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Resource Description: 
The National Eye Institute (NEI) was established by Congress in 1968 to protect and prolong the vision of the American people. Their site provides a good primer on the eye and related diseases and disorders.
The American Academy of Ophthalmology (AAO) is the largest national membership association of Eye M.D.s (ophthalmologists). A section for patients/public covers a variety of eye health topics including Laser Surgery in Ophthalmology, LASIK - Is It For You?, LASIK Risks and Selecting a Refractive Surgeon.
The American Academy of Ophthalmology (AAO) is a membership organization for optometrists and optometric educators. The Public Info section includes links to sites that provide detailed information on eye health and vision correction options.
The American Association for Pediatric Ophthalmology and Strbismus' (AAPOS) mission is to provide ethical leadership for comprehensive medical and surgical eye care of children and adults with strabismus (the condition where the eyes are misaligned). The site includes a public resources section.
The American Foundation for the Blind (AFB) is a national nonprofit devoted to expanding possibilities for people with vision loss. This site includes information about new tools and technology as well as information about independent and healthy living for people with vision loss.
The American Optometric Association (AOA) is a federation of state, student and armed forces optometric associations. Through these affiliations, the AOA serves members consisting of optometrists, students of optometry, paraoptometric assistants and technicians. Their site includes general information on vision conditions and eye diseases. Information is also provided on contact lenses, children's vision, and sports and vision.
Prevent Blindness America is a volunteer eye health and safety organization with the mission of preventing blindness and preserving sight. This site includes information about vision screening programs and services, the eye and how we see, and eye problems in adults and children.
If you’re thinking about undergoing this type of surgery or are waiting for your operation date to come through, this guide will answer some of the most frequently asked questions about refractive laser eye surgery.
This is a site from the U.S. Food and Drug Administration specifically devoted to LASIK surgery. It includes sections on who is an appropriate candidate for LASIK surgery, risks, finding the right doctor, expectations, FDA-approved lasers and more.
Episode number: 
204

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There was a time when doctors, medical practices, and pharmaceutical companies selling prescription medicines did not advertise to the general public.  Today, that's no longer the case.  The health care industry in general (and drug companies in particular) now spend hundreds of millions of dollars on advertising.  And one of the leading medical specialties in terms of the amount of advertising it does is eye care.

 

While advertising can be a good initial source for information, some of it is designed to simply appeal to our emotions so strongly that we feel we "must" have that product and demand it from our doctors.  We all need to be educated medical consumers.  We need real information so we can make intelligent decisions.  Only then can we take charge of our health. 

 

Of course, frauds, quacks and cults have plagued the medical profession since ancient times.  What's new is the ease with which modern media, especially television and the web, can spread their message. In the 1920s, a doctor wrote a book claiming that eye exercises could cure nearsightedness, farsightedness and other eye conditions.  He quickly attracted a cult following, and today variations of his system are still heavily advertised and sold, especially on the web. But no peer reviewed clinical studies were ever done to prove the claims, no serious evidence exists to support them, and no reputable eye physicians believe in them.  In fact, exercises cannot change the shape of the eye, and the shape of the eye causes nearsightedness and farsightedness. (For more information about this, go to Vision Correction Key Point 1). 

 

More recently, extravagant claims have been made for the power of diet and nutritional supplements to cure all sorts of eye conditions.  In this case, the situation is more complicated.  Diet and nutrition can play an important role in preventing and treating certain serious eye conditions, such as glaucoma and age-related macular degeneration. (For descriptions of these conditions, go to Vision Correction Specific Interactive Medical Search)  But no evidence exists to support any claim that they can cure nearsightedness or farsightedness.

 

As for refractive surgery, specifically LASIK surgery, there's no question that it can greatly improve nearsightedness and farsightedness.  It is a sound, medically proven form of treatment with a very high rate of success.  But not everyone is a good candidate for it.  So we still need to be suspicious of overblown advertising and overly extravagant claims found all over the web – and elsewhere.

 

A good rule of thumb is always to check as many sources of information as possible. Read conflicting reports.  Get as many sides of the story as you can.  Avoid "sponsored" websites whose main purpose is to sell something.  For medical information, go to the websites of well-known university teaching hospitals, recognized medical organizations, such as the American Academy of Ophthalmology and the American Academy of Optometry, and government groups, such as the National Eye Institute.  

 

The non-informative brand of advertising tends to make things seem glamorous and glitzy – and trivial.  Medicine is not glitzy – and it certainly isn't trivial. So be especially suspicious of ads that make refractive eye surgery seem quick, easy and routine.  Remember, you're choosing someone to operate on your eyes.       

 

The final, most important point is simply this: in medical care, as in everything else, the rule is always, "Buyer beware. Buyer be aware."

 

Quick Facts

  • LASIK surgery has an extremely high success rate. Federal Food and Drug Administration statistics say that 92% to 95% of patients achieve 20/40 vision within six months of surgery. That's good enough to drive without glasses.

  • One of the earliest forms of refractive eye surgery, radial keratotomy, was discovered by accident. After a Russian doctor, Svyatoslav Fyodorov, removed glass from a patient's eye, he found that the patient's vision had unexpectedly improved.

  • Presbyopia is a natural condition that affects everyone as they get older. The lens of the eye becomes less flexible, making it harder for us to focus on close objects, such as reading matter. That's why we need "reading glasses" starting around 40.

  • Myopia, hyperopia, and astigmatism can be greatly improved by refractive surgery. Presbyopia cannot.

  • There are no clinical studies that support the claims that eye exercises or nutritional supplements can cure myopia, hyperopia, or astigmatism.

  • Eye care providers spend nearly $200 million per year on advertising. It works. Americans spend nearly $2 billion per year on vision correction.

  • Be wary of extravagant health care ads (including those for prescription drugs). The product advertised may not be appropriate for your problem, and probably will have side effects. Get your medical treatment from your doctor, not your television.

  *Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.

Ask Your Doctor

Vision Correction: Ask Your Doctor

 

  • Where did you get your training in refractive surgery? 
  • Why did you decide to do this kind of surgery?
  • How long have you been doing it and how many have you done? 
  • How many complications or problems have there been? 
  • Will you do the surgery yourself, or will you be directing an assistant?
  • What will the recovery period be like?
  • What are the long and short term side effects?
  • What follow-up care will I need?  How often will I need to see you after my surgery?
  • If I have pain, how will it be managed?
  • Can I wear my contacts before my surgery?
  • Can you work with my regular eye doctor?
  • Is there an alternative (less risky, less costly, fewer side effects) to the surgery?
  • How does the surgery work?
  • Am I a good candidate for the surgery?
  • Am I too old to have it?
  • How safe is the surgery?
  • Does the surgery hurt?
  • How long does it take to do it?
  • How accurate is it?
  • What if I blink or move during the procedure?
  • How soon after the surgery will I be able to see?
  • When will I be able to drive?
  • What are the possible complications?
  • Does the surgery cause night vision problems?
  • How long will the effect of the surgery last?
  • Do you offer financing?

Key Point 1

If you're interested in refractive eye surgery, be a smart consumer.  Do the research you need to make an informed choice for yourself – and avoid ads that sound too good to be true.

 

First of all, it's important to distinguish between the three kinds of specialists who provide different levels of eye care. 

 

  • Ophthalmologists are M.D.s (doctors of medicine) with advanced training in eye conditions (just as, for example, a cardiologist has advanced training in heart conditions).  As medical doctors, ophthalmologists are legally allowed to diagnose eye conditions and diseases, prescribe medications, and do eye surgery. 
  • Optometrists have an O.D. (doctor of optometry) degree, but they have not gone to traditional medical school and are not MDs.   Normally, they test and evaluate vision, diagnose some eye conditions, prescribe glasses and contact lenses, and make referrals to ophthalmologists for more serious conditions.  Some states may allow them to prescribe some medicines, but they do not do surgeries. 
  • Opticians are essentially eyeglass makers.  They fill prescriptions for eyeglasses, making the lenses and assembling and fitting the glasses.  Some states allow them also to sell and fit contact lenses. But they do not provide direct patient care; they do not do eye exams nor prescribe glasses.

 

Your primary care physician is not an eye specialist, but you should discuss your interest in refractive surgery with her or him.  Your doctor knows your medical and eye history, has information about whether you're a good candidate for the surgery, and can suggest questions you should ask an eye surgeon.  Your doctor can also recommend eye surgeons.  When requesting a recommendation, always ask "If you or your children were having this procedure, who would you want to do it?" 

 

Many ophthalmologic practices offer open houses and patient education seminars to prospective eye surgery candidates.  They can be a good source of information and allow you to hear questions asked by others, avoid possible feelings of intimidation that can arise when you speak to a doctor individually, and leave without making any commitments.  Of course they can also be full of hype and both high pressure – and very subtle – marketing techniques.  Go to several so you get can compare them.

 

When you do go to an eye surgeon individually, be prepared with lots of questions, including: 

 

  • Are you a board-certified ophthalmologist?
  • Where did you get your training in refractive surgery? 
  • Why did you decide to do this kind of surgery?
  • How long have you been doing it and how many have you done? 
  • Do you specialize in refractive surgery?  Some doctors include all laser eye procedures, including cataract surgery, in their numbers, so be sure to ask about the specific surgery you want.
  • How many complications or problems have there been?  What percent of the total number of procedures is this?  Be wary of doctors with problem rates above 1 percent – or who do not know their rate or refuse to discuss it.
  • Will you do the surgery yourself, or will you be directing an assistant?
  • How often will I need to see you after my surgery? Will I see you or an assistant or technician?  One reason why prices for LASIK surgery vary is that the surgeon may not be available for follow-up care or the follow-up care is abbreviated leaving the patient with suboptimal care.
  • What will the recovery period be like?
  • What are the long and short term side effects?
  • What happens if I need an enhancement, a further procedure, a second surgery?  Under what conditions will you do it?  Who pays for it?
    • Get these answers in writing, to protect yourself. 
    • One reason why prices vary is the number of follow-up procedures included in the original cost. 
  • What type of laser do you use, and why?  Do most other ophthalmologists use it?
  • Are your lasers inspected and maintained weekly?
  • Do you do studies testing new technologies for the companies?
  • Have you published articles or presented papers at national/international meetings on refractive surgery?  Check the doctor's website to see if his or her CV is available.
  • Do you have pupil-tracking or computerized eye-tracking systems to target the laser over the center of the cornea?
  • Can I wear my contacts before my surgery?
  • Can you work with my regular eye doctor?
  • Do you offer financing?
  • Have you been sued or have litigation pending?

For more questions to ask about refractive surgery, go to Ask Your Doctor

If any of the answers feel rushed or evasive, if the doctor seems impatient or insulted that you presume to ask them, then think seriously about choosing another.  Remember, you are deciding who will operate on your eyes, and you have every right to learn as much as you can about that person.  You should also be wary of anyone who spends less time collecting your medical history and more time trying to "up sell" you, that is, convince you to buy more than you intended. 

 

The doctor should spend time establishing a true doctor/patient relationship.  That means the doctor should get your complete medical history, ask about your lifestyle and other pertinent information, and do a complete eye exam. Of course it's your responsibility to give full, honest answers.  Only then can you and the doctor decide if you really need the surgery, will benefit from it, and if you're a good candidate for it.  (For more information about what makes a good candidate for refractive surgery, go to (Vision Correction Key Point 3)

 

Your other responsibility is to be sure you have realistic expectations for the outcome of the surgery – and discuss them with the doctor.  If you expect "perfect vision," and don't get it, you won't be happy, even though your vision has improved enormously.

    

Key Point 2

The eye is a complicated organ, with many components working together as a unit. It changes over time.  Understanding your own vision can help you make good decisions.

 

When light enters the eye, it passes through the cornea (a clear, rounded surface in front of the iris) and travels to the lens (a clear, flexible surface behind the pupil).  The cornea and the lens refract (bend) the light, so that it will focus on the retina, the eye's inside back wall.  (A small muscle around the lens helps the lens change shape.  If the light is coming from a closer object, the muscle squeezes the lens, increasing its curvature.  If the light is coming from a distant object, the muscle relaxes, lessening its curve.  These changes in shape change the focusing power of the lens, that is, the way the lens bends the light.)

 

If everything is normal, the light rays are focused (come together) onto the retina.  The retina consists of millions of visual cells.  They convert the light into electrical impulses and send those impulses through the optic nerve to the brain. As a result, we see a clear, sharp image, with everything – both near and far objects – in focus. 

 

But if the eyeball is too long, or the cornea is overly curved, the light rays will be improperly focused.  They will come together in front of the retina.  Then, close objects will appear sharp, but distant ones will be blurry.  This condition is, of course, known as nearsightedness or myopia. 

 

If the eyeball is too short, or the cornea has less of a curve than it should, the opposite happens.  The light focuses on a spot behind the retina. Near objects appear blurry; more distant ones are sharp.  This condition is farsightedness or hyperopia.  

 

A third possibility is that the cornea (or, much less often, the lens) is unevenly curved.   The result is that light may focus on the retina, but not on one focal point. This causes a blurry image, a condition known as astigmatism.  A person can have astigmatism alone, or combined with either nearsightedness or farsightedness.

 

Despite what you may be been told, reading in bad light, squinting, and sitting close to the television will not cause or worsen any of these three conditions (though they may strain your eyes).  They are known as refractive errors because they involve problems with the way the eyes refract light.  There are many theories about what causes them, but in general people do seem to be born with them (though astigmatism can develop after an illness or surgery of the eye, or an accident).  Often they are first noticed in childhood, worsen through adolescence, then become stable.

 

Refractive errors are the most common eye conditions and have been traditionally treated by wearing glasses (technically called corrective lenses) and contact lenses. Today there are several types of contact lenses: hard, soft, rigid gas-permeable, disposable, extended wear, etc. You should discuss these options with your eye doctor and understand what's best for you before making any choices. 

 

These three conditions are also the ones that may be alleviated by refractive surgery.  This surgery uses lasers to change the shape of the cornea, which then changes how the cornea refracts light.   But there is a fourth refractive error, known as presbyopia that is generally not correctable by refractive surgery.

 

Presbyopia occurs naturally as we get older.  Unfortunately, in this context "older" can mean as young as forty.  That's when we may start to notice that we're holding what we read further from our eyes.  We're losing the ability to focus on closer objects because the lenses in our eyes are becoming less flexible.  Despite the action of the muscle surrounding it, the lens changes shape less easily.  So even if we've never had glasses before, we now need "reading glasses."

 

Various types of glasses can compensate for presbyopia, ranging from simple, over-the-counter magnifiers (no need to spend $10.00 or more for them at the pharmacy; you can get perfectly good ones at a $1.00 store) to prescription lenses to contact lens.  If you already wear glasses, then you'll need either a separate pair of glasses for close vision (reading glasses) or bifocals. 

 

There are many types of bifocals available today: traditional (with a visible line), lineless (often called progressive), trifocal (also called multifocal, and available with or without lines).  Bifocal contact lenses are also available, as well as monovision contacts, in which one eye uses a lens for distance vision, and the other eye uses one for a close vision; a more recent option is modified monovision: a bifocal contact in one eye, a lens for distance vision in the other.  Again, you need to discuss the options with your eye doctor and understand what's best for you before making any choices.

 

However, remember that refractive surgery generally has no effect on presbyopia.  If you wore reading glasses before the surgery, you'll still need some form of them after it.

    

Key Point 3

Refractive surgery changes the way your eye refracts light.  It isn't for everyone.  But if you are a good candidate, it can dramatically change the way you see.

 

So what makes a good candidate?  The basic requirements include:

  • be over 18 years old (if you're younger than that, your vision may still be changing)
  • have no active eye disease, such as glaucoma
  • have a stable eyeglass prescription for at least two years.
  • have vision correctable to at least 20/40.
  • have healthy corneas.

 

You're probably not a good candidate if you have:

  • extreme myopia (high myopes can get a phakic IOL which is an implant placed inside the eye)
  • thin corneas
  • large pupils
  • very dry eyes
  • severe autoimmune diseases such as rheumatoid arthritis and Sjogren's Syndrome (some patients have very mild autoimmune disease which is no longer a contraindication)  
  • advanced glaucoma or other serious eye conditions (some patients with well controlled glaucoma may have refractive surgery)

You're not a candidate if you:

  • have cataracts
  • are pregnant
  • are taking certain drugs (including the acne medicine Accutane)

 

Also, if you're seriously involved in contact sports such as wrestling, boxing, and martial arts, be aware that a severe eye injury after this surgery could cause your vision to worsen.  In these instances, most doctors recommend not having Lasik but rather PRK where there is not risk of flap dislocation with severe eye trauma.

 

The goal of refractive surgery is to change the way the eye refracts light by changing the shape of the cornea.  One of the earliest forms of this surgery is called radial keratotomy (RK), discovered by accident by a Russian doctor, Svyatoslav Fyodorov.  After removing glass from a patient's eye, the doctor found that the patient's vision had unexpectedly improved.

 

By the late 1970s, RK was being practiced in the U.S.  In RK, the surgeon makes a series of radial incisions in the cornea using a precision calibrated diamond knife.  Radial means the cuts extend out from the center of the cornea to its edge, like the spokes of a wheel.

 

Today, lasers are used instead of knives, and RK has largely fallen out of favor in the U.S.  A few years ago, the most popular form of laser based refractive surgery was PRK, an acronym for photorefractive keratectomy.  In this procedure, the surgeon first removes the thin outer layer of the cornea, called the epithelium, then uses an excimer laser (a type of laser that does not produce heat) to shave off cells from the cornea, changing its curvature.  A computer system assures precision by guiding the laser's movement.  The epithelium grows back naturally, forming itself around the cornea's new shape.

 

LASEK, an acronym for laser-assisted sub-epithelial keratectomy, is a variation of PRK in which the epithelium is not removed.  Instead, the surgeon cuts into it and peels it back, like a flap.  Then, as in PRK, the excimer laser reshapes the cornea. After the reshaping, the flap of epithelium is put back into place.  About 10% of refractive surgeries are done using PRK or LASEK.  PRK or LASEK are often recommended to patients with thin corneas or marginally dry eyes, or in individuals who are at risk for a severe eye injury, such as a boxer. 

 

But today, the refractive surgery of choice – and the subject of this episode of Second Opinion – is clearly LASIK, an acronym for laser in situ keratomileusis.  In this procedure, the surgeon makes a flap in the cornea itself, using an instrument called a microkeratome, or a special cutting laser.  The process takes only a few seconds. 

 

Then, as in the other procedures, an excimer laser removes a very small amount of tissue from the inner portion of the cornea.  Again, a computer system guides the surgery.  The laser's action has been pre-programmed to reshape the cornea to the precise dimensions that will give the patient the maximum correction.  This part of the surgery normally takes no more than a few minutes.  Finally, the flap of cornea is put back into place, where it quickly bonds to the reshaped cornea's surface.  This also takes only a few minutes.

 

If you choose to have LASIK surgery, you'll find it's an outpatient procedure, and usually takes less than 10 minutes per eye.  But you'll probably be at the doctor's office for about an hour-and-a-half.

 

You will need someone to drive you home from the surgery and will need a day or two of recovery time.  It may take a month or two for your vision to fully stabilize, but normally you'll notice the results of the surgery within a few days. You may also notice that distant objects don't look as crisp and clear as they might.  This problem has been common enough that artists, photographers, craftspeople and others should be aware of it.

 

After surgery, roughly 5-10 percent of patients have problems, such as under or over correction, that might require one or more secondary procedures.

 

The most common potential complications from the surgery are:

  • dry eye
  • problems with night vision
  • hazy or blurry daytime vision

 

However, these side effects usually disappear after three months. 

 

A second set of problems occur less than five percent of the time, six months to a year after surgery, and seem to depend on the type of laser used.  These are: 

  • seeing halos, glare and starburst patterns when looking at lights
  • ghosts and double images
  • problems seeing in dim light
  • feeling that "something" is in your eye
  • sensitivity to light
  • red eyes

 

Finally, serious complications happen to less than one percent of patients.  These include:

  • infections in the corneal flap
  • pain or discomfort
  • loss of best corrected vision (your vision with glasses or contacts)
  • swelling or pressure in the eye

However, in general, LASIK surgery has an extremely high success rate.  Federal Food and Drug Administration statistics say that 92% to 95% of patients achieve 20/40 vision within six months of surgery. That's good enough to drive without glasses.

Medline Plus

Medline Description: 

Conduct an off-site search for Vision Correction information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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