News & Politics

Lasik and Beyond

Ready to throw away your glasses? New technology has made laser eye surgery better, while procedures beyond lasik offer more ways to get 20/20 vision—and even eliminate reading glasses.

Six years ago, I wrote a series of articles for The Washingtonian about lasik, the vision-correction procedure that’s now a household word. After researching lasik, I decided to have it myself. I’d had glasses since first grade, contact lenses since fifth grade.

Dr. Roy Rubinfeld, a Chevy Chase ophthalmologist, did the surgery. For the most part, I’ve been very happy with the results. I now see 20/20. Except for some occasional dryness, my eyes feel good.

When people ask me if I recommend lasik, I do wonder: Are there now better vision-correction procedures? If I were to have my eyesight corrected again, would I do the same thing?

Lasik is the most common vision-correction procedure in the United States. To understand the surgery, it helps to know how the eye works.

Light enters the eye through the cornea, the clear, dome-shaped tissue at the front of your eye. The cornea refracts, or bends, light rays as they hit the eye.

The light then travels through the pupil—which widens or narrows depending on how much light is available—and through the lens of your eye. The lens is a clear, flexible structure about the size of an M&M. Its job, with the cornea, is to help focus the light rays on the retina, their final destination. Once the rays land on the light-sensitive tissue at the back of the eye, they are converted into electrical signals and sent to the brain. The brain interprets them as images.

If you wear glasses or contacts, it’s because you have a refractive error: Due to the shape of your cornea or the length of your eye, your eye doesn’t bend light correctly. You see blurred images. Lasik corrects vision by reshaping the cornea.

In lasik, the surgeon cuts a small flap—about two-thirds the size of a contact lens—in the cornea. He or she uses a computer-controlled laser to remove a certain amount of tissue under the flap. Then he replaces the flap, which readheres almost immediately. There’s little to no postoperative discomfort; at most, patients experience a few hours of scratchiness and irritation. Most people see well enough to drive the next day.

Depending on the thickness of your cornea and other factors, lasik may correct up to 14 diopters of nearsightedness, 6 diopters of farsightedness, and 6 diopters of astigmatism. Diopters are the units doctors use to measure errors in focusing. (You can find diopters on the outside of the packets your contact lenses come in: –3 for 3 diopters of nearsightedness or +3 for 3 diopters of farsightedness, for example.) Because about 90 percent of nearsighted patients have errors of less than 6 diopters and 80 percent of farsighted patients less than 5 diopters, most people who need glasses are candidates for lasik. The more correction needed, however, the more likely the person is to experience complications or to need a second procedure, called an “enhancement.”

It’s not just those who wear glasses or contacts all the time who opt for lasik. Farsighted people who don’t need glasses to drive or watch movies, say, but who have a bit of blurriness in their distance and middle vision, are helped, too. “I thought people who were 20/5,000 would be the most grateful, but it turns out those who were 20/40 are deliriously happy with the clarity,” says Rubinfeld. Especially athletes, as some patients get better than 20/20 vision. “That can make a huge difference to golfers and tennis players,” he says. “If you can see the spin on a ball 5 percent better than your opponent, you have an advantage.”

In 1999, some half a million patients had lasik. Today, about 1 million patients undergo the procedure each year. Although the lasik market peaked in 2000, the numbers have started to climb again in the past two years. Doctors credit a stronger economy and improved technology. “The new technologies make it safer and more effective than ever,” says Rubinfeld.

The Latest in Lasik

The recent rise in lasik surgery has coincided with the advent of something called wavefront. Wavefront—now called custom laser treatment—is a technology, not a procedure, but it’s mostly used in reference to lasik—as in “custom lasik.” Approved by the Food and Drug Administration three years ago, one type of custom lasik is based on technology used to fix distorted images from the Hubble Space Telescope. Surgeons can program the laser with more information about the patient’s eyes for more customized results.

A major advantage of custom is that it generally doesn’t induce the night-vision symptoms, such as halos, glare, and starbursts, that can occur with regular lasik. It can also improve night vision from what the patient sees with contacts or glasses.

There are two types of custom procedures: “wavefront optimized” and “wavefront guided.” It’s up to the surgeon to determine which is best for a patient, but both yield good results. According to one study, 97 percent of patients who had one form of custom lasik saw 20/20 six months after surgery, compared with 88 percent of patients who had the standard procedure. Results from other studies weren’t as impressive, but most show that between 85 and 95 percent of custom patients achieve 20/20.

Currently, custom lasik is approved for up to –14 diopters of nearsightedness, 6 diopters of farsightedness, and 6 diopters of astigmatism. This allows doctors to treat people who wouldn’t necessarily be treated with conventional lasik.

Custom lasik costs about $5,600 for both eyes—about $1,000 more than the conventional procedure. The fee for custom, as with regular lasik, usually includes any additional procedures until the patient is satisfied with his or her vision. This doesn’t include checkups more than a year after surgery. At one point after my own procedure, I made an appointment because I thought I might need an enhancement. The doctor visit wasn’t covered.

if you Can’t Have Lasik

Some people with thin corneas, severe nearsightedness, or other problems can’t have lasik. For those patients, alternatives include photorefractive keratectomy (PRK) and epi-lasik.

PRK was the precursor to lasik. When laser vision correction was approved in 1995, surgeons brushed off the top layer of the cornea with a brush, laser, or other instrument. They corrected the cornea’s shape with a laser, then let the cells grow back. Lasik works the same way, except the top layer of the cornea is cut in a flap, folded back, and then reattached. The only reason lasik prevailed over PRK is that the recovery time is shorter and less painful. PRK patients usually experience three to five days of discomfort and blurry vision.

Today, some doctors use a variation of PRK called epi-lasik. Instead of brushing off the top layer of cornea or cutting a flap, they remove surface cells in a sheet and push it aside, and laser treatment is performed.

Because surgeons don’t go as deep into the cornea, and it leaves more corneal tissue untouched, PRK or epi-lasik is often the best choice for people with high prescriptions and thin corneas. The procedures are also ideal for professional athletes and military personnel because, unlike with lasik, there’s no flap that might be disrupted in the weeks after surgery.

Epi-lasik can be “midway between lasik and PRK” in terms of recovery time and pain, says Rubinfeld.

Whether a surgeon does PRK or epi-lasik boils down to preference. DC ophthalmologist Melanie Buttross thinks “PRK is a much more straightforward procedure. If something goes wrong, it’s not as big of a problem” as with lasik or epi-lasik, she says.

Some experts think epi-lasik and PRK are better procedures altogether than lasik. Studies are mixed as to whether the results are superior; at the very least, they’re equivalent. The cost of the three procedures is approximately the same.

It’s hard to sell the public on epi-lasik and PRK, some doctors say. It’s like selling the 2004 model of a car in 2007—though it might suit a patient just as well or better.

If You’re Very Nearsighted

Another option for extremely nearsighted patients is phakic intraocular lenses (IOLs). Lasik, epi-lasik, and PRK are limited in how much nearsightedness they can treat. This is because they require removing corneal tissue; the greater the nearsightedness, or myopia, the more cornea needs to be eliminated. If a patient’s eyesight is bad enough and the corneas thin enough, there might not be enough cornea left over to preserve safety and good vision.

Phakic IOLs avoid this problem. Instead of reshaping the cornea to correct vision, they target a different part of the eye: the lens. A phakic IOL is an artificial lens—almost like a permanent contact—that is placed in front of the eye’s natural lens to improve its focus. Verisyse, a lens with a long track record in Europe, was approved in the United States in 2004.

To implant Verisyse, surgeons make an incision through the cornea and clip it onto the front of the iris, which lies in front of the natural lens. Another implant, called the ICL, is placed behind the iris and in front of the natural lens. ICL was approved by the FDA some 11 years ago.

Results are good: 84 percent of those with a Verisyse lens rate their vision as “favorable,” and 92 percent would recommend the procedure to others. “I’ve been recommending it to everyone,” says Susan Riggs, a foreign-service officer now overseas. “I’d worn glasses since I was six years old, but doctors told me my eyes were too bad for lasik.” With phakic IOLs, she sees 20/15 in each eye.

Some doctors recommend waiting for the technology to improve. The Verisyse lens is so close to the cornea that it could theoretically damage that part of the eye. Verisyse requires a relatively large incision, so healing time is longer than with lasik, and eyes are usually done separately. And Verisyses are sometimes visible in the eye—as small, glittery disks—if you look closely.

“Down the road, they could be a solution for very high myopes,” particularly those with dry eyes, says Chevy Chase ophthalmologist Dr. Neil Martin. In the meantime, “I tell them to stick it out with contacts a little longer.”

IOLs are typically used on patients with 10 to 20 diopters of nearsightedness. They cost $4,000 to $5,000 an eye, compared with $2,500 to $3,000 an eye for lasik.

Goodbye Reading Glasses?

Perhaps the most interesting development in the past few years is the ability to correct presbyopia. Presbyopia is the natural stiffening of the eye’s lens over time, which almost inevitably results in the need for reading glasses after age 40.

A procedure known as refractive lens exchange (RLE) can correct this problem. Like phakic IOLs, RLE involves an artificial lens. But while a phakic IOL is implanted along with the patient’s own lens, RLE is a replacement: The doctor removes the natural lens of the eye.

Replacing the eye’s lens is not a new idea; doctors have been doing it for decades to treat cataracts, a clouding of the lens that causes blurry vision. In addition to treating cataracts, RLE can correct nearsightedness, farsightedness, and focus problems that come with age.

Some doctors use “accommodating” lenses such as Crystalens, which employ the natural muscles of the eye to adjust the focus of the artificial lens. The other choice is a “multifocal lens” such as Rezoom or ReStor. This works like a bifocal, allowing the patient to switch back and forth between near and distance vision.

The best candidates for RLE tend to be farsighted patients (up to 12 diopters) who now need reading glasses or any with cataracts who want to avoid reading glasses.

Results vary depending on the lens, but about 92 percent of patients with Crystalens see at least 20/25 and can read a newspaper without glasses. Dry eyes and thin corneas aren’t an issue with RLE. Recovery is quick: Most patients go back to work the next day.

Proponents like RLE because it can address all of a patient’s visual problems at once. “Patients who get it will never need reading glasses or cataract surgery,” says Dr. I. Howard Fine, clinical professor of ophthalmology at the Oregon Health & Science University in Portland and a pioneer in the procedure.

Patricia Smith, an Alexandria real-estate agent, needed both reading glasses and driving glasses before her RLE surgery in 2004. “I had five different pairs of glasses,” she says. But she could never see everything perfectly. When she woke up the morning after her surgery, “It was amazing. I looked in the mirror and thought, ‘Look at all the wrinkles—I need to start wearing a heavier night cream!’ I haven’t had a pair of glasses on since.”

There are downsides. “These lenses that ‘correct’ presbyopia do so at some cost,” says Dr. Walter Stark, professor of ophthalmology at Johns Hopkins University’s Wilmer Eye Institute. “They degrade the overall quality of vision.” Side effects include glare, halos, and loss of contrast, especially at night. With Crystalens, about 14 percent of patients report moderate nighttime vision problems; about 6 percent say their night-vision problems are severe. Why, asks Stark, would you accept this just to avoid reading glasses?

“It’s a foreign body in the eye, and its chance of complications is higher than I would think acceptable,” says Stark. He says the same of phakic IOLs.

Advocates acknowledge the risk but say it’s decreased dramatically with newer antibiotics and methods. According to both Fine and Martin, infection occurs in fewer than 1 in 1,000 patients and is treatable.

Most doctors are cautious about using RLE on extremely nearsighted patients, for whom the risk of retinal detachment—which can lead to blindness—is higher. Those patients, and others wary of RLE, can instead consider monovision. Monovision is a laser treatment that corrects one eye for distance and leaves the other one slightly nearsighted to allow for close vision without glasses. Doctors recommend a trial period with monovision-like contacts or glasses before choosing this option.

Another controversy surrounding RLE is whether to use it on patients who do not have cataracts but simply need reading glasses. That procedure is known as clear-lens extraction rather than RLE. Dr. Martin says almost all of his Crystalens patients have cataracts; he’s done only a few procedures for presbyopia alone. At this point, Crystalens is approved for treating presbyopia only in the presence of a cataract—although doctors can use the technology “off-label,” a common practice for all kinds of procedures and prescriptions.

The concern is that doctors are trying too aggressively to tap into the baby-boomer population. “They may not have the patients’ best interests at heart,” says Stark. “It’s a money thing.”

The bottom line? For those who need cataract surgery, RLE is a no-brainer. For everyone else, sorting through the opinions can be tough. Dr. Fine predicts that RLE will replace lasik as the dominant refractive procedure. It’s already the second-most-popular vision-correction technique behind lasik.

“We view this as probably a better option in the long run,” Fine says. “In my mind, it’s the biggest triple slam dunk in medical history.”

Others think “there’s a lot of hype but not a lot of information about the results over the long term,” as Stark puts it. “I personally would not have one in my eye.”

If done for cataracts, RLE costs about $2,900 an eye beyond what Medicare and insurance pay. If done out-of-pocket, or for presbyopia alone (which insurance doesn’t cover), it costs about $5,000 an eye.

A Doctor You Trust

Nine out of ten people with healthy corneas can now have their vision corrected through surgery.

“We have a whole tool kit to choose from, not just one technology,” says Martin. “It’s really a question of what has the best benefit-risk ratio for the individual.”

Most doctors I talked to said they would still recommend lasik—wavefront, though—if I were to have my vision corrected today. One surgeon said he might choose epi-lasik, given my extreme nearsightedness to start.

The most important thing is to find a doctor you trust. Doctors need to weigh more than just your prescription: Eye dryness, pupil size, and corneal thickness and steepness matter.

It’s best to choose a doctor who has extensive experience with the procedure you’re considering. Good lasik surgeons have performed thousands of procedures; the best train others. Finding a lasik surgeon with experience is easier than in the past, when even doctors in shopping malls were offering the procedure; many of these operations are out of business now. Phakic IOLs and RLE are newer, so it’s hard to find doctors who’ve done thousands of surgeries. If you’re interested in these procedures, look for a doctor with a background in cataract surgery.

It’s also smart to pick a group of ophthalmologists that does a range of procedures, so your surgeon isn’t biased toward a particular surgery. At the very least, he or she should tell you about the options.

One thing hasn’t changed since I last wrote about lasik: To see clearly, you still need to do your homework.

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