LASIKblog

The first FDA clinical trial in the United States began in 1989. At that time, LASIK was not available, so the early procedures were PRK, or photorefractive keratectomy. PRK treats the surface of the cornea with the excimer laser. In contrast, LASIK creates a thin flap in the cornea, laser treatment is applied to the corneal bed, and the flap is repositioned. We still perform PRK in about 10% of our patients, and seeing these patients after fifteen or twenty years reminds me what a great procedure PRK is. LASIK is probably even a better procedure than PRK, and this is why 90% of our patients chose LASIK. The use of the femtosecond laser (IntraLase) has improved the safety and accuracy of LASIK by leaps and bounds.

The visual results in LASIK and PRK are the same. The big difference is in the recovery time. LASIK patients obtain good vision a day or two after their procedure, whereas PRK patients may take a week, or two, to recover. There is also more postoperative pain with PRK, although we have some pretty good ways of minimizing the pain. So, why do some patients still have PRK rather than LASIK? There are four reasons. 1. The cornea may be too thin for LASIK, but thick enough for PRK. 2. There may be some corneal irregularities, or scars, which make PRK a safer procedure than LASIK. 3. There may be concern about displacement of the LASIK flap in people subject to head, or eye, trauma. 4. If previous corneal surgery was done, PRK may be a better option.

Both LASIK and PRK are remarkable for the stability of the vision correction. Less than 10% of patients require a touch-up, or “enhancement” procedure. In our practice, 92% have not needed an enhancement. And when enhancements are done, the cost is minimal, the improvement is predictable, and recovery is quick. Looking back over the last two decades, a few facts are striking. Patients often say that laser vision correction was the best thing they ever did. The elimination of glasses or contact lenses overnight is a truly remarkable feature for any ophthalmic procedure, or any surgical procedure at all. The safety of LASIK and PRK with modern technology is impressive. Serious adverse events are far less than one percent.

Laser vision correction is probably the best procedure to come along in ophthalmology during the last fifty years. What are the challenges for the future? Well, it would be nice to create a bifocal effect in the cornea, so people over 43 years of age would not have to wear reading glasses. But, this seems like such a difficult optical feat, it may be many years before someone figures out how to do it. In the mean time, patients over 43 can chose monovision, or buy reading glasses in the drug store.

Earlier this week, I performed LASIK on a friend in his late forties. This man had a +2.00 distance correction. That is, he was moderately farsighted, or hyperopic, in both eyes. Before surgery, he was having trouble biking, seeing road signs, and reading small print. When he returned the day after surgery he was 20/20 in both eyes, and reading the newspaper without his glasses. He was thrilled! He had not been able to see clearly for either distance or near for many years. I call this the “double whammy” of performing LASIK for farsightedness in people over 42. Their distance vision becomes excellent. Their reading vision also improves. Sometimes they end up in a “sweet spot” with good distance vision and good reading vision. I tell farsighted patients that their distance vision will be superb, and their reading vision will improve about 30%. I tell them they will, at some point, need reading glasses for fine print. They will probably need to make a trip to the drugstore to get over-the-counter magnifying glasses. My friend was probably a little disappointed when I told him his good reading vision may not last permanently. With age, and possible regression of the laser correction, he might need reading glasses in the next few years. I am sure he will enjoy good reading vision while it lasts, but he won’t be too surprised if he needs the help of magnifying glasses down the road. With nearsighted people, distance vision is also superb after LASIK. But, in people over 42, reading vision may be worse. In nearsightedness, or myopia, there is a “yin and yang” between distance and near. Most people prefer good distance vision over good reading vision. But, it is important that they be forewarned. We spend a good deal of “chair time” discussing presbyopia, the need for reading glasses, with our LASIK patients.

It is sometimes said that farsighted people are easier to please with LASIK. It is this double whammy of improved distance and reading vision that is responsible for their satisfaction.

We see many people who had LASIK several years ago, and do not see as well as they did right after their procedure. The usual reason is "regression". This can be due to a loss, or "wearing off", of the LASIK treatment, or a natural change in the focusing of the eye. A good remedy for this is an enhancement, or touch-up. Many of our colleagues have suggested a variety of methods to enhance a LASIK. We find the most effective treatment is "PRK Enhancement". This involves treating the surface of the cornea with some additional laser spots. There is no need to make another LASIK flap. And, we find that if we treat only the center part of the cornea, the part you look through, healing is rapid, and discomfort is minimal. It is not necessary to use wavefront treatment for PRK Enhancement. In fact, wavefront treatment slows down healing and visual recovery. It also removes too much corneal tissue. So if you had LASIK several years ago, and vision isn't as good as it use to be, consider a PRK Enhancement. It could improve your vision considerably.

Mitchell Friedlaender, M.D.
Head, Division of Ophthalmology
Director, Laser Vision Center
Scripps Clinic
La Jolla, CA
858.554-8143

2008 has been a rough year for LASIK surgeons. The weak economy, high gasoline prices, and the ailing stock market have combined to strain peoples' budgets. When this happens, elective surgical procedures, such as LASIK, become a low priority. As with most markets, the strong survive better than the weak, and in the world of LASIK, doctors need to perform procedures every week, or nearly every week, in order to maintain their skills, and deliver a consistent, high quality product. In addition, the April 25 FDA Ophthalmic Devices Advisory Panel hearings on LASIK made consumers wary about the safety of the procedure. Despite some anecdotes about unfavorable experiences, most testimony at the FDA was highly supportive of the safety, and effectiveness, of LASIK. In fact, 95% of patients worldwide are satisfied with the outcome of their LASIK. On the positive side, LASIK is safer, and more accurate, than ever before. This is partly due to the technology allowing the LASIK flap to be created with the femtosecond laser, or IntraLase. The IntraLase creates a perfect corneal flap every time, much better than the microkeratome. Presently, 28% of LASIK practices use the IntraLase. Eventually, every LASIK surgeon will need to adopt this technology. LASIK has been performed since 1989, nearly 20 years. It appears that it is a safe, effective, and permanent procedure when it is properly performed. At Scripps Clinic Laser Vision Center, we continue to be impressed with LASIK, and the high level of satisfaction among our patients. For more information about LASIK, please see our website, JoyOfLasik.com, or contact tfleisler@scrippsclinic.com.

Having just returned from the American Academy of Ophthalmology meeting in New Orleans, we had an opportunity to hear many lectures, and chat informally with colleagues from all over the planet. Here are some thoughts about where we have been and where we are headed. Laser vision correction has been around for 20 years. Patients in whom PRK was performed many years ago are stable, and seeing well. There is still concern about complications, particularly ectasia, a progressive thinning of the cornea. This is a rare complication. It occurs more with LASIK than with PRK. Patients with ectasia may have had abnormal corneas before having LASIK. But LASIK seems to hasten the thinning process. Bewer instrumentation seems to be helpful in detecting abnormal corneas.The average LASIK patient is 39 years old and equal numbers of males and females have the procedure. Corneal flaps made with the IntraLase femtosecond laser have fewer complications than those made with the microkeratome. Currently, 28% of cases are performed with the IntraLase. Phakic intraocular lenses are being used for higher corrections (above -10), but most patients are reluctant to have an intraocular procedure.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLasik.com
ArtOfLasik.com

LASIK is a useful technique for people over 18 years of age, and this includes people in their 70s, 80s, and 90s. There really is no upper age limit for LASIK. However, there are some special considerations in the elderly. Last week, I saw a 75 year old, nearsighted patient who wanted LASIK. But, she had mild cataracts in both eyes. While she did not need a cataract operation right away, it appeared that she might need one within the next 5 years. I suggested that she not do LASIK. When she eventually has cataract surgery, an intraocular lens of the appropriate power can be selected in order to correct her nearsightedness. If she had LASIK this year, she would also need to have a cataract operation in the near future. It's better to avoid two surgeries, if the goal can be accomplished in one surgery. On the other hand, we sometimes perform LASIK after cataract surgery. If the cataract surgery does not fully correct the eye, LASIK can often be used to make the vision better.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLasik.com
ArtOfLasik.com

We have avoided performing LASIK during pregnancy or nursing. Some feel it is because the refractive error (that is, the glasses or contact lens prescription) can change when the body's endocrine system is altered. We have not been impressed with refractive changes during pregnancy, or nursing. The main reason we wait has to do with the use of eyedrops, or other drugs used after LASIK. Most of these drugs are eye drops, and probably very little would cross the placenta, or enters the mother's milk. But, why take a chance. After all, LASIK is elective surgery, and it can be performed before, or after, pregnancy and nursing. The same can be said of other medical procedures. It is preferable to clear up more serious conditions before performing LASIK.
Mitchell H. Friedlaender, M.D.
Director, Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLASIK.com
ArtOfLASIK.com

Enhancements are another name for "touch-ups" after a LASIK procedure. If the vision is not full corrected by the initial procedure, an enhancement is usually recommended. Enhancements are rarely done sooner than three months after the initial procedure. In our practice, most enhancements are performed between the third and twelfth post operative month. During the first year, it is uaually easy to "lift" the LASIK flap, and add a few spots of laser treatment to the bed. After the first year, it becomes more difficult to lift the flap, especially when the flap was created with the IntraLase. IntraLase flaps adhere more tightly to the underlying cornea than microkeratome flaps. While many LASIK surgeons maintain they can lift a flap many years after the initial procedure, we would note that complicationns, such as tearing the flap, or epithelial ingrowth are more likely as time goes by. For this reason, we are big fans of PRK enhancments 18 months, or more, after the initial procedure. In our experience, flap lift enhancements work well for the first 18 months. After that, PRK enhancements offer greater safety and effectiveness. We are not enthusiastic about creating a second flap under any circumstances. The old flap edges may join up with the new, and create an undesirable "splintering" effect.

Mitchell Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
ArtOfLASIK.com
JoyofLASIK.com