The LASIK "miracle"

Thousands of people swear by the laser eye surgery, but are they throwing away their glasses too soon?

Published March 8, 2000 5:00PM (EST)

When I'm not wearing my glasses, people lose their uniqueness and their faces become large fleshy balls attached to colored stick figures; crowds meld together and begin to resemble Jackson Pollock paintings. These visual effects might actually be interesting if my stomach weren't prone to fits of nausea.

Despite constant evidence that my eyesight is challenged, when the alarm clock sounds I inevitably squint and strain my eyes to make out the flashing digital numbers. I'm always giving my eyes another chance, hoping that they'll have made a miraculous recovery.

Last year, I made a misstep and felt my metal frames crumple beneath my feet. It was near 4 on a Sunday afternoon, and I had no idea if there were any eye doctors available. Luckily, I had a friend who offered to drive me to a nearby optical store. But what would have happened if I'd been alone? Do eye doctors have an ambulance service for emergencies like mine, for people so blind they can't find a bus stop?

Without my glasses, I felt completely vulnerable. But then I saw an advertisement for LASIK -- Laser Assisted In-Situ Keratomileusis. Could I really be 15 minutes and $3,000 away from 20/20 vision? In the ensuing months I saw many such ads in magazines, on TV and on billboards, but I still didn't believe the claims. It sounded too good to be true, so I decided to research it.

That's where I found Kirk Carver, who first had LASIK in September 1998. Kirk had always wanted to scuba dive with his wife, but he couldn't see well enough underwater without his glasses and prescription goggles were expensive. In fact, Kirk's lenses interfered with all of his athletic pursuits. When he fished, water got on his glasses and on the rugby field they weren't allowed at all. Like many athletes, Kirk tried wearing contact lenses but he got headaches if he wore them for longer than a couple of hours.

Kirk considered the earlier refractive eye surgeries, which have been an option for Americans for more than 20 years, most recently with photorefractive keratectomy (PRK). But he was hesitant about them because of their longer healing time and potential for infections. With PRK, the surgeon scrapes the epithelium off the cornea and then uses lasers to shape it.

But LASIK, which was introduced in July 1998, was touted as safe and quick -- surgery fast-food style. The surgeon could correct both eyes in less than 20 minutes. Kirk's ophthalmologist told him that people with similar astigmatisms had been having the surgery with no problems, and Kirk decided to give it a try.

But since the surgery, Kirk has become very familiar with terms like diopter, the standard measurement of vision, myopia (nearsightedness), hyperopia (farsightedness) and astigmatism (which he has), a condition in which the eye is more oval than round. He's also learned much more about LASIK than the average person should ever have to know. He's consulted with doctors, joined an organization where he talks with other LASIK patients, and even consulted a few lawyers. For Kirk, the surgery did not go well.

An estimated 700,000 people will get LASIK this year, and you can even have it done (or watch it being done) at shopping malls across the country.

When correcting nearsightedness, the surgeon performs a tiny cut in the cornea with a machine called a microkeratome to create a flap the width of a human hair, which he or she then lifts and shapes the cornea underneath with the laser. In essence, post-operative patients have a reshaped cornea that bends the light entering their eyes in much the same way that their glasses or contacts previously did.

In a recent study, 92 percent of eyes were corrected to 20/40 vision or better (the legal threshold for driving without corrective lenses) and 47 percent were corrected to 20/20 or better.

But 20/20 vision does not come cheaply. LASIK can cost from $1,000 to $2,500 per eye, and it's not likely to get cheaper anytime soon. The lasers cost nearly half a million dollars each and there are royalty fees paid to the manufacturer every time it's used. But with LASIK, you don't always get what you pay for.

"The places that charge the most market the most effectively, not provide the best service, necessarily," says Dr. Kerry Assil of the Sinskey Eye Institute. "They're your eyes, not a pair of tires."

Kirk decided to have both eyes done at once. Like most LASIK patients, he wore his street clothes and a surgical cap for the procedure and sat back while the surgeon put drops in his eyes to numb any discomfort. He was told to look at the red light, but as the surgeon began, he wondered when they were going to discuss his questions and concerns in more detail.

The surgery did not hurt, but afterward Kirk noticed that his vision was blurrier. It's a common side effect of LASIK, but one that clears up quickly for the majority of patients. Kirk also began to see four-pointed stars around bright objects at night, get headaches and sometimes feel nausea after trying to focus too hard. (A recent study found that only 3.5 percent of patients experienced severe halos and 1.7 percent severe glare.)

"People think 20/20 is a measure of vision but it's not," says Kirk. "It can only tell you if you can read something across the room on a highly contrasted chart." He believes that the use of this chart, which does not take factor in glare, starbursts and hazing, account for many of the favorable statistics about LASIK.

Two months after his initial procedure, Kirk had another, more painful surgery in an attempt to correct his problems. Between 5 and 10 percent of LASIK patients require another surgery or retreatment to touch up the first one due to over- or under-correction. In the vast majority of patients, the second surgery does the trick. But Kirk experienced more bad luck and that didn't work either. He is disputing the cost of the surgery with his doctor. No procedure exists to adequately fix Kirk's eyes.

"They're playing a game of high volume where the occasional casualty doesn't impress upon them all that heavily because they don't have to deal with it," says Ron Link, the executive director of Surgical Eyes, an organization dedicated to helping people who have suffered as a result of eye surgery. "If it works out, that's great. If it doesn't, it's hell."

In Kirk's case, his doctor didn't take the shape of his cornea into consideration when he performed the surgery. Now, when his pupils enlarge at night, they expand beyond the part of his eye that was fixed by the surgery. Light comes in and is distorted by the portion of the eye that hasn't been treated. Now Kirk sees double images at night, and it's hard for him to focus. Although Kirk was given the impression that LASIK is a custom surgery, he has since learned that doctors use a "regression analysis technique" or a profile based on past patients to perform the surgery.

"They take numbers based on the prescription, thickness of cornea and curvature and plug it into a formula," says Dr. Kristin Pisacano of the New York Eye Surgery Center.

Kirk's case is by no means unique. For many dissatisfied people, the main problem with LASIK is that nobody told them about all the potential side effects. This may have more to do with lack of training than any malicious intent. Assil, who has performed more than 4,000 procedures, suggests that many doctors do not have the knowledge to screen for potential problems and recommends that surgeons be trained in a full one-year fellowship instead of relying on weekend certification courses given by the makers of the LASIK equipment.

LASIK is not right for everybody. People with diabetes and glaucoma may experience longer healing times, and people who are severely nearsighted or farsighted may find that the surgery will not result in the same miraculous results.

Pregnancy is also a consideration. "Doctors should always question a women about whether or not she is pregnant or intends to become pregnant any time in the next six months, but many, primarily men, do not think to ask," said Pisacano.

Kirk claims that his doctor never advised him that his surgery carried any great risk. Indeed, many people complain that they're not told about certain side effects or even misled outright. Although in the past it was difficult to check the claims of doctors, Assil says that may be changing. "The Internet is becoming a powerful policing tool," says Assil. "If they're noteworthy at all, their name will start popping up."

Patients should get all guarantees in writing, ask about their doctor's malpractice record and make sure that the laser the doctor will be using has been approved by the FDA, says Assil.

Dr. Barrie Soloway, the director of the Laser Vision Center of Excellence at the New York Eye & Ear Infirmary, suggests that people ask to see the doctor perform the procedure. If the doctor says that he operates every other Wednesday from 3 to 5 p.m., they should be avoided. "Do more research about it and about your doctor than you would about a television you're going to buy."

Phil and Polly Meagher researched LASIK and flew to Montreal for the procedure six months ago. They were pleased that in Canada, the procedure only cost $1,000 per eye, significantly less than was being advertised in their area. They felt comfortable with their surgeon, who had an excellent track record and was willing to guarantee his results. Although neither had any severe problems with LASIK, their differing expectations have affected their attitudes about it. Phil's vision is better than Polly's, but he isn't as happy with his results as she is.

"I would not be a good poster boy for the procedure," says Phil. "I miss the nice crisp vision with glasses. I could spot a fly a block away." Although Phil appreciates the convenience of not having to deal with glasses, his vision fluctuates at different times of the day, although his ophthalmologist is surprised since his vision is 20/20 in one eye and 20/30 in the other.

Polly, on the other hand, is elated with the results of the surgery. Before she had the procedure, Polly was legally blind without corrective lenses. "What other people could see at 800 feet, I had to be at 20 feet to see," says Polly. Polly's doctor advised her that because of her thin cornea, she was not the best candidate for LASIK surgery.

He said he could only correct her from 20/800 to 20/60, but that was good enough for her. Although she still needs corrective lenses since her operation, she has been able to get rid of her Coke bottle glasses. Polly is representative of most LASIK patients. "The great majority of patents are satisfied," says Assil.

Future advancements may make the already safe procedure much safer. Newer lasers are making it possible to correct severely nearsighted and farsighted people who weren't eligible before, and efforts are being taken to customize the procedure for individual patients. In addition, a new phakic intraocular lens implanted in the eye eliminates the need to cut the cornea, and can be reversed by removing the lenses.

All the success stories in the world, however, don't change the fact that Kirk's life has been changed for the worse. Before the surgery, he and his wife enjoyed going to movies, but now in order to see the screen, he has to put strong eye drops in his eyes that cause him pain and dryness the next day. "The industry still doesn't have a Plan B," says Kirk. "They might say they can take care of it with drugs, but they're still in the development phases of techniques that might fix me." Kirk still has to wear glasses, and he never has scuba dived with his wife.

When I searched the Web for information about the surgery, I came across hundreds of success stories and tons of hype, but I kept pausing to stare at the car crashes. I don't want to risk my eyesight, and I don't want to have to find a lawyer, no matter how small the risk. Although every doctor I talked with reminded me that it's possible to get an infection from contact lenses, the bottom line is that contact lenses aren't surgery. I can take my contacts out. For now, I'll buy an extra pair of glasses and give my eyes another chance to go into a total remission.

By Tate Gunnerson

Tate Gunnerson is a writer in San Diego.

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