Hi,
I had a patient in today who is R-10.00/-3.00 and L-7.25/-0.50. She has been advised against PRK and is obviously borderline for LASIK. She is now considering a Lensectomy. She is under 40 and has good amplitude of accomodation. She is quite aware of most of the pros and cons, but is looking for advice.
Personally I would think that LASIK would be better, even if it can't fully correct the right eye.
Any thoughts/comments would be appreciated.
Regards,
Euan
Fit the woman with a good pair of contacts and forget it. They are reversable if things go wrong.
Chip
If it were my eyes, I'd have the lensectomy, but they only do them for cataracts in America. I would think it would be less risk than refractive corneal surgery, and possibly about zero out the refractive error. Do you see much success in the UK with that procedure? Al.
As a -4.75 myope, I was fairly confident in having LASIK performed. I don't know if I would have had the same enthusiasm if I had the Rx you describe.
I concur with Chip on this one- if it is at all possible to fit this patient with contact lenses, that's what I'd advise.
If the patient is dead set on having some kind of procedure, I'd have to say the lensectomy would be the most appealing to me. The bummer being the immediate and permanent need for +2.50 add. Perhaps you could cyclo her for a day and give her some sample bifocals to show her what she'll be getting into?
Good Luck,
Pete
Chip,
She already wears contacts and hogh index specs.
She wants to be able to get up in the middle of the night and see. Skiw, swim, do sports, etc, without the hassle of lenses.
It is not really a vanity thing.
Euan
Euan, what is "skiw"?
I think he meant ski....Mullo
mullo, who knows what means what in Scotland?
Could have a few under his belt....Mullo
The Scottish are quite hard, I'd choose your words carefully :)
I am of Scottish and Irish decent. I don't know what you mean.****, I spilled my ****en beer..........Mullo
[This message has been edited by mullo (edited 05-01-2001).]
[This message has been edited by mullo (edited 05-01-2001).]
[This message has been edited by mullo (edited 05-01-2001).]
Hi,
For the picky and pedantic out there the typos are "high" and "ski".
Now it would be useful to actually get advice and opinions that might be of some help to this patient, if you would be so kind.
Euan
[This message has been edited by McGinty (edited 05-02-2001).]
Hello,
She NOT right candidate for lensectomy.
As for lasik we do not know long term effects of it as yet,anyway she will still need to wear glasses or contacts with her type of ametropia even after lasik.
Best is contact lenses for her.If she must go for lasik,let it be done in one eye i.e.left eye and leave right eye for contacts(for good reasons).
Shabbir
Euan,
I can understand her desire to be "free" of relying on her glasses and/or contacts. Even if her vision isn't 20/20 uncorrected, she should at least be able to function without correction. Post LASIK, I'm 20/15 OD 20/25 OS uncorrected. Makes a huge difference at the beach, in the shower (I can tell the shampoo from the conditioner now ;), etc.).
My concerns regarding LASIK are 1.) the 3D of astigmatism, and 2.) the thickness of her corneas (after all, to correct 10D of myopia you're going to have to flatten out the stromal layer of the cornea quite a bit).
Regarding the lensectomy, I hate to see someone lose all accommodation permanently at a young age.
Given thick enough corneas and a very reputable MD, I'd say go with the LASIK (as long as the common complications of LASIK- halos, mainly won't cause a big problem for her lifestyle). For example, my brother makes his living driving trucks (mainly at night). For him, decreased night vision due to halos would be job threatening.
Good luck, and let us know what decision your patient makes.
Pete
A thought provoking article:
Eric Vance of the Tampa Bay Buccaneers had successful LASIK recently. Athletes should be very careful to protect their eyes against trauma after surgery. Photo courtesy of Updegraff Lasik Vision.
Before You Choose Refractive 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.
"Just because someone is advertising, it doesn't necessarily mean they're more qualified."
--Penny Asbell, M.D.
"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."
5 Tough Questions
to Ask
The Council for Refractive Surgery Quality Assurance is a new organization that reviews credentials of refractive surgeons. The Council's website includes a long list of tough questions you can ask a surgeon before opting to use his or her services, as well as answers to look for. Here are just a few:
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.)
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.
Offshore powerboat racer Michael Allweiss had worse than 20/400 vision before surgery and couldn't read the big E on the Snellen visual acuity chart. Now his vision is normal. Photo courtesy of Updegraff Lasik Vision and the American Power Boat Association.
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.
"If you don't have a good surgeon, you can have the most precise laser in the world and still get poor results."
--Steve Updegraff, M.D.
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."
[This message has been edited by rfish777 (edited 05-02-2001).]
Another thought provoking article:
YOU ARE HERE: Home > LASIK & Vision Surgery > Outcome Statistics ... ON THIS PAGE: Hard-to-find statistics on results and complications of LASIK, Intacs, and other corrective eye surgery procedures.
By Liz Segrè
Possibly the most important question you can ask about vision correction surgery is, "What are my chances of seeing 20/20?"
The real answer is that there's no absolute guarantee of seeing 20/20 afterward, but many people do achieve that result or better.
Clinical Studies
and the FDA
The Food and Drug Administration relies heavily on clinical studies when determining whether to approve a laser, a surgical procedure, a drug treatment, or a medical device (such as contact lenses or corneal inserts).
Criteria include patient safety, efficacy both short- and long-term, and adequate product labeling. The process can take several years, since it involves a lot of discussions with FDA panel members as well as testing on both animals and people.
Depending on the product or procedure, many companies find it is easier to obtain marketing approval in other countries before the United States, because the FDA is so rigorous. In fact, in the early 1990s many Americans traveled to Canada for laser vision correction because it was available there before it was approved in the United States.
Sometimes the FDA's pace may seem slow, but the good part is that American refractive surgery patients benefit from the experience that clinical researchers have gained by using the device or procedure in other countries.
It's not easy to find statistics about refractive surgery results, so we've gathered some figures for you -- many from pre-FDA approval clinical trials -- that may help you decide one way or another whether you want to go ahead with the procedure. We'll be adding new information to this page from time to time, so please revisit soon.
Study Methods and Goals
Most studies try to determine how many people achieve 20/20 or better vision postoperatively without correction from glasses or contact lenses. They also examine how many people reached 20/40 or better. (In most of the United States, 20/40 is the minimum visual acuity you need in order to obtain a driver's license.)
Since vision changes a bit as your eyes heal -- usually for the better -- many studies measure patients' eyes right after surgery, a few days later, a month later, and six months later.
LASIK and PRK
LASIK and PRK results have been notably consistent ever since the FDA approved the first excimer lasers in 1995. Best results are achieved by low to moderate myopes, with not as good results for high myopes or hyperopes. Astigmatism can be treated as well, though the particular type and severity of astigmatism a person has will affect results.
Here are some numbers:
In recent studies, 98% of laser patients achieve 20/40 vision or better after one or more treatments. (Source: TLC Laser Eye Centers)
As of May 15, results showed that 32% of eyes undergoing LASIK for nearsightedness achieved 20/20 or better and 83% achieved 20/40 or better the day after surgery. Six months following surgery, 46% of eyes were seeing at least 20/20, with 90% seeing 20/40 or better. (Source: data.site, an outcomes database for eye doctors)
Recent studies reveal that two thirds of PRK patients reach 20/20 or better vision, while 95% reach 20/40 or better. (Source: American Academy of Ophthalmology)
Studies of 1,013 LASIK-treated eyes showed 92% were corrected to 20/40 or better and 47% were corrected to 20/20 or better. (Source: FDA report of its 1999 approval of the Summit Autonomous excimer laser for use in LASIK)
Of 1,736 eyes with low to moderate nearsightedness with or without astigmatism, about 87% achieved 20/40 or better a month after LASIK, and 93% saw 20/40 or better six months later. The number was 45% rising to 50% for achievement of 20/20 or better. (Source: Cataract and Refractive Surgery LASIK Study Summary of PMA Data, as reported by LASIK Institute)
An Argentina study of highly nearsighted eyes (-10.25 to -15.00 diopters) showed average refractive error of -0.55 diopters and average best corrected visual acuity of about 20/30. (Source: 1998 study as reported by LASIK Institute)
Corneal Ring Inserts
FDA-approved for mild myopia (-1.00 to -3.00 diopters), Intacs are the only corneal ring inserts being used in the United States now.
In U.S. clinical studies, 97% of patients achieved 20/40 or better vision, 74% saw 20/20 or better, and 53% saw 20/16 or better. (Source: KeraVision)
What Is "Sands of Sahara"?
"Sands of Sahara," or diffuse lamellar keratitis (DLK), has occurred in some patients. This is a concentration of white blood cells on the surfaces of the corneal flap that was cut during LASIK. The cells accumulate in the tiny pattern, resembling sand dunes, that the blade (or microkeratome) creates during the cut.
Researchers have theorized that microscopic substances on the blades, such as oil from the blade motor or tiny particles remaining from the blade manufacturing process, may be inflaming the corneal tissue. Another cause may be tiny bacterial toxins not always eradicated when microkeratome blades are sterilized. Researchers also wonder if debris in the tear film is to blame.
Dr. Roger Steinert, an ophthalmologist who performs LASIK, wrote in the Sept. 2000 issue of Refractive Eyecare for Ophthalmologists that LASIK "creates a potential space within the cornea" where inflammatory cells triggered by foreign particles or by trauma (in this case, the LASIK procedure) would tend to accumulate. He takes a variety of precautions to avoid this "inflammatory response process," including: careful patient selection to avoid those prone to inflammation; inspection of the microkeratome handle, blade and motor under the operating microscope; and meticulous instrument sterilization protocols that were developed recently in response to the Sands of Sahara problem.
Treatment for Sands of Sahara generally involves steroids to eliminate the inflammation and may include irrigation of the flap area with a salt solution to get rid of accumulated white blood cells. Dr. Steinert emphasizes the need for fast, aggressive treatment for Sands of Sahara.
Side Effects
Halos and glare from bright lights at night, pain, starbursts, blurred vision, night vision problems, infection, dryness, and itchiness are the main complications that patients have reported after vision correction surgery. "Sands of Sahara" has also been noted in some patients (see sidebar).
Fortunately, these problems don't occur to most patients, and when they do, they are usually temporary and treatable. Even so, you should take side effects seriously and into account when you decide whether to have refractive surgery.
Several clinical studies report that the chance of having a vision-reducing complication is less than 1%. No cases of blindness resulting from laser vision correction have been reported. (Source: TLC Laser Eye Centers)
Short-term side effects of LASIK performed on 1,013 eyes included pain for one to two days, corneal swelling, double vision and light sensitivity; some patients experienced the effects for several weeks. Six months later problems included under-correction in 11.9%, over-correction in 4.2%, severe halo in 3.5% and severe glare in 1.7%. Glare and halos were worse in people with larger pupils. (Source: FDA report of its 1999 approval of the Summit Autonomous excimer laser for use in LASIK)
In U.S. clinical studies, a few Intacs were removed from patients' eyes, but all patients were able to be corrected to 20/20 or better. (Source: KeraVision)
If you have refractive surgery statistics you'd like to share with our readers, please send us a note at editor@allaboutvision.com. Thanks!
BTW, I can't quite go along with the idea of having LASIK in the OS only. Although this would avoid dealing with the higher powered right eye, the result would be extreme anisometropia which would make wearing glasses impossible (due to aniseikonia). Again, I think the biggest issues are the suitability of her corneas and the expertise of the physician.
Pete
Have her go to www.surgicaleyes.com to read about the good and the bad of LASIK surgery.
No pun intended, it is an eye opener.
Bob V.
Lasik has made you unable to read postings correctly,go get your glasses fast Pete.
Regards,
Shabbir
[This message has been edited by SHABBIR KAPASI (edited 05-03-2001).]
Euan,
I think rfish and BobV make a good point- why not give your patient access to copies of articles in professional publications like Review of Optometry (or whatever the equivalent is on your side of the Atlantic).
It sounds like this patient is determined to do something permanent concerning her vision, so perhaps the best course of action would be to give her as much info as possible on the various procedures.
Most of the internet sites I found were either skewed towards the promotion of LASIK or were the ventings of people who felt they had an "ax to grind" after experiencing complications.
I think statistics like those given by rfish probably give the patient the best idea of the probable outcome of a LASIK procedure. However, I would caution her to consider the level of correction that the statistics represent (i.e., I'd like to see stats on how people with her Rx fared after LASIK).
Pete
PS- Shabbir ???
I agree with Pete give her all the information and let her make an informed
choice. But I also have reservations about
that -3.00 cyl.I would go very slow on that one if it were my eye's.
[This message has been edited by rfish777 (edited 05-03-2001).]
The other point I would make is I could not find any long term data on how laser surgery
will effect the patients eyes in the long term. Say 10 or 20 years down the road. I don't know how true this is but I was told that most surgeons are not worried because they have corneal transplants to fall back on if any thing starts to happen to these patients cornea's. How much of this laser surgery is price driven and how much is for the patient to be able to see better I can't answer. But
it sure seems price plays a big part on how much the surgeon can make in one day.
Sorry got off on a tangent.
[This message has been edited by rfish777 (edited 05-03-2001).]
Corneal transplants are great and all, but geesh! I'd hate to think this is though of as an acceptable "fall back" position. First, there is an undersupply of donor corneas. Second, the results of corneal transplantation- while much better than the alternative of blindness- are far from perfect.
I continue to agree with rfish, while giving this patient as much info as you can, I think it should be repeatedly stressed that- were these our own eyes- we'd think long and hard before taking a course of action as permanent as LASIK or lensectomy.
Pete
Pete I totally agree. I said it was only some
thing I heard, about the corneal transplants.
But it does bring to discussion, what or how
is laser surgery being promoted? As a benefit
to the patient or are the companies involved
in laser surgery telling these doctors here
is a way to make up for the medicare cuts in
reimbursements for cataract surgery. I heard
this myself from a well know MD who said that
this new laser surgery would make up for the cuts in medicare for cataract surgery. So I
ask what is really driving the laser surgery
craze? The need to give the patient better
vision or the need by the doctor to supplement his or her income well into the
six figure's. Sorry got off on to another
tangent or was that a geometric circle or
cube squared? All I know is there is not
significant evidence to be promoting this
surgery as safe. Where do you find the studies going back 5,10 or 15 years? You
can't find it because it's not there. You
don't find this in other area's of medicine.
In other areas you find studies going back in some cases 40 years. I know you can go back maybe 8 years if you want to stretch it.
My gosh man it's your eye's you cannot get another set. I quess what I'm saying is you
better be very careful you only get one set of eye's.
[This message has been edited by rfish777 (edited 05-03-2001).]
[This message has been edited by rfish777 (edited 05-03-2001).]
I get the general feeling that everyone is coming to the same conclusion as I had already, ie that she should have informed choice and give the matter serious thought.
I have a gut feeling that the refractive lensectomy isn't the best choice, I may offer cyclo and varifocals with +2.75 Add so that she can experience accom loss.
The most reasonable conclusion that I can come to is that if I was pushed for an opinion I would recommend LASIK, aiming for a final refraction of R -2.00/-2.00 and L plano.
This seems to be within the boundaries of achievable LASIK correction, slightly lessening the anisometropia and if anything she may be more thankful of it as a correction in 10-15 years time than plano R&L.
How does that sound?
Euan
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