LASIKblog

22 Years of LASIK

2011-05-07T17:53:00.000-07:00

The first FDA clinical trial in the United States began in 1989. At that time, LASIK was not available, so the early procedures were PRK, or photorefractive keratectomy. PRK treats the surface of the cornea with the excimer laser. In contrast, LASIK creates a thin flap in the cornea, laser treatment is applied to the corneal bed, and the flap is repositioned. We still perform PRK in about 10% of our patients, and seeing these patients after fifteen or twenty years reminds me what a great procedure PRK is. LASIK is probably even a better procedure than PRK, and this is why 90% of our patients chose LASIK. The use of the femtosecond laser (IntraLase) has improved the safety and accuracy of LASIK by leaps and bounds.

The visual results in LASIK and PRK are the same. The big difference is in the recovery time. LASIK patients obtain good vision a day or two after their procedure, whereas PRK patients may take a week, or two, to recover. There is also more postoperative pain with PRK, although we have some pretty good ways of minimizing the pain. So, why do some patients still have PRK rather than LASIK? There are four reasons. 1. The cornea may be too thin for LASIK, but thick enough for PRK. 2. There may be some corneal irregularities, or scars, which make PRK a safer procedure than LASIK. 3. There may be concern about displacement of the LASIK flap in people subject to head, or eye, trauma. 4. If previous corneal surgery was done, PRK may be a better option.

Both LASIK and PRK are remarkable for the stability of the vision correction. Less than 10% of patients require a touch-up, or “enhancement” procedure. In our practice, 92% have not needed an enhancement. And when enhancements are done, the cost is minimal, the improvement is predictable, and recovery is quick. Looking back over the last two decades, a few facts are striking. Patients often say that laser vision correction was the best thing they ever did. The elimination of glasses or contact lenses overnight is a truly remarkable feature for any ophthalmic procedure, or any surgical procedure at all. The safety of LASIK and PRK with modern technology is impressive. Serious adverse events are far less than one percent.

Laser vision correction is probably the best procedure to come along in ophthalmology during the last fifty years. What are the challenges for the future? Well, it would be nice to create a bifocal effect in the cornea, so people over 43 years of age would not have to wear reading glasses. But, this seems like such a difficult optical feat, it may be many years before someone figures out how to do it. In the mean time, patients over 43 can chose monovision, or buy reading glasses in the drug store.

Hyperopia Double Whammy

2011-05-07T17:49:00.000-07:00

Earlier this week, I performed LASIK on a friend in his late forties. This man had a +2.00 distance correction. That is, he was moderately farsighted, or hyperopic, in both eyes. Before surgery, he was having trouble biking, seeing road signs, and reading small print. When he returned the day after surgery he was 20/20 in both eyes, and reading the newspaper without his glasses. He was thrilled! He had not been able to see clearly for either distance or near for many years. I call this the “double whammy” of performing LASIK for farsightedness in people over 42. Their distance vision becomes excellent. Their reading vision also improves. Sometimes they end up in a “sweet spot” with good distance vision and good reading vision. I tell farsighted patients that their distance vision will be superb, and their reading vision will improve about 30%. I tell them they will, at some point, need reading glasses for fine print. They will probably need to make a trip to the drugstore to get over-the-counter magnifying glasses. My friend was probably a little disappointed when I told him his good reading vision may not last permanently. With age, and possible regression of the laser correction, he might need reading glasses in the next few years. I am sure he will enjoy good reading vision while it lasts, but he won’t be too surprised if he needs the help of magnifying glasses down the road. With nearsighted people, distance vision is also superb after LASIK. But, in people over 42, reading vision may be worse. In nearsightedness, or myopia, there is a “yin and yang” between distance and near. Most people prefer good distance vision over good reading vision. But, it is important that they be forewarned. We spend a good deal of “chair time” discussing presbyopia, the need for reading glasses, with our LASIK patients.

It is sometimes said that farsighted people are easier to please with LASIK. It is this double whammy of improved distance and reading vision that is responsible for their satisfaction.

LASIK Thought Of The Day: PRK Enhancements

2008-11-01T11:52:00.001-07:00

We see many people who had LASIK several years ago, and do not see as well as they did right after their procedure. The usual reason is "regression". This can be due to a loss, or "wearing off", of the LASIK treatment, or a natural change in the focusing of the eye. A good remedy for this is an enhancement, or touch-up. Many of our colleagues have suggested a variety of methods to enhance a LASIK. We find the most effective treatment is "PRK Enhancement". This involves treating the surface of the cornea with some additional laser spots. There is no need to make another LASIK flap. And, we find that if we treat only the center part of the cornea, the part you look through, healing is rapid, and discomfort is minimal. It is not necessary to use wavefront treatment for PRK Enhancement. In fact, wavefront treatment slows down healing and visual recovery. It also removes too much corneal tissue. So if you had LASIK several years ago, and vision isn't as good as it use to be, consider a PRK Enhancement. It could improve your vision considerably.

Mitchell Friedlaender, M.D.
Head, Division of Ophthalmology
Director, Laser Vision Center
Scripps Clinic
La Jolla, CA
858.554-8143

LASIK Update

2008-07-25T14:55:00.000-07:00

2008 has been a rough year for LASIK surgeons. The weak economy, high gasoline prices, and the ailing stock market have combined to strain peoples' budgets. When this happens, elective surgical procedures, such as LASIK, become a low priority. As with most markets, the strong survive better than the weak, and in the world of LASIK, doctors need to perform procedures every week, or nearly every week, in order to maintain their skills, and deliver a consistent, high quality product. In addition, the April 25 FDA Ophthalmic Devices Advisory Panel hearings on LASIK made consumers wary about the safety of the procedure. Despite some anecdotes about unfavorable experiences, most testimony at the FDA was highly supportive of the safety, and effectiveness, of LASIK. In fact, 95% of patients worldwide are satisfied with the outcome of their LASIK. On the positive side, LASIK is safer, and more accurate, than ever before. This is partly due to the technology allowing the LASIK flap to be created with the femtosecond laser, or IntraLase. The IntraLase creates a perfect corneal flap every time, much better than the microkeratome. Presently, 28% of LASIK practices use the IntraLase. Eventually, every LASIK surgeon will need to adopt this technology. LASIK has been performed since 1989, nearly 20 years. It appears that it is a safe, effective, and permanent procedure when it is properly performed. At Scripps Clinic Laser Vision Center, we continue to be impressed with LASIK, and the high level of satisfaction among our patients. For more information about LASIK, please see our website, JoyOfLasik.com, or contact tfleisler@scrippsclinic.com.

LASIK Thought Of the Day: Trends

2007-11-13T16:16:00.000-08:00

Having just returned from the American Academy of Ophthalmology meeting in New Orleans, we had an opportunity to hear many lectures, and chat informally with colleagues from all over the planet. Here are some thoughts about where we have been and where we are headed. Laser vision correction has been around for 20 years. Patients in whom PRK was performed many years ago are stable, and seeing well. There is still concern about complications, particularly ectasia, a progressive thinning of the cornea. This is a rare complication. It occurs more with LASIK than with PRK. Patients with ectasia may have had abnormal corneas before having LASIK. But LASIK seems to hasten the thinning process. Bewer instrumentation seems to be helpful in detecting abnormal corneas.The average LASIK patient is 39 years old and equal numbers of males and females have the procedure. Corneal flaps made with the IntraLase femtosecond laser have fewer complications than those made with the microkeratome. Currently, 28% of cases are performed with the IntraLase. Phakic intraocular lenses are being used for higher corrections (above -10), but most patients are reluctant to have an intraocular procedure.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLasik.com
ArtOfLasik.com

LASIK Thought of the Day: LASIK in the Elderly

2007-10-13T11:27:00.000-07:00

LASIK is a useful technique for people over 18 years of age, and this includes people in their 70s, 80s, and 90s. There really is no upper age limit for LASIK. However, there are some special considerations in the elderly. Last week, I saw a 75 year old, nearsighted patient who wanted LASIK. But, she had mild cataracts in both eyes. While she did not need a cataract operation right away, it appeared that she might need one within the next 5 years. I suggested that she not do LASIK. When she eventually has cataract surgery, an intraocular lens of the appropriate power can be selected in order to correct her nearsightedness. If she had LASIK this year, she would also need to have a cataract operation in the near future. It's better to avoid two surgeries, if the goal can be accomplished in one surgery. On the other hand, we sometimes perform LASIK after cataract surgery. If the cataract surgery does not fully correct the eye, LASIK can often be used to make the vision better.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLasik.com
ArtOfLasik.com

LASIK Thought Of The Day: Pregnancy

2007-09-28T15:19:00.000-07:00

We have avoided performing LASIK during pregnancy or nursing. Some feel it is because the refractive error (that is, the glasses or contact lens prescription) can change when the body's endocrine system is altered. We have not been impressed with refractive changes during pregnancy, or nursing. The main reason we wait has to do with the use of eyedrops, or other drugs used after LASIK. Most of these drugs are eye drops, and probably very little would cross the placenta, or enters the mother's milk. But, why take a chance. After all, LASIK is elective surgery, and it can be performed before, or after, pregnancy and nursing. The same can be said of other medical procedures. It is preferable to clear up more serious conditions before performing LASIK.
Mitchell H. Friedlaender, M.D.
Director, Scripps Clinic Laser Vision Center
La Jolla, CA
JoyOfLASIK.com
ArtOfLASIK.com

LASIK Thought of the Day: Enhancements

2007-09-19T16:33:00.000-07:00

Enhancements are another name for "touch-ups" after a LASIK procedure. If the vision is not full corrected by the initial procedure, an enhancement is usually recommended. Enhancements are rarely done sooner than three months after the initial procedure. In our practice, most enhancements are performed between the third and twelfth post operative month. During the first year, it is uaually easy to "lift" the LASIK flap, and add a few spots of laser treatment to the bed. After the first year, it becomes more difficult to lift the flap, especially when the flap was created with the IntraLase. IntraLase flaps adhere more tightly to the underlying cornea than microkeratome flaps. While many LASIK surgeons maintain they can lift a flap many years after the initial procedure, we would note that complicationns, such as tearing the flap, or epithelial ingrowth are more likely as time goes by. For this reason, we are big fans of PRK enhancments 18 months, or more, after the initial procedure. In our experience, flap lift enhancements work well for the first 18 months. After that, PRK enhancements offer greater safety and effectiveness. We are not enthusiastic about creating a second flap under any circumstances. The old flap edges may join up with the new, and create an undesirable "splintering" effect.

Mitchell Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
ArtOfLASIK.com
JoyofLASIK.com

LASIK Thought Of The Day: "Am I a good candidate for LASIK?"

2007-09-17T21:38:00.000-07:00

Many people are told they are not good candidates for LASIK, and indeed, some truly are not good candidates. Others may be good LASIK candidates but are simply told they are not. There may be many explanations for this. The eye doctor who discouraged them may not perform LASIK, and may not want to lose a patient. They may prefer to continue fitting the patient with glasses or contact lenses. Furthermore, someone who was not a LASIK candidate a few years ago may be a good candidate today because of improved technology. For example, people with thin corneas and high corrections may have been turned away in the past, but can now be treated with the IntraLase, or with PRK. People who had radial keratotomy (RK) years ago may have poor distance vision, but they can usually be improved dramatically with laser vision correction. Some patients who have poor vision after cataract surgery, or corneal transplantation, can also be improved with laser vision correction. So, even if you were told you are not a good LASIK candidate, get a second opinion. You may be pleasantly surprised.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
ArtOfLASIK.com
JoyOfLASIK.com

LASIK Thought Of The Day: Presbyopia

2007-09-16T11:47:00.000-07:00

Correction of presbyopia (the need for reading glasses after age 42) has long been considered the "holy grail" of laser vision. We feel the most promising approach is multi-focal ablation, that is, creating a laser pattern in the cornea somewhat like a bifocal glasses lens. Some progress has been made, especially in Canadian studies, but the procedure has been slow in making its way to the U.S. This suggests that multifocal ablations are not quite ready for prime time, and we really don't know if presbyopic corrections are months, or years, away. Other approaches have been to implant synthetic lenses in the central cornea, or replace the crystalline lens inside the eye with a "focusing" intraocular lens. Both approaches seem more invasive than multi-focal ablations, and much more work needs to be done before they gain acceptance by most ophthalmologists. Those waiting for the perfect method to correct both distance and near vision may have a long wait. In the mean time, reading glasses, or monovision (one eye corrected for distance, and one for near), seem to be reasonable alternatives.

Mitchell Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
ArtOfLASIK. com
JoyOfLASIK.com

Thought For The Day: Healing Time

2007-09-15T09:37:00.000-07:00

Seeing postoperative patients Saturday morning reminded us that healing time, and visual recovery after LASIK, can vary depending on a number of factors. A 24 year old patient with a -5.00 correction in both eyes was 20/15 in both eyes 20 hours after "All-Laser LASIK". A 55 year old patient with a great deal of astigmatism was only 20/30 in one eye, and 20/40 in the other eye, 20 hours after "All-Laser LASIK". While we expect this lady to be 20/20 in both eyes when we see her next week, it reminds us that visual recovery can be slower due to age, astigmatism, or high amounts of nearsightedness, or farsightedness. No doubt the healing process is more complex when a patient's cornea is more complex. We feel that touch-ups, or enhancements, are also more common in these complex patients. Such observations teach us patience, and the importance of preparing certain patients for a slower visual recovery than they might expect. However, it is the end result that we are truly interested in, and when we achieve excellent vision, a few days here or there seems less important.

Mitchell H. Friedlaender, M.D.
Scripps Clinic Laser Vision Center
La Jolla, CA
ArtOfLASIK.com
JoyOfLASIK.com

Thought For The Day:EpiLASIK

2007-09-12T16:57:00.000-07:00

There is some buzz (although, not much) about a new LASIK procedure, called EpiLASIK. The surface layer of corneal cells, the epithelium, is removed with an oscillating, plastic blade, and the uderlying cornea is treated with the excimer laser. This seems to be a variation on LASEK, an older, seldom-used procedure, but one which has its advocates. Some doctors replace the epithelial sheet, while others remove it permanently. The sheet is suppose to act like a bandage, but it eventually gets replaced by regenerating cells. We've always thought that LASEK and EpiLASIK are misguided approaches to LASIK. Both are associated with significant pain, and a slow visual recovery. The selling point of these procedures is their safety when the cornea is too thin to perform conventional LASIK. However, we are not convinced that EpiLASIK, or LASEK are as good as PRK, the direct laser treatment of the cornea. They are certainly more difficult for the surgeon to perform. And, increased complexity often leads to increased complications. Our advice is to stick with LASIK, preferably using the IntraLase femtosecond laser to make the flap. If the cornea is too thin, opt for PRK rather than EpiLASIK, or LASEK.

Mitchell Friedlaender, M.D.
La Jolla, CA
ArtOfLASIK.com
JoyOfLASIK.com

LASIK Thought Of The Day

2007-09-10T18:49:00.000-07:00

We've commented before about the beauty and symmetry of LASIK flaps created by the femtosecond laser, known by its brand name, IntraLase. The flaps are so precise and reproducible, that they seem to be perfect every time. Contrast this with the corneal flaps created by the cutting device, the microkeratome. Aside from varying in size, shape and thickness, microkeratome flaps can often be off center. While only about 30% of LASIKs are done with the IntraLase, so-called "All-Laser LASIK", we see no reason to perform LASIK with a microkeratome when a far more precise method of flap creation is available.

Mitchell Friedlaender, M.D.
La Jolla, CA
JoyOfLasik.com

Dry Eye After LASIK?

2005-11-17T16:47:00.000-08:00

More nonsense has been written about dry eye than almost any other eye condition. Dry eye is caused by a deficiency of tears, the fluid that constantly bathes the eyes, and keeps the surface moist and clear. Tears are slightly reduced as we age. They are also reduced by certain drying medications, like antihistamines and diuretics. The most severe form of dry eye is caused by an autoimmune disease known as Sjogren's Syndrome. People with Sjogren's Syndrome typically have dry eye, dry mouth, and an autoimmune condition, such as rheumatoid arthritis, or lupus. LASIK reduces tear production temporarily, because when the LASIK flap is created, corneal nerves are cut, and the neural pathways that signal the production of tears are interrupted. But the dryness is temporary. The nerves regenerate completely in six months, and symptoms of dryness rarely last longer than a few weeks. Artificial tears, available without a prescription, are the mainstay of dry eye treatment. They are soothing, and can be used safely as often as desired.

Phakic Intraocular Lenses

2005-11-17T16:38:00.000-08:00

Many LASIK surgeons are now recommending intraocular lenses to correct nearsightedness and farsightedness, instead of LASIK or PRK. Intraocular lenses are the plastic or silicone lenses that are implanted in the eye after cataract removal. "Phakic" intraocular lenses are implanted without removing a cataract. They are placed in front of the natural lens of the eye. I have not been impressed with these lenses. I believe the science is in its infancy. Most patients do not want an intraocular procedure. They want a laser procedure that is as non-invasive as possible. You have to be an incredibly good surgeon to insert a phakic intraocular lens without damaging the natural lens or some other delicate structure inside the eye. You don't want to be part of the surgeon's "learning curve". The better part of valor, at this juncture, is to pass on a phakic intraocular lens, and stick with conventional LASIK or PRK.

State-Of-Art LASIK

2005-11-17T16:15:00.000-08:00

LASIK, or laser vision correction, has evolved rapidly into an astonishingly good procedure. New innovations occur almost daily. Some are important, but most are "bells and whistles", and do not change LASIK in any meaningful way. At Scripps Clinic, we consider state-of-the-art LASIK to consist of:
1. An up to date excimer laser. We use the VISX Star S4 (the latest model and software).
2. Wavefront technology. This individualizes the treatment and produces high definition.
3. Intralase. This is a femtosecond laser that creates the LASIK flap. No cutting involved.
Your LASIK surgeon should have these, or similar, equipment available. Keep in mind, not everyone is a candidate for LASIK. In some eyes, it is safer to use PRK, or photorefractive keratotomy, the original laser vision procedure. And some eye conditions, like presbyopia (the need for reading glasses in people over 42), may not be correctable with current technology.