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Viewpoints: What Surgeons Want You to Know

Before You Choose Laser Eye Surgery...
We ask surgeons what you should consider first.

By Liz Segre

It's like a miracle: one day you're wearing glasses, and the next day you don't need them anymore! No wonder so many people are considering refractive surgery to correct their nearsightedness, farsightedness, and astigmatism.

But just like any surgery, it's serious business. If you're thinking about it, first consider these important issues that two eye surgeons shared with us in recent interviews:

Should You Believe the Ads?

One reason that refractive surgery is being talked about so much is, you can't turn on a radio without hearing an ad for it. Not that there's anything wrong with advertising. Most surgeons and medical centers are doing a good job of educating the public about LASIK, PRK, corneal ring implantation, and the various lasers and other machines used in the surgery. Radio and print ads are the first step, but these centers also have detailed brochures and videos that tell you exactly how they plan to correct your vision problems.

But don't assume too much from advertising, says Penny Asbell, M.D., Professor of Ophthalmology at Mount Sinai School of Medicine and Director of the Cornea Service and Refractive Surgery Center in New York. "Just because someone is advertising," she says, "it doesn't necessarily mean they're more qualified."

Dr. Asbell, who is a refractive surgeon herself, recommends asking the surgeon if he or she is associated with an academic medical center, such as a teaching hospital or one that is well known for advanced technology.

"Those who work in or are at least associated with academic medical centers are more likely to keep up with current information," she explains. "They are more likely to have more constant exposure to new things and to issues related to new procedures, than if they are related to an (albeit busy) isolated office setting with little contact with the academic world."

"A lot of companies make LASIK sound like it's a flap-and-zap commodity. But the truth is, it's surgery," comments Dr. Steve Updegraff, medical director of Updegraff Lasik Vision in Tampa Bay, Fla. He recommends choosing a doctor who is a Fellow of the American College of Surgeons. "The credentialing process there is pretty steep; also, that group is diligent about advancing the field of surgery."

Watch out for misleading advertising claims, Dr. Updegraff adds. "If someone says he's been using a laser for 15 years, don't accept that - he's probably talking about another type of laser or procedure, because LASIK hasn't been around that long."

The Personal Touch

"As with any relationship you have with someone in the medical profession, it has to be one of trust," says Dr. Asbell. "You have to feel that you trust the person and that they're personally interested in you."

She adds, "If you can't develop that rapport, I would be concerned. If everything goes well, you probably won't have to see that person too often, and that's the end of it. But if for any reason you're not happy with the quality of the result, or there's any issue with healing that's going to require more attention, you want to know that you have someone who is personally connected to you and is working hard to address your concerns - someone who isn't just running a mill where they don't even remember who you are."

Dr. Asbell stresses that you should expect complete honesty from a surgeon, and Dr. Updegraff agrees: "Be very, very specific as far as what you ask the doctor," he says. "Be like a good reporter - don't accept vague information. If a doctor doesn't answer your questions fully, leave and go somewhere else."

What Could Go Wrong

Inexperienced Surgeons. In laser surgery, says Dr. Updegraff, "the laser is just a surgical tool. If you don't have a good surgeon, you can have the most precise laser in the world and still get poor results. We've seen a plethora of doctors who are generalists that go through a short training course and then go home and start cutting." As one of the early investigators of LASIK, Dr. Updegraff has performed more than 7,000 procedures. But he says he's still learning new things.

In the past year, he says, "I've noticed an increase in complex cases being referred to me. I'm seeing patients with corneal flaps that were cut irregularly or too thin; or the cases weren't managed very well, and the patient may need a corneal transplant in order to see better."

Dr. Updegraff says that when something goes wrong during the flap-cutting stage of LASIK, some less experienced surgeons may go ahead and perform the laser ablation (tissue removal) anyway, instead of stopping surgery and trying again at a later date. He says this is one reason for poor results.

Patients Who Aren't Ideal Candidates. Another problem has to do with physiology. "There is a subset of patients who have weak epithelial attachments [which connect the outer layer of the cornea to underlying corneal tissue]," he comments. "They may show no signs of it pre-op, and you don't discover it until during surgery. If that happens, you need to stop and maybe do PRK [a laser-only procedure] at a later time."

Unfamiliarity with Cutting Tool. In LASIK, Dr. Updegraff believes it's worthwhile to ask if the surgeon owns the microkeratome that will be used to cut the flap. If a surgeon uses various microkeratomes, there may be nuances about the way each one operates or feels in the hand that could affect performance. He also prefers to use disposable microkeratome blades just once, because with each use they become duller.

Side Effects. A common side effect of LASIK and PRK is seeing glare, starbursts, and/or halos for a few days, especially when looking at lights during nighttime. However, says Dr. Updegraff, this usually diminishes or disappears altogether. If it doesn't, surgeons may want to retreat the eye, which isn't that unusual. "But too much redoing can lead to hyperopia [farsightedness]," he says.

Glare is more likely to occur in people who have very large pupils, as well as people who must do exacting work in low light or at night. "We can look at the pupil with infrared to see how much it dilates. Many times we screen athletes who must perform under different lighting conditions, such as bright stadium lights," says Dr. Updegraff.

Finally, dry eye is a common occurrence. "The corneal nerves are severed when we make the flap in LASIK," says Dr. Updegraff. "The nerves in the cornea sense dryness, so when that feedback loop is disconnected, patients' eyes get dry but they don't feel it. The reestablishment of the tear film and re-enervation of the cornea takes some time, so patients with dry eye need an aggressive lubricant program after surgery." In fact, if you have chronically dry eyes, you may not be a good candidate for refractive surgery at all, since dryness interferes with healing.

Post-Op Injury. Be very careful not to traumatize the eye after surgery. Dr. Updegraff has several patients who are professional athletes, and he recommends that they wear a face mask or other protection for the first year so they won't be hit in the eye. And airbags can be especially dangerous to eyes after surgery.

How Refractive Surgery Can Make Life Safer

The purpose of this article is not to scare you, but rather to make you think. Despite their words of warning, Dr. Updegraff and Dr. Asbell are strong proponents of refractive surgery - both perform it often and have seen many patients who are very satisfied with their new vision.

In fact, some of Dr. Updegraff's patients are leading safer lives after their surgery. "Mark Royals [of the Tampa Bay Buccaneers] is seeing things in the field that he never saw before with his contacts, so for him, that's added safety," he says. "And [powerboat racer] Michael Allweiss was very blind without his glasses. He also had contact lenses blow out of his eyes while racing. So his surgery made all the difference."

To sum up, the decision to proceed with refractive surgery should be based on a careful weighing of pros and cons. As Dr. Updegraff says, "These are your eyes, and you are your own best advocate."

Tough Questions to Ask

  1. How long have you been performing refractive surgery? (At least 3 years.)
  2. How many total procedures have you done? (Not less than 500.)
  3. How many of my particular procedures have you done? (Not less than 100.)
  4. What percentage of your patients have achieved uncorrected visual acuity of 20/40 or better (meaning, 20/40 without glasses or contacts)? (Be suspicious of a number greater than 90%.)
  5. May I have a list of 10 previous patients I can contact? (Yes, here it is.)