An Eye on LASIK -- Bill Lloyd, MD -- 02/27/03

By Bill Lloyd
WebMD Live Events Transcript

Tired of wearing glasses or contacts but can't see without them? How might refractive surgery benefit you? What are the risks? We talked about the latest techniques and options to improve your vision when our Ask the Eye Doc expert, Bill Lloyd, MD, joined us once again on WebMD Live.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Hello Dr. Lloyd. Welcome back to WebMD Live. Just what can LASIK do for you and what can't you expect from LASIK?

Lloyd: LASIK is an abbreviation for a special kind of refractive surgery. Don't worry what the abbreviation stands for! LASIK is intended to reduce or eliminate refractive errors. This includes

nearsightedness (myopia), farsightedness (hyperopia), with or without astigmatism. Earlier forms of refractive surgery worked well with low amounts of refractive error and low amounts of astigmatism.

The wonderful thing about LASIK is that it can help people with much stronger refractive errors. LASIK is FDA-approved as safe and effective. But as we will discuss today, it doesn't mean it's for everyone. LASIK will not eliminate scarring or other problems with the clear cornea that blur vision. It is intended only to reverse refractive errors.

Moderator: Who is a good candidate for LASIK? Is age a factor?

Lloyd: Patients with healthy eyes are the best candidates for LASIK. All who undergo eye surgery (of any kind) typically develop dry eyes after surgery. This can last a few days or it can persist for a much longer time. Therefore, individuals who already have a dry eye condition are poor LASIK candidates.

People with corneal disorders are also generally unfit for LASIK. One example is a condition called keratoconus. People with this disorder have an extremely thin cornea. Since LASIK creates a flap in the middle of the cornea, patients with keratoconus could develop severe complications due to perforation caused at the time the flap is created.

You and your doctor can decide if you are a suitable candidate. Let me emphasize that you have this discussion with the surgeon scheduled to do your procedure, not the representative of the clinic.

Member: Dr Lloyd, I am 55 and need glasses to see far away, as well as reading now. My arms just aren't long enough anymore (grin). Would LASIK surgery be good for me?

Lloyd: What you are experiencing is a condition called presbyopia. It is age-related loss of near focusing (accommodation). Here is what is important for you to know. Do not undergo LASIK simply to correct the presbyopia. You will be unhappy with the results. LASIK works best on distant vision. Being farsighted as you are, there are LASIK treatments that can help you reduce your hyperopia, but it won't do a thing for your near vision. Life is full of compromises!

This raises another important issue for all members. After LASIK surgery, your eyes are returned to "normal." No refractive error. What that means is at around age 40 you can expect to start having the same symptoms described in this question. That's because you are now "normal" and normal people get presbyopia around age 40. Guess what? You will need to buy reading glasses to help you read. But didn't you pay for LASIK to get out of your glasses? Vision researchers are working hard to resolve this puzzle. Hopefully there will be laser correction available in the near future that can correct for BOTH distant and near vision.

Member: Dr. I had LASIK about four years ago and I developed some cell growth beneath my cornea and it keeps coming back. The cells I have were called epithelia cells and keep coming back. Do you have any advice that I could share with my doctor?

Lloyd: You are experiencing a very common complication from LASIK surgery. The outermost layer of cells on the corneal surface is called the epithelium. When the LASIK flap is created, a new pathway for these cells is created. The LASIK flap never heals. As an experienced eye pathologist, I can tell you that the LASIK flap NEVER heals. That means there is a thin layer of corneal tissue resting on the remaining cornea for life. No scar forms because (once again) there is no healing.

This raises two critical points: The LASIK flap remains available to both epithelial cells and germs for the remainder of your life. Secondly, the LASIK flap can be easily dislodged from simple contact with the eye such as a finger poke. Once the flap is lost the eye is in serious trouble. It will require a corneal transplant (a much more serious operation) to regain useful eyesight. Anyone who has had LASIK needs to wear eye protection when outdoors, working in the yard or participating in vigorous activities. These precautions must be followed for a lifetime.

A local ophthalmologist specializing in corneal diseases knows about the most helpful ways to eliminate those trespassing epithelial cells. Consider a consultation as soon as possible.

Member: My ophthalmologist keeps removing my cornea and performing an "epi wipe" on me. Is there another procedure that another doctor might use or would they merely perform yet another epi wipe?

Lloyd: For the sake of other visitors this patient is describing a procedure wherein the surgeon lifts the tissue flap that was created during LASIK. Remember, the LASIK flap never heals. It is more like a contact lens. For each of these procedures, the surgeon uses a delicate instrument to lift the flap and remove those wandering epithelial cells. This can be achieved with a handheld blade, with chemicals, or with (guess what?) more laser. Afterwards, the elevated flap is returned to its original position.

It sounds to me like your doctor is aggressively and properly managing this post-operative complication. If concerns persist, it may be time to meet with the doctor. It is the privilege and responsibility of your surgeon to fully advise you of all options available to help resolve this problem.

Member: I've stayed with semi-hard gas-permeable contact lenses all of these years because they give me such sharp vision. Over the past few years I've heard complaints that laser eye surgery can affect depth perception and night vision. Is this still the case? I want to be free of contacts but not at the expense of my perfect vision.

Lloyd: Every patient responds differently to LASIK. The standard of success is 20/40 vision three months after surgery. That vision is good enough to get a driver's license. I expect that you see 20/20 or even 20/15 wearing those RGP contact lenses. Even if you get a superior surgical result, you might still end up with 20/40 or 20/30 vision. Good enough for most people; but you will be very disappointed.

Other post operative phenomenon include:

  • Glare
  • Halos around lights
  • Weaker vision under dim lighting
  • The prospects of having a dry irritated eye

Since you value your crisp vision, now does not seem to be the time to experiment. You and your eye doctor can weigh all of the risks and benefits before making such an important, life-changing decision.

Member: I had LASIK surgery in March 2002. After several months of post-op office visits they concluded that my right eye does not have enough tissue to make an enhancement (my right eye went from 9 to 1.5 of myopia and astigmatism), now my left eye is perfect (after a second LASIK surgery) but the right one isn't. Can I have another kind of procedure to fix my right eye? Is it all done or there is any hope to get my eye perfect?

Lloyd: You have clearly described a frequent experience among LASIK patients. I always chuckle when I hear the word "enhancement." We used to call that a re-operation, because the surgeon didn't get it right the first time. If the LASIK procedure overcorrects or undercorrects the refractive error, then a return visit to the operating room is required to improve the situation. This is what they call an enhancement.

Other refractive procedures are available that can supplement previous LASIK and hopefully eliminate your residual myopia. Consult with an expert corneal surgeon with enormous experience in this field. Stay away from the mall.

Having said that, being left 1.50 is not so bad. You can rely on this result to help you read without glasses. This makes your current situation something called monovision. You see at distance with one eye and prefer to read with the opposite eye. This may in fact end up as a satisfactory situation if you give it time. Waiting is always preferable to more surgery.

One final precaution: Severely myopic people like yourself have a very thin retina. That's because myopic eyes are larger than normal and it stretches the retina. High myopes are more likely to develop holes, tears, and detachments in the retina. Even though LASIK eliminates the refractive error, it's still a myopic eyeball with a stretched retina. That means you still need to have periodic visits with an experienced ophthalmologist to make sure you don't develop any of these retinal problems.

Member: There are so many places that offer the surgery. How do you pick a competent surgeon?

Lloyd: There is no such thing as "minor eye surgery," and this includes LASIK. It's true that LASIK is successfully performed in clinics and outpatient facilities. The procedure doesn't take much time. The recovery is usually prompt. The technology is such that the surgeon has far less to do than a comparable cataract extraction. Despite all this good news, you need to put yourself in the hands of the most experienced LASIK surgeon you can find. When you do your research you are looking for surgeons with the most experience in recognizing and managing complications. Think about it: If every case came out 20/20, then the janitors would be doing LASIK.

In the unfortunate event that your LASIK procedure did not come out perfect, then you want a doctor who can immediately identify and fix the problem. Do you follow me? Don't shop for best price. You will have to live with the results for the rest of your life. Many of the $300 LASIK centers end up boosting the final bill to $1200 anyway, so why not start with the best surgeon around? And pay the real price up front? Stay away from magazine ads, TV commercials, and the yellow pages. Word of mouth remains the best form of marketing for outstanding doctors.

Member: How effective is the surgery nowadays with regard to astigmatism and night blurriness?

Lloyd: Much data have been gathered over the past decade regarding the safety and success of LASIK surgery. The vast majority of LASIK patients are deemed "surgical successes." As mentioned earlier, that means best vision without glasses measures 20/40 or better. Be careful about this kind of data. It is a collection of numbers from many different centers in many different cities.

It may not have any relevance to the individual doctor you plan to visit. Don't be afraid to discuss post-operative results with your physician. Ask brutally direct and frank questions. If the surgeon is hesitant or defensive, it may be time to consider a substitute. Statistics regarding post-operative symptoms like halos, glare, and weak night vision are far more fluid. Just be aware that the risk of these symptoms is present in every case, and it is near impossible to predict beforehand which patient will have trouble afterwards. The simple truth is that most LASIK patients are satisfied with the results. If a specific risk is only, let's say, 1% and it happens to you, then it's 100%, isn't it?

Member: I have a fairly strong astigmatism and have worn glasses for years. My eyeballs are small football shaped. Is it difficult to do LASIK with this shape of eyes?

Lloyd: The cornea is round whether the patient has astigmatism or not. The curvature on the surface of the cornea is what varies, and that's what contributes to astigmatism. Having a small hyperopic eye with astigmatism. Astigmatism does not disqualify you for consideration with refractive surgery. There may be other effective procedures besides LASIK that can help you. Your situation is relatively uncommon, and therefore you should seek out the most qualified LASIK provider in your area in hopes of getting the best results and the most expert care.

Member: If the patient has excellent vision with lenses, why should he accept the risks of LASIK?

Lloyd: Congratulations for such an "insightful" question. As I mentioned earlier, there is no such thing as minor eye surgery. Complications of eye surgery can be devastating and long-lasting. I agree with you. It seems unreasonable to expose yourself to the low risk of complications in the hopes of achieving vision that you already possess.

Nevertheless, there are always people who want to try something different. There are people who do not want to wear eyeglasses. Others cannot tolerate contact lenses. These individuals accept the risk of potential complications in return for a permanent solution. Anyone having LASIK is familiar with the 20- to 40-page consent document. It is full of fine print and scary writing. If you actually read the full document, and still signed the consent -- well, it's hard to believe anyone would still sign the consent!

Moderator: Dr. Lloyd, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Lloyd: Much of today's discussion centered on the need for improved communications between patients and their doctors. When it comes to elective surgery you need to be in charge. Ask direct questions and demand clear answers. Don't put too much emphasis on price. Remember like any eye operation, you will have to accept the results of LASIK surgery for the rest of your life. Choose wisely!

I look forward to answering additional questions that you may have by simply visiting our vision and eye disorder community here at WebMD. Thanks for chatting with me today.

Moderator: Our thanks to Bill Lloyd, MD for joining us today. For more information, please Dr. Lloyd on the WebMD message board Eye and Vision Disorders with Bill Lloyd, MD. And please check out the information about eye and vision disorders on WebMD.

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