Eye Surgery: It's Getting Sharper

LASIK has improved, and newer techniques can fix trickier vision problems.

Dr. Robert Maloney envisions a world without glasses. Maloney, a Los Angeles ophthalmologist, was an early practitioner back in 1991 of laser eye surgery, or LASIK, to correct nearsightedness. He has also tested other vision-correction technology for the Food & Drug Administration (FDA). Based on that, he has concluded that in 20 years eyeglasses will be obsolete. "I think my grandchildren won't even know what they are," he says.

LASIK alone won't get us there. But other techniques are evolving to fix all kinds of vision problems, including near- and farsightedness and presbyopia -- the focusing condition that makes reading glasses ubiquitous among middle-aged people. Among the treatments are phakic intraocular lenses, which are implanted directly in the eye, improvements in LASIK, and new radio-wave technology.

Lens implantation has been around for several decades. But because it typically required removal of the eye's natural lens, it was performed mostly on cataract patients nearing blindness. In the new phakic approach, the contact lens is attached to your natural lens and held in place with tiny stitches. Based on Maloney's experience, the results are better than with lasers. "Unlike LASIK, the procedure is reversible" if there are negative side effects, he says. One type of phakic lens, called Verisyse, was approved by the FDA in September. Another, ICL, should win final approval in the next few months.

Traditional intraocular lenses, which require the natural lens to be removed, also have improved dramatically with the advent of Crystalens, approved by the FDA last November. These lenses adjust their focus with a patient's eye muscles to give them seamless near or distance vision. "In the past, implanted lenses for cataract patients provided clear vision only at a single fixed focus, usually distance," says Neil Martin, a cataract surgeon in Chevy Chase, Md. "Patients still needed reading glasses." Because the Crystalens surgery involves removing the patient's existing lenses, Martin recommends it for cataract patients. Such focal adjustability may not be available in phakic lenses for at least four years.

FEWER SIDE EFFECTS

Compared with LASIK, phakic lens implantation seems to cause fewer cases of hazy or spotty vision, dry eyes, and other side effects. On the other hand, "entering the eye introduces greater surgical risks for a large number of patients who do beautifully with LASIK," says Douglas Koch, an ophthalmology professor at Baylor College of Medicine in Houston. In addition to infections, there is a risk of developing glaucoma or cataracts, triggered by abrasion of the natural lens.

Still, for Clark Miller, a Manhattan Beach (Calif.) lawyer, the phakic lens surgery was worth the risk. At 39, he had worn glasses or contacts his entire adult life, but they cramped his style. "I climb mountains, backpack, sail," he says. "Cleaning the dust from a hiking trail off your contact lenses is almost impossible."

Miller's vision was so poor that LASIK was not an option. That's why last October he became one of the FDA trial cases for the Verisyse lenses. Miller had each eye operated on separately. He wore an eye patch for a few days and didn't see perfectly at first, but his vision improved gradually. A month after the surgery, he had 20/40 vision. Today, it's 20/15.

LASIK itself has improved in the past two years, thanks to two new technologies: a diagnostic technique known as wavefront and a proprietary laser procedure developed by IntraLase. Approved in 2002, wavefront tools measure the acuity and quality of a patient's vision 25 times more accurately than traditional vision tests. They record how the eye processes light and map out distortions unique to each individual. Ophthalmologists study this map before shaping the patient's cornea to correct for distortions.

IMPRESSIVE RESULTS

The results from wavefront procedures have been impressive. In one FDA study, 94% of wavefront LASIK patients had at least 20/20 vision after the procedure; 74% had better than that. "Twenty-four hours after my surgery, my vision was 20/15," says Matthew Opremcak, a Calabas (Calif.) pharmaceutical sales rep who had wavefront LASIK last month. "I get in my car, and I can see the differentiation in the leaves on trees, and my night vision has vastly improved." Treatment of both eyes with LASIK, customized with wavefront, runs about $5,000. Some insurers cover LASIK, but many don't.

In addition, instead of using metal blades to cut a flap in the cornea to perform LASIK procedures, doctors can now wield a secondary laser from IntraLase, leading to a more precise cut, says Baylor's Koch. Some surgeons debate the need for the device, however. "The standard microkeratome blade gives you a more precise cut than the laser if used properly," says Maloney. "Intralase offers an advantage for inexperienced surgeons because it's harder to make a mistake."

Although LASIK is less invasive than implanting contacts, it still involves the removal of corneal tissue. Conductive keratoplasty (CK) uses radio waves to shrink the collagen, a fibrous protein, in the eye -- and there's no cutting. This procedure increases the curvature of the cornea, improving near vision. Approved by the FDA in March, conductive keratoplasty is mainly for those who need reading glasses but whose vision is fine otherwise.

The procedure runs about $1,500 per eye and is only a temporary fix: "The improved vision lasts about three to five years," says Ernest Kornmehl, an ophthalmology professor at Harvard University. Still, given how rapidly vision technology is evolving, it probably won't be long before someone figures out a way to throw out those glasses for good.

By Lewis Braham

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