery involving the central portion of the cornea, says Mitchell.

Cons: Patients report fluctuations in vision for weeks afterward, and some still need glasses or contacts. Worse, CK isn't permanent; over time--six months, a year, or more--the eye reverts to its earlier shape, which is why some surgeons deliberately overcorrect. In some cases, CK can be repeated. It's not recommended for patients who have untreatable dry eye, serious allergies, or a pacemaker or defibrillator.

* LTK, or laser thermal keratoplasty, uses a laser in much the same manner as CK--not to cut but to heat and reshape the peripheral cornea.

Who might benefit: Slightly to moderately farsighted patients over 40, with or without astigmatism, looking to gain close vision--if only temporarily.

Pros: FDA-approved two years ago, LTK is noninvasive and takes seconds to perform. Whereas lasik has rare but serious complications, so far LTK has none.

Cons: Some patients have found lasting improvement, but for most, the gains recede steadily. In 1 percent of patients, a scratchy feeling persists for a few months; dry eyes are a problem. Overcorrection can help here as well. But "every time you do it, you lose some precision and form some fibrosis," says Dr. James Park of Annandale, one of the few area practitioners. "I wouldn't want to do it more than twice."

why so much interest in some of these technologies when results can be fleeting and risks large?

"People want to get rid of reading glasses or avoid getting them at all," says Adi. Presbyopia--the stiffening of the lens that forces everyone over about 40 into reading glasses or bifocals--"is very disturbing to someone who's never had to wear glasses."

NO MORE VISION LOSS?

age-related macular degeneration (AMD) afflicts some 13 million Americans--and it's the chief cause of legal blindness past age 55.

In the "wet" version, abnormal blood vessels grow like ivy behind the retina, distort your sight, then leak, blocking your vision, usually in both eyes.

Although only 10 percent of those with AMD have the wet kind, it accounts for 90 percent of severe vision loss from the disease. (The dry kind involves retinal-cell breakdown.) AMD tends to run in families. Most in danger, Helfgott says, are "fair-skinned, blue-eyed older white women who never eat spinach." (See "Eat Your Carrots--and Eggs," page 122.)

Once AMD sets in, any lost sight can't be restored. But now, with photodynamic therapy, ophthalmologists can laser new blood vessels before they cause further damage. The treatment's effectiveness depends on where the blood vessels are relative to your macula and how far they've grown; repeated treatments may be needed, says Adi.

Early signs of wet AMD are blurred vision and seeing straight lines as wavy. Risk factors include high cholesterol and tobacco use. If you're at risk, get tested by a doctor. Your ophthalmologist can also give you an Amsler grid--it looks like graph paper--for easy self-testing at home.

Can you prevent AMD? The causes may be genetic, but the American Academy of Ophthalmology recommends sunglasses that block both UVA and UVB rays, no smoking, and a diet high in antioxidants and zinc.

SUNGLASSES: PROTECT THOSE PEEPERS

cheap sunglasses are as good as pricey ones, eye experts say, as long as they block both types of rays: UVA and UVB.

Ultraviolet light harms eyes--burning, inflaming, and eroding the cornea--as well as the delicate tissue around them. In a study of 838 Chesapeake Bay fishermen, those who used no eye protection had three times as many cataracts as those who wore a brimmed cap or sunglasses.

Look for shades with a label saying they block 99 to 100 percent of both A and B, and wear them regularly. "Clouds do not completely reduce UV levels," says Dr. Krista Davis of Columbia Lighthouse for the Blind. Protection is especially important if you've had laser eye surgery, which often makes eyes more light-sensitive.

Big frames are best; wraparounds and goggles are even better, especially if you sail, ski, or frequent the beach at midday. "Reflected sunlight (for example, off water and snow) can be the most dangerous type of UV light because it is intensified," notes the American Academy of Ophthalmology.

Though more expensive, polarized lenses are worthwhile for cutting glare. Here's what else to look for:

* Gray lenses give the clearest view of colors. "Gray is best for blocking brightness, and it's the most neutral," Mann says.

* Brown deepens contrast and sharpens the horizon--it filters blue light, thus helping sailors and golfers. If unpolarized, brown lenses make things look a bit red; if polarized, your view is more natural.

* Pink or rose is good for driving: It improves contrast and is comfortable to wear for long periods, says Elkin.

* Amber is great for definition and depth perception; in haze and near day's end, it gives better visual acuity, says Mann.

* Blue and purple, though fashionable--picture Brad Pitt and Bono in azure wraparounds--have no functional advantages. *

 

Eat Your Carrots--and Eggs

WHAT A COINCIDENCE: The foods recommended to fight cancer, heart disease, and other common maladies promote eye health as well. A varied diet, low in processed foods and saturated fat, high in produce and whole grains, is best. Some highlights:

****FRESH VEGETABLES AND FRUITS provide beta carotene, vitamins C and E, and bushels of micronutrients (which haven't been successfully duplicated in pill form) that may protect against cataracts and slow the progression of AMD.

****YELLOW AND ORANGE PRODUCE such as carrots, squash, and sweet potatoes supply nutrients essential for night vision. Kale, spinach, and other BRIGHT-GREEN VEGGIES provide lutein and other carotenoids, which appear to ward off cataracts.

*** ZINC. Top food sources to fight macular degeneration are lean meats, oysters, crab, lobster, and fortified cereals. Recommended daily intake is 12 milligrams for women, 15 for men.

****EGG YOLKS. They're full of lutein and zeaxanthin, antioxidants linked to reduced risk of cataracts and macular degeneration. Even for those on lowfat, low-cholesterol diets, the American Heart Association says seven or fewer eggs a week is fine.

 

MORE RESOURCES

***Vision Council of America, 703-548-4560; www.visionsite.org. See the "consumer info" section for a SightSaver Test and a "frame game"--plug in your face shape, hairstyle, and other details, and up pop your best choices in eyeglass frames.

Several for-profit companies provide good explanations of eye care. At www.eyefacts.org, the makers of a drug called Visudyne explain age-related macular degeneration and treatment options. Bausch & Lomb's site, www.bausch.com, divides its wealth of information by age group, eye concern (laser surgery, astigmatism, and a dozen more), and product (soft contacts, eye drops, vitamins).

***American Optometric Association, 314-991-4100; www.aoanet.org. Useful, reader-friendly discussions of contact lenses, children's vision, sports and the eye, and conditions such as "lazy eye" and "floaters."

****American Society of Cataract and Refractive Surgery, 703-591-2220; www.ascrs.org. Includes an eye-care glossary, cataract facts, and a list of members byspecialty in eight types of eye surgery.

****Lasik Institute, 703-591-2220; www.lasikinstitute.org. Dependable facts, in English and Spanish, about how lasik works, its pros and cons, how to choose a surgeon, and questions to ask--plus details on LTK, PRK, lasek, and other refractive surgery.

****National Eye Institute, 301-496-5248; www.nei.nih.gov. This NIH site includes info in English and Spanish on eye disease, a glossary of terms, and resources for living with low vision.

****Research to Prevent Blindness, 800-621-0026; www.rpbusa.org. Access 32 scientific papers--on topics like "The Aging Driver" and "Role of Tear Evaporation in Dry Eye" (click on "RPB Eye Research Seminar Book").

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