When deciding whether refractive surgery like LASIK or PRK is right for you, one of the most important factors to consider is expectation. A patient must have realistic expectations BEFORE having any procedure in order to be happy with the results.

Important factors to consider are time of healing, vision during that time, pain/discomfort, final results and side effects. Looking at each of these issues time of healing leads the pact. LASIK will most likely have the shortest healing time. The day following surgery most people have some discomfort, redness and 20/20 or very close to it. However, there is no guarantee that all will be perfect on day 2. There are some patients that will need days to weeks to reach the final best vision and eye drops are required for at least a week. Glare, haloes aroung lights and dryness are very common side effects following the procedure. These may last several days to months. Any one having surgery must be prepared to live through these visual effects until they resolve. In addition, if the final vision is not what was expected before surgery, then an enhancement may have to be done. This is the same procedure as was initially done to refine the results.

PRK takes at least several days and most often several weeks to reach the best vision and there is considerable discomfort during that time. Several eye drops are taken to help in the healing, but individuals should not expect perfect vision during the first few weeks. Ultimately, the vision should be great, but the path there is longer and less comfortable then with LASIK.

The bottom line is that any one having refractive surgery should not c0mplain that the healing process is taking too long or that they are uncomfortable during that time. It is part of the process and patients must be willing and able to accept this as a part of what they must do to reduce their need for eye glasses. We had a patient recently that 3 weeks after PRK was complaining bitterly that his eyes were still not clear and that it was affecting his job performance. He said that he was very unhappy that he had to keep taking eye drops and that it was not what he expected. It should be noted that he was 20/25 in each eye ( and was worse then 20/400 before surgery) and he had read, signed and was explained to before the surgery all the side effects and healing time required. He had a very short memory.

Go into all eye surgeries with both “eyes open” and understand that it will take time.

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With the summer coming and people of all shapes and sizes trying to get into shape, we start seeing patients in the office complaining of worsening vision after working out. For most people, fatigue following a strenuous work out is normal, but when this is accompanied by decreased vision, it may indicate a serious medical condition.

Uhthoff’s sign is when an individual experiences decreased vision following exercise and/or increased body heat. This may also occur by simply sitting in the sun or even being in a hot room for a certain period of time. There may be no other symptoms at that time, but the change in vision is always noticeable.

This sign is a classic sign of Multiple Sclerosis. It may be the first time there has ever been any symptoms , but it will certainly not be the last. If you experience this type of vision change, see your eye doctor as a starting point. Refractive error and corneal issues must be first eliminated, but if it is Uhthoff’s sign medical follow up is required by a Neurologist.

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Keratoconus is a genetic recessive condition that results in the steepening and thinning of the cornea. There are several degrees of severity of this condition which may cause mild corneal change and decreased vision to a severely distorted cornea and very poor vision. Treatment and best corrected vision will be determined by how much this genetic condition is expressed.

The mildest display will simply require eye glasses and should permit the patient to see 20/20. As the condition appears worse, special contact lenses such as custom design soft lenses, lenses with hard centers and soft skirts, hard contact lenses and ultimately hard lenses with soft lenses underneath may be required. If acceptable vision still can not be achieved, then most often corneal transplants are required.
Some studies have demonstrated that a small percentage of these corneal transplant patients will have the new grafted corneas become Keratoconic again. This requires the same treatment plan as before the surgery.
Keratoconus patients should NEVER have LASIK or PRK since that may results in permanently distorted corneas and may even cause corneal rupture.

There is a surgical procedure called Intacs, which implants a plastic ring in the stromal ( middle) layer of the cornea to flatten out the cone and improve vision. Hard contact lenses may then permit the individual to see much better with out a corneal transplant which requires a long recuperation period and often a large amount to astigmatism.

The point to remember is that if you have Keratoconus you should be seen by an eye doctor that has a lot of experience with that condition.

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LASIK, surgery to reduce or eliminate the need for eye glasses, has become very popular over the past 5-10 years. While most cases proceed quite well, the potential for complications does exist, and is often not discussed prior to surgery. It should be noted that all but one of the complications is NOT due to surgeon error. Most potential problems are simply physiological, and have nothing to do with how well the surgeon performed the procedure.

The first is infection. While topical antibiotics are employed prior to, and after the surgery, there is always the possibility of infection if the individual is exposed to an infectious agent. The cure is simple; proper follow up and more antibiotics. There is minimal risk of further issues.

The second, is movement of the flap. This will occur if the individual rubs his/her eye before the flap has had proper time to reattach itself to the underlying tissue. The patient will experience pain, blurry vision and redness if this occurs. It is an emergency, and does require being brought back into surgery to move the flap back into position. Once this is done, the individual should heal normally without further complications. This flap movement tends to occur more frequently when Intralase (laser is used to lift the flap) is performed. While the incision is more precise, it results in a very thin flap which tends to move easier post surgically. Once the flap heals though, the incision area is barely noticeable.

The third complication is epithelial (outside) cell growth under the flap. This may occur days to months after surgery. These cells grow around the edge of the flap, and move inward causing haziness under the flap. When this occurs, the flap must me lifted up and these epithelial cells washed away. No further problems will occur after this procedure is done.

The fourth issue is striae, or wrinkles in or under the flap. This is corrected by lifting the flap and flattening it out. No long term issues after this point.

Issue five is extreme swelling often called ” Sands of the Sahara”, because it looks like a sand dune to the examining eye doctor. This may occur more frequently, but is dealt with higher doses of steroid eye drops to reduce the inflammation. As with the other complications, the results are most often successful.

The final and most serious of the potential complication is ectasia. This occurs when the inner most layer of the cornea, the endothelium, has irregularities in it. If this issue is not detected prior to surgery the final results after LASIK may be terrible. The patient may have poor, distorted and irregular vision that is NOT surgically correctable, nor corrected with glasses. Most often the individual will either have to wear hard contact lenses, and may even require a cornea transplant to improve his/her vision. This complication is the only one that could be surgeon related. A test called the Orbscan MUST be performed prior to surgery, and the potential for ectasia can be easily detected. NO INDIVIDUAL SHOULD EVER consider LASIK with out having an Orbscan done. Any office that does not have an Orbscan should not perform LASIK.

As with all surgical procedures, patients must be comfortable with the surgeon and the office they choose, and understand all the potential complications prior to surgery.

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Conductive Keratoplasty or CK is a surgical procedure that attempts to reduce or eliminate the need for reading glasses in people over 40 years old. Specific wavelength energy waves are introduced to the peripheral cornea in a focal point that burn the protein in the corneal tissue. This results in contraction of the tissue and thus steepening of the cornea. In doing so, it reults in an increase in power to the cornea and thus makes it easier to read.

This procedure was first performed in the United States by Dr. Norman Stahl in the 198os , but was called Thermokeratoplasty because he used heat not radio waves to burn the cornea. Essentially the same procedure being done with different means.

It is best performed on individuals that have no distance prescription and it results in one eye being mildly nearsighted permitting the person to read. The other eye remains normal and thus can see the distance. In order for the patient to be happy, he/she must be able to adjust to have the two eyes seeing at different levels. Most good surgeons will have any potential candidate wear a contact lens on one eye prior to surgery to see if he can adjust to the new visual environment. If the individual is comfortable seeing that way, then the procedure should be successfull. The only problem is that there is a fairly high rate of regression that will mean the patient will need reading glasses again in a few years. It is a good procedure with limited longevity.

Before going forward with this procedure, patients must “have both eyes open” as to the ultimate results.

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As the number of people 40 years old increases, so does the need for contact lenses that correct both the distance and near vision. Until recently, there have been bifocal contact lenses that have attempted to deal with this problem, but have fallen very short. The introduction of Bifocal disposable contacts has further complicated this issue. While these lenses are convenient with regard to replacement, the poor optics most often results in less then happy patients. They usually create a great deal of glare, and poor vision at distance, near or both.

Recent improvements in the quality of non disposable, multifocal contact lenses has resulted in a vast increase in the quality of the vision in the distance and near, better comfort and little or no glare at night. The combination of spherical and aspheric curves and thinner edge design has vastly improved all aspects of patient satisfaction with multifocal contact lenses.

The level of expertise and time required for fitting these contacts is much greater then the simple disposables and thus requires an Optometrist that has much more experience and is willing to spend the time required. Our office fits many of these lenses per day and has the answers to the difficult questions that arise when fitting the lenses.

We have patients coming all the way from Europe and South America to be fit with these contacts because of our high success rate. We are constantly researching new developments in this field and modify our fitting philosophy based on the most current information available.

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Determining which refractive surgery is best for you is as important as weather or not you are a candidate. While most patients think that LASIK, which is the most advertized surgery, is the best, PRK may be better for you. Depending on corneal thickness, shape and several other factors will determine which procedure will give you the best result and reduce the likelihood of future complications.

The worst complication could be Ectasia, which results in poor, uncorrectable vision, that may require special hard contact lenses or a corneal transplant to correct. In our office, we take special care to determine which procedure will get the best result and reduce potential future complications. The best care, in the best office is crucial with surgical procedures like LASIK and PRK.

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