April 23, 2009

Like many people, I hated wearing glasses. I needed them to drive, watch TV, play sports, socialize. But since contacts weren't a comfortable option for me, I was stuck.

So when news of a new "miracle" procedure called LASIK (Laser-Assisted In-Situ Keratomileusis) made countless headlines and magazine covers in 1999, I rustled up the requisite $4,000 and started looking for an ophthalmologist. I did everything right: I ignored discount fliers and bargain surgeries advertised in the paper, and settled on a doctor who'd performed over 1,000 LASIK procedures, at one of Los Angeles' most prestigious hospitals. In just 10 minutes, using a special laser, he corrected the vision in my left eye from 20/200 to 20/15. Results of the correction to my right eye (from 20/300 to 20/40) weren't as satisfying, yet still better than I'd expected. Suddenly, not only could I leave my glasses at home, I could read street signs from three blocks away.

But within a month, something peculiar happened: The vision in my left eye started to change. At first, it only slipped to 20/20. A few months later, it was 20/25. After a year, my left eye had regressed to 20/40, the minimum needed to pass a driver's license test. Two years after I had LASIK surgery, my vision had deteriorated so dramatically that my doctor decided it was time to do a "touch-up."

LASIK enhancements, or touch-ups, are needed by a significant number of LASIK patients, according to the American Academy of Ophthalmology (AAO). Of the 835,000 patients who had LASIK in 2001, 5.8 percent -- more than 48,000 people -- will need to have surgery more than once, to correct surgical error or to treat complications, according to Market Scope, a Missouri-based consulting firm that keeps tabs on the refractive-surgery market. Specific statistics on how many of those touch-up surgeries are due to surgical error and which are attributable to unanticipated patient outcome are difficult to find, however, because such numbers are not tracked. Indeed, all findings on LASIK enhancements (including those used by industry analysts) are gathered through voluntary doctor surveys.

When LASIK is performed, the doctor numbs the eye with drops before making a semicircular eye-flap incision with a microkeratome cutting device. The surgeon then lifts the flap and exposes the cornea. A computerized laser vaporizes a predetermined portion of the cornea. After surgery, a doctor might provide anti-inflammatory drops and an antibiotic to use at home for the next few days to prevent swelling of the tissues, infection and inflammation.

According to the AAO, there are two primary reasons why results that are less than optimal occur. One, the eye is undercorrected, meaning that not enough corneal tissue is removed to bring the eye to 20/20 vision. In these cases, a patient's vision is often subpar immediately after surgery, and touch-up surgery is needed to optimize the correction. Other touch-ups are necessary because of adverse "wound healing," or how the eye responds to the laser. "Everyone heals differently, and there's a small percentage of patients whose wound healing is such that their vision undergoes a regression," says Ernest W. Kornmehl, M.D., medical director of Kornmehl Laser Eye Associates in Boston and an AAO spokesman. As the eye recovers, unintended visual shifts can take place that sabotage an otherwise successful correction and leave a patient with progressively weakening vision over time. In the worst cases, patients might experience visual halos around light sources (especially at night), blurred vision and extremely dry eyes. And while the risk may be slight, some patients have even experienced the most devastating "complication": blindness.

Will LASIK work for you?

Your risk of LASIK complications and potential need for touch-up surgery depends on a number of factors, Kornmehl says, including what your pre-operative vision is. Those seeking LASIK should ask their prospective surgeons not just how many LASIK surgeries they have performed, and what laser equipment they use (check whether the equipment has been FDA-approved, and if so, for which specific treatment ranges, at fda.gov/cdrh/lasik), but should be able to discuss in detail previous patients' complications and results of follow-up care. "A doctor who is very careful and thoughtful will track all his statistics, and will be able to print them out for you right off of his computer," Kornmehl says.

While a patient should choose a surgeon carefully, doctors say it is imperative for patients to have realistic expectations about LASIK too. Be aware that complications do happen, and remember that the surgery might not

be a "cure-all" for everyone. "What is attempted surgically is not always what people get," explains Brian Chou, O.D., F.A.A.O., a San Diego optometrist who specializes in refractive-surgery care.

"One of the things inherent in any surgery is that there is no guarantee of the final outcome," Chou says. "While there is some predictability in it, everyone heals differently." Some patients may still need distance glasses after surgery, for instance, and patients who wore reading glasses before LASIK (and most people do need reading glasses after age 40) will still require them after surgery. In addition, LASIK results may not be as good if you either have very small amounts of astigmatism or very large refractive errors.

In addition, it's important to know that not everyone is a good candidate for LASIK surgery. There are a number of conditions that preclude surgery. For example, you're more likely to have refractive instability -- and thus shouldn't opt for refractive surgery -- if you've had to change your eyeglass or contact lens prescription in the past year significantly; you're in your early 20s or younger; you're pregnant; or you're breastfeeding. Other conditions that rule out surgery would include insulin-dependent diabetes, herpes simplex, autoimmune diseases, large pupils and thin corneas.

Touch-up surgery failures

Though I looked forward to my LASIK touch-up, I soon realized that follow-up surgery is every bit as serious as the first time around. (Touch-ups were included in the fee structure for my initial LASIK correction, though an additional charge of $300 to cover some hospital and equipment-related expenses was necessary; my doctor agreed to split the cost with me.) Touch-ups tend to hold, according to the AAO: Because they usually burn a lesser percentage of cornea than in the first round of surgery, the eye isn't as likely to shift significantly after the second surgery.

But during my touch-up, the microkeratome cutter malfunctioned and my eye flap was completely detached. Though the flap was quickly reattached, my vision was impaired for days and I needed to take antibiotics. At this writing five months later, my left eye is now overcorrected, meaning distance vision is near 20/20, but reading vision remains blurred, so I've had to buy reading glasses. With my right eye nearsighted and my left eye farsighted, I may again need distance glasses to regain 20/20 vision and full depth perception. Right now, though, my distance vision is fairly good.

Whether the possibility of multiple surgeries -- and a less-than-perfect outcome -- is a risk worth taking is something prospective LASIK patients must decide for themselves -- preferably, doctors say, well before they have surgery. "Enhancements are part of the procedure," Kornmehl cautions. "I always tell patients if an enhancement sounds unpalatable to you, don't have the procedure to begin with because somebody is going to fall into these numbers. The numbers don't come out of nowhere. They're based on real people."