Eye Surgery? Take A Close Look

Russ Welti flunked his first eye exam at age 7. By the time he was an adult, the Seattle software engineer depended heavily on thick lenses to see. So when Welti heard about a new laser surgery last year that could treat nearsightedness, he researched his options and flew to Windsor, Ont., where a top surgeon did the operations. It was a turning point in his life. From the minor joy of seeing a clock clearly from bed every morning to a newfound confidence in dealing with other people, he says, "I felt like a new person."

Testimonials similar to Welti's are becoming a staple for eye surgeons eager to spread the word about a new procedure called LASIK (laser in-situ keratomileusis) that can remedy extreme nearsightedness. It is one of a series of operations involving surgical incisions or lasers. Developed in other countries, the procedures are gradually revolutionizing eye care in the U.S., especially the treatment of nearsightedness, or myopia. The surgery flattens the curve of the cornea, the clear window at the front of the eye, which refracts light onto the retina, at the back. Some surgeons believe it won't be long before contact lenses and spectacles begin to disappear from the 66 million American "myopes" who wear them.

But the other side of these highly praised procedures is less exhilarating. Cornea-sculpting surgery can cost up to $2,500 per eye, isn't covered by insurance, and involves risks, inconvenience, and pain that are sometimes glossed over by ardent proponents. To complicate the decision, today's contact lenses and eyeglasses are much improved.

Debate about when and how to perform refractive surgery clouds the issues even more. For example, U.S. ophthalmologists generally frown on performing surgery on both eyes in a single session. The Food & Drug Administration recommends a three-month waiting period after the first eye is done. But some surgeons still do bilateral surgery. Most ophthalmologists also discourage colleagues from performing surgery with custom-designed lasers unapproved by the FDA. Yet some doctors do that, too.

The FDA has also specifically prohibited ophthalmologists from advertising LASIK as safe and government-approved. But the FDA, which doesn't have the authority to ban the procedure, says it's up to doctors to inform patients of risks and alternatives.

Radial keratotomy (RK) is the best known and longest-practiced refractive surgery. In RK, the surgeon uses a special scalpel to make incisions in a spokelike pattern around the cornea. One big drawback: It may be necessary to return for more surgery to achieve your target vision.

HAIR-SPLITTING. Photorefractive keratectomy (PRK) has been gradually replacing RK in many countries. Because PRK uses the hair-splitting precision of a laser, it requires much less surgical skill than the other procedures. Early last year, the FDA approved the PRK technique using lasers made by two American companies, Summit Technology and VISX. In PRK, the surgeon directs the laser's ultraviolet pulses to the center of the cornea and removes some of its inner layer. Nine out of 10 PRK patients came away with at least 20/40 vision--the acuity needed to legally operate a car, according to a 1994 FDA investigation.

PRK has more potential postoperative problems than RK. First, the healing process takes longer and can be more painful. About 5% of PRK patients need a narcotic painkiller in the first week after the operation. Second, some PRK patients develop a haze from the healing corneal layers that clouds their vision. The haze often clears within a few months, but for a few, it's bad enough to require more laser treatments.

RK and PRK work best with mild to moderate levels of myopia. The greater the correction, the more likely you will run into problems such as haze and vision fluctuations. One woman who had PRK suffered from glare that blurred her vision so badly she still couldn't drive at night three months after her operation. And there is always the chance of infection. No matter how minimal your correction, be prepared for unexpected results.

FLAP-AND-ZAP. LASIK expands the possibilities for treating extremely nearsighted people, those who need thick, Coke-bottle-bottom lenses. It's a hybrid procedure requiring both the laser and surgical cutting. During LASIK, the surgeon uses a microkeratome--an automated carving tool--to slice a flap in the fast-healing outer layer of the cornea. Next, the surgeon directs the laser beam pulses onto the cornea's inner layer. Finally, the doctor lays down the flap. Dubbed flap-and-zap, the procedure heals faster and produces less discomfort than other treatments, but involves greater surgical skill and risk. No one has ever been blinded, but surgeons have accidentally perforated corneas, a vision-threatening mishap requiring extensive repair.

A small number of LASIK patients end up with many of the same problems that plagued some patients who have had RK and PRK, says Spencer P. Thornton, a Nashville-based surgeon who has performed all three. Jerry Maida, a surgeon who is chairman of Global Vision, a Jacksonville-based laser treatment chain, says 1% of his LASIK patients acquire an irregular or asymmetric astigmatism, a focus problem that can be hard to correct. Sudden losses of acuity are another hazard of all types of refractive surgery. That's what happened when Russ Welti returned home to Seattle. One eye dropped below 20/20. While his vision remained much better than his pre-operative eyesight, the experience threw him into a panic. After talking to his doctor's associates, Welti calmed down and survived a week of mild dizziness and nausea until he adjusted to his new vision.

Another, more far-reaching issue is that all refractive surgery for myopia tends to turn forward the clock on the eyes' natural progression toward farsightedness. As you pass 40, your eye muscles weaken and lose some ability to focus on close objects. With the surgery, you can lose some of your close vision in exchange for correcting your far vision.

One way around the problem, say ophthalmologists, is to correct each eye to slightly different refractions. That provides the patient with monovision, where one eye dominates for distance viewing and the other eye takes charge when focusing on close objects. So your ophthalmologist ought to take the time to determine if you are more bookworm than windsurfer, says James Salz, an ophthalmologist at Cedars Sinai Medical Center in Los Angeles.

OFF THE HOOK. In the end, your decision should hinge on your confidence in the surgeon. You want someone who is extensively trained in the procedure, who has performed a high number of surgeries, and whose patients have experienced minimal side effects.

Even if you accept the risks, be wary of doctors who try to rush your decision or who boast that you soon will be able to discard your glasses. No one can make such a guarantee. Also, review the informed-consent form in advance; it lets the doctor off the hook for most situations short of disaster. Finally, discuss your options with and use referrals from your optometrist, who may end up handling your postoperative care. Your optometrist also knows you better and is more likely to keep your best interests in mind.

The treatment for nearsightedness is now more convenient than ever before. But if you are not sure it's worth the risks, discomfort, and expense, there's no hurry. Your eyes are one part of your body you won't want to put on the medical cutting edge.

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