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Our Patient Frequently Asked Laser Vision
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- Is laser vision correction safe?
Laser vision is extremely safe and we feel that it is greatly misunderstood and underused in the United States of America and the rest of the world. There is no chance of losing your eye, as there is with contact lenses or intraocular surgery. No lost eyes have been reported since its inception regardless of the laser or microkeratome used. Approximately one out of every thousand patients lose one to two lines of vision; however, 670 patients per 1000 treatments gain one or two lines of vision. Patient fears are disproportionate and overshadow the statistical safety facts. Laser vision correction since its inception has always been safe; consequently, the quality of vision has improved in the 21st century so that it now exceeds glasses and contact lenses.
Jorge L. Alio, Am J Ophthalmol, 2008;145:55-64
Why do patients undergo laser vision correction?
Patients come to our office initially with the desire to get rid of their glasses and contact lenses. They are unhappy with their glasses and contact lenses because they interfere with their specific occupational needs such as police officers, fire fighters, and military personnel as their life are dependent upon good vision in unusual circumstances. Others feel that glasses and contacts interfere with their everyday activities, sports and recreational needs. Finally, many patients are unhappy with the underlying but usually not admitted intolerance of contacts and contact solutions and the continuous costs or replacement and maintenance of glasses and contact lenses.
Our goal is to produce vision superior to eyeglasses and contact lenses, better described as high definition and high performance vision. This high definition vision has been has been made possible through advancements in technology and thus 98% of our patients see better than they have ever seen before with vision at a higher level.
What is high performance-definition vision?
High performance vision is like the picture produced on your plasma screen television. Objects are seen in a crisp focus with more vivid colors. This is also knows as high definition or high-resolution vision. The comparison of today’s laser vision results with the results of just a few years ago is analogous with the picture on today’s televisions when compared to televisions in the 1950s. High performance vision is like looking through the Hubble telescope at the universe as compared to looking the Galilean telescope on Earth.
Am I a candidate for laser vision correction surgery?
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With today's fast-paced active lifestyles, the need for unimpaired vision becomes more and more obvious and the hope for freedom from glasses and contact lenses lead many people to consider laser vision correction. Many of us have friends or family members that have already undergone laser vision correction treatment and their satisfaction bring new patients to our office.
Patients who request refractive treatment want to be less dependent on their glasses or contact lenses. Many patients enjoy sports such as swimming, boating, hiking, and water-skiing. Some elect to have laser vision correction treatment to enable them to become pilots or policemen. Many patients feel visually and socially limited in their every day life activities. Occasionally a patient may have one myopic or hyperopic eye making his or her vision unbalanced. Patients may develop myopia or astigmatism after an unrelated eye surgery, such as cataract surgery; which can be corrected with laser vision correction treatment.
Patients should have a prescription that has been stable for approximately 12 months. Therefore, candidates as a rule should be 18 years of age or older, with no upper age limit. Nearly all prescriptions can be treated with laser vision treatment. Most will have near normal uncorrected vision.
Hyperopic corrections may be reduced or eliminated by using laser treatments that steepen the cornea, whereas; myopic corrections may be reduced or eliminated by using laser treatments that flatten the cornea. Both types of prescriptions require that the cornea be made round to eliminate all degrees of astigmatism, whether small or large. We have corrected from 0.25 diopters up to 7.00 diopters of astigmatism.
Small numbers of candidates are lesser ideal for laser vision treatment, but still may have treatment if they are in the following group. The following groups must be evaluated on an individual basis to determine whether they are good candidates now or in the future:
● Your age is under 18 and your prescription has changed within the last six months.
● Severe glaucoma with loss of vision field.
● Keratoconus, a corneal irregularity. Slight degrees of Keratoconus may be treatable on the surface or with riboflavin cross-linking.
● Inflammation of the eye; uveitis, blepharitis or iritis.
● Herpes simplex that has infected your eye.
● Previous severe eye injuries or corneal scars.
● Unstable refraction due to contact lens wear or diabetes.
● Other diseases of the eye that are affecting the retina significantly
● Patients who have rapidly progressing cataracts that will require cataract surgery within the next three months.
● Dry eyes with corneal staining or a Schirmer test of less than 20mm.
Who is NOT a good candidate for laser vision correction?
Patients with active Keratoconus (or family history of severe eye rubbing and subsequent Keratoconus), mongolism, or atopy with or without psoriasis are not candidates for LASIK. These patients may have topographical abnormalities such as inferior corneal steeping of 1.4 diopters or more to indicate they may have Keratoconus. We will not operate on a patient with one useable eye, which is the policy of 62% of the ophthalmologists in the United States.
What if I was told I’m not a candidate for laser vision correction by another doctor?
We have found that advances in technology make most patients candidates for laser vision correction that were not considered to be candidates in the past. We have even told some of our patients in the past that they are not good candidates, but with today's technology it is possible that they may now be candidates. If you have been told in the past that you were not a candidate for laser vision correction, ask again!
Can I go blind from the LASER used in laser vision correction?
The answer is “No.” No one has ever been blinded by the laser and no one is ever likely to be. The excimer laser works on the very topmost layer of eye tissue. Each successive pulse of the laser removes just a tiny amount of tissue from this topmost layer. No energy from the laser penetrates the surface of the eye. This is what makes the excimer laser so safe!
This does not mean that nothing can go wrong with laser vision correction. There are risks and you should be aware of them, however being blinded by the laser is NOT one of the risks.
Reference: Bochner Eye Clinic and Shealy Eye Laser Center
How much time do I need off work, and how long does treatment take?
Femtosecond and Thin-Flap SBK LASIK patients go back to work that evening or the next day and 98% see almost 20/20 immediately. Many patients can drive home long distances of 50 miles or more within 2-3 hours. About 98% of the visual recovery occurs within the first 4 to 18 hours after surgery. The procedures in 2009 have catalyzed our laser vision correction practice, with high performance vision and unparallel safety of 99+%.
The laser application time is less than 30 seconds, which is less time than is required to pour a cup of juice. The actual treatment time is about 15 minutes. Please allow 1 to 3 hours for the pre and postoperative treatment process.
Patients are free from glasses 99.9% of the time if they're corrected totally for distant activities. If glasses are needed after treatment less than 1% of all patients, we will provide a light RX for our patients to be obtained at their own expense. Those patients who have elected to have blended vision will wear glasses occasionally for night driving and or reading being free from glasses 95 to 98%. Patients above age 62 are more likely to wear a thin pair of glasses for night driving if they have blended vision.
What if I have questions about the technology at the Shealy Eye Laser Center?
Dr. Shealy tries to be available at all times for patients and he tries to be one on one with each patient candidate. He is one of a few ophthalmologists that completely dedicates his practice to laser vision correction and does not perform routine eye care or fit glasses and contact lenses. We release our patients back to their eye care professional of choice after we have achieved a satisfactory outcome so that the professional can diagnose and treat eye conditions unrelated to laser vision correction, especially for patients that travel long distances.
Which occupations require laser vision correction?
The United States Department of Defense requires no-cut Superficial Epi-Laser for Navy pilots, Navy Seals and Air Force fighter pilots. This is also recommended for patients involved in police enforcement and fire fighting. Recently we've recommended this procedure for Brahma bull riders, ultimate fighters, and patients playing all major contact sports. In 2009, many Department of Defense workers, including astronauts, were allowed to have SBK Thin-Flap laser vision correction.
"I like my glasses or contact lenses," said many patients. "Why would I want laser vision correction treatment?"
With any type of laser vision correction, you can eliminate the distortions, minification or magnification effect of glasses. Although contact lenses can provide some relief, we find more risks and ongoing complications with them as compared to laser vision correction. This is well documented across the world.
What if my eye moves during laser vision correction?
Our laser performs fast active tracking in which it tracks each of the 200 laser pulses per second 4 times each second, the tracker changes its tracking patterns 6,000 times per second and thus responds to any eye movement. Watch our video of the Allegretto Wave in action.
If I need glasses after treatment, is that included in the treatment fee?
No. Patients are free from glasses 99.9% of the time if they're corrected totally for distant activities. Those patients who have elected to have blended vision will wear glasses occasionally for night driving and/or reading, but will be free from glasses 95% of the time. Temporary glasses may be necessary for patients that are temporarily overcorrected for hyperopia. Patients are responsible for the purchase of glasses, either temporary or permanent, after treatment. Some may occasionally wear a contact lens in the case of blended vision, however this is very rare and relegated to specialty sporting enthusiasts.
How long before treatment, should contact lenses be discontinued?
Contact lenses should be discontinued to achieve a natural corneal shape before treatment. Soft contact lenses should be out 1 to 3 days prior to treatment. Toric soft contacts should be discontinued 1 week before treatment. Patients with gas permeable hard contact lenses should discontinue contacts until the best-corrected visual acuity is obtained.
When does Shealy Eye Laser Center schedule laser vision treatments?
We now perform laser vision treatments and consultations on the same day for new patients on Monday a.m. and Thursday all day. We will perform laser vision correction treatments on Fridays and Wednesday a.m. if prearranged in advance according to our staffing availability. Patients can expect a quick visual recovery time and most can return to work the very next day. This will vary depending upon individual circumstances. Our center is totally committed to laser vision correction.
What causes my eyes to be red or bloodshot after laser vision correction?
Sometimes the blood vessels in the conjunctiva will break and bleed. Many patients will notice this especially if they have worn contact lenses over a period of years. It usually takes at least 3 weeks for redness or bloodshot to disappear, but please remember this will not affect your vision.
When can I allow water to get in my eyes after laser vision correction?
Please allow 10 days to 2 weeks before entering a natural body of water such as a pond, river, lake, or ocean. You may get into a spa or chlorinated pool one week after treatment. You may shower or bathe at any time after treatment; however please avoid getting water or soap in your eyes by keeping them closed while performing such activity.
What type of sunglasses do you recommend?
We have found that avoiding high intensity ultraviolet light during the first 6 to 12 months, cuts down on the incidences of corneal haze. This hazing is a mild sun burning of the superficial cornea. We recommend polarized UV sunglasses such as Maui Jim that are available at the Sunglass Hut. Patients that have Surface Ablation should wear these sunglasses for at least one year especially in the mountains or at the ocean for protection from the sun's UV rays. They are especially advantageous for patients who work and drive during dimly lit conditions since they do not reduce light intensity like regular sunglasses during the non-daylight hours.
When will my vision improve after laser vision surgery?
All laser vision patients have an immediate improvement in their vision in the range of 20/20 to 20/30 immediately after surgery. The visual improvement seems to be faster with all laser vision correction as compared to AST or superficial Epi-laser. Recently we've noticed that the visual recovery time of AST is almost the same as All-laser LASIK. This has been due to the improvements in contact lens and pharmaceutical management. With proper management, most of our surface patients are pain free, but rather the patients may complain of slight scratchiness after their surgery. All of our patients see in the 20/20 range within the first week of their surgery.
What does LASIK "board certified" mean?
LASIK board certified means that the doctor has had 50 of his surgical patients evaluated. These patients have been studied and followed up on after surgery for their clinical results for a six-month period and their outcomes have been determined. Three random surgical cases by the doctor have been video taped and have been reviewed by a board of independent ophthalmologists from the American Board of Eye Surgery.
How soon can I wear make-up after laser vision correction?
You may wear make-up the day after laser vision correction. Note: Please remove all eye makeup before your planned laser treatment.
How many laser vision correction treatments has Dr. Shealy performed?
We have performed over 21,000 laser vision correction treatments at the Shealy Eye Laser Center.
Our Technology Questions at the Shealy Eye Laser Center:
What are the changes that we've made at the Shealy Eye Laser Center to improve laser vision correction outcomes?
Advancements in technology continue to make laser vision correction safer and produce vision superior to eyeglasses and contact lenses known as high definition and high performance vision. This includes:
● Wavefront guided and Wavefront optimized with the Allegretto Wavelight Laser.
○ Wavefront-Guided Photorefractive Keratotomy in Eyes with Prior Radial Keratotomy; A Multicenter Study
Conclusions: Wavefront-guided photorefractive keratotomy with mitomycin-C in eyes with prior radial keratotomy improved the uncorrected visual acuity significantly and was safe over the short follow-up of this series. Although haze occurred, no eye suffered persistent visual loss of 2 or more lines.
Reference: Ophthalmology 2009; 116:1688-1696 © 2009 by the American Academy of Ophthalmology
● SBK or Thin-Flap laser vision correction for improved safety. At our Center, we have found that the thin flap of SBK is necessary to create the appropriate correction of a patient’s prescription and is planar and optically neutral. Because of the edge design of the flap, and following the normal contour of the cornea, the cornea system represents a multifold advancement in microkeratome technology. We have found that partial flaps opacities in the cornea do not affect vision with visual aberrations. Thin-Flap laser vision correction has the same treatment nomograms as in Amoils surface laser vision correction.
● Surface Epi-Laser or Advanced Surface Treatment
Surface procedures have the same comfort level as SBK laser vision correction.
*We have found at our center that the use of eye medications make surface laser treatment comfortable, as the irritation of wearing a contact lenses. Our patients normally use only Motrin, Tylenol or aspirin for minor discomfort. In particularly sensitive patients we may select SBK thin flap LASIK because of unusual patient sensitivity. It is important that the contact lens be fitted tightly to avoid friction and prospective studies indicate that the vision is superior or equal to thin flap LASIK vision over time. This is especially with lower prescriptions less than 5 diopters of myopia without the use of Mitomycin-C during the treatment in our laser room.
● Development of the No Touch Trans-epithelial Laser Vision Correction.
● Z-LASIK with the mobile Ziemer Laser. This is being offered to our patients currently.
● Improved screening: We are testing for dry eyes and ectasia risks.
● Multiple on-site lasers: This includes the
Allegretto WaveLight 200Hz Laser and the Nidek EC5000 Excimer Laser which are owned, operated and maintained by our center. This allows us to have better quality control over our patient outcomes.
● Encouraging the use of new applications for our current laser technology:
- 1. Educating our patients about corneal cross-linking surface treatments to halt and treat Keratoconus.
- 2. Presby-LASIK for developing a multi-focusing cornea in which the center is for near vision and the peripheral cornea is for distance vision. This applies in patients with initial hyperopia. In the case of myopia, the patient does better with the center for distance vision and the periphery is for near vision.
- 3. Offering patients the advantages of mobile Ziemer lasers that eliminate femtosecond laser vacuum failures and interface bubbles, with less corneal haze.
- 4. Improved treatment for dry eyes, like the Oasis Medical form-fit intracanalicular plug.
- 5. Eliminating or reducing the need for reading glasses in patients who have had previous cataract implant surgery. Vision is improved in these cataract patients and frees them from glasses for the rest of their life the majority of the time if they have healthy eyes free from macular degeneration and glaucoma.
● Offering higher cost effectiveness to benefit technologies to our patients.
● SBK thin-flap with the mechanical microkeratome is more cost effective than bringing in the mobile Ziemer femtosecond laser without sacrificing quality.
Ocular Surgery News, October 2009, Gustavo E. Tamayo, MD.
● Reducing the need for multi-focal and accommodating intraocular lens technology with blended vision.
What is All-Laser LASIK and how is it used at the Shealy Eye Laser Center?
 All-Laser LASIK means that a femtosecond laser is used to create a corneal flap before surgery. The instances of complications are low and have been projected at less than 1%. The major complication is diffused lamellar keratitis (DLK), which has been successfully treated with topical prednisone drops. The Intralase, because of it's high energy level, has been associated with vertical gas blow through, horizontal gas blow through, rough stromal bed, gas bubbles in the anterior chamber, opaque bubble layer, and pocket related opaque bubble layer. Newer generation femtosecond lasers have decreased the complications of the Intralase by being lower in energy and creating a smoother surface for treatment with better overlying spot patterns. The patient must exhibit adequate corneal thickness and have sufficient tear production.
Recently we have been in consultation with doctors who have seen epithelial ingrowth like that of mechanical microkeratomes in patients that have undergone Intralase treatment. We prefer to recommend the DaVinci Femtosecond laser as it is the newest high-repetition laser that cuts into the cornea making the flap under the surface layers. The Allegretto Wave Laser treatment is then performed under the flap, in the stroma.
Why does Dr. Shealy prefer to use the mechanical microkeratome in most of his laser vision correction patients?
At the Shealy Eye Laser Center, we have been persuaded by the: May 2008 publication, Moria, moria-surgical.com
● With the femtosecond laser product, a line has been crossed with the intense barrage of marketing. Marketing from the industry and peers at times has tried to prey on surgeons' fears and has been successful in some cases. I've always been an advocate of the truth above all else. I say what is exactly on my mind. At times, I have passed up some pretty good money, but when I lay my head down on my pillow every night, l sleep well. Because I've always believed in telling the truth even if it's ugly, people value my opinion. If you've already bought a femtosecond laser and have "buyer's remorse" deep inside, hopefully next time a new product comes out you're pressured into buying it, you might consider resisting that pressure and waiting for more data to come out before making a decision.
Brian Boxer Wachler, MD
● Cost-Effective LASIK: I Choose the Microkeratome
Stephen E. Pascucci, MD, MACS
My current preference is for a modern mechanical microkeratome, because I believe that it offers very acceptable patient safety and a cost effective means to have LASIK for the patient and surgeon. The fact that a femtosecond laser LASIK procedure is more expensive does not make it better. To those who claim superiority of a femtosecond laser procedure, I challenge them to show me the data that prove an advantage for patients, as this should always be our ultimate consideration. Until such time, the mechanical microkeratome is not dead.
● Femtosecond Laser Offers Surgical Precision and Versatility, But at a Higher Price
Stefanie P. Binder, MD & Theo Seiler, MD
Actually the femtosecond laser is medically indicated in a minority of our patient probably less than 5%. Seducing patients to get femtosecond LASIK as a standard procedure is at least an overkill, if not unethical, according to some. The femtosecond laser has versatility for some medical indications, William Culbertson, MD from the Bascom Palmer Eye Institute said. Considering the added expense of€600 to €1000 more for femtosecond LASIK then conventional LASIK, however there is evidence suggesting that the patient does not necessarily profit from better visual results.
● Femtosecond Laser versus Mechanical Microkeratome for LASIK
Sanjay V. Patel, MD, Leo J. Maguire, MD, Jay W. McLaren, PhD, David O. Hodge, MS, William M. Bourne, MD
The method of flap creating did not affect visual outcomes during the first 6 months after LASIK. Although corneal backscatter was greater early after femtosecond LASIK than LASIK with the mechanical microkeratome, patients did not perceive a difference in vision.
● Should We Ditch Our Microkeratomes for Lasers?
Amelia Tope & Richard J. Duffey, MD
The femtosecond laser is no better overall.
● Successful Surgery with a Mechanical Microkeratome
Roy Rubinfeld, MD
I find the visual recovery with the Moria (mechanical microkeratome) is actually faster than with some femtosecond keratomes. The femtosecond flap creation causes more inflammation and more steroids are required which increase the risk of glaucoma and cataract. Keratomes either mechanical or laser do not do all the work. Re-cutting the flap can cause some serious long-term vision loss. Surface ablation is a good idea to avoid re-cutting or re-lifting a flap.
● Lasers, Mechanical Microkeratomes Contrasted
Cheryl Guttman & Cesar C. Carriazo, MD
Femtosecond laser and mechanical microkeratomes both have advantages and limitations. These features provided subject matter for a point-counterpoint discussion on choosing technology for LASIK flap creation. Complication incidence is similar using a mechanical microkeratome or a femtosecond laser, although safety differs. "I think it simply generates revenue for the manufacturer," Dr. Carriazo said.
● Is the Mechanical Microkeratome Dead?
Evgenia Konstantakopoulou, MSc, George Charonis, MD
Do not throw your trusty mechanical microkeratome in the wastebasket yet. Mechanical microkeratomes are by no means inferior to the femtosecond laser when flap creation is considered. Certainly, when lamellar graft surgery is considered, femtosecond laser technology is an exciting and promising tool.
● Latest Generation Femtosecond Laser Taps into Growing Market
Dermot McGrath, Andromachi Frangouli, MSc, Ourania Frangouli, MD
More precise flap creation, faster performance and an ability to deliver even smoother stromal beds are among the defining characteristics of the current generation of femtosecond lasers, according to researchers.
● Low Complication Rate Found with Mechanical Keratomes
David Laber & Robert K. Maloney, MD
Bad flaps are reported with both technologies, and while surgeons aim for no complications, nothing is complication-free.
● A Need for the Mechanical Microkeratome in Refractive Surgery
Suphi Taneri, MD
Another issue is the current trend of thin-flap LASIK. This is not advisable with current femtosecond lasers. The reason is the gas bubbles in the stroma, created by the femtosecond laser, may diffuse through Bowman's membrane under the epithelium and obstruct further laser application if the overlying stroma is too thin. I think, when a doubt that a LASIK flap may cause problems, the best advice is to avoid it completely and perform a surface ablation. Surface procedures create the smoothest possible stromal surface, leave as many corneal nerves unaltered as possible, and weaken corneal tectonic stability by the least possible amount. Mechanical microkeratomes are a time-proven technology. They have evolved in their safely, predictability, and simplicity in creating lamellar flaps for the LASIK procedure.
● Point: Should We Abandon Mechanical Microkeratomes?
Y. Ralph Chu, MD
Mechanical microkeratomes have evolved in their safety, predictability, and simplicity in creating flaps for LASIK patients. Increased use of surface ablation procedure and having a device that can create both lamellar and epithelial flaps is not only convenient by also critical. From his perspective, this raises the bar for new technologies such as the femtosecond laser as they enter the microkeratome market.
What has the Allegretto Wave Laser added to your practice at the Shealy Eye Laser Center?
The Allegretto Wave Laser has provided faster treatment times, and superior clinical results. It eliminates glare and halos, by maintaining the natural shape of the eye. This maintenance of the natural shape of your eye reduces higher order aberrations. These higher order aberrations are not reduced with glasses or contact lenses, since these treatments eliminate only lower order aberrations of astigmatism, nearsightedness and hyperopia. In 2009, we have learned that the decentration of the laser is absolutely necessary to produce high quality vision in most hyperopia and some myopic patients.
How does the Allegretto Wavelight platform represent an improvement over lasers we have used at the Shealy Eye Laser Center in the past?
Lasers were originally large beams without fast active tracking. Beam quality and fineness of calibration required that newer laser platforms be manufactured with fast active tracking and flying spot technology. These lasers took into account wave front principles to reduce aberrations so that larger optical zones reduce nighttime glare and halos. Recently we have acquired new aberrometry driven capabilities to our laser to reduce preexisting or existing aberrations. Thus the overall quality of vision after laser vision correction with advanced surface ablation and speed of application of the beam determine how accurate the eye prescription is eliminated and how the quality of vision is obtained. We compare our Allegretto Wave Laser results with all the doctors using this laser throughout the world. This allows us to make the best nomograms.
Describe the Allegretto Wave Laser and how does it produce high performance vision?
There are two basic types of lasers that include traditional or large beam lasers and wave front based lasers. The Allegretto Wave Laser represents flying spot, the latest advance in small beam laser technology. The energy level can be measured at three points within the laser beam path due to its small spot size. Each spot is half overlapped nine treatment pulses later. This is necessary to provide a clean path for each overlapped ablation spot without interference of the plume emanating from the first pulse. The pattern of pulse placement has a repetition rate of 200 to 400 Hz so that tracking pattern is changed 6,000 times each second, thus providing a very smooth ablation profile resulting in a crisper, less scattered focal point.
The Allegretto Wave Laser ablation is applied in a manner to maintain the original curvature of the cornea. The resulting shape factor value, known as the Q factor, results in a -0.41 to -0.61 value. This provides the purest prolate focus for reducing aberrated vision. We now feel that current laser technology in 2009 exceeds any of the capabilities of excimer lasers that we have used in the past to provide higher quality and high performance vision safely.
Larger beam lasers unlike the Allegretto Laser remove larger amounts of tissue within a fixed time period. The ablations must be delivered at lower repetition rates. Consequently the lower repetition rates and larger beams results in more corneal dehydration and swelling between pulse placements which is more delayed resulting a less smoother ablation with more crater and ridge formation. The beams tend to be less homogeneous with hot and cold areas adding to the focus scatter. The peripheral ablations result in more spherical aberration and coma causing night glare and haloes and reduced quality of vision as the pupil changes in size.
The Allegretto’s small beam size and Gaussian beam profile with fast active tracking allow a more precise and finer ablation pattern. This is likened to a finer artist’s paintbrush use for the precise detail of masterpiece oil paintings. At our center we can attest to the quality outcomes with the Allegretto system, since we have experienced the outcomes with our other three owned excimer lasers since 1995. We have a combined laser experience with Dr Steve Hollis of 15 different excimer laser systems in the same time frame. The Allegretto Wave Front Laser has the largest range of approval of up to 6 diopters of hyperopia with 6 diopters of astigmatism and 13 diopters of myopia with 6 diopters of astigmatism.
In the Supplement to Cataract & Refractive Surgery Today, November /December 2006, Roy Rubinfeld has stated that after using 9 different excimer laser systems, he considers the Allegretto Wavelight laser the best laser on the market. The laser's reliability and advance technology provides excellent enhancements and primary treatments. His enhancement rate has been reduced to the 4% range for corrections from +5.00 diopters to -12.00 diopters with up to 6.00 diopters of cylinder, the lowest of any laser he has used. Most ophthalmologists feel that patients’ night driving symptoms are significantly reduced with this laser.
After gaining experience with four excimer lasers, we noted that the Allegretto Wave Laser represented an improvement in our visual outcomes, with nearly 95% of our patients seeing 20/20 or better. We noticed an improvement in visual quality due to the maintenance of the natural curvature of the cornea. Treatment times are faster and more comfortable for our patients allowing minimal irritation post-operatively responsive to Motrin or Tylenol.
The Allegretto Wave Laser represents flying spot, the latest advance in small beam laser technology. The energy level can be measured at three points within the laser beam path due to it's small spot size. Each spot is half overlapped nine treatment pulses later. This is necessary to provide a clean path for each overlapped ablation spot without interference of the plume emanating from the first pulse. The pattern of pulse placement has a repetition rate of 200 to 400 Hz so that tracking pattern is changed 6,000 times each second, thus providing a very smooth ablation profile resulting in a crisper, less scattered focal point.
In 2010, we perform Amoils advance surface treatment and SBK thin flap laser vision treatment and have noticed improved quality of our vision outcomes. Our patients are taking advantage of the high quality vision provided with the advances of this refractive laser.
What is high performance vision and how can it be achieved at our Center?
Laser vision correction technology has improved in the first decade of the 21st century to give the outcomes of high quality or high performance vision. This vision results in sight that exceeds that allowed by their eyeglasses or contact lenses. This vision gives our patients as a more crisp focus for both distance and near objects. This is likened to our plasma screen or high definition televisions. One of the first statements that our patients say, "Colors are more vivid than they have ever seen before with glasses or contact lenses."
Color and night vision more define this quality of vision than the 20/20 Snellen chart used in eye care offices in the 20th century until today. This outdated vision measurement system is based on black on white and high contrast targets is an outdated system dating back to the 1900’s and the early development of eyeglasses well before the development of contacts in the 1950’s. High performance vision is reported 98% of the time as the patients report seeing better than they ever have with glasses or contact lenses. They also report seeing better than their friends, who have not had laser vision correction.
In cap or flap laser vision correction striae (cornea lines), epithelial ingrowths, and ectasia may result in an irregular corneal surface. Nighttime glare, halos, and blurred vision may result, even though there may not be much residual prescription, in the form of mild myopia, hyperopia or astigmatism. Also detracting from high performance vision will be the Wavefront error as measured by Zernike Polynomial coefficients, a system of mathematics developed in the 16th century by the physicist Fritz Zernike. These higher order aberrations have been reduced with pharmaceutically modified no cut surface AST or Epi-laser in 2009. SBK Thin-Flap LASIK laser vision correction has eliminated striae, epithelial ingrowths, and ectasia.
These advanced procedures address the issue of lower performance or quality of vision after making a cap or flap in laser vision correction. The surface smoothness is maintained by not making a cap or flap, thus decreasing wavefront aberrations. By eliminating the cap or flap some scaring may be prevented as well as making dry eyes worse, which can reduce the quality of vision. Working on the surface may result is less wavefront light scatter and a higher standards of visual quality, crispness, more vivid colors, and better vision 98% of the time than ever experienced with either glasses or contact lenses. Prescription strength is the most important predictor.
The quality of vision is determined through Wavefront measurements. With these measurements a grid of light is projected through the optical system to include the cornea and lens. As these rays of light are bent, the scatter is measured mathematically with Zernike Polynomial coefficients. They are classified in 2nd order (myopia, hyperopia & astigmatism), 3rd order (tetra foil and coma), and 4th order coefficient measurements. A 4th order coefficient spherical aberration is the major measurement for nighttime glare and haloes, seen primarily when the pupil dilates at night. Any process that affects the smoothness of the corneal curvature can result in aberrated or distorted visual acuity. If there isn’t any astigmatism, nearsightedness or farsightedness and the spherical aberration is less than .01, the quality of vision is extraordinarily high and better than that produced with conventional eyeglasses and contact lenses.
What is the most significant realization of the practice at the Shealy Eye Laser Center in 2008?
Ectasia (bulging forward of the cornea) can be avoided most of the time by staying on the surface or sub-surface of the cornea. LASIK involving the deeper layers of the cornea decrease acute inflammation and decrease biomechanical weakening. Although not every case of ectasia is preventable, we know that ectasia does not completely disappear due to structural and genetic pre-disposition. There are lingering mysteries to this condition so that ectasia will never completely go away and per say, does not constitute medical malpractice.
Mark Manus, MD, David Huang, MD & J. Bradley Randleman, MD.
What are the patient outcomes in the first two to six weeks after laser vision correction at the Shealy Eye Laser Center?
We have found that 90% of our patients see as well or better than they did with their glasses during this time period. About 50% of our patients gained vision over their contacts or glasses compared with the global average of about 20%.
| Shealy Eye Laser Center Data |  |
The Laser Vision Correction Process
SBK (Sub-Bowman's Keratomileusis):
Why did Dr. Shealy abandon conventional LASIK and substitute Thin-Flap SBK LASIK and DaVinci Femtosecond LASIK in 2009?
Epithelial ingrowth has been decreased with the use of the DaVinci Femtosecond laser and Thin Flap SBK in laser vision treatments using a cap or flap. This epithelial ingrowth occurred in 53% of the patients above 50 years of age and having dry eyes. The epithelial ingrowth was statistically greater in retreated patients and was necessary 20% of the time. Our no-cut technique has eliminated epithelial ingrowth and scarring, which can occur when lifting the cap or flap in about 6% of patients (see April, 2007 Ophthalmology Times, Thomas E. Clinch, MD, or see our consent form). Dr. Shealy prefers the no-cut technique since it has eliminated ALL epithelial ingrowth.
Recent FDA panels have scrutinized LASIK safety data that in many older lasers led to nighttime glare and haloes, predisposition to ectasia, and dryness of the eyes secondary to certain collagen vascular diseases such as rheumatoid arthritis. These safety issues have been addressed by making more superficial flaps with less invasion into the cornea, stroma and nerves. The satisfaction patients have with laser vision correction far overshadows its risks especially when compared to the wearing of thick glasses and contact lenses which have their safety concerns also.
Our experience with the modern laser vision correction of 2009 indicates that microkeratome technology has advanced beyond Femtosecond laser vision technology in flap creation. Whether SBK laser vision correction is performed using a Femtosecond laser or with a thin flap SBK microkeratome, both have produced a faster and safer visual recovery far exceeding glasses and contact lenses 98% of the time. These SBK flaps are smooth, planar and uniformly thin. The details and the economics of the Intralase and Ziemer technology have resulted in ophthalmologists switching from the Intralase to Ziemer lasers in seven of my fellow laser vision ophthalmologists. Each of these ophthalmologists had a capital outlay of at least $800,000 to make this switch.
In 2009 Dr. Shealy is aware of only one ophthalmologist who switched from the Ziemer laser in favor of an SBK microkeratome. At the present time, Dr. Shealy is unconvinced of the superiority of femtosecond technology compared to his outcomes with the SBK thin flap microkeratome. Being an open-minded ophthalmologist, Dr. Shealy will continue to offer such to his patients but only with a mobile Ziemer laser. His patients must also be fully knowledgeable that the cost of laser vision correction in each individual patient using a Femtosecond laser will be approximately $2000-$3000 higher than his current price for thin flap LASIK. Ophthalmologists like Dr. Shealy are only seeing 1 in 50 of our patients asking for Femtosecond LASIK. They easily accept this recommendation when they review the economics and choose SBK microkeratome thin flap LASIK.
The advancement we have experienced in SBK microkeratomes is that of less interface inflammation, increased smoothness and uniform flap thickness as compared with older microkeratomes that we have used in the past. Each microkeratome is a single patient use system, which is safer and avoids infection and inflammation. The risk of loss of vacuum has been reduced with dual port suctions as compared with vacuum designs in microkeratomes. Quality control of the production of these microkeratome heads has been improved so that scanning electron microscopy shows unrivaled bed smoothness as compared to any flap making devices that have been seen in the past. These planar flaps are optically neutral and can be discarded with few or no complications. If a patient needs retreatment, there is little difficulty in lifting flaps as compared to the difficulty of lifting flaps made with older microkeratomes and Femtosecond lasers. Patient comfort is greater with the SBK microkeratomes.
How does SBK LASIK represent an improvement over previous types of LASIK surgery with a cap or flap?
Better mechanical microkeratomes make flaps more superficial on the cornea. These flaps have a more silk-like smoothness in the top of the cornea as compared with the burlap-like, coarse areas of the deeper cornea. Thus thin flap LASIK is less disruptive to the cornea cutting fewer corneal nerves and giving a higher quality of vision with quicker visual recovery time.
LASIK procedures can disrupt the production of tears by cutting corneal nerves. The lack of continuous tears and reflex tears results in dry eyes. Patients with dry eyes are less likely to achieve optimal vision. In most cases dry eyes are worse especially when making a cap or flap as compared to no cap or flap with surface Epi-Laser. Patents who seek laser vision correction may have underlying dry eye symptoms such as scratchiness, mucous discharge, irritation from wind or smoke, eyes sticking together when awakening in the morning, light sensitivity, contact lens discomfort and contact lens solution sensitivity. Dryness of the eyes occurs as we naturally age along with medications and autoimmune disease such as rheumatoid arthritis. We recommend the use of artificial tears and tear duct plugs in most patients above the age of 47. This will greatly diminish dry eyes symptoms, which are mostly temporary after laser vision correction.
About 14% of the US population already has dry eyes. The causes of dry eyes may be related to lack of tears or improper tears. As we age, tear production decreases especially after menopause and during pregnancy in women. Contact lenses also result in increases in tear evaporation and general irritation causing contact lens discomfort. A wide variety of medications can reduce tears especially antihistamines, sleeping pills, decongestants, et al. Autoimmune disease like rheumatoid arthritis can produce Sjogren's Syndrome and is accompanied by dry eyes and dry mouth. Environmental factors like dust, smoke, high altitudes, work settings, heaters, and air may reduce eye lubrication.
Below is a check list of dry eye symptoms:
q Dry Sensation
q Scratchy, Gritty Feeling
q Burning
q Stinging
q Itching
q Excess Tearing (Watery Eyes)
q Mucous Discharge
q Irritation from Wind or Smoke
q Redness
q Tired Eyes
q Light Sensitivity
q Contact Lens Discomfort
q Contact Lens Solution Sensitivity
q Soreness
q Lid Infections/Sites
q Sensitivity to Artificial Tears
q Eyelids Stuck Together at Awakening
What can a person expect for their uncorrected visual outcome on the first day postoperatively with Thin-Flap or SBK LASIK? How does it compare to Femtosecond SBK flap making technology?
See our chart:
How has thin flap LASIK or SBK (Sub-Bowman's Keratomileusis) been found to have some additional benefits over femtosecond laser flap production?
With new generation mechanical microkeratomes, Richard Norden has found that patient operation time is decreased and the uncorrected visual acuity at 10 minutes is impressive with no radiation induced inflammation or pain in his first 50 consecutive patients. Dr. Shealy theorized that less is more when it comes to creating a planar flap in which the thickness is the same through all parts of the cornea. These flaps adhere more readily because they conform to the normal corneal curvature architecture. Unlike thicker flaps produced by femtosecond lasers and older generation microkeratomes, the corneal curvature is maintained in it's natural state. This provides for more safety in case the flap is incomplete due to loss of keratome vacuum. These thinner flaps become adherent rapidly while producing less visual distortions.
At our center we have found that SBK is more comfortable during the first five hours after surgery, in most cases, as compared to reports with femtosecond lasers. Mostly Ibuprofen is necessary with one to two tablets (200mg) in the first twenty-four hours after surgery with the use of polarized-UV protective sunglasses for mild light sensitivity. On July 4th 2009 a Michigan State police office followed me to Coldwater, Michigan on Interstate 69 and was able to function with 20/15-20/10 vision the very next day. He was very self confident about his vision and had no difficulties, as he need to return to home to celebrate the holiday with his family.
See our chart:
Although we prefer mechanical SBK in our practice along with the Ziemer femtosecond laser, both technologies have lead to a rebirth of corneal refractive surgery in 2009. For more discussion, read this article.
How has laser vision correction for high myopia with SBK Thin-Flap laser vision treatment improved in 2010 as compared to 1994?
Studies have been conducted for high myopic LASIK in terms of safety and efficacy. 196 eyes of 118 consecutive patients treated for myopia >-10 diopters. The eyes were followed at 3 to 5 months and 10 years after surgery. At 10 years, 40% were still spectacle independent. Almost 30% of the eyes have undergone retreatments. 42% of eyes were within 1 diopter of targeted refraction and 61% were within 2 diopters. The conclusion of the study indicates LASIK is no longer favored as a procedure of choice for the treatments of high myopia. The surgeries were performed with a VISX laser and an automated corneal shaper, both of which are less advanced technology. Many of the eyes that were operated on at this time would have been excluded today from having LASIK. At the Shealy Eye Laser Center, SBK and Wavefront lasers have made the outcomes much more stable and predictable and at our center we will perform laser vision correction for up to -14 diopters of myopia with up to 6 diopters of hyperopia.
LASIK is the procedure of choice for -4 to -10 diopters according to Ioannis Pallikaris, MD, PhD. In almost all cases it is possible to have a residual corneal thickness of more than 300 microns. Almost 50,000 LASIK cases that average -7 diopters in Hong Kong have been treated; 2,535 high myopes ranging from -8 to -16.75 diopters have been followed and fewer than 0.4% were very dissatisfied with the results, less than with low myopes of 1%. The need for spectacles in the high myope group was 3.7% compared to 2.2% in the low myope group. In either group, no eye lost no more than two lines of best-corrected vision. One eye in the low myope group lost two lines and three eyes in the high myope group lost two lines.
Jorge L. Alio, Am J Ophthalmol, 2008;145:55-64
AST Amoils Advance Surface Treatment or Surface Epi-Laser:
Who can be treated with Surface Epi-Laser?
Up through 2007, we generally treated patients that are up to -15 diopters of myopia, up to +6 diopters of myopic cylinder, up to +4 diopters of hyperopia, or up to +4 diopters of hyperopic cylinder. Our highest mixed astigmatism is about -6 diopters. These numbers may vary depending upon our goal with our patient. Some patients are happy to be have their astigmatism reduced and to correct spherical residual prescriptions with glasses or spherical contact lens. Since that time, and the development of SBK LASIK, we have been treating many of our patients with hyperopia of over 3 diopters and myopia of over 10 diopters with this procedure.
The graphs shown below indicate the improvement of hyperopic Epi-Laser vision correction seen in our results in the 2007 studies. Please note that a slight early over correction occurs producing initial slight near-sightedness and markedly exaggerated improvement in near vision which over time, two weeks or so, results in marked high performance distance vision.
.png) | .png) | Global Data; Hyperopic Ablation | Dr. Shealy's Results; Hyperopic Surface Ablation |
We have found that nearly 100% of our selected patients will see 20/20 or better when patients desire distance correction only. Since the advent of SBK for hyperopia in 2009, we reserve hyperopic AST to less than 3 diopters of hyperopia. In 2009 we use SBK for hyperopic patients greater than 3 diopters of spherical equivalent.
Why did the Shealy Eye Laser Center switch to Surface Epi-Laser treatment for myopia in 2007?
The graphs below show the global data results for conventional flap or cap LASIK treatments performed with all lasers.
 |  | Global Data; Myopic Surface Ablation | Dr. Shealy's Results; Myopic Surface Ablation |
Nearly all of our myopic patients achieve 20/20 vision or better with surface Epi-Laser and the use of Mitomycin C when indicated. Those patients with high myopia sometimes lost some lines of vision due to corneal haze and were retreated for such. In 2009, we limit surface treatment to less than -5 diopters of myopia and prefer SBK Thin-Flap LASIK for higher degrees of myopia if the corneal thickness permits.
Although surface ablation has advantages in terms of safety and visual outcome, it has been associated with some significant problems, including haze, pain, slow visual recovery, and regression. The combination of frozen BSS to chill the cornea after surgery, a tight bandage contact lens, and aggressive pharmaceutical management has reduced the incidence of pain to the point where 85% of surface ablation patients have roughly the same comfort level as LASIK patients. Use of mitomycin-C has removed significant haze as a complication of surface ablation. The smooth ablation surface that current flying spot lasers deliver speeds recovery following surface ablation, although the pace of visual recovery is still significantly slower than with LASIK. Larger optical zones have greatly diminished the incidence of regression following surface ablation, to the point where enhancement rates for surface ablation are lower than for LASIK. Visual outcomes have been stellar. Advanced surface ablation opens up the possibility of extending the range of laser vision correction to -12D.
Techniques for Advanced Surface Ablation by Raymond M. Stein, MD, FRCS(C)
Why has the Shealy Eye Laser Center stopped performing conventional LASIK and switched to SBK (Sub-Bowman's Keratomileusis) Laser or AST (Superficial Epi-Laser)?
Dr. Shealy stopped using conventional LASIK in 2006 because of its complications. Dr. Shealy agrees with several leading ophthalmologists like Ming Wang, MD, PhD, that "newer technologies and better medical management of post-op discomfort have allowed us to offer superior results with patient safety in mind." 90% of LASIK complications are related to the flap or cap formation.
Our center has found that Wavefront laser vision correction improves nighttime driving visual performance in most of our patients as compared with conventional LASIK performed before 2005. Laser retreatments have dropped significantly by using the laser on the corneal surface or directly underneath Bowman's layer. Retreatment rates have dropped to below 2% and we have seen improvements in the quality of vision after surgery. Our former office manager can attest to the satisfaction of his night vision as compared with patients who have had conventional non-wavefront laser vision correction previously in our center or in other centers. Our surgical assistant, Chi Yip, can attest to the improvements in her vision with AST over small prescriptions treated with either glasses or contact lenses.
Dr. Shealy has found that surface ablation is absolutely necessary in the treatment of farsightedness when a patient desires the least invasiveness. Intraocular implants may not be centered in the pupil so that when you make a cap, with either a laser or bladed keratome, decentration off the visual axis may occur. The decentration of the cap or flap can be avoided with the use of surface ablation and the area of treatment can be centered nicely along the visual axis that is tracked by the Allegretto Wave eye tracker. Our results have been spectacular and patients can practice monovision by having the non-dominant eye predictably overcorrected, making the patients independent of reading glasses or bifocals 90 to 95% of the time.
The Allegretto Wave Laser corrects up to 6 diopters of farsightedness with 6 diopters of astigmatism. We've noticed almost no haze formation and a very low retreatment rate as compared to hyperopic LASIK techniques. Since the cornea is more prolate or parabolic after surgery, patients have better near vision than would be expected from myopic LASIK or Epi-LASIK surgery. We have found at our center that large amounts of farsighted astigmatism is better corrected with Advanced Surface Treatment.
We have learned that lifting the flap or cap in a post-LASIK patient increases the risk of infection, scarring or epithelial ingrowth, and other complications that can affect vision like striae and ectasia. Recently we have found that SBK thin flap laser treatment greatly reduces striae lines in the flap and that the vision is maintained without any loss of best-corrected vision. We now know that the risk of loss of your eye from laser vision correction is virtually nonexistent. We have found that the risk of loss of your eye with invasive intraocular procedures is 1 per 1000 surgeries in Dr. Shealy’s experience. With laser vision treatment, we lose 1 to 2 lines of chart vision in a patient at the rate of 1 per 1000 treatments whereas; we gain 1 to 2 lines of chart vision at the rate of 670 per 1000 treatments.
Most of our patients are retreated by surface ablation either with a trans-epithelial approach, if we do not want to disturb a previous complete or partial flap. This is especially important in patients who have had associated relaxing incisions or any flap LASIK procedure either SBK or conventional flap LASIK surgery. Mitomycin-C may be used if necessary as in the case of high myopia. A protective contact lens is placed on the eye for approximately 5 days and may be removed by our patient. Topical non-steroidal and steroidal anti-inflammatory drops are necessary to promote healing and provide comfort.
It is commonly agreed that patients with greater than 2 diopters of astigmatism are likely to have retreatments. Retreatments are higher in patients with hyperopic astigmatism. We offer an additional charge of $300 per eye to avoid the expense of retreatments, which is normally 80% of our original fee. The Wavelight laser with its large range of astigmatism treatment has reduced retreatments to less than 1%. In 2009, we are treating up to 6 diopters of astigmatism under an SBK thin flap.
In 2009, we have recognized that treatment of small residual refractive errors results in a large increase in patient satisfaction with higher quality of vision. We have found that small magnitude adjustments of less than 0.5 diopters of astigmatism are well worth repeating laser vision treatment. Our lasers are extremely accurate and patients can appreciate the improvement to 20/15-20/10 vision over their original 20/20 vision. These patients are treated on the surface and are given artificial tears to aid surface healing.
What is the preferred treatment at the Shealy Eye Laser Center for re-treatment if conventional LASIK surgery and Radial Keratotomy surgery has been performed in the past?
Flap lifting after LASIK surgery is considered obsolete after six months and is not a minor consideration because of scarring complications. Surface ablation is the only present form of treatment used with either LASEK using alcohol, or the Amoils epithelial brush. This is also true for cutting procedures like previous radial keratotomy patients. Buttonhole flaps and partial flaps are one of the most devastating complications of LASIK and require off label use of Mitomycin-C and photorefractive keratotomy to correct patients prescriptions on the cornea surface. Refer to News & Updates for more information.
What is the comparative enhanced video imaging assessment of corneal bed texture in LASIK, Surface Epi-Laser, and Thin Flap SBK?
New methods of determining the smoothness of the bed architecture were found to be superior in Surface Epi-Laser by Dr. James Lewis and the Wills Eye Surgical Network. Click here for the comparative photos.
What is Superficial Epi-Laser or Advanced Surface Treatment (AST)?
Advanced Surface Treatment separates the epithelium from the Bowman's membrane, creating a thin epithelial sheet, which is discarded. This makes possible laser vision correction for more patients, especially those with thin corneas or dry eyes. Uncorrected visual acuity was significantly better with cell removal on postoperative days three to seven as compared to keeping the epithelial cells intact. This is much safer as compared to cutting procedures like Intralase, RK, or even mechanical cutting LASIK. All of our patients prefer this to other procedures. Using the Allegretto Wavelight Laser has given us the highest quality of vision compared to other lasers that we have used.
AST has been developed with improved technology, better pharmaceuticals, and increased concern over conventional LASIK complications. Our center has found that the risk for kerectasia has decreased dramatically, especially in patents with no preoperative warning signs. Epithelial ingrowth has been eliminated since there is no flap or cap.
Other Frequently Asked Questions (optional reading)
General Laser Vision Survey Information:
Refractive surgeons know best according to 2008 survey of the American Academy Ophthalmology
● The segment of the population knows the benefits of laser vision correction more intimately than the lay-public, a refractive surgeon says.
● 35% of refractive surgeons have undergone LASIK or surface procedures such as PRK. This compares to a ten-fold more usage than the lay-public at 3.5% out of the 175 million contact or eye glass wearers.
● The more you know about modern laser vision correction, the higher the likelihood that you would have surgery.
● Additionally 30% of the surgeons spouse, 20% of their children and 40% of their sibling have had laser vision correction according to the FDA since 1996.
● The FDA had special hearing to discuss dissatisfaction and suicides, stating that ophthalmologists should avoid laser vision correction. As refractive surgeons, we feel that this is as far from the truth as it can be.
● Spreading the word. Dr. Duffey said a number of physicians have undergone laser vision correction including urologists, pediatricians, anesthesiologists, and are spreading the interest in laser vision corrections among other physician specialties at a much increased rate.
● Most family members of Dr. Shealy, who has been a practicing refractive surgeon since 1991, have undergone refractive surgery include his brother, his daughters and their families, most of his staff, to validate these national survey claims.
● Dr. Shealy has had keratomileusis for his own presbyopia performed by Dr. Steve Hollis in Auburn, Alabama in 1994. Dr. Hollis has performed over 110,000 refractive procedures.
Laser Vision Correction in The United States Military
● The US military's decision to adopt laser vision correction-first PRK and then LASIK-to improve it troops' visual function was not taken lightly. It was based on the results of more than 45 clinical trials. 74% were 20/16 or better, 94% were 20/20 or better and 98% were 20/32 or better.
● 41% were positively influenced the patients ability to identify a simulated target at night, while only 3% were reduced in their ability in such.
● The complication rate. Only one of 112,000 patients complained of poor quality of vision, he was retired and was not returned to active military duty.
● The Shealy Eye Laser Center has operated on over 500 military personnel, Army and Navy, who have for the most part benefited from laser vision correction and have performed in Iraq and Afghanistan.
Review of World Literature and Quality of Life After LASIK, 1987 to 2008
Video Journal of Ophthalmology, Second Quarter 2008, and Kerry Solomon, MD
● A formal study was conducted by the ASCRS (American Society of Cataract and Refractive Surgery), AAO (American Academy of Ophthalmology), and the FDA (Food & Drug Administration). About 2,915 abstracts were studied from all parts of the world with 1,334 of these abstracts determined to be not relevant because that pertained to animal studies, et al. Almost 1,581 abstracts were found to be pertinent with 1,461 of these abstracts written in English and 120 were translated from non-English sources. Of the 1,581 pertinent abstracts, 309 were found to be acceptable from a scientific, controlled studies standpoint. They were grouped as prospective randomized and non-randomized studies and retrospective randomized studies. All of the abstracts were found in the major journals, published around the world between 1994 and 2008.
● The patient study concluded that 95.6% were satisfied and 4.6% were dissatisfied after having LASIK since its inception. The study applied to all patients regardless of whether they were nearsighted or farsighted, or where the surgery was performed in the world. No difference was found in satisfaction whether the survey was performed in the first 6 months after surgery or after the first 6 months. There was a tendency for the satisfaction rate to improve over time and it approached 98.5% over the long term.
● A quality of life comparison was made between patients that wore glasses or contact lenses and those that underwent LASIK surgery. The quality of life comparison compared 104 eye glass wearers, 104 contact lens wearers, and 104 patients that underwent LASIK surgery. The quality of life score in those subjects undergoing LASIK surgery was many fold higher than those who wore glasses or contact lenses. The main complaints of those dissatisfied LASIK surgery patients was nighttime glare and haloes, dry eyes, and under or over corrections.
● The satisfaction of patients who underwent LASIK surgery was higher than patients who underwent other elective cosmetic such as rhinoplasty, breast augmentation, or other cosmetic procedures performed throughout the world.
● The quality of life comparison of the patients undergoing LASIK correction was about the same as those emmetropes who have never had to wear glasses or contact lenses. The quality of life of the LASIK patient approaches that of patients who have never needed glasses or contact lenses.
● The most common areas of dissatisfaction were dry eyes, nighttime glare and haloes, and over/under correction. Nighttime glare and haloes were found to be present before surgery in most patients, but increased to 10% after LASIK surgery. 32% of the patients had dry eyes before LASIK surgery, and 34% had dry eyes after LASIK surgery, which tended to decrease over time.
● 16,000 eyes were studied intensively for adverse side-effects in a clinical study in the United States.
● Over 28 million people world-wide have had LASIK surgery. We find that the satisfaction rate may increase to 98.5%, over time, but we need a goal of 99%+ as we learn more about patients and apply new innovations in laser vision correction.
What has been the conventional LASIK dissatisfaction rate in national research studies conducted by Wills Eye Institute in Philadelphia, Pennsylvania? How has our experience at the Shealy Eye Laser Center nullified and reduced this dissatisfaction rate in 2009?
109 patients and 157 eyes were studied that showed that dissatisfaction seems to have plateaued over the last three years from 2006 to 2009. The two main complaints were: 68% had poor distant vision and 20% had primary dryness of the eyes. Best overall vision was 20/40 or better. The most common diagnosis was; 28% had dry eyes, 12% irregular astigmatism, 9% epithelial ingrowth, 5% haze and scarring, 6.6% ectasia, and 5% over-correction. Most patients with ectasia had been operated on before 2001. Only 25% of all patients that had surgery went on to have enhancements done later. Most were suggested to wear spectacles or contact lens fitting. Dry eyes have been reduced through better treatment and less invasive laser vision correction. Thin flap laser vision correction and surface Epi-laser reduces dry eyes by not affecting corneal nerves. We have more advanced artificial tear formulations in 2009 and also know a great deal more about the inflammatory conditions causing dry eyes. According to Kerry Solomon, MD and Paul Karpecti, OD the starting point has been adopted with the use of artificial tears 4 x a day. A course of topical steroids 4 x a day for 2 weeks and then maintenance therapy with Restatis (Cyclosporine ophthalmic emulsion, Allergan) can begin. In patients that have lid margin disease, hot compresses as well as lid scrubs may be used to free up lid secretions. Omega 3 fatty acids in topical azithromycin or oral doxycycline may be needed. Extreme measures may include hourly dosing of preservative-free tears, nighttime ointments and moisture chamber glasses. Please remember that different treatments are required for individual patients depending on their underlying conditions.
Our practice has found the primary stimuli to dry eyes are aging, gender, medications, previous ocular surgery, low dietary omega-3 fatty acids, and artificially dry environments (heating, and air conditioning). Patients feel grittiness, foreign body sensations, blurry vision, and tired eyes when reading. Inflammatory blepharitis and tear deficiency both play roles; however, the number one reason for patients seeking laser vision correction is contact lens intolerance. This intolerance may usually mean underlying dry eyes. Topical restasis starting one month before surgery and combined with a low dose topical steroid post operatively help. At our center we are now placing punctal plugs in our patients nearly all of the time in females with a history of hysterectomy or hormonal changes related to physiological biochemical aging.
Specialized Questions from Eye Care Professionals:
How is the integrity of the cornea affected with laser vision correction?
John Marshall PhD (FRC) states that more fibers are cut with deeper refractive procedures, whether on the surface or inside of the cornea body or stroma. Since the cornea is under constant stress, we need to pay attention to its cornea biomechanics to avoid structural weakening.
What is the new assessment model that can assist in selecting patients for refractive surgery?
Theo Seiler in 1998 described iatrogenic ectasia for the first time. It is estimated that between 0.2% and 0.6% develop ectasia. Based on a review of 150 cases, there are four pre-operative factors in order of importance: topography, predicated residual bed thickness, age, and preoperative spherical equivalent. Each factor was given a point score of 1 (with 0 to 2 being a low risk) in which LASIK or PRK could be performed. With patients at moderate risk (level 3), the potential hazards of LASIK must be discussed. At level 4 LASIK is contraindicated.
Surface ablation is a low or no risk procedure that requires only topography and pacymetry. Other risk factors should include history of Keratoconus, ocular aberrometry. The 4% occurrence of ectasia after PRK is about the same in eyes that did not have any refractive procedure.
Can patients be treated with laser vision correction if they've had Herpes Simplex Keratitis?
Dr. Herbert Kaufman has performed the Herpetic Eye Disease Study associated with testing, cultures and treatments. He found 1. oral medications have nothing to offer us for treating stromal disease and iritis, 2. oral medicines did not effect the incidents of stromal disease in patients with herpes epithelial disease, 3. oral medicines did prevent recurrence of herpes in only 1/2 of the patients with recurrent stromal disease. Secondly, he found that steroids benefited acute disease of the stromal cornea and that there was no damage caused by them. The study also determined that true bilateral herpes keratitis is very rare but can occur. He uses Viroptic for epithelial disease and has a new hope, Ganciclovir, which inhibits viral DNA synthesis for use in the future as it comes in from Europe. Dr. Kaufman feels that patients that have had Herpes are good candidates for refractive surgery in which he performs LASIK. If a patient has active disease, he starts Viroptics a couple days before LASIK and keeps it up for two weeks after LASIK. He will perform laser vision correction surgery in patients that are asymptomatic for a few weeks by giving them oral Valtrex 500mg twice daily for a few days and two weeks after surgery. He's noted no reoccurrences of herpes in these patients with LASIK. Dr. Shealy follows his recommendations at his center.
Potential Complications
What is the most important advancement in laser vision correction to eliminate over, under, and residual astigmatic corrections?
The most common complication with laser vision correction is unwanted residual prescription, which occurs less than 1% of the time. Elimination of residual prescriptions and accuracy of lasers improved with eye tracking and beam quality. With the advent of Allegretto "flying spot" technology, we were able to reduce our retreatments from about 15% down to less than 1%. The advent of flying spot technology allowed us to maintain the corneal curvature with less breaks and interruptions so that when the pupil widened at night, glare halos and visual distortions were decreased. Data linking has allowed us to develop performance nomograms to determine the specific treatment for each patient prescription. When we switch from broad beam lasers like Nidek and Summit, we were able to determine the range of prescriptions that could be performed with these lasers, which were equal to the more advanced flying spot lasers. Read his article. The following link shows craters and ridges induced by broad beam lasers and how these irregularities were smoothed out with flying spot tech. Click here. The most important factor that we take into consideration in choosing lasers is the amplitude of astigmatism that is corrected with the laser. To date the Allegretto Wavelight laser has been the most effective in treating astigmatism above 3.5 diopters. We also know that the Wavelight laser can reduce higher levels of hyperopia and hyperopic astigmatism. At this time we now understand the Wavelight laser gives less retreatments for higher ranges of astigmatism and higher degrees of hyperopia and myopia. With lower degrees of astigmatism in myopia we will not hesitate to use broad beam technology since it is equivalent to the Wavelight laser with these prescriptions.
What is the best treatment for recurrent extensive epithelial ingrowth?
Pictured here is a patient who has undergone surgery for recurrent extensive epithelial. The cells were meticulously removed from the stromal bed and stitched with 10-0 nylon sutures. Extensive recurrent epithelial ingrowth has been almost eliminated with thin-flap SBK laser vision correction. We've found that epithelial ingrowth can be resolved with ND-YAG spot application to epithelial ingrowth areas requiring one or two treatment sessions. Treatment of epithelial ingrowth with the ND-YAG laser has produced dramatic improvement in vision in a patient that we performed flap surgery 16 years ago. In 2009, the vision was improved to the point where they were a candidate for surface treatment with the Wavelight laser and possibly can function without bifocals. This patient had almost given up hope about return of her eyesight, but now knows that technology advancements allow us to improve on past surgical patients. Our preferred practice pattern at the Shealy Eye Laser Center is to treat all epithelial ingrowth with the Nd YAG laser.
A researcher in Spain, Jorge Alio, MD, has been using the Nd YAG laser, have found an innovative way to treat epithelial ingrowth that is easier and less invasive than previous corrective measures and decrease the risk of the problem coming back. Over a four-year period he successfully treated 200 eyes affected with this new laser procedure. In some cases, a second session was required, usually three weeks after the initial treatment. Dr. Shealy prefers several treatment sessions if necessary and to limit the treatment to 3mm of affected area. There have been no complications from the procedure and no incidences of recurrence. In 80% of eyes the patches disappeared completely, and the visual acuity increased at least one line in 60%.
American Journal of Ophthalmology, Vol. 145, No. 4.
What is the best non-surgical solution for management of iatrogenic Keratoconus?
The term Keratoconus encompasses a spectrum of topographical shapes whose only common denominator is central or paracentral corneal steepening. For those patients who cannot be fitted with glasses, 90% of the patients with Keratoconus have contact lenses as the best treatment option throughout life. Only 10% of patients with a diagnosis of Keratoconus require penetrating keratoplasty or PK. The designs available are gas permeable contacts, large diameter Scleral gas permeable lenses, piggyback contact lenses, and lastly soft toric contact lenses.
How often are people retreated after laser vision correction?
Our re-treatment rate is less than 0.25%. This compares much more favorably than a 5% to 10% rate noted with less advanced lasers and less experienced ophthalmologists.
I still have a question.
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