Throw Away Your Glasses?
Laser Eye Surgery Can Improve Your Vision to 20/20-- but There's No Guarantee You'll See as Well as You Did Before
By Alicia Abell
February, 2000
On a recent episode of the TV game show Greed, a contestant was asked what part of the body the word "LASIK" refers to: the abdomen, eyes, or breasts. "That's easy, he said. "A friend of mine just had LASIK a few weeks ago. It refers to the eyes."
Two years ago, hardly anyone had heard of the laser vision-correction procedure called LASIK. Now it's becoming a household name. Here in Washington, LASIK--short for Laser In-Situ Keratomileusis--is advertised on the radio and on Metro; there are kiosks in malls and discount coupons in newspapers. You can even watch the procedure being done live at the Visual Freedom Center in Fair Oaks Mall.
LASIK is not just an operation but a big business. At least half a million US patients had the surgery in 1999; that number is doubling annually. Luckily for doctors, there's a huge pool of consumers to draw from. About 160 million Americans--nearly half the population--suffer from vision problems and wear glasses or contacts. More than 98 percent of those who are nearsighted and 80 percent of those who are farsighted are potential candidates.
How does LASIK work? Are you a candidate? How can you find the right doctor? With all the hype surrounding the procedure, the answers aren't always easy to find. Because I'm considering the procedure myself--I've had glasses since the first grade and contacts since the fifth--I decided to do some research.
To understand LASIK, it helps to know how the eye works. Light enters the eye through the cornea, the clear, dome-shaped tissue at the front of your eyeball. The cornea's job is to refract, or bend, light rays, as they hit the eye.
Next, the rays travel through the pupil--which grows wider or narrower depending on how much light is available--and through the lens of your eye. The lens changes shape as necessary, either curving or flattening, to refract the light rays further and focus them on the retina, their final destination. The retina is the light-sensitive tissue at the back of the eye that converts light into electrical signals and sends them to the brain. The brain interprets these signals as images.
If you wear glasses or contacts, it's because you have a refractive error: Due to its shape, your eye doesn't bend light correctly. You see blurred images.
Many refractive errors can be corrected by reshaping the cornea. In people with myopia (nearsightedness), the cornea's dome is too high--or the eye is too ling. This causes light to focus front of the retina instead of directly on it, blurring faraway objects. In people with hyperopia (farsightedness), the cornea is too flat--or the eye is too short--causing light to focus behind the retina, and blurring close objects.
Astigmatism, which can occur with either myopia or hyperopia, is caused by a cornea whose curvature is irregular; the astigmatic eye is shaped more like a football that a basketball. This means light doesn't come to a point of focus but instead focuses on different areas of the retina. This makes both near and distant objects appear blurry.
Glasses and contacts "correct" refractive errors by redirecting light rays before they enter the eye. Refractive surgery, or surgery that reshapes the eye's cornea so it will refract light properly, attempts the same goal.
Doctors have been practicing refractive surgery for 20 years. But until a few years ago, they had only one common option: radial keratotomy (RK), in which the surgeon uses a scalpel to make deep, freehand slits on the outside of the cornea to flatten it so light will hit the retina properly.
Although RK, which came to the US in 1978, was the first widely performed refractive surgery, it never became very popular. It worked only for mild nearsightedness and not at all for farsightedness. RK also weakened the cornea, and its results could be unpredictable: Because the incisions from RK might never completely heal, the cornea could continue to flatten throughout a patient's lifetime. This meant that after having the surgery, some people went from nearsightedness to good vision to farsightedness.
A new procedure, photorefractive keratectomy (PRK), was developed in the mid-'80s. In PRK a laser is used to cut and reshape the cornea. After numbing the eye with eye drops, the surgeon scrapes away the thin, protective layer of skin that covers the front of the eye--the epithelium--with a blade, brush, or laser. Once this layer is removed, a laser removes the proper amount of cornea.
The laser used in PRK is called the excimer laser, which was developed in the 1970s for etching microchips. This laser is so precise and delicate that it would take 200 of its pulses to cut through a human hair. The excimer laser is also a "cool" laser, meaning that it can remove tissue without causing heat damage. Instead of burning away tissue, it erodes it. The size, shape, and pulses of the laser beam determine how much tissue is removed from the cornea; the more that is taken away, the more the refractive power is changed.
Because it didn't weaken the eyeball and it could treat farsightedness, astigmatism, and higher levels of nearsightedness, PRK quickly replaced RK. About 98 percent of PRK patients achieved 20/40 vision or better, which meant they could drive without glasses legally. But even though PRK represented a big advance in vision correction, it wasn't long before doctors discovered an even easier, less painful way to reshape the cornea: LASIK, the refractive surgery that dominates the market today.
LASIK uses the same computer-controlled "cold" lasers as PRK. But instead of scraping away the outer layer of the cornea, LASIK relies on a tiny blade called a microkeratome, which partially detaches a flap in the top of the cornea. Surgeons lift this flap--which is about three times the thickness of a hair and resembles a contact lens--to gain access to the eye. The laser is applied, usually for less than 30 seconds, and the appropriate amount of corneal tissue is removed--hence LASIK's nickname: "flap and zap." The surgeon then replaces the flap, which re-adheres almost immediately.
In nearsighted patients, the laser cuts layers of tissue from the center of the cornea to make it flatter. In farsighted patients, the laser steepens the too-flat cornea by removing tissue from the sides. The laser also can correct astigmatism by rounding the cornea, making it a more regular refractive surface.
LASIK's flap procedure doesn't disrupt the surface of the eye as much as the scraping of PRK, which causes some pain and hazy vision as the outermost layer grows back. PRK also can leave patients susceptible to infection, and unpredictable healing can mean fluctuating vision for months. At best, PRK involves several days of discomfort and wearing clear contact lens "bandages" to protect the eye, and then a week to achieve clear vision. The tiny incision used in LASIK causes much less trauma to the eye, so there is little or no postoperative pain, and recovery time is only a day or two. There may be a few hours of scratchiness and dryness after the procedure, but no bandage is required. Most people see well enough to drive the day after surgery.
Overall results from LASIK are about the same as those from PRK. According to the American Academy of Ophthalmology, seven out of ten LASIK patients achieve 20/20 vision, and 95 percent achieve 20/40 or better. But LASIK works better that PRK does for farsightedness and astigmatism.
The average cost of LASIK is $2,500 an eye, although in Washington the figure is closer to $2,700. This includes a preoperative evaluation, the procedure and enhancements if needed, medicated eye drops, and postoperative care for a year. Most insurance companies consider LASIK a cosmetic procedure and won't cover it.
Why does LASIK cost so much?
The equipment is expensive, and doctors have to pay a licensing fee every time they use the laser. Each laser costs more than half a million dollars, plus $40,000 to $50,000 a year for maintenance; the licensing fee is $250 an eye.
But LASIK generally costs less than ten years of wearing contact lenses. Disposable contacts, for example, can cost $700 a year. And if you compare the cost of LASIK to a lifetime of contacts, glasses, and eye exams, the gains are even greater.
To many people, LASIK is nothing short of a miracle. Most patients don't need contacts or glasses after surgery, although some wear them for fine detail work or driving at night. And although a small percentage of people do not get to 20/20 after LASIK, another small group sees even better than 20/20.
LASIK cannot correct presbyopia, the natural stiffening of the eye's lens over time, which almost inevitably results in the need for reading glasses sometime after age 40. LASIK corrects the eye for distance, an adjustment which--when combined with presbyopia--makes close objects harder to see. So if you have LASIK, you will almost inevitably need reading glasses at some point.
One way to circumvent presbyopia through LASIK is to have something called "monovision." By fully treating one eye but leaving the other slightly nearsighted, monovision gives you more visual flexibility than does adjusting both eyes for distance. The disadvantage of monovision is that you have to give up a little distance sharpness to gain near vision. Fortunately, monovision is reversible: Additional laser treatment can bring the "reading eye" to distance correction at any time.
About 30 percent of patients don't get to 20/20 on the first try, so the cost of LASIK usually includes "enhancement." These repeat procedures to sharpen vision further are possible as long as the cornea doesn't get too thin. About 10 percent to 15 percent of LASIK patients have an enhancement--the rate is a bit lower for slight myopes and a bit higher for severe ones. In fact, extremely nearsighted people might need to view LASIK as a staged process. Some surgeons use a gold analogy to explain this: It's harder to sink a 30-foot putt than a 5-foot one; you may need a couple shots to get the ball in the hole.
Long-term studies are not complete, but most doctors expect LASIK to be a stable fix for people with low to moderate myopia; the results for extreme myopes are somewhat less certain. But there is very little data about the procedure beyond ten years; there could be unanticipated side effects, and it can't really be billed as a "permanent" correction yet.
The discomfort experienced immediately after the surgery is usually very minor--three to four hours of mild irritation for most people, akin to wearing a dirty contact lens. But during the first three to six months, some patients find that their vision blurs occasionally and their eyes are sensitive to light and irritants. In some cases, it can take up to a year for eyes to adjust fully.
Predictable side effects from LASIK include glare, halos, and "starbursts" (shooting rays) around lights at night. Almost everyone experiences these effects to some extent, but they usually go away within six months. About 5 percent of patients continue to be bothered by glare and halos long-term. Some ophthalmologists think that some of these patients had starbursts and halos before LASIK but didn't notice them until afterward. In fact, one surgeon says that 80 percent of his effort goes toward "controlling patient expectation and anxiety."
Another possible side effect from LASIK can be slightly less crisp vision than you're accustomed to. People who've worn soft contact lenses aren't likely to notice this, but those who wear hard lenses, which create sharper images, might.
Serious complications from LASIK appear rare, although infections and scarring are possible. There is no recorded US case of blindness from LASIK. A recent study put the risk of catastrophic complication in one eye from LASIK at 1 in 3,129, and in both eyes at 1 in 10,000. By comparison, the average person's lifetime risk of being involved in a fatal car crash in 1 in 80. And if you wear contact lenses daily for more than ten years, the risk of ulcerative keratitis, a potentially blinding condition, is 1 in 250.
As with any surgery, there is always a risk or infection. Other possible complications--all listed in the scary informed-consent form you must sign before the surgery--include haze, corneal scarring, irregular astigmatism (permanent warping of the cornea), unintentional under-or overcorrection (which can usually be fixed with an additional procedure), an inability to wear contact lenses, and a decrease in best corrected vision (the best vision you can achieve, including with contacts or glasses).
There are no reliable statistics on the number of patients who have these kinds of complications. Estimates range from fewer than 1 percent of patients operated on by corneal specialists to 5 percent of patients of less-experienced ophthalmologists.
The most common complications involve the flap: irregular flaps, incomplete flaps, "free flaps" (flaps cut off entirely), and ingrowth of cells under the flap. Once again, the most important variable is surgeon experience. On study found only a 1-percent chance of flap complications, but another found that while complications occur only 0.3 percent of the time in experienced hands, the number can be as high as 8.6 percent for inexperienced surgeons.
Some complications are beyond the surgeon's control. Flaps can be dislodged easily soon after the procedure, so any sport or activity that carries a risk of a blow to the eye should be avoided for a few months. With treatment, flap-related complications rarely lead to a permanent decrease in best corrected vision.
Researchers have found that between 1 percent and 2 percent of LASIK patients experience a deterioration in vision that can not be corrected by glasses. These problems include double vision, overcorrection, irregular astigmatism, and halos and starbursts so bad that night vision is seriously impaired.
Patients who have had such outcomes have launched grassroots groups and Web sites. These include a New York-based group called Surgical Eyes at www.surgicaleyes.com and a group at members.aol.com/eyeknowwhy/. Although some stories of bad outcomes seem questionable or overblown--as one doctor says, "Happy people don't get on the Internet"--some are bona fide nightmares. Disasters can happen.
One Chevy Chase surgeon says he sees at least on patient a day complaining of "messed-up LASIK." Most of the time, he says, the patients are doing fine but need an enhancement or haven't been appropriately informed about what to expect post-operatively. But occasionally he sees significant problems, usually the result of badly performed LASIK but sometimes from operations by good surgeons. Some patients turn out to have been poor candidates because they had undetected problems to begin with.
Dr. Anne Sumers, a board-certified ophthalmologist in private practice in New Jersey, explains that about 1 in 10 patients achieves 20/20 but has "degraded" vision after LASIK. Actually, 20/20 does not mean perfect eyesight. When you look at the eye chart in your doctor's office, the contrast between black and white is high. For reasons that aren't understood, LASIK can cause a decrease in this contrast sensitivity, sometimes described as "fuzziness," "ghostliness", or a "too gray" picture. Usually this effect goes away, but sometimes it doesn't. Once again, the problem seems to be more common in people whose vision was especially bad before surgery.
Poor results can occur when patients aren't screened or warned carefully. Patients who experience problems often complain that they were not adequately informed about what could go wrong or that some potential problems were uncorrectable. Some say they felt pressured. The most frustrating part, they say, is knowing that they could see fine with glasses beforehand.
Dr. Leo Maguire, an ophthalmologist at the Mayo Clinic, thinks that the power of LASIK, plus the aggressive marketing of it, has created a worrisome casualness on the part of both doctors and patients. He warns that LASIK surgeons may be creating "a refractive underclass"--people who can see 20/20 on the eye chart but who have lost visual sharpness in other ways.
Future technologies are likely to solve some of these problems. Current lasers can only operate on corneas that are for the most part spherical. But instruments being developed will account for individual differences in shape and aberrations in a patient's cornea, lens, and retina. This will be especially helpful for irregular astigmatism. "Custom LASIK"--sometimes called "custom ablation"--also has the potential to correct vision up to 20/10. Widespread use of custom LASIK, however, is five to ten years away.
Technology that will arrive sooner--it's been in clinical trials at the Rockville TLC Laser Eye Center since November--is a laser that uses radar developed for the Strategic Defense Initiative (Star Wars), to track and freeze eye movement during the operation. Today you keep your eyes steady during LASIK by looking at a blinking red dot of light. If your eye shifts suddenly, the doctor can turn the laser off in less than a second. But he can't do anything about the small, involuntary eye movements we all make--and which may account for some of the variability in LASIK's results. The new technology allows tracking of eye movement within millions of a second.
An alternative to LASIK already in use is Intacs, tiny plastic rings inserted into the cornea to change its curvature. They were approved by the FDA last year for the correction of mild myopia. As with LASIK, the Intacs procedure takes about 15 minutes and is done using a topical anesthetic. Unlike in LASIK, the cornea remains intact--there is no laser or cutting--and the procedure is reversible; the rings can be removed. But Intacs are good only for people with low myopia, and can't correct farsightedness or high degrees of astigmatism.
Intacs cost $2,000 to $2,500 an eye--roughly the same as LASIK--and are comparably effective. In clinical trial data presented to the FDA, 98 percent of patients within the recommended range could see 20/40 after a year, and 78 percent could see 20/20 or better. For extremely nearsighted patients, another possibility in the works is the "phakic intraocular lens implant," a plastic, acrylic, or silicone lens placed in front of the eye's natural lens to improve its focus. Like Intacs, these lenses have the advantage of being removable, and they leave the cornea intact. They also can work for farsighted patients. Disadvantages are that they may lead to corneal injury, cataracts, and inner-eye infections. Phakic intraocular lenses are still being studied in the US.
Other technologies under investigation include laser thermal keratoplasty (LTK), which is similar to LASIK but heats the collagen in the cornea with laser beams, and radio-frequency keratoplasty, which uses radio waves to do the same. Scientists and ophthalmologists also are working on techniques to correct presbyopia, the natural aging of the eye that occurs around age 40. Some surgeons predict that by a decade from now, refractive techniques will have advanced so far that 90 percent of patients will see better than 20/20.
How do you know if you should have LASIK? Because doctors aren't required to follow specific guidelines, it is up to individual doctors to decide who is a good candidate.
The first consideration is your prescription. Most people think of visual acuity in terms of the 20/20 eye chart--a person with 20/40 vision needs to stand 20 feet away from something that a person with 20/20 can see fine from 40 feet--but this rudimentary measurement dates from the 1800s.
Ophthalmologists measure refractive errors in something called diopters. For contact-lens wearers, this is the number on the outside of the packet your contacts come in.
Generally speaking, LASIK can treat patients who have from 1 to 14 diopters of nearsightedness and 1 to 6 diopters of farsightedness. (Some doctors, however, won't operate on people who have greater than 12 diopters of nearsightedness and 4 diopters of farsightedness). Since about 90 percent of myopes have errors of less than 6 diopters--and fewer than 1 percent of them have errors of more than 10--nearly all nearsighted patients are candidates for LASIK. And about 80 percent of all farsighted people have errors of less than 5 diopters. LASIK can also treat 4 to 5 diopters of astigmatism when accompanied by nearsightedness, and 2 to 4 diopters of astigmatism when accompanied by farsightedness.
Because young eyes can change significantly, candidates should be older than 18--some doctors say 21--and have a prescription that hasn't changed significantly in a year. They also should have healthy corneas. Autoimmune diseases like lupus or rheumatoid arthritis--which can interfere with the healing of the cornea--almost always count you out, as does pregnancy. Patients with advanced glaucoma, inflammatory diseases of the eye, keratoconus (a cone-shaped cornea), chronic herpes, or diabetes usually are not good candidates. Neither are those with a tendency to scar easily, cataracts, or extra-thin corneas (the only way to tell is to have them measured). And although people with unusually large pupils, extreme astigmatism, or very dry eyes can have the procedure, they often have more severe side effects.
The less nearsighted or farsighted you are, the easier it is to achieve 20/20 vision through LASIK. And the greater the degree of correction needed, the more likely you are to have complications. The risk also increases if your pupils are bigger than 5 millimeters in room light or enlarge to more than 7 millimeters in near darkness.
The reason people see halos after LASIK is that the procedure leaves a circular edge in the cornea where the tissue was treated. This edge is more pronounced the more nearsighted you are; it is usually not a problem in people with very low prescriptions. But for many patients, light crossing the edge between the treated and untreated parts of the cornea will initially create halos around bright lights, especially at night. This effect usually decreases in about three to six months as the edge smoothes over.
In people with unusually large pupils, the halos often don't go away. This is because most lasers currently in use operate on only a 6- or 6.5-millimeter portion--the "optical zone"--of the cornea. Because some patients' pupils widen to up to 9 millimeters in the dark, their dilated pupils allow light through both the corrected and "uncorrected" areas of the cornea. This means there is about a millimeter of "nearsighted light" entering their eyes in the dark, causing blurriness around lights.
Note that 6 millimeters or so is the basic optical zone of most gas-permeable contact lenses (meaning only the central 6 millimeters of the contact has the prescription); so some people have been walking around in this situation for years. Also, nominal pupil size can vary depending on how it's measured, and actual size depending on your emotional state or how much caffeine you've had. And while pupil size and optical zone are important, there are other variables, including level of astigmatism, corneal curvature, and individual aberrations on the surface of the cornea, that can affect the incidence of starbursts and halos.
After doing all this research on LASIK, I still didn't know if I was a candidate. Like a quarter of the population of the United States, I'm nearsighted. Unlike most people, I fall in the high-myopic range. My contact-lens prescription is -9.5 in my right eye and -11 in my left.
My first step was a visit to my own ophthalmologist, Michael Tigani, a trusted family physician and a regular on The Washingtonian's Top Doctors list. The first thing Tigani did was dilate my eyes so he could fine-tune my prescription. Dilating the eyes freezes their focusing ability so the doctor can get an objective reading of your prescription; when the eyes aren't dilated and you're able to use your focusing power, the reading is subjective.
Luckily, my eyes hadn't changed in the past year. Tigani doesn't do LASIK on people under 21 because their eyes can still change, and he recommends against it for people experiencing vision problems- graduate students, for example, who strain their eyes a lot.
Washington's two biggest names in LASIK, Dr. Mark Whitten and Dr. Roy Rubinfeld, are also part of TLC. I planned to visit them both, so I had the tests done at their offices.
Next he did an eye exam to make sure my eyes were healthy. He measured my corneal curvature and my pupils, which he said were fairly large. (I later found out that people with light irises-mine are blue-are likely to have bigger pupils. And the younger you are, the bigger your pupils are, too.)
Tigani doesn't have LASIK equipment in his office, but he's a member of TLC Laser Eye Center, the largest network of LASIK surgeons in the country, where he would send me for some other measurements. The first would examine the topography of my eye to make sure I didn't have an irregular astigmatism or a cone-shaped cornea, a condition called keratoconus. The lasers and software programs currently used in LASIK aren't designed to operate on eyes with these conditions. The second would check my pachymetry-the thickness of my corneas-to make sure I would have enough tissue left after my corneas had been cut.
Whitten is perhaps the best-known LASIK surgeon in the area-and one of the busiest in the country. He has performed about 20,000 LASIKs; he does about 800 to 1,000 eyes per month, and has operated on professional athletes including golfers Tiger Woods and Fred Funk.
Rubinfeld, a corneal specialist, is also one of the nation's busiest laser surgeons-he does between 60 and 100 procedures a week. He and another partner, Dr. Neil Martin, were among the first doctors to send patients to Canada in the early 1990s, when the Excimer laser was not yet FDA-approved. Rubinfeld speaks at many national conferences, and he and Whitten train and certify other doctors in LASIK.
I visited Rubinfeld first. I was at his office for an hour and a half. I spent the first half hour with an optical technician who refined my prescription by checking my vision with and without glasses and contacts and measured my pupil size. She asked me which eye I use to look through a camera. This was in case I was interested in monovision. The eye you use for such tasks is your dominant eye and the one that should be corrected for distance. Your dominant eye has nothing to do with which eye sees better-it's a decision made by your brain, like whether you're right-handed or left-handed.
Next, the technician checked my topography and pachymetry. Because she had to touch my eyes with instruments, she put in some anesthetic drops to numb them first. These made my eyeballs feel swollen. The sensation lasted about 20 minutes. Then she did a glaucoma check.
After sitting for a few minutes in a waiting area, I was ushered into an examining room to see Rubinfeld. He did his own examination and explained what the technician had found. He started off by saying that I was an excellent candidate. First, by having LASIK now, I could be free of glasses for nearly 20 years. (I'm 26 and won't need reading glasses until sometime in my 40s.) Second, my corneas were quite steep, meaning that they wouldn't end up too flat after LASIK. Third, he said I had very thick corneas. The average is about 500 microns (a micron is 1/25,400th of an inch); mine were about 580. In order to have LASIK, you need to have about 250 in the bed of your cornea even after the flap, which is about 160 microns, has been made.
Rubinfeld told me a few other things about my eyes. My pupils, he said, were somewhat large, measuring much less than 6 in normal lighting but 7.5 millimeters in the dark. The laser he would use on me has a 6.5 millimeter optical zone, so I would be more likely than most patients to experience glare or halos at night. But he said that, most of the time, this is a transient effect of LASIK. He does occasionally see pupils that are simply too big; he recently had turned away someone who had both 8.5-millimeter pupils and astigmatism. Rubinfeld told him to wait a year, when the optical zone of the newest lasers might be larger.
Rubinfeld also told me that my eyes are quite dry and that because LASIK can make eyes drier for about three months after surgery, that effect might be heightened for me. He said I had some neovascularization, extra blood-vessel growth around my cornea-something I'd been told before. This was because my corneas were starved for oxygen because I had worn contacts for so long. He would have to take extra care when making the flap so as to avoid cutting these veins.
I expressed some concern about my level of myopia, but Rubinfeld said he had done many like me-and worse. His usual cutoff point is about 14 or 15 diopters of nearsightedness, and can go even higher if the eye shape permits it. Pupil size and dryness, not my prescription, would be my main issues, he said.
Finally, Rubinfeld suggested that I talk to one of his technicians, Rietta Coetzer, who had a prescription similar to mine, 9 and 10, until she had had LASIK about a month earlier. Coetzer's corneal steepness and thickness were similar to mine, although her pupils were smaller.
Overall, Coetzer told me, the experience had been "great." She had worked for Rubinfeld for a year and a half but had been reluctant to have the procedure because contact lenses were so easy for her. But she says LASIK has had a major impact on her life. "My whole routine is different," she says. "I have to remind myself that I'm not wearing contacts."
She did caution that "the halos surprised me a little bit even though I knew about it." She drove on the Beltway about a week after the surgery and "it was kind of scary." But a few weeks later, she drove there again, and "it was fine-some halo but like with contacts. Some patients drive themselves crazy noticing things they probably had before," she added.
She said that the surgery was a little more traumatic than she expected. For three hours "it was like I had a hair under my contacts. I could hardly open my eyes after the procedure, they hurt so much." From her experience as a technician, she thought that the level of pain she experienced was uncommon. She said she and her colleagues have noticed that fair-skinned people with light eyes tend to experience more pain.
My experience at Dr. Mark Whitten's downtown office a few weeks later was similar. First I saw a technician, who asked me about my overall health and measured my prescription, again with and without glasses. Then, as at Dr. Rubinfeld's, she measured the topography and pachymetry of my eye.
Then she took me in to meet Dr. Ted Komm, an optometrist, who again checked my prescription and measured my pupils. (Dr. Whitten himself does mainly surgery; his consultations are handled by optometrists and other ophthalmologists.)
Although Komm found my pupils a little smaller than Rubinfeld had-7 millimeters in the dark-he wound up advising against the surgery. He said that because of my high myopia and large pupils-both risk factors-I would almost certainly experience significant glare and halos. The best I could hope for was that these would lessen and eventually be similar to what I already experienced with contacts.
With a prescription as high as mine (my glasses give new meaning to the term "Coke bottles"), he'd say go ahead and have LASIK if I couldn't wear contacts. But if I was functioning fine with contacts-which I was-then I should come back in a year or so, when lasers with larger optical zones were likely to be in use. Or, I thought, I could go to Canada, where the procedure is cheaper and surgeons are using larger optical zones.
So here I was with two opinions-from the two best laser surgeons in town. Normally, if even one doctor says no to LASIK, you shouldn't look for a second or third opinion. But as a journalist, I was curious. So I made an appointment with Dr. Rajesh Rajpal, widely considered the number-three guy in town. As the former director of the George Washington Refractive Laser Eye Center, Rajpal has done more than 10,000 LASIKs and was one of the principal investigators in the FDA trials of the excimer laser for LASIK.
Rajpal didn't know I was writing article about eye surgery. As word spread that The Washingtonian was doing an article on LASIK, I had been bombarded with phone calls from public-relations people-and from doctors themselves. Expensive equipment makes the start-up costs of LASIK high, and because the potential profits are so huge-an estimated $900 per eye goes to the surgeon-lots of doctors want a piece of the action. The appointment at Rajpal's office started with a technician calibrating my prescription. The technician checked for astigmatism, measured my pupils (this time about 7 millimeters), and did a glaucoma test. Then he talked for a few minutes about the procedure. He said that I was on the high end of myopia but that I would be eligible if my eyes were healthy. He added that most of his patients like to use glasses about 5 percent to 10 percent of the time, for fine detail work and night driving-and that I should be prepared to see some halos at night.
Then Rajpal came in and checked my eyes. He spent a few minutes talking and answering my questions. He said that because my prescription was so high, I would probably either need an enhancement or always be able to use a thin prescription (glasses or contacts) after LASIK. In his experience, about 70 percent to 75 percent of patients in my refraction range get to 20/20 on the first try; about 90 percent get 20/40.
He told me that while I would be likely to see halos and glare, they would probably be no different from what I see now. People often-big-pupiled people especially- experience starbursts and halos even without LASIK. It has to do with the optics of the cornea. Like LASIK, glasses and contacts have an optical zone; it's just bigger. I see halos with glasses, which have optical zones larger than the eye itself.
According to Rajpal, the laser with the 6-millimeter optical zone is still the one most surgeons use, even in countries where there are no FDA restrictions. This is because the wider the zone, the deeper you have to cut into the cornea, and it's good to leave as much tissue intact as possible.
He concluded that I would be a good candidate for LASIK, but, because of the likelihood of side effects, I might want to consider doing one eye at a time. Some doctors advocate this technique so they can see how the first eye heals before operating on the other one.
Now that I had two yesses and a no, I again consulted my regular ophthalmologist, Dr. Tigani-an unbiased source because he wasn't going to do the surgery himself. His first reaction was that the optometrist at Dr. Whitten's had been "right on the money." Then he said that the newest lasers have a 6.5- to 7-millimeter optical zone, and that these might be fine for me. He also reiterated what Rajpal had said: the bigger the optical zone, the deeper the corneal cuts have to be. And since I was young, it was possible that the cuts would have to be even deeper in order to overcorrect my eyes, which would probably worsen a little with age.
In the end, he said that I could probably have LASIK with any of the surgeons I'd seen and get a good result. He would advise waiting, because he is very conservative. He believes that lasers are only going to get better, especially for fixing extreme cases like mine, and that the procedure probably will get cheaper.
I also asked Rubinfeld more specific questions about pupil size and optical zone. He said that while I did have large pupils, he'd done hundreds of people with pupils my size, and only a handful among them had problems with halos after six months.
Why shouldn't I simply wait for the 8-millimeter laser, I asked? First, he made the point that with technology-computers, cell phones, and such-you can always ask, "Why buy now?" The answer: "Because you live for years without the benefits!" More important, he echoed what Rajpal had said about the larger the optical zone, the deeper the cut-and the greater the possibility that you will start running out of corneal tissue. And according to recent data submitted to the FDA, he said, the 8-millimeter laser didn't significantly reduce glare.
Rubinfeld said that in his experience, the most important factor in whether halos bother people is personality. The basic question to ask myself, he said, was whether I was willing to exchange small halos and starbursts at night for better vision during the day. If I'm very persnickety, he said, I might want to wait.
I asked if I could have my optical zone enlarged with a later enhancement. He said yes but that the 6.5-millimeter laser "is the latest and greatest right now." He also noted that he himself has 9-millimeter pupils in the dark, had his eyes lasered with a 6-millimeter optical zone, and is very happy.
To try to simulate the glare and halo I would be likely to have after LASIK, Rubinfeld suggested that I wear a pair of special contact lenses for a few days. It sounded like a good idea, so Rubinfeld ordered contacts with my exact prescription but only a 6-millimeter optical zone, meaning only the middle 6 millimeters of the lenses would actually have the prescription.
A few weeks later, the trial contacts came in and I had them fitted to make sure the optical zone covered the center of my eye. I wore them for a week and saw no differently-even at night-than I normally do.
During that time, I also got a phone call from Dr. Whitten. He told me that when I had seen the optometrist in his office he and his partners were still using the 6-millimeter laser on most patients, but they had started using the 6.5-millimeter laser more frequently, and he thought I'd have a good result with it. Now I'm left to decide whether to have the surgery.
The one thing I knew for sure after my research on LASIK was that if I hadn't been a reporter-inquisitive and very determined to ask lots of questions-I'd probably be "zapped" by now. I would have gone not to three doctors but to one, who would have told me that I'd have some chance of halos but that they probably wouldn't be a problem, and I would have booked the procedure.
Would that have been a good thing or not? I'm still considering the surgery. Stay tuned.