Some sent me an email with links about LASIK...

[Barry Santini]

And the vids on You Tube were *all* negative. They all discussed how "so many people" are "unsatisfied" with their LASIK vision outcomes...

It got me to thinkin'...

What's the real difference between that scenario, and the one's we're familiar with every day with eyewear and Cls...

A: Nothing!

Well then the real insight here is that when it comes to their eyes,

The public just takes their vision too much for granted. They are ill-informed about what to reasonably expect from the nature of the individual and their expectations about their vision, and just how much can be predicted with absolute certainty in advance of working with them.

Thoughts?

Barry

[For-Life]

With vision corrective surgery, I am a firm believer that it can be done right without any problems. The reason why their are problems is the person doing it. They are rushing through and are not properly trained.

You find someone who does it right and takes the time to do it, and I believe you will be okay.

[Uilleann]

I'm not even certain that the doctor can be 100% to blame. Much of the onus falls with the patient themselves as well. There are many documented cases of patient non-disclosure pertaining to poor eye health history etc. and they elect to proceed with LASIK or some other type of refractive surgery. Clearly this is a poor and sight threatening choice for the patient. But it is their choice in those types of cases.

Not everyone is a good candidate for the procedures and a good doctor, backed by a reputable clinic (in those cases where a clinic or company are the top management tier) is the best possible choice for any potential patient, and that should well include turning away patients who the doctor feels are not very good candidates. Knowledge is also key- making ABSOLUTELY CLEAR to the patient what a reasonable expectation of outcome is, given their known health history, as well as current and future visual needs.

Remember - without negative reporting or legislation, both the American media (in general) and Congress would have precious little to do with their time. :( And honestly...how many videos of a perfect LASIK procedure would you want to watch on YouTube if there were just as many showing what seemed to the uneducated public to be catastrophic failures? We love a spectacle...the ancient Romans were no different with the Colosseum.

[fjpod]

With vision corrective surgery, I am a firm believer that it can be done right without any problems. The reason why their are problems is the person doing it. They are rushing through and are not properly trained.

You find someone who does it right and takes the time to do it, and I believe you will be okay.

Agreed, but there are also situations where the patient is not a good candidate, and they should be counseled not to have the procedure. Some places "oversell" the product. And it's not like a pair of glasses where you can go back and try to get an adjustment or a remake. Once it's done, it's done. So we should all be very cautious and thoughtful when advising patients about something permanent like LASIK ( or multi-focal IOLs). That being said, my daughter had LASIK 4 years ago. She was a -7.00. She is doing fine with 20/20 in each eye.

[orangezero]

Has anyone ever had a patient who could actually explain what presbyopia is? Or, how lasik may actually make their functional near vision worse?

I never cease to be amazed at how so many eye professionals don't see a problem with a lifetime -2.00DS myope is going to be happy getting lasik at 50.

To 95% of the population, lasik "cures" your bad "eyesight" and you'll never need glasses again. Advertising has worked.

[Barry Santini]

Has anyone ever had a patient who could actually explain what presbyopia is? Or, how lasik may actually make their functional near vision worse?

I never cease to be amazed at how so many eye professionals don't see a problem with a lifetime -2.00DS myope is going to be happy getting lasik at 50.

To 95% of the population, lasik "cures" your bad "eyesight" and you'll never need glasses again. Advertising has worked.

Couldn't agree with you more, orangezero! And, I think for ECPs to use "20/20" as an acceptable sight benchmark is inappropriate.

We all know better than that!;)

Barry

[Andrew Weiss]

Nice thread, Barry. Orangezero spoke for me in his post, so I'd like to address another issue which you raise in your last paragraph:

The public just takes their vision too much for granted. They are ill-informed about what to reasonably expect from the nature of the individual and their expectations about their vision, and just how much can be predicted with absolute certainty in advance of working with them.

My observation is that we take all of our body's functioning for granted unless something is permanently compromised. Think about it, Barry: do you take your breathing for granted? Now, what if you had severe asthma? Well, you'd realize that you can't take breathing for granted, but then you could use an inhaler and get relief. A bit like getting glasses, contacts or Lasik that'll give you "normal" vision. Now, what if you have cystic fibrosis? Maybe all the treatments don't get you to the point where you can ever breathe freely. Your breathing is permanently compromised.

My point here is this: it isn't just our eyes and our vision that we take for granted. How we relate to these impairments will depend on our temperament. Some of us will accept the impairments and make the best of it. Some of us will resent it and make our lives, and the lives of others, miserable. And I've even met some who see the impairment as a gift, an opportunity to deepen their love, compassion and generosity. Each one of those people will take in information about their impairments differently. And if we're the resentful ones, we'll most likely expect a complete "cure" and be mad as h*** when it doesn't happen (and resentful about paying every dime for the treatment).

[Barry Santini]

Good, informative points, Andrew. Thanks for contributing!

Barry

[LasikExpert]

My perspective may be a little different. I work for a nonprofit Lasik patient advocacy. We don't provide Lasik, just Lasik information and we certify refractive surgeons' patients' results.

At the FDA's Opththalmic Devices Panel meeting in April 2008, where most of those anti-Lasik videos originated (I made four presentations), our organization provided the preliminary results of the USAEyes Competence Opinion Relative to Expectations (CORE) patient survey. Refractive surgery patients at least six months postop were sent a detailed survey that was returned directly to our organization. The results may or may not be surprising:


Preliminary results of the USAEyes CORE patient survey:

• 99% report quality of life as expected, better, or much better after vision correction surgery
• 98% state day vision as expected, better, or much better
• 98% report no complications or complications that are seldom problematic
• 98% would recommend surgery to family and friends.
• 97% would have surgery again, knowing what they know now
• 96% wear corrective lenses as often as expected, less than expected, or much less than expected
• 96% report postop vision without lenses as expected, better, or much better than expected when compared to preop vision with lenses
• 96% report overall quality of vision as expected, better, or much better than expected
• 91% report no complications at any time
• 91% state night vision as expected, better, or much better than expected
• 7% report complications seldom problematic, however 91% of these same patients would have surgery again
• 2% report complications frequently or always problematic, however 22% of these same patients would have surgery again

The full report with graphs is at Lasik Patient Survey.

There is comfort in the thought that all bad Lasik outcomes can be traced to an inferior surgeon or a poor candidate or poor communications or too much sales pitch, but that simply is not the case. There are patients who preoperatively had no history that would indicate a poor outcome, were well informed, had reasonable expectations, and went to excellent surgeons whose names we all recognize, yet they have a bad outcome.

Sometimes everything is done right and the result is wrong.

Fortunately, as is affirmed by the USAEyes CORE patient survey, this is very rare and overall patients are very satisfied with their outcomes, but sometimes it is not so easy to find blame to aim one's finger.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

[For-Life]

Agreed, but there are also situations where the patient is not a good candidate, and they should be counseled not to have the procedure. Some places "oversell" the product. And it's not like a pair of glasses where you can go back and try to get an adjustment or a remake. Once it's done, it's done. So we should all be very cautious and thoughtful when advising patients about something permanent like LASIK ( or multi-focal IOLs). That being said, my daughter had LASIK 4 years ago. She was a -7.00. She is doing fine with 20/20 in each eye.

I can agree with that.

Fyi, when my family retires and gets out of the business, I will probably have it done. I do not trust any of the optical shops here, and I know what to look for in a MD for the surgery.

[orangezero]

Thanks for the post lasikexpert. Do you have any stats on the age group of those surveyed? Were most 6-12 months out? (edit: answered my own question with your link)

I tend to see a lot of patients who have had "great" lasik results and are super excited about their surgery, even calling it the best thing they've ever done in their life. But they came in because they can not see to drive at night. Or they can't read the computer at work. Or they have fluctuating dry eyes. I know I wouldn't be real happy if I paid that much for surgery and two years later I need glasses. Perhaps thats just me...

My biggest beef is the advertising. A lot of times its just false, even from the more well respected surgeons in my area. We don't have any "in and out" places or bottom feeders in my area. Generally they are general ophthalmology surgeons who do a fair amount of lasik.

A lot of the patients in my area tend to think of it as paying for all of their eyecare up front. In other words, now they don't need to ever get another eye examination again.

Certainly, this surgery is linked to a whole host of psychological issues and a fair amount of good ol' human nature.

[LasikExpert]

Do you have any stats on the age group of those surveyed?

Yes, but they were not presented in the FDA report. We should have an updated report with additional patient data before the end of the year.

I know I wouldn't be real happy if I paid that much for surgery and two years later I need glasses. Perhaps thats just me...

I spoke to a 41 year old 4.00D myope this morning. I advised her to Google "Sudden Presbyopia" and "Monovision Lasik" before she made a move toward refractive surgery.

We get many people who want Lasik to get rid of reading glasses. Oh, if only it were possible without some sort of trade-off.

My biggest beef is the advertising. A lot of times its just false, even from the more well respected surgeons in my area.

I find today that outright lies are rare, but the impression of perfection in advertisement can be dangerous. As an example, "20/20 Guarantee". I think it is great that a surgeon is confident enough to put the cost of surgery on the line, but this kind of "warranty" may lead the public to believe that Lasik is infallable and that 20/20 means perfect vision. Nieither are true.

A lot of the patients in my area tend to think of it as paying for all of their eyecare up front. In other words, now they don't need to ever get another eye examination again.

Of course continued eye care is necessary, but there is some truth in the idea that after successful Lasik there will be a reduced cost of glasses, contacts, solutions, etc. It is something to consider when considering cost.

Certainly, this surgery is linked to a whole host of psychological issues and a fair amount of good ol' human nature.

Don't get me started on that. I've dealt with the dark side of some peoples' psychological issues.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

[nickrock]

Mr. Hagele,
I've had a chance to look at your website and I am thoroughly impressed. I had bilateral myopic astigmatic LASIK over 8 years ago and my vision has remained stable at 20/20+2 OU. I now work with several corneal specialists that do a fair amount of refractive surgery and it has given me a unique outlook regarding elective surgery. I think that the biggest factor that we address with our patients is expectations. I believe that for the most part if your patient and the doctor (or staff) mutually establish a realistic outcome, the patient will be extremely satisfied.
I also believe that the practice I work in is not the typical refractive "outfit." Our patients, believe it or not, are actually well educated regarding the procedues, presbyopia, monovision, and the need for correction after surgery if that is the established target outcome. Rarely, but occasionally, we have the presbyopic emmetrope that wants to get rid of their reading glasses. We immediately explain presbyopia and the inherit "trade off" of correcting that type of prescription, discourage that treatment and the patient is sent on their merry way, happy with our honesty.
Anyway, I think this is a great thread. Let's keep it going!!

[chip anderson]

Talked with a very find ophthalmolgist today. That said amoung other things that very large corporations all over the country are opening lasic centers in Mall's and will hire anyone with a medical degree to do walk in lasics on anyone with x00 dollars.
Also remarked that unlike the previous batch of ophthalmolgists who all wanted to be catarac jockeys, now they just want to be refractive surgeons. Won't even attened lectures and instruction on medicine and optics in residency, just want the slice and dice line.

Scary ain't it?

Chip

[nickrock]

I can't imagine why malpractice insurance is so expensive.:drop:

[LasikExpert]

Nickrock;

Thank you for your kind words. I personally appreciate your opinion as I wrote just about every article on the website.

Chip;

I've been around long enough to remember when organized ophthalmology said exactly the same things about the "Cataract Buccaneers". I'm sure the ophthalmologist of whom you speak is a fine person and probably honestly believes that a high volume Lasik clinic would hire anyone and do surgery on anybody, but I just don't buy the blanket condemnation. And I'm in a unique position to have some insight.

Some of the surgeons participating in USAEyes patient outcome certification would be considered by some as...shall we say...high volume. Since part of my job is to compare each participating surgeon's patient results to the norms and their peers, I know for a fact that their patients have virtually the same rate of satisfaction.

What is probably the greatest concern with the "Lasik Jockeys" is when something goes wrong. While someone who is doing a few hundred Lasiks a month is probably going to be pretty good at it in short order, when something goes awry s/he may not have the rounded experience necessary to get the patient out of trouble. A backup is needed.

Then there is the issue of corporate greed. Yes, I said it. The two largest national chains are publicly traded corporations. They have shareholders that want a return on their investment and about the only thing that can make the value of a Lasik chain’s stock lower than gross incompetence by its surgeons, is consumer confidence lower than a snake’s belly button.

Glenn Hagele
Council for Refractive Surgery Quality Assuranc
http://www.USAEyes.org

[Barry Santini]

Preliminary results of the USAEyes CORE patient survey:

• 99% report quality of life as expected, better, or much better after vision correction surgery
• 98% state day vision as expected, better, or much better
• 98% report no complications or complications that are seldom problematic
• 98% would recommend surgery to family and friends.
• 97% would have surgery again, knowing what they know now
• 96% wear corrective lenses as often as expected, less than expected, or much less than expected
• 96% report postop vision without lenses as expected, better, or much better than expected when compared to preop vision with lenses
• 96% report overall quality of vision as expected, better, or much better than expected
• 91% report no complications at any time
• 91% state night vision as expected, better, or much better than expected
• 7% report complications seldom problematic, however 91% of these same patients would have surgery again
• 2% report complications frequently or always problematic, however 22% of these same patients would have surgery again

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

Glenn:

It also my opinion that people state their quality of life is better after refractive surgery, in many cases, because:

Eyewear (and Contacts) quality is so poor in the United States.

Thoughts?

Barry

PS - And I guess people's vision is no longer fluid after surgery, nor do UV rays need to be blocked from the cornea and surrounding adnexa. (Said somewhat sarcastically)

[fjpod]

Has anyone ever had a patient who could actually explain what presbyopia is? Or, how lasik may actually make their functional near vision worse?

I never cease to be amazed at how so many eye professionals don't see a problem with a lifetime -2.00DS myope is going to be happy getting lasik at 50.

To 95% of the population, lasik "cures" your bad "eyesight" and you'll never need glasses again. Advertising has worked.

I've been in practice thirty years. I think I have gotten one patient to understand presbyopia.

Oh, and just yesterday for the hundredth time, a patient taught me about how there is a new laser procedure for removing cataracts.:hammer:

[LasikExpert]

It also my opinion that people state their quality of life is better after refractive surgery, in many cases, because:

Eyewear (and Contacts) quality is so poor in the United States.

Thoughts?

Perhaps quality of eyewear is an issue, however if you look at the sample of the USAEyes CORE patient survey you will see that the baseline of nearly all questions is "As Expected", such as:

17) Describe the quality of your current nighttime vision
without glasses or contacts.
��Much better than expected
��Better than expected
��As expected
��Worse than expected
��Much worse than expected

What we see is that by and large, vision correction surgery patients are getting what they are expecting. This is as much an endorsement of participating doctors' informed consent as it is the success of the procedure. Many patients who state that they use eyewear "Frequently" also state that this use of eyeware is "As Expected".

The USAEyes CORE patient survey has not been administrated outside the US, so I have no data to show that non-US patients have a higher or lower rate of satisfaction.

Anecdotally, I have traveled outside the US a bit and my wife is from Eastern Europe. Based on her experiences and mine, Americans complain a whole lot more than Europeans. I suspect our litigation rates prove that out.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

[LasikExpert]

Oh, and just yesterday for the hundredth time, a patient taught me about how there is a new laser procedure for removing cataracts.

Oh bother. I'm probably guilty of perpetuating that myth.

In addition to my duties at the Council for Refracative Surgery Quality Assurance I have recently founded Cataract Free America, a nonprofit cataract patient advocacy. At that website we state that secondary cataracts (posterior capsule opacification) are often resolved with a laser.

Of course we do not suggest that a laser is used for primary cataracts.

I've also learned that you cannot "unteach" what a patient already "knows". You can explain all day the difference between Phaco/ECCE and a YAG laser, but the patient will simply ignore you because s/he "knows" a friend had laser surgery for cataracts.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

[fjpod]

One other thing...when you look at a survey like the one above...human nature being what it is, we (as a patient) don't like to admit mistakes about something like surgery that cost us $2-5,000. People tend to convince themselves that everything is alright, when in fact, it is only half alright. We're also the same way about buying cars and houses...after making a big commitment we don't like to acknowledge that we may have made a mistake.

I'm not saying that LASIK is a terrible thing...just that you have to be careful of surveys. A wise person once said, "There are lies. There are damn lies. And then there are statistics."

[LasikExpert]

One other thing...when you look at a survey like the one above...human nature being what it is, we (as a patient) don't like to admit mistakes about something like surgery that cost us $2-5,000. People tend to convince themselves that everything is alright, when in fact, it is only half alright. We're also the same way about buying cars and houses...after making a big commitment we don't like to acknowledge that we may have made a mistake.

I'm not saying that LASIK is a terrible thing...just that you have to be careful of surveys. A wise person once said, "There are lies. There are damn lies. And then there are statistics."

Ohhh so true. Cognitive dissonance is most certainly at play. Just look at the percentage of people who have complications that are frequently or always problematic, and yet would have the surgery again. Some of that is CD, some is true delight in not needing eyewear.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

[Barry Santini]

Perhaps quality of eyewear is an issue, however if you look at the sample of the USAEyes CORE patient survey you will see that the baseline of nearly all questions is "As Expected", such as:

17) Describe the quality of your current nighttime vision
without glasses or contacts.

I maintain, as do other dispensers, that the American public does not:
1. Keep their eyewear clean
2. understood that they have been *victims* of sub-quality, scratch and peel off AR coatings for over 10 years.
3. The psychology of justifying their decision to have the surgery means that they're statements will be supportive to avoid cognitive dissonance (as desscribed below).

What we see is that by and large, vision correction surgery patients are getting what they are expecting. This is as much an endorsement of participating doctors' informed consent as it is the success of the procedure. Many patients who state that they use eyewear "Frequently" also state that this use of eyeware is "As Expected".

The USAEyes CORE patient survey has not been administrated outside the US, so I have no data to show that non-US patients have a higher or lower rate of satisfaction.

Anecdotally, I have traveled outside the US a bit and my wife is from Eastern Europe. Based on her experiences and mine, Americans complain a whole lot more than Europeans. I suspect our litigation rates prove that out.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

Thank you Glenn, for contributing to this thread!

Barry Santini

[Barry Santini]

I've also learned that you cannot "unteach" what a patient already "knows". You can explain all day the difference between Phaco/ECCE and a YAG laser, but the patient will simply ignore you because s/he "knows" a friend had laser surgery for cataracts.

Glenn Hagele
Council for Refractive Surgery Quality Assurance
http://www.USAEyes.org

This statement so completely embodies the totality of the culture of American hubris, IMHO.

Barry

[Happylady]

I have talked to several people who have had bad outcomes due to extremely dry eyes, horrible night time vision, flap loss (or something like this), and double vision. The man with double vision was still happy with his outcome despite seeing two of everything with his one eye.

Of course, most people are happy with their results. But, 2% very bad outcome rates don't seem so bad unless you are in that 2%, then it is 100% for you.

Google Kathy Griffin and Lasik, she had a poor outcome in one of her eyes that has never been resolved completely.