As seen in Men's Health

Can laser surgery turn our four-eyed editor into a man of vision?

By Lou Schuler

In an hour, I am going to lie on an operating table and watch as my eyeballs are sliced open and zapped into shape by a laser. I will, in theory, be able to see without glasses for the first time in 33 years when I leave that table. For weeks, the notion of being able to go to the bathroom in the middle of the night without first putting on my glasses has left me excited beyond words. Before the glasses-free midnight pee, though, I must read and sign a consent form, which is why I'm feeling very nervous right now. Consent forms (and lasered eyeballs) have that effect on me.

I'm not going into this with my eyes closed, so to speak. I've done my homework. I know that this procedure (called laser-assisted in situ keratomileusis, or LASIK) is complex eye surgery, demanding both a skilled, experienced surgeon and efficient, dependable hardware.

My ophthalmologist, Roy Rubinfeld, M.D., is one of the most prolific laser jockeys in the country. He performs several dozen LASIK procedures a week at the TLC Laser Centers in Rockville, Maryland, and Fairfax, Virginia, and he has done a couple thousand in his career. He even teaches other surgeons how to do them. He tells me that about 15 percent of his patients need a follow-up procedure to achieve satisfactory vision, and that the worse my vision is for starters, the better the chance I'll need that second surgery. My vision is 20/800, so I figure I'll be back.

The first few pages of the single-spaced, 13-page consent form tell me what I already know:
· My vision will fluctuate considerably in the months after the surgery.
· I'll suffer some discomfort, possibly a lot, for a day or two after the operation.
· Lights may appear to be surrounded by halos or starry patterns for months.

Then come the warnings that open up entirely new avenues of fear: There's a chance I'll suffer from infection, drooping eyelids, or total blindness. There's even a caution about something called guttata, defined as "orange-peel-like irregularities on the inner layer on the cornea." On top of the medical caveats, the photographer who's documenting my surgery hands me a consent form saying that I can't sue if his pictures end up being used in a way I'm not expecting. I'm starting to wonder whether I'll even be able to see the pictures through orange-peel-like irregularities.

Fortunately, Dr. Rubinfeld knows exactly what to say to put me at ease. "I woke up feeling pretty lousy this morning," he says, "and I got into a pretty bad fight with my wife. But then I had a couple of drinks, and now I feel okay."

FIFTEEN MINUTES before the surgery, a technician puts anesthetic drops on my eyes. It feels as if someone has massaged my eyeballs with sandpaper. I'm instructed to close my eyes as we wait for the anesthetic to take effect.
My lifetime of myopia flashes before me: Third grade. I walk into a classroom and watch as three dozen little jaws drop. I'm the first kid in my class to wear glasses. Overnight, I stop being a normal, boozing, brawling, skirt-chasing 8-year-old and become a four-eyed freak. My broken glasses held together by white medical tape. I become a freak and a weenie. Los Angeles, mid-1980s. I consider buying contact lenses, but then I look at my contact-lens-wearing actor/screenwriter/waiter friends. The dry, BMW-exhaust-filled air makes their eyes look as if they're all coming off five-day benders. The Caribbean, three years ago. My wife and I are snorkeling around a coral reef. We have have been warned not to touch the coral, that it would kill a fragile ecosystem hundreds of generations in the making. I try to swim really close, to see the coral. I smack into the reef. Thousands of tiny coral suffer an agonizing death. My house, a week before the operation. My 2 1/2 year old son and I are playing tyrannosaurus versus triceratops. Triceratops swings wildly and knocks the glasses off T Rex, who picks them up and looks at the very pregnant Mrs. Rex through smudged lenses and crooked frames. I'm ready for a change.

DR. RUBINFELD, three technicians, a photographer, a photographer's assistant, and a half-million-dollar Visx laser await me in the operating room. I lie down on a table, my head a little lower than my feet, and Dr. Rubinfeld pops a couple of clamps over and under my right eye to hold the lids open. It's not the end of the world if my eye wavers, he tells me; he can shut the laser off in a quarter of a second, minimizing the damage. Still, it's easier on everyone if I don't test the doctor's reflexes.

My right eye stays on that dot as if it were the crucial 8 seconds of the Zapruder film. I manage to keep my eyes on the place where the dot is even when the microkeratome--a scalpel that looks like your father's old safety razor but buzzes like a new Norelco--cuts open my cornea and blocks my view of the dot. I can't feel the actual slicing. All I sense at this point is pressure from the microkeratome, which has a sucking mechanism that lifts my cornea up and squeezes it, as if it were a big zit.

When Dr. Rubinfeld lifts the microkeratome off my eye, the pressure lets up. But I still feel a throbbing scared-witlessness throughout my body, a feeling that gets worse when my vision returns and I can see the doctor peel back the top of my cornea. I'm back to focusing on the red dot, but I can still see his hand moving the laser around as it shaves my eyeball into shape.

The laser makes a rhythmic thumping noise. At this point the room fills with the smell of zapped cornea. Dr. Rubinfeld warned me of this, and he swore in advance that the smell wasn't burning tissue, that the laser doesn't heat tissue enough to burn it. Since I've never actually smelled burning tissue, I'm in no position to argue the point.

Dr. Rubinfeld eases some of the tension of the moment by telling an assistant to turn the pages of the instruction manual faster. I appreciate the joke, but it doesn't diminish the stench of zapped eyeball.

Dr. Rubinfeld replaces the flap, pulls off the clamps, tells me to close my eyelids, and tapes my right eye shut. Then he repeats the procedure on my left eye: the clamps, the pressure, the flap, the terror, the zaps, the smell. When my left eye is finished, Dr. Rubinfeld untapes my right eye and asks me to sit up. I can see the second hand on a wall clock 5 feet away. Without glasses. I briefly sense that a miracle has occurred. It's not like going to Lourdes, exactly, but it's as if they'd franchised Lourdes and this was the suburban Maryland branch. Lourdes-sur-Potomac.

THE MEDICAL ADVANCES that led to my miraculous sight began in the 1880s, when doctors on two continents independently discovered that cuts in the cornea change its shape. Since the shape of the cornea determines where light hits the retina, and thus how clearly the eye sees whatever it's focusing on, this was important information.

Still, the idea of systematically reshaping corneas to produce sharper vision--refractive surgery--didn't emerge until the latter half of this century.
Radial keratotomy, or RK, the first widely practiced refractive surgery, was first used in America in 1978.

During RK, a surgeon uses a blade to make spoke like incisions around the cornea. The effect flattens the cornea so that light hits the retina properly. Today, about 90 percent of patients end up with 20/40 vision or better. But RK, which was good only for mild nearsightedness in the first place, can have a significant drawback: The deep incisions may never fully heal, which means that a patient's cornea can continue to flatten throughout his life. This takes many patients on a heartbreaking ride from flawed vision (nearsightedness) to good vision to flawed vision (farsightedness).

Photorefractive keratectomy, or PRK, improves the odds. A surgeon scrapes off the outer layer of the cornea, then uses a laser to reshape its surface. The Visx and Summit lasers were approved by the FDA for PRK in 1995, and the procedure bats a pretty high average: About 98 percent of patients achieve 20/40 vision or better, allowing them to drive legally without glasses in all 50 states.

But even PRK has drawbacks. It takes about a week for your eyes to function properly after surgery, and patients have to wear protective contact lenses for several days post-op while the epithelium, the layer of cornea that was scraped off, grows back. Many patients choose to have one eye operated on at a time, which means going through the trauma and recovery twice.

LASIK procedures about the same results as PRK--a major Emory University study found that 96 percent of LASIK patients achieve 20/40 vision or better. But it improves upon PRK by reducing discomfort and speeding up recovery. The key is the microkeratome, which can lift the epithelium up and over (hence the flap), letting the surgeon reshape the cornea underneath, using the laser. The epithelium naturally re-adheres to the cornea without any need for stitching or a contact lens.

In my case, the period of discomfort following surgery is only a few hours. It feels as if a family of easily distracted worms has taken up residence on my eyeballs. Four ibuprofen tablets blunt the pain, and every few hours I drop an anti-inflammatory steroid and antibiotic called Tobradex into my eyes. After a 2-hour post-op nap, I can watch TV or read a book without problems.

THE MORNING AFTER the surgery, Dr. Rubinfeld measures my vision: I'm now at 20/30 in my left eye, 20/50 in my right. By the end of the day, I can see leaves in the tops of trees. But by the next morning my vision is fuzzy. Activities I can do in natural light, such as driving, are easy; but finding things in stores with high ceilings and fluorescent lighting is more like fishing. I almost ask a hardware-store employee to pick out towel bars for my home--trying to find and distinguish among them in the store feels like one of those dreams in which you're sitting in a strange office trying to do a job no one has taught you how to do.

"It's normal to achieve quantity of vision before you achieve quality," Dr. Rubinfeld told me, and this turns out to be prophetic. I can see well enough to get by in any situation, but from time to time the object I'm focusing on is so blurry that I reach up to clean the dust off the glasses I'm no longer wearing.

Within a few weeks, my vision has stabilized to the point that I have to remind myself to marvel at the fact that I'm seeing clearly without prosthetic devices. (I write these reminders in my appointment book: "Tuesday, 2:30-2:35: Marvel.")

At four weeks post-op, my optometrist, Neil Boderman of Allentown, Pennsylvania, measures my vision at 20/20. He tells me that my eyes are fully healed. Although he was no fan of vision-correction surgery before lasers came along--"You're operating on healthy organs," he warned me--he says he's thoroughly impressed by the results.

THE REAL TEST of my vision comes about five weeks after surgery, when my wife goes into labor and I drive her to the hospital in the middle of the night. My spectacularly uneventful life gives me almost no need to drive after dark, so this is a challenge. Every light I see erupts in a starburst, and every shiny object my headlights hit is encased in a ghostly sheath.

I feel a little surge of panic. But then I notice that the starbursts disappear as my car approaches the source of light. And I can read signs perfectly well if I focus on the words and not on the ectoplasm surrounding them. A few hours later, my daughter is born. I watch her little arms flailing away, and I get a warm feeling. Never, I think, will those tiny hands be able to grab glasses off my face.
- Research by Shelley Drozd

WILL YOUR EYES HAVE IT?
How to decide whether you should have LASIK

YOU'RE A CANDIDATE FOR LASIK IF...

· You have mild to moderate myopia, or nearsightedness. "The less nearsighted you are, the easier it is to attain 20/20 vision," says George O. Waring, M.D., professor of ophthalmology and director of refractive surgery at Emory University's Vision Correction Center. LASIK can also be used to treat astigmatism--a distortion or blurring of faraway and nearby objects.

· You're over 18 and you don't suffer from an autoimmune disorder, such as lupus or rheumatoid arthritis. Immune-system problems can interfere with the healing of your cornea.

· Your glasses or contacts are a major imposition on your health, career, or lifestyle. Maybe you're a policeman or a fireman whose life and livelihood depend on sharp vision. Maybe you want to see the boat when you're water-skiing, or the movie (and your date) without squinting. An Emory University study found that nearly 95 percent of patients undergo LASIK for function, not cosmetic, reasons.

· You have realistic expectations for the procedure. About 70 percent of LASIK patients end up with 20/20 vision or better. "You may have LASIK and still need to wear glasses for night driving," cautions Dr. Waring. "If you're over 40, you may still need reading glasses. There's a 1 percent chance of complications, such as the flap slipping out of place after surgery and requiring sutures to put it back in place." And if you're still somewhat nearsighted after surgery, there's a 10 to 15 percent chance you'll need a second procedure in a few months to fine-tune your vision.

FORGET LASIK IF...

· You are a better candidate for another procedure. For very mild nearsightedness, some doctors consider PRK (photorefractive keratectomy) a better choice. For very large vision corrections, one alternative is the still-experimental "phakic intraocular lens implant," a plastic or silicone lens that's inserted in front of your natural lens.

· You think insurance will pay for it. LASIK is an elective procedure. Expect to pay about $2,500 per eye out of your own pocket. That fee should include the procedure, follow-up exams for a year, and any enhancement procedures you may need.

· You will not be satisfied with anything less than perfect vision. The best surgeon in the world can't guarantee that.

HOW TO CHOOSE A SURGEON TO DO THE DEED

Just as there is no such thing as emergency liposuction, there's never a rush to have elective eye surgery. So take your time and interview any doctor you're considering for the procedure. If he's unwilling to answer your questions, or if he answers every question with a sales pitch, find someone else.

"Have you had special training in LASIK? What did it entail?"

Before a surgeon learns LASIK, he has to achieve proficiency in PRK. Then he has to learn how to operate the microkeratome (the special scalpel used to make a flap in the cornea), practice on the eyes of animal cadavers, and, finally, perform several LASIK procedures while monitored by a surgeon who has mastered the technique. "Ten to 12 supervised, successful cases should sufficiently establish an experienced surgeon's skill in LASIK," says Terrence P. O'Brien, M.D., director of refractive surgery at the Wilmer Eye Institute at Johns Hopkins University School of Medicine.

"How many LASIK surgeries have you personally performed? What is your success rate? What percentage of your surgeries have required second procedures?"

Don't assume that quantity means quality. "Just because a surgeon performs thousands of procedures doesn't mean he's doing it right," warns Dr. Waring. Ask for success rates in terms of "achieved visual acuity" (20/40 or better) and for the number of follow-up operations.

"What type of laser are you using? Is this device FDA-approved or exempt?"
It's important to find a surgeon who is working with either a laser approved by the FDA specifically for LASIK or PRK or one that is under an FDA exemption because it is being used in an approved LASIK clinical trial," says Morris Waxler, Ph.D., ophthalmic-devices chief of the FDA's diagnostic and surgical devices branch. Lasers by Summit Technology and Visx have been approved by the FDA for PRK. (One laser has also received approval for LASIK, but it's not yet widely available.) Lasers under the FDA exemption for LASIK trials include those by Summit, Visx, Nidek, and Autonomous Technologies.

"Are you a corneal specialist? What other types of refractive surgery do you perform?"

Look for a doctor who has demonstrated expertise in more than one kind of refractive surgery. Good candidates are those who have served fellowships or pursued additional studies in corneal surgery, says Dr. O'Brien.

September 1999: "How is your editor who had laser eye surgery doing? Have the starbursts of light he was seeing gone away? How about the sheaths around shiny objects? I'm thinking about having LASIK surgery, but I want to know what's going to happen."

Lou Schuler replies: "I still have the starbursts and halos, but they don't bother me at all. I recently took a long driving vacation, much of it predawn or postsunset, and didn't have any problems. One eye is now 20/15, the other 20/20. I actually see better than I ever did with glasses-possibly better than I ever have, period."