Hi,

I've been through several LASIK screenings over the years and am getting conflicting advice ... I was hoping for another opinion here.

My contact prescription is -6.0/-6.5 D. I can see 20/15 with my left eye and 20/20 with my right eye with contacts - daily disposable. I have a small astigmatism that we don't correct in my right eye. I'm 44 and my vision has been stable for many years. My reading vision is still good. I stay active, Mountain biking, playing ultimate, volleyball, softball, etc.

At my most recent screening, my corneas were ~ 480 um and the Dr. suggested traditional LASIK with IntraLase for the flap. Correction would remove about 100 um, and wavefront would require another 20 um. He uses 250 um as a lower bound to prevent echnasia. My pupil's under standard lighting are 5.5 and 6.0 mm. The prescription from this exam was R:7.50+0.75, L:8.00+0.25. The Dr. had essentially no concerns about doing Lasik.

Dr. #2 suggested PRK. He siad I should be concerned about echnasia.

I checked back with another clinic that had turned me down a couple years ago to see if technology had changed and they suggested that I wait for the new microkeratome that does 100-120 um flaps and that I would be elligible with it (and also with the current microkeratome that removes 140-160 um).

I've had several discussions with Dr. #1 and he said he's seeing good results with wavefront PRK and that's now his recommendation. He wanted me to come in for another exam specific for that technique. I haven't done this yet. I have a feeling that he might be recommending PRK cause I told him Dr. #2 recommended it.

Anyways, I looking for a bit of guidance. My main concern with PRK is that, if I get eye surgery, I want good vision and would choose to have enhancements if things don't come out close to 20/20. With PRK, including the healing and stabilization time, and enhancements, doing 1 eye at a time, this could be a long process ...

A secondary concern is echnasia - I couldn't find any statistics suggesting how often this occurs, etc.

Sorry for the long email, but I tried to include all the essentials.

Thanks!

-Bob Estes, Cupertino

Bob,

Ectasia is a very rare complication of LASIK (and even less common with PRK), but can be extremely difficult to correct if you get it.

ANY flap-making device has a standard deviation (including the Intralase and "newer" microkeratomes), so no surgeon can guarantee that you will actually get a flap of 100 microns (it could be as high as 140 or more!) when it is cut. Once it is cut, you are committed to LASIK.

I would recommend you consider PRK (wavefront or conventional), OR even an implantable lens inside the eye where no thinning of your cornea occurs at all. These have risks, too, but you can find additional information about these by going to http://www.staar.com/index.php?sitecode=US or http://www.amo-inc.com/site/products/verisyse.asp

Good luck!

Dr. Furlong

The doctor has a valid point in surface ablation. If you were to get a flap, theres no guarantee itll be 100um. Intralase does produce very consisant flaps and usually varies little. Microketerome varies much more. Ive done the math and youd be at 280 cornea left with tradational lasik, 260 with wavefront *if* the flap is 100um and not more. You wont have enough for an enhancement or even think about one. Plus the doctors I know like to keep the minimum to 300um because its much safer than 250um. 1:5000 vs. 1:250 risk of ectasia.

Very nice BCVA! Of course the contacts help by not minifying things like glasses do. Im a -5 in glasses with BCVA of 20/30 +2 accroding to the optometrist. If I wore contacts, they would be -4 and I should be 20/25. Your -6 and -6.5 contacts would equal -7.5 and -8 glasses in which is the case due to vertex distance.

Your smaller pupils are a big advantage reguarding night vision and saving corneal thickness. You can do PRK, epi-lasek or clear lense extraction. There are risks to each. PRK and epi-lasik give you risks of corneal haze, especially for severe myopes. Are you a candidate for wavefront with your high pescription and low amount of high order aberrations due to 20/15 BCVA? Ask the doctors about clear lense extraction. This is where they remove your natural lense and put a clear lense in its place which will fully correct you without enhancements needed plus youll never have to worry about cateracts. Your gonna need reading glasses unless you opt for monovision or perhaps multifocal IOLs

*not a doctor, what I said is my opinion :)

See below for a sumamry of what I've learned since.

Thanks for the advice!

>Hi,

>I've been through several LASIK screenings over
>the years and am getting conflicting
>advice ... I was hoping for
>another opinion here.

>My contact prescription is -6.0/-6.5 D.
>I can see 20/15 with my
>left eye and 20/20 with my
>right eye with contacts - daily
>disposable. I have a small
>astigmatism that we don't correct in
>my right eye. I'm 44
>and my vision has been stable
>for many years. My reading
>vision is still good. I
>stay active, Mountain biking, playing ultimate,
>volleyball, softball, etc.

>At my most recent screening, my corneas
>were ~ 480 um and the
>Dr. suggested traditional LASIK with IntraLase
>for the flap. Correction would
>remove about 100 um, and wavefront
>would require another 20 um.
>He uses 250 um as a
>lower bound to prevent echnasia.
>My pupil's under standard lighting are
>5.5 and 6.0 mm. The
>prescription from this exam was R:7.50+0.75,
>L:8.00+0.25. The Dr. had essentially no
>concerns about doing Lasik.

>Dr. #2 suggested PRK. He siad
>I should be concerned about echnasia.
>

>I checked back with another clinic that
>had turned me down a couple
>years ago to see if technology
>had changed and they suggested that
>I wait for the new microkeratome
>that does 100-120 um flaps and
>that I would be elligible with
>it (and also with the current
>microkeratome that removes 140-160 um).

>I've had several discussions with Dr. #1
>and he said he's seeing good
>results with wavefront PRK and that's
>now his recommendation. He wanted
>me to come in for another
>exam specific for that technique.
>I haven't done this yet.
>I have a feeling that he
>might be recommending PRK cause I
>told him Dr. #2 recommended it.
>

>Anyways, I looking for a bit of
>guidance. My main concern with
>PRK is that, if I get
>eye surgery, I want good vision
>and would choose to have enhancements
>if things don't come out close
>to 20/20. With PRK, including
>the healing and stabilization time, and
>enhancements, doing 1 eye at a
>time, this could be a long
>process ...

>A secondary concern is echnasia - I
>couldn't find any statistics suggesting how
>often this occurs, etc.

>Sorry for the long email, but I
>tried to include all the essentials.
>

>Thanks!

>-Bob Estes, Cupertino

We have an Intralase and although it is true the standard deviation for flap thickness is excellent, you can rarely still get a 130 flap even when you aim for 100. Because of that, I would recommend PRK with mitomycin to reduce the risk of haze. Your chances of excellent vision are just as good as with LASIK and you can still have a reoperation in the event you are not happy with the result . We have 3 lasers, Visx, Alcon and Alegretto and each has its pros and cons. With your average pupils, you might not need a custom wave front based treatment so you could consider a wavefront optimized treatment which tend to induce less aberrations than a conventional treament and would save some tissue. Which treatment I would recommend would depend on an evaluation of your preop wavefront reading of your higher order aberrations. Although it does take a bit longer to heal, PRK is very safe, proven (we did our first one in Los Angeles in 1990),gives excellent results and is easy to touch up even years later in the rare event that you progress. This may not be true with LASIK as it might be difficult to lift the flap and you may not have enough thickness under the flap to avoid the risk of ectasia. good luck in your decision
Dr. Salz, Los Angeles

Thanks!

The possiblity of ending up with a 130um flap, which leaves no room for correction and puts me on the low end of the remaining recommended corneal thickness, has convinced me that I should choose PRK.

I've recently went in for another exam. I liked the Dr. this time (Scott Hyver) and they did a more thorough exam than others have.

He suggested classic PRK, potentially using mytomycin to prevent haze. After further inquiry, he did a wavefront scan and said there might be some benefits to it. He claims that there is no downside other than cost. Both eyes for custom wavefront are $5K, which is about $1.5K more than classic PRK.

I'll probably do the custom wavefront, but now have to wait until his VISX S4 laser is enabled for my prescription, which he claims should be any day. He claims this isn't so much a SW upgrade, but just a relaxation of the parameters, which was FDA? approved a few months ago. Does this sound right?

Once again, thanks all for the advice. You're never quite sure if you can trust the Drs. at the clinic where you're about to give them large sums of money. Neutral advice such as this is very useful!

Bob,

Sounds like you are feeling comfortable with the technology and the process.

If you are interested in another opinion, I'd be happy to see you in my Campbell office as well. I have a Visx S4 laser and a B & L, too. The higher myopia upgrade for Wavefront is available on our laser.

Best!

Dr. Furlong

Hey, if you have thin corneas you're also in trouble with that high correction. You will want to have an otical zone that is larger than the largest size your pupil can POSSIBLY get under conditions where you would expect to be able to see. If you expect to be able to walk on a moonless night, your doc had better let you dark adapt in a VERY DARK room using only a penlight as a light source when he measures your pupil. Your fully dark-adapted pupil could be a fairly large area (if it is over 6mm WATCH OUT). To create a fully corrected area over a larger size consumes more corneal tissue than making a small corrected area!

VISX lasers are one of the worst offenders in pupil size/optical zone mismatch problems because they have small maximal treatment zones. Don't let anyone talk to you about having refractive surgery with a 'blend zone' inside the diameter of your pupil. This will give you horrible vision when your pupil expands within that area.

I know people who have been completely disabled by surface treatments. No refractive surgery is safe. All refractive surgeries thin the precious corneal tissue, a non-renewable resource. Once the cornea is thinned it will NOT regenerate.

Patients who receive surface treatments are more likely to end up with corneal haze. This condition can rob you of vision. I know someone who had haze so severe that a corneal transplant was required.

Perhaps you should be happier with your glasses! They are the safe and healthy alternative to vision correction! I envy you your untouched 'virgin' corneas. I regret the day I ever visited a LASIK surgeon's office, and I will for the rest of my life. Every waking hour my bad vision reminds me how bad a bad LASIK outcome can be.

By the way I was treated at a 'top' LASIK center (supposedly) on the VISX S4.

You know alot about lasik and your experience reminds us that lasik is not without risks. Keep in mind that you very well could of had a good experience, the vast majority do. Your taking a small, calculated risk to rid or reduce your dependancy on glasses(or irritating contacts) However the risks are greater for some depending how good a candidate they are. While I have nothing against some doing lasik if the right conditions are met, I havent done it myself. Not sure when or if ill get it(huge pupils, mild presbyopia, mild dry eyes). I know technology will keep advancing and the outcomes keep improving and who knows, there might be something new all together. I am still young and in no hurry.