By Dr. Barry Drucker
While I believe that refractive surgery, and more specifically LASIK, or laser in situ keratomileusis, is one of the greatest medical breakthroughs in ophthalmology of the last millennium, others may say it is a needless, frivolous procedure.
Certainly most of the patients who elect to have this procedure are able to see the eye chart clearly with the aid of either contact lenses or spectacles. But that doesn't measure their inability to see a clock upon awakening, their inability to see where they are, recognize faces after swimming in the ocean or take into account their fear of being helpless if their crutch (eyewear) is lost.
This fear is what drove our brilliant president and “Rough Rider,” Theodore Roosevelt, to pack away no less than 11 pairs of glasses when going off to the Spanish American War in the late 19th century.
I was actually enlightened about the significance of good uncorrected visual acuity some 20 years ago when my cataract patients, who had been dependent on eyeglasses since childhood, were amazed and incredibly appreciative of the ability to see a TV without glasses.
The smiles on the faces of 70-year-olds and the stories of torment from age 7 on were enough to convince me that there was nothing frivolous or unimportant about good unaided vision. Today I see the same smiles on my refractive surgery patients and now realize how important this is to active people.
Types of refractive surgery
In the late 1980s, Radial Keratotomy was popular and quite successful in correcting nearsighted patients. However, due to limitations on the degree of correction and occasional changes following the procedure toward farsightedness, RK is rarely done today.
Ten or 12 years ago, Photorefractive Keratomileusis, which is known as PRK, began in Canada and soon overshadowed RK, due to its safety and consistent results that have held up over the ensuing years. With PRK the laser penetrates only 5 percent to 10 percent of the cornea (the clear glasslike structure overlying the colored iris) compared with the 90 percent depth reached by incisions made under RK.
But relative discomfort and haze requiring long-term use of anti- inflammatory drops has caused ophthalmologists to favor LASIK, which utilizes the same laser technology performed under a protective corneal flap that avoids both pain and haze. Today, more than 95 percent of refractive surgery is LASIK. While no procedure is without potential side effects, LASIK is one of the most successful and complication-free surgical procedures done in medicine.
What types of visual problems can be corrected?
Most anyone over the age of 18 who has relatively healthy eyes, with little or no change in their degree of near or farsightedness can undergo LASIK. Unfortunately, for those of us who need reading glasses due to the aging process, LASIK will not be of help. A separate surgical procedure for middle-aged presbyopia (dependence on reading glasses) is now in clinical trials and may someday provide an answer to this focusing problem.
How is LASIK done?
The actual procedure takes about 10 minutes per eye – an astonishing fact considering the lifelong and dramatic change better eyesight can bring to one's lifestyle. Preoperative evaluation is done, and all calculations are carefully planned with contact lenses discontinued for two weeks to allow the cornea to return to its natural state. Antibiotic drops are prescribed to prevent infection and anesthetic drops are used to make the procedure painless.
A small springlike instrument is placed between the lids to keep the patient from blinking. The surgeon then shapes a corneal flap of less than 1 percent of an inch in thickness utilizing an extremely fine instrument. The flap is gently folded back and about 20 seconds of laser beam is applied while the patient fixates on a target light.
The flap is repositioned and allowed to dry for two minutes so as to adhere to its normal position. The procedure is now complete.
Natural body forces keep the flap in place. Patients can do most activities, but are warned about rubbing their eyes for several weeks. Many people return to work the next day.
The ophthalmologist should go into greater detail about activities. Post operatively, little pain is felt and usually is treated with Tylenol or similar analgesics. Drops are usually prescribed for four to five days. I always see the patient the next day. Depending on the surgeon and patient's preference, the other eye is either done the same day or a week or two later.
What kind of results can you expect?
Most people get their full visual improvement within the first few days. Farsighted patients can expect a shift to nearsightedness that will gradually return toward neutral over a few months. However, the temporary nearsighted shift does give a bonus of good reading without glasses. Generally speaking, one should expect the vision after LASIK to equal that of a soft contact lens.
The most common side effects and complications
It has been reported that about 10 percent of LASIK patients will need an enhancement or touch-up to get the desired final visual goal. In the first few months this can be done without having to reform the flap, using the laser to treat both overcorrections and undercorrections. I have actually found the necessity to enhance to be rare, but the possibility of this nuisance complication should be kept in mind. However, depending on the preoperative refractive error, more than 90 percent of patients see better than 20/40 unaided. Other less common potential side effects should be explained and fully understood prior to any refractive procedure.
Are you a good candidate for LASIK?
The only way to answer this question is to have a full evaluation by a trained refractive surgeon. He or she should perform a complete ophthalmic exam to rule out any disease which might preclude such a procedure. Fortunately, the vast majority of eyeglass-dependent people are good candidates for LASIK.
Dr. Barry Drucker is a board certified ophthalmic surgeon who has performed refractive surgery since 1988. He is a Fellow of the American College of Surgeons in practice in Bayside since 1976.
