Refractive Surgery (Laser Vision Correction)

Myopia, or nearsightedness, occurs when light rays are focused in front of the retina instead of directly on the retina. This is normally caused when the cornea is too steep or the eye is too long.

Hyperopia, or farsightedness, occurs when the eye does not have enough focusing power and light focuses behind the retina instead of on it. The eye is either too short or the cornea too flat.

Astigmatism is an uneven curvature of the cornea. Different curves result in more than one focal point, resulting in distorted vision.

Laser Vision Correction (LASIK / PRK) for the Correction of Nearsightedness, Farsightedness, and Astigmatism

The two procedures available for laser vision correction are LASIK (laser assisted in situ keratomileusis) and PRK (photorefractive keratectomy). Both are able to correct broad ranges of nearsightedness and astigmatism and, more recently, farsightedness. Both use excimer laser technology to precisely and painlessly reshape the surface of the cornea. In LASIK the laser treatment is performed beneath a protective flap of the cornea, whereas in PRK the laser is applied to the surface of the cornea.

Laser Assisted in situ Keratomileusis, or LASIK, is a procedure that involves two steps. First an instrument called a microkeratome creates a thin flap of the cornea. This is done in an automated fashion, is painless and takes just a few seconds. The creation of a corneal flap is based on a procedure called ALK(automated lamellar keratoplasty), which has been performed for over three decades but only recently has been combined with laser technology. Next, the flap is retracted and the excimer laser is used to treat a precise section of corneal tissue. The exact quantity of treatment is determined by computer based on measurements and mapping of the eye done prior to the procedure. The actual laser treatment takes approximately 30-60 seconds. The flap is then placed back in its original position and heals very securely. In fact, it is often difficult for the surgeon to see the flap even under magnification on the very next day after the procedure. The entire procedure takes 5-10 minutes per eye. Both eyes are generally treated at the same session.

PRK (Photorefractive Keratectomy) uses the same excimer technology to reshape the cornea. However, it is performed on the surface of the eye instead of beneath a protective flap.

Both procedures are painless and work well. While LASIK involves an extra step, namely, the creation of the corneal flap, it does have some distinct advantageous over PRK, especially for more nearsighted eyes. Specifically, LASIK offers a rapid recovery of vision and comfort with most people seeing quite well by the next morning. Many people are able to resume their normal routine the next day after the procedure with a very low frequency of haze or infection. As with all procedures there is some risk, and these issues are discussed prior to the procedure with the physician.

The Laser Vision Correction Process

1) Preoperative evaluation - A thorough preoperative ocular evaluation is required to determine the advisability of laser vision correction. In our practice we offer a free, no obligation evaluation during which a complete eye examination with corneal measurement is obtained. A video is shown that highlights important features of laser vision correction. We then offer a full discussion addressing your specific situation and concerns. Specifically, we will bring to your attention any issues that are relevant to your decision. We value this step in the process and have set aside specific and ample time slots for laser vision evaluations.

2) Scheduling laser vision correction - We seek to accommodate your schedule and often have convenient times available for the actual procedure. Typically the time required is two hours at the laser center. Note: soft contact lenses must be discontinued seven days prior to the procedure and hard contact lenses four weeks prior to the procedure (if desired we can often provide you with soft contact lenses to use up to seven days prior to the procedure if you are a hard contact lens wearer).

3) The procedure itself - Both eyes are generally treated at the same session. Corneal topography and repeat refractive measurements are taken at the laser center. Corneal topography creates a 3 dimensional mapping of the surface of the cornea and provides additional data for the treatment process. We will review with you specific features and steps of the procedure prior to the actual procedure being done. Numbing drops are all that are required to anesthetize your eyes. Antibiotic drops to prevent infection are also used both before and after surgery. Mild sedatives can be requested preoperatively but are used by less than one-quarter of our patients. The procedure is performed in the laser suite painlessly taking approximately 5-10 minutes per eye.

4) Postoperative period - After surgery you will spend approximately twenty minutes in the recovery area, and then your eyes will be checked. You will be provided with antibiotic and steroid eye drops to use for approximately three days postoperatively. Gritty sensations, tearing, and light sensitivity are typical for 3-5 hours after LASIK and for 2-3 days after PRK. No patches are required postoperatively. Follow-up appointments are generally scheduled at one day, one week, one month, three months, six months, and one year after your procedure. Additional appointments may be required on an individual basis. Most patients are quite comfortable and seeing well by the very next day after LASIK. However, some fluctuations are common, and it can often take several days or weeks for the vision to completely stabilize.

Other Refractive Procedures

Radial Keratotomy (RK)
This is an ocasionally used procedure to correct low to moderate degrees of nearsightedness and has been performed for more than 15 years. Two to eight small radial (spoke-like) incisions are made on the surface of the outer cornea to flatten it. RK is performed in our in-office surgical suite.

Astigmatic Keratotomy (AK)
Astigmatism is corrected by small, arcuate incisions into the surface of the outer cornea. This can be performed simultaneously with RK and/or Laser Vision Correction.

Small-Incision Cataract Surgery
A cataract is an age-related clouding of the lens that interferes with good vision. Fortunately, cataracts can be corrected through outpatient surgery. Small-incision surgery using "no-stitch" closure provides faster return of good vision, more comfortable recovery, less visual distortion (astigmatism), and more rapid visual stability. Your astigmatism (uneven curvature of the cornea) can also be reduced at the time of cataract surgery. Our goal is the best possible distance and/or near vision without glasses. A needle-less technique to numb around your eye is used, thus removing one of the past risks of surgery. No patch is needed and you are able to use your improved sight starting on the day of surgery. Most patients see considerable improvement soon after the surgery and are ready for their glasses prescription one week after surgery. Please call for additional information.

New Developments in Glaucoma Management
Glaucoma is a silent illness in which the high pressure within the eye causes damage to the optic nerve leading to loss of vision. In the past, we have relied upon topical drops, oral medication, and laser surgery for treatment. Recent studies have found that other treatment options can be beneficial including a laser procedure called Laser Trabeculoplasty. This procedure can provide longer control of glaucoma before additional laser treatment or drops are needed and it eliminates the need for daily drops with their potential side effects, compliance problems, and expense. A new drop (Trusopt), formerly only available as an oral medication, gives another alternative for controlling glaucoma without the side effects of oral medications. Another new drop called Xalatan offers yet an additional treatment option. Please call for additional information.

Diabetes
In diabetic retinopathy, leakage and hemorrhage occur in the retina (the back of the eye) leading to the loss of vision. Laser treatment at the appropriate time can prevent bleeding within the eye and vision loss from macular edema (swelling in the central retina). It is essential that anyone with diabetes have an annual eye exam by an ophthalmologist who is trained to diagnose and treat diabetic retinopathy. The American Academy of Ophthalmology has initiated a project entitled "Diabetes 2000" with the goal of eliminating preventable blindness from diabetes by the year 2000.

Corrective Lenses
Eyeglasses and contact lenses are another alternative for the correction of vision problems involving focusing or "refraction." For your convenience we provide a carefully chosen variety of glasses and contact lenses in our offices. We recommend the purchase of your glasses at our optical dispensaries. Our doctors work closely with our opticians to assure quality and accuracy in each pair of glasses. Your satisfaction is always guaranteed.

10 Commonly Asked Questions About Laser Vision Correction by Mark Schefkind, M.D.

Would you have the procedure yourself?
As a matter of fact, I did have bilateral LASIK to correct nearsightedness and astigmatism. I include myself among the many thousands of satisfied laser vision correction patients. I would not hesitate to recommend the procedure to family members and I have performed the procedure on a number of my staff members. Having had the procedure provides me with valuable insight into the experience from the perspective of both surgeon and patient.

Can the procedure be repeated?
If any significant under-correction remains, an enhancement procedure can be done 1-3 months or later after the original procedure.

Is the procedure covered by insurance?
Generally, no, although it is recommended that each individual check with their insurance carrier to find out their individual coverage. Fees are all-inclusive and cover a laser vision evaluation, the postoperative appointments for one year, and any enhancement procedure that becomes necessary after the procedure. The policy on enhancement procedures is carried for life. If any additional procedure is required, it is done without charge provided it is considered necessary and appropriate.

What are the common side effects after this procedure?
The common side effects include fluctuations in vision, dryness of the eyes for the first few weeks, seeing halos or rainbows around lights at night, (this last symptom typically occurs for the first few weeks after surgery but will typically subside) and some reduction in contrast sensitivity under low illumination.

Can I go blind from this procedure?
Although there has never been a documented case of blindness from laser vision correction in now over one million cases, it does remain a potential although extremely unlikely possibility. It is important to discuss the risks of complications of any procedure with your doctor.

What if I move or blink during the procedure? Will this interfere with the results?
While some cooperation is required, the procedure is done in a very controlled and stepwise fashion. The eyelids and eye are immobilized during certain parts of the procedure making this concern unnecessary. Patients (even quite anxious patients) generally tolerate this procedure without difficulty.

Will I still need reading glasses after this procedure?
The need for reading glasses as you get older is inevitable whether you have laser vision correction or not. This is termed presbyopia and generally becomes manifest around the age of forty. This occurs because of a loss of flexibility in the focusing mechanism of the eye. The laser has no effect either positive or negative on the focusing mechanism of the lens of the eye. Some patients opt to have one eye intentionally under-corrected. This is called monovision and allows some retention of reading ability. This is an approach that has worked well, however the approach needs to be individualized and discussed in detail with the physician prior to the actual procedure.

Are there any restrictions on my activities after the procedure?
After LASIK it is recommended that you go home and rest. Taking a nap is often helpful in getting through the few hours after the procedure that are moderately uncomfortable. Many patients are able to return to their normal routine by the next day. It is recommended that you do not rub your eyes or wear make-up for one week after the procedure. No swimming or bathing in hot tubs for one week after the procedure. Avoid gardening or any other dusty environment for one week and avoid contact sports that could result in injury to the eye for one month. Driving may be resumed only after it is cleared by the doctor at your postoperative visit. You may shower by the first day but avoid any direct contact of the water or soap with your eyes.

Which procedure do you feel is best?
Having performed many hundreds of refractive procedures, I have generally settled on LASIK as the preferred procedure for most patients. However, PRK or even RK (radial keratotomy) can be appropriate and preferred in some patients. This decision should be a mutual one between patient and physician.

Can you wear contact lenses after laser vision correction?
While it is not expected that contact lenses will be necessary, they can usually be tolerated after adequate healing is allowed. If any significant under correction remains, an enhancement procedure is generally considered after 1-3 months.