Sight seeking

It's the surgery of the new millennium, and more than a million Americans are expected to have it this year alone. It is, of course, LASIK, and it's become the most commonly performed surgery in the country. Used to correct everything from nearsightedness to astigmatism, LASIK has gained popularity over its predecessors, radial keratotomy (RK) and photorefractive keratectomy (PRK), because vision usually stabilizes within 24 hours and there's less discomfort. (RK was the groundbreaking refractive -- but not laser -- surgery of the late '70s that's now largely obsolete. PRK, introduced in 1987, is laser corneal resurfacing.)

But LASIK's popularity comes with a price: Recently, it's been reported that the number of dissatisfied patients has started to climb (see "What Can Go Wrong?"). So, for those of you in the 50 percent of the population with less-than-stellar vision, be aware that other options are available -- ones for which you may be a better candidate. Here's a rundown, along with tips on finding the right ophthalmologist for you.

LASIK (Laser-Assisted In-situ Keratomileusis)

Works best for: Moderate myopia (nearsightedness; vision better than 20/800) or mild astigmatism (vision distortion).

How it's done: Laser reshapes the outer cornea to redirect light to proper focal point on retina. Flap is cut in outer layers of cornea (which are like pages of a book) and peeled back; cornea reshaped via laser; flap closed; 15 minutes per eye. Vision improves within about 24 hours.

Success/failure rate: 20/40 vision or better in 95 percent of patients; 20/20 vision in 65 percent of patients who had moderate myopia (up to 20/800); 10-20 percent need enhancement surgery.

Potential downside: Possible corneal-flap damage; distortion caused by irregular healing of flap; infections; undercorrection, overcorrection or induced astigmatism; mild foreign-object sensation to scratchiness; light sensitivity and tearing for first 24 hours. Potential for second surgery. Patient may still need glasses for night driving, or may have glare or a halo effect from lights for a few months. "Also, if someone has very large pupils, she can pick up distortions from seeing the edges of the surgery site," says Richard L. Abbott, co-director of refractive surgery and professor of ophthalmology at the University of California, San Francisco.

Cost: $1,900-2,500 per eye.

KeraVision Intacs (intrastomal corneal rings)

Works best for: Mild to moderate myopia (20/80 to 20/800) or mild astigmatism.

How it's done: The surgeon creates a little tunnel underneath several layers of the cornea, then slides the Intacs into them; 15 minutes per eye; incisions seal shut immediately; vision correction is usually immediate. "Intacs are placed outside the visual axis within the cornea so there's no chance of scarring [which impairs vision] over the central visual part of the eye," says Brian Boxer-Wachler, M.D., director, UCLA Laser Refractive Center, Jules Stein Institute.

Success/failure rate: 20/20 or better in 74 percent of patients. (For the 26 percent this doesn't work for, doctors usually recommend trying LASIK next.) If the patient is unhappy with the result, the Intacs can be removed.

Potential downside: Undercorrection or overcorrection, requiring a second procedure.

Cost: $2,000-$3,000 per eye.

PRK (Photorefractive Keratectomy)

Works best for: Mild to moderate myopia; mild astigmatism (then it's called PARK, Photo Astigmatic Refractive Keratology).

How it's done: The cornea's surface layer is reshaped using a laser-delivered ultraviolet light beam. Surface of cornea is scraped with a laser to flatten; 10 minutes per eye. May take one week for vision to improve, but PRK eliminates risks associated with corneal flap.

Success/failure rate: 95 percent achieve 20/40 or better; 66 percent achieve 20/20.

Potential downside: Possibility of severe post-op pain for up to four days; foreign-body sensation in eye; dryness; itchiness; light sensitivity; halo effect at night.

Cost: $1,900-2,500 per eye.

Ortho-K (Orthokeratology)

Works best for: Mild to severe myopia; mild astigmatism. Claims to halt progression of myopia in children.

How it's done: Over a period of weeks to months, a series of gas-permeable rigid contact lenses ("orthodontics for the eyes") are fitted to progressively reshape the cornea. Introduced in 1962; regaining popularity for those who aren't good surgical candidates.

Success/failure rate: May never achieve 20/20 if myopia is severe; most achieve functional vision of 20/40 or better.

Potential downside: Discomfort, similar to "tightening braces," each time new lenses are introduced. Must wear retainer lenses several days or nights a week. Not permanent.

Cost: $1,200-$2,000 per eye

Finding Dr. Sight

While the number of LASIK surgeries continues to soar, so has the number of physicians performing the procedure. What's more, many inexperienced surgeons have begun to discount their prices in an attempt to lure prospective patients away from their more-qualified colleagues. "You get what you pay for," warns Boxer-Wachler, "so you have to wonder what part of care they may be omitting to lower the price."

So before lying down for the laser, experts insist that you should have an exhaustive eye exam, including eye pupil measurements, by the surgeon who will be performing your procedure, and don't even think about sealing the deal until you have the following guarantees in writing:

* All surgical staff members wear high-quality, biocompatible (powderless) gloves, masks and caps.

* All disposable supplies, particularly the microkeratome blade used for the corneal flap, are discarded and all instruments are sterilized between patients. It is also preferable between operating on the first and second eye.

* Your surgeon is board-certified by the American Board of Ophthalmology.

* Your surgeon has completed a one-year fellowship in corneal or refractive surgery.

* Your surgeon offers alternative treatments including Intacs, PRK and incisional refractive surgeries like RK.

In the hands of a properly trained, experienced surgeon, experts agree, you can expect the best possible results from LASIK surgery. "A patient may come in requesting LASIK, not even realizing that there's something out there that would be even better for her," says Kerri Assil, M.D., an ophthalmologist in Santa Monica, Calif. "A doctor can't take a one-size-fits-all approach [to laser surgery]."

What can go wrong?

You won't go blind, but refractive surgery is not foolproof, either. "I'm now spending about 10 percent of my time just fixing people who have had LASIK done by other surgeons and are unhappy with the results," says Robert Maloney, M.D., M.A., director of the Maloney Vision Institute in Los Angeles. "Overcorrection occurs in about one-third of these patients. Another third have night-vision problems; the rest have experienced other kinds of surgeon error."

Maloney says that one cause for overcorrection is that people heal differently, affecting the curvature of the cornea -- and there's no way to predict that. The other problem is surgeon error. "Fortunately that's fairly rare," Maloney says, who says there are two kinds of surgeon errors. One type is that the eye surgeon has programmed the laser incorrectly. The second is that the surgeon is too slow in completing the procedure. "As the procedure is going on, the patient's cornea dries out and the laser removes more tissue than it should," explains Maloney. "So we definitely see that inexperienced doctors have a much higher rate of overcorrections."

The best patients for LASIK are those with moderate vision distortion (vision better than 20/800) who have no other eye-related problems (like dryness, ocular herpes, diabetes, or vascular, autoimmune, retinal or corneal diseases). Though short-term side effects -- dry eyes, sensitivity to bright lights, vision fluctuation, glare halos, tiny red spots in the whites of the eyes -- are normal, it's when these symptoms last for three months and begin to interfere with your vision that they become complications. "And complications," says Kerri Assil, M.D., "are generally the result of a surgeon's gathering insufficient information about the eye." Though some patients have experienced vision problems that can't be corrected with subsequent LASIK surgery, most doctors stand by it. "I believe LASIK is remarkably safe," says Maloney.

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