Vision Surgery

In recent years there have been tremendous advances in the field of vision correcting eye surgery which is also known as refractive or laser surgery. Corrective eye surgery offers patients clear vision without the use of glasses and contact lenses. There are a number of types of refractive surgeries that are able to correct different vision problems, so if you are considering surgery here are some of the options you should know about.

LASIK

LASIK (laser-assisted in situ keratomileusis) surgery is perhaps the most well-known refractive surgery today. LASIK can help patients with myopia (nearsightedness), hyperopia (farsightedness) and astigmatism. During the procedure, the doctor makes a flap in the outer layer of the corner to reach the underlying tissue and then uses a laser to reshape the tissue which allows the cornea to then focus light properly. The procedure is usually painless and vision is usually clear within a few hours.

Recent advances in the field have developed subcategories of LASIK surgery such as Bladeless LASIK, which uses a laser rather than a mechanical tool to make the initial flap or Wavefront (custom) LASIK which uses computer mapping to guide the reshaping of the cornea and is able to create a much more precise visual correction for very subtle optical imperfections. There is also a procedure called Epi-LASIK in which following the procedure, the doctor applies a soft contact lens to protect the surgical area, holding the flap in place while it heals.

PRK

PRK (photorefractive keratectomy) also uses a laser to correct mild to moderate myopia, hyperopia and astigmatism. PRK was a precursor to LASIK which eliminated many of the complications of prior surgeries such as glare, seeing halos around lights, blurred vision and regression of vision. Unlike LASIK, the procedure only reshapes the surface of the cornea and not the underlying tissue. Consequently, there is often some discomfort for a couple of weeks until the outer layer of the cornea heals. Additionally, the patient may experience blurred vision during this period of healing. PRK does offer an advantage over LASIK in that there is less risk of certain complications. Wavefront technology is also available for PRK surgeries.

Due to the increased comfort of LASIK there was a period that PRK saw a decline. Recent studies show however that LASIK and PRK have similar long-term success for improved visual acuity and with the assistance of newly developed effective pain medications, PRK has become more popular again as an option.

LASEK

In LASEK or laser-assisted sub-epithelial keratomileusis, the doctor creates a flap smaller but similar but to LASIK, and then uses an alcohol solution to loosen the tissue around the cornea which is pushed aside, and then a laser is used to reshape the cornea itself. In an Epi-LASEK procedure, the doctor may apply a soft contact lens to hold the flap in place to assist in reattaching to the cornea as the eye heals. Patients that undergo LASEK generally experience less discomfort and quicker vision recovery than PRK patients. LASEK may be preferred over LASIK as a safer option for patients with a thin cornea.

Cataract Surgery

Cataract Surgery is a very common refractive surgery that removes the clouded natural lens of the eye and replaces it with an artificial lens called an IOL (intraocular lens). Many patients these days will receive a lens that also corrects any refractive error they have such as nearsightedness, farsightedness or presbyopia.

RLE

RLE or refractive lens exchange is a non-laser procedure the replaces the natural lens of the eye. This is the same as the surgery that is used to treat cataracts, ,yet for non-cataract patients, RLE is used to correct severe nearsightedness or farsightedness. The procedure involves the doctor making a small cut in the cornea, removing the natural lens and replacing it with usually a silicon or plastic lens. It is particularly useful for patients with minor corneal problems such as thin corneas or dry eyes.

RLE is more risky than the other procedures mentioned and can affect the patient’s ability to focus on close objects, possibly requiring reading glasses following the procedure. However, in cases of severe vision correction it is often the preferred method.

PRELEX

PRELEX or presbyopic lens exchange is for patients with presbyopia, the age-related condition in which you lose the flexibility of your lens and can no longer focus on close objects. Patients that prefer not to wear reading glasses or multifocals, can opt for a procedure in which the doctor removes the natural lens of your eye and replaces it with a multifocal artificial lens. This procedure is often done in conjunction with cataract surgery.

Phakic Intraocular Lens Implants

Phakic IOLs are implants that are used for individuals with very high nearsightedness who do not qualify for LASIK or PRK. The implant is attached to your iris or inserted behind your pupil, while the natural lens remains intact. Because this is a procedure that involves the inner eye, it is more risky than LASIK or PRK and is therefore also typically more expensive.

Conductive Keratoplasty (CK)

CK uses a hand-held radio wave device to shrink tissue on the cornea to reshape it. The procedure is typically used to treat mild farsightedness and presbyopia, particularly for patients who have already undergone LASIK.

Any surgical procedure has risks and may have some side effects or complications that you should research before you decide to go ahead with the surgery. Nevertheless, as technology advances these complications are being significantly reduced making refractive surgery a great option for vision correction in many patients.

LASIK can correct nearsightedness, farsightedness and astigmatism. With a special technique called monovision, it can also reduce the need for reading glasses among patients over age 40 who wear bifocals.

Am I a good candidate for LASIK?

Chronic dry eye problems, corneal diseases and other abnormalities may disqualify you from having LASIK surgery. In order to know for sure if you are a good candidate, a comprehensive eye exam is required. For your convenience, we are happy to provide LASIK pre-operative exams and consultations at our office. Call us for details.

Important considerations when deciding whether or not to have LASIK are your expectations and your ability to accept a less-than-perfect outcome. LASIK can reduce your dependence on glasses and almost always gives you the ability to function well without the need for glasses or contact lenses. But there are no guarantees, and LASIK doesn’t always create perfect vision. In some cases, your vision after LASIK may be permanently less clear than it was with glasses before the procedure. You have to ask yourself if you’re willing to accept the risk of such an outcome before you decide to have LASIK surgery.

Remember: LASIK is an elective procedure, not a required one.

The LASIK procedure

LASIK is an ambulatory procedure. You walk in the surgery center, have the procedure and walk out again. The actual surgery usually takes less than 15 minutes for both eyes, but expect to be at the surgery center for an hour or more.

LASIK is a two-step procedure. In the first step, the surgeon creates a thin, hinged flap of tissue on your cornea with an instrument called a microkeratome or with a laser. This flap is folded back and the second step – the laser reshaping of your eye – begins. After the laser treatment, which usually takes less than a minute, the flap is repositioned and the surgeon moves on to your other eye.

What is wavefront LASIK?

Wavefront LASIK (also called wavefront-assisted, wavefront-guided or custom LASIK) means the laser treatment (or “ablation”) is determined by a computerized mapping of the power of your eye called wavefront analysis. Wavefront-guided procedures are more precise than ablations determined by using only an eyeglasses prescription, and they can correct subtle optical imperfections of the eye called “higher-order aberrations” that regular ablations can’t treat. Several studies show wavefront-guided ablations provide sharper vision than conventional, non-wavefront LASIK and may reduce the risk of nighttime glare and halos.

After LASIK surgery

After the procedure, your surgeon or an assistant will apply medicated eye drops and clear protective shields over your eyes. You can open your eyes and see well enough to walk without glasses, but you must have someone drive you home.

You will be expected to use medicated eye drops several times a day for a week or so to protect your eyes from infection and help them heal properly. You will also be told to use artificial tears frequently to keep your eyes moist and comfortable.

You should rest and not use your eyes much when you get home from surgery that day. You may also be more comfortable if the lights in your house are dimmed.

The following day, you should be seeing well enough to drive and can resume most activities. Be careful, however, not to rub your eyes until your eye doctor tells you it is safe to do so.

Usually, you will be asked to return to the surgery center the following day so your surgeon or another eye doctor at the center can check your vision and make sure your eyes appear as they should. At this visit, you typically will be given additional instructions about using eye drops and artificial tears, and you will be able to ask the doctor any questions you have.

From this point forward (and sometimes for this “day one” visit as well), your post-operative care may be performed by an eye doctor other than your LASIK surgeon. When your post-operative care is provided by a doctor other than your surgeon or another doctor at the surgery center, it’s called co-management. We are happy to provide post-operative care for you at our office through a co-management agreement with your surgeon. Call our office for details.

What if my vision is still blurry after LASIK?

Though most patients see quite clearly in a matter of days after LASIK, it can take several months before your eyes are completely stable. Until then, improvements in your vision can still occur. But if several months pass and your vision is still blurred, see your LASIK surgeon. Usually a second LASIK surgery (called an enhancement) can sharpen your eyesight further.

If for some reason an enhancement is not indicated or desired, eyeglasses or contact lenses may help. We will be happy to examine your eyes and discuss the different options with you.

Eyewear after LASIK

Keep in mind that, even if your vision seems perfect after LASIK, you still need eyewear.

When outdoors, it’s important to protect your eyes from the sun’s harmful rays with sunglasses that provide 100% UV protection. If you play sports when wearing sunglasses, make sure the lenses have polycarbonate lenses for extra protection. And any time you’re working with power tools or doing anything else when an eye injury is possible, you should wear safety glasses with polycarbonate lenses.

If you’re over 40 (or soon will be), it’s likely you’ll need reading glasses after LASIK. Also, many LASIK patients can benefit from a pair of prescription eyeglasses for night driving. Though these lenses may have only a mild prescription, they often can make your vision sharper for added safety and comfort.

Eye care after LASIK

And don’t forget to continue to have routine eye exams after LASIK. Even if your vision is perfect, you still need to have your eyes checked for glaucoma and other potential problems on a regular basis. Routine exams also help you make sure your vision stays stable after LASIK. We are happy to serve all your eyewear and eye care needs after your LASIK surgery.

LASIK is the most common refractive eye surgery, partially due to the fact that the risks and complications are low. The majority of patients don’t experience any long term complications as a result of the surgery. Nevertheless, as with any surgical procedure there are some risks, however rare they are and it is important to know them and to discuss them with your eye doctor or surgeon prior to undergoing the surgery.

Side effects of LASIK

There are a number of side effects that are somewhat common immediately post-op and in some instances can last longer – sometimes indefinitely. Those include:

Dry Eyes

About half of LASIK patients experience dry eyes, which are usually a temporary side effect that resolves within 3-6 months after the surgery. Your doctor will likely prescribe artificial tears in the days and weeks following the surgery which should be continued as long as the symptoms persist. Because of this, it is usually recommended that patients with a history of chronic dry eyes opt for another type of refractive surgery such as PRK, another style of laser refractive surgery with reduced risk.

Eye Infection or Irritation

While not common due to the eye drops and checkups prescribed post surgery, there is a chance of developing an eye infection. If this does occur, it can be treated with antibiotic eye drops, anti-inflammatories or sometimes may require other treatment such as oral antibiotics. If you are experiencing symptoms of an eye infection such as redness, pain, discomfort, discharge or any change in vision, see your eye doctor immediately. As a precaution, it is imperative to follow your surgeon’s instructions for your post-operative care including prescription medications and doctor’s visits.

Vision Issues

Following surgery, you may experience certain vision issues such as such as poor night vision, double vision, halos around lights or glare. These side effects are common and can last up to a few weeks, but typically go away. Some patients report a lasting reduction in vision in low light conditions and may require vision aids for seeing better at night.

Other risks of LASIK include surgical errors, many of which can be corrected by a follow-up surgery. These include:

Overcorrection or Undercorrection

The key to vision improvement in LASIK is accurate reshaping of the corneal tissue. If too much is removed or not enough is removed, your vision will remain imperfect and when possible may require a follow up procedure to obtain the clear vision being sought.

Flap Complications

Perhaps the greatest risk involved in LASIK is the accurate creation and healing of the flap of the cornea that is lifted to reshape the underlying tissue and replaced after. If the flap in the cornea is not made accurately, cut too thick or too thin and not carefully replaced back on the eye, it can cause complications in the shape of the eye surface and therefore clear vision. Studies indicate that these complications occur usually in under 6% of cases and the experience and skill of the surgeon play a large role.

There can also be complications in the healing process of the flap which include infection or excessive eye tearing.

Vision Loss

There is a chance, albeit small that the surgery can result in a loss of vision or reduction in visual clarity due to complications with the surgery.

It is quite rare for any permanent damage or vision loss to occur as a result of LASIK and usually any vision problems can be corrected by a follow-up procedure. However, as with any surgical procedure, there are risks, so it is important to reduce your risks by finding an experienced surgeon and carefully considering your suitability for the surgery in the first place.

• Certain systemic and autoimmune diseases may be disqualifiers, too. Examples include rheumatoid arthritis, type 1 diabetes, HIV and AIDS. Basically, if your body has any trouble with healing, your corneas may not heal properly after LASIK. Opinions vary among surgeons as to which diseases are automatic disqualifiers and which ones might pose acceptable risks in certain cases.
 
• Your prescription must be within certain limits. For example, very high amounts of myopia, which would require removal of too much corneal tissue, may preclude LASIK or make another type of refractive surgery a better option. For example, many surgeons feel a phakic IOL procedure provides a better visual outcome and poses less risk than LASIK for nearsighted prescriptions higher than -9.00 diopters.

To find out if you’re a good candidate for LASIK, visit our office for a comprehensive eye exam and refractive surgery consultation.

Photorefractive Keratectomy or PRK is a type of refractive laser eye surgery used to correct a patient’s vision to eliminate or reduce their dependence on glasses or contact lenses. PRK is the style of laser eye surgery that preceded LASIK, having been the former most common type of refractive surgery until LASIK came along.

PRK is effective in correcting nearsightedness (myopia), farsightedness (hyperopia) and astigmatism and has very similar rates of success and outcomes as LASIK. PRK remains a common option for laser eye surgery.

How Does PRK Differ From LASIK

PRK and LASIK both permanently reshape the cornea to improve vision by using a laser (an excimer laser to be exact) to remove part of the tissue underneath the corneal epithelium. The epithelium first needs to be removed in order to get access to the tissue and how this is done is what differentiates the two procedures. While LASIK creates and lifts a flap on the outer corneal layer, reshapes the corneal tissue underneath and then replaces the flap, PRK removes the outer layer of the cornea completely. The outer layer will regenerate usually within a few days.

Advantages of PRK

Since PRK completely removes the outer corneal layer, there is a greater area of the cornea to work with. This is ideal for patients with a thin cornea who would otherwise be at risk with LASIK. It is also usually recommended for patients with chronic dry eyes. With PRK, there is also less risk of infection or issues having to do with the flap and the related healing process. This is an advantage for individuals who lead a lifestyle in which they are at risk for eye injuries (athletes, military, law enforcement etc.) which may subject the flap to injury or complications.

So, Why Is LASIK More Popular?

The main advantages that LASIK has over PRK are two-fold and mainly have to do with comfort and recovery time. First of all, PRK patients usually experience slightly more discomfort during the first couple of days of recovery, mainly because it takes time for the outer corneal layer to heal. They will be prescribed eye drops to be taken for several months to prevent infection, increase comfort and assist the healing process. LASIK patients on the other hand, typically experience less discomfort and if they do, it subsides very quickly.

Additionally, vision recovery takes longer with PRK. While LASIK patients can typically see normally within a few hours after the surgery, with vision gradually continuing to improve within the next few months, PRK patients may experience blurred vision for up to three days and it can take up to six months until they achieve full visual clarity. While patients who undergo LASIK can usually drive and resume normal functioning within a day or two, PRK patients shouldn’t plan on returning to normal for at least several days until the outer layer of the cornea has grown back.

Whether PRK or LASIK is a better option for you depends on a number of factors, including the health and structure of your eye. This is a decision that your eye doctor or surgeon will help you make. Rest assured however, that both procedures have been shown to be incredibly successful in correcting vision, with minimal complications.

What You Need to Know About PRK

Prior to any laser correction surgery, you will meet with a surgeon for a thorough exam to assess your eye health and determine whether you are a candidate and if so, which type of surgery would be best suited to your needs. During this exam it is essential to tell the doctor any relevant medical history (injuries, hospitalizations, diseases etc.) and existing conditions you have. The surgeon will determine if you are currently eligible for surgery and if not, if you will be at a future point, and whether you require any specialized care pre or post surgery.

The surgery itself is an ambulatory procedure. It takes about 15 minutes or less for both eyes and you go home the same day. You will need someone to drive you home from the procedure.

The first step in the procedure is that your eye will be anesthetized using numbing eye drops and then a device will be inserted to prop your eyelids open so you won’t blink. Once the eye is numb, the surgeon will remove the outer epithelial layer of the cornea to expose the underlying tissue. Then the surgeon will use the laser to reshape the corneal tissue. You may feel a small amount of pressure during this step. Lastly, the surgeon will apply medicated eye drops and place a temporary contact lens that is used as a bandage to protect the eye.

Following the surgery you will be instructed to apply medicated eye drops multiple times each day to reduce the risk of infection and you may also be given prescription pain relievers to alleviate any pain or discomfort.

As with any type of surgery, it is critical to carefully follow your surgeon’s instructions after PRK. Make sure that you take your medication as prescribed, get enough rest, and call your eye doctor immediately if you experience any problems.

It is normal for it to take several days or even weeks for your vision to improve and up to 3-6 months for full recovery to clear and stable visual acuity. Usually, your doctor will require you to refrain from driving for a week and up to three weeks depending on how fast your vision recovers.

Risks and Complications of PRK

While serious complications are rare, like any surgery, there are some risks to PRK, and these happen to be very similar to any laser corrective surgery like LASIK. They include:

• Dry eyes- this condition usually goes away within a couple of months, but there is a chance that it could become chronic.
• Infection or Inflammation- the risk of infection is greatly reduced if you take proper care to follow your doctor’s instructions following the procedure.
• Vision Problems- which can include glare, seeing halos around lights poor night vision and sometimes a general haziness.
• Incomplete Vision Correction – sometimes an additional procedure might be needed to achieve optimal visual acuity.

In general, PRK is considered to be a relatively safe and effective treatment for vision correction. If you wish to live a life without depending on your glasses or contact lenses, speak to your eye doctor about whether PRK is an option for you.

Presbyopia is a common age-related condition in which near vision worsens due to the hardening of the lens of our eye. It causes people to have difficulty reading and performing other tasks that require sharp and focused close vision.

Symptoms begin around the age of 40 when you begin to see people with untreated presbyopia holding books, magazines, newspapers, and menus at arm’s length in order to focus properly and avoid eye strain. Other symptoms include headaches or fatigue when trying to focus on something at close range.

Causes of Presbyopia

During our youth, the lens of our eye and the muscles that control it are flexible and soft, allowing us to focus on close objects and shift focus from close to distant objects without difficulty. As the eye ages however, both the lens and the muscle fibers begin to harden, making near vision a greater challenge.

Surgical Treatment for Presbyopia

The most common form of treatment for presbyopia is wearing reading glasses, bifocals or progressive lenses. Bifocal and multifocals are also available in contact lenses for those who prefer to be glasses-free. A third option, however, is a number of surgical procedures that allow you the freedom of correcting your near vision without the use of glasses or contact lenses.

LASIK

Monovision LASIK

Monovision is a technique that began with presbyopia-correcting contact lenses designed for individuals with presbyopia and nearsightedness or astigmatism. Each eye gets a different lens power – one lens is used in the dominant eye to correct for distance vision and the other for near vision. The eyes adapt to the two lens powers by learning to use the appropriate eye for the necessary distance power. Monovision LASIK surgery is based on the same principle of correcting each eye for a different refractive power and has shown just as high if not higher success rates than the contact lens technique. Usually, patients will try out monovision with contacts first to ensure that it works and that the eyes adapt properly.

PresbyLASIK

PresbyLASIK is a procedure that is currently available in Canada and Europe and undergoing clinical trials in the United States. As opposed to monovision LASIK, this procedure is a multifocal alternative in which different rings of refractive power are created on the cornea, similar to multifocal lenses. This provides vision correction at all distances simultaneously.

Conductive Keratoplasty (CK)

Conductive Keratoplasty uses radio waves via a hand-held instrument to mold the corneal surface to improve near vision. The procedure can be done on one eye using the monovision principle and is a good solution for those that do not need vision correction for nearsightedness or astigmatism. The effects of CK, however are not permanent and the improvement in near vision will diminish over time.

Corneal Inlays or Onlays

Corneal inlays and onlays involve surgically implanting a small lens into the eye to increase focus and near vision. The distinction between inlays and onlays is in where the lens is placed on the eye.

Refractive Lens Exchange

In refractive lens exchange the eye’s hardened lens is replaced with an artificial lens called an intraocular lens (IOL) to provide multifocal vision. This surgery is similar to and often done in conjunction with cataract surgery.

Corneal inlays and onlays are corneal implants that are used to correct presbyopia, a common condition for individuals over age 40 in which the eyes have difficulty focusing on near objects. Presbyopia occurs as the lens of the eye begins to age and weaken, reducing the ability to focus on close objects without the assistance of reading glasses or another visual aid.

Corneal implants, such as inlays and onlays, offer a treatment solution to correct presbyopia as an alternative to using reading glasses or multifocals to obtain clear vision at a close range. Corneal inlays and onlays are like tiny contact lenses that are inserted into the cornea which reshape it to improve the refractive power and thereby improve near vision. Unlike corrective laser surgery such as PRK or LASIK the actual corneal tissue isn’t touched, but rather the shape of the cornea is changed by the transplanted lens.

Corneal inlays are placed in the stroma, the middle layer of the cornea (thus the name “in-lays”), while onlays are implanted closer to the surface of the cornea, under the epithelium, which is the thin outer layer of the cornea. The procedures for both inlays and outlays are relatively simple and quick, with minimal recovery.

Corneal Inlay and Onlay procedures are still in the early stages of development and with a number of clinical trials in progress, the technology should only improve in coming years.

The cornea refers to the clear, front surface of your eye. When a corneal transplant is done, officially termed keratoplasty (KP), the central part of the cornea is surgically removed and replaced with a “button” of clear and healthy corneal tissue donated from an eye bank.

According to the National Eye Institute, approximately 40,000 corneal transplants are performed annually in the United States. The overall success rate for keratoplasty is relatively high, yet up to 20% of patients may reject their donor corneas. Aggressive medical treatment with steroids is generally given in response to signs of rejection, and it is often effective at subduing the negative reaction and saving the cornea. At five to ten years after KP surgery, studies report an encouraging success rate of 95% to 99%.

Why are corneal transplants done?

Corneal transplants are typically done when the cornea becomes damaged or scarred in a way that uncorrectable vision problems occur. These types of vision conditions are not resolved by eyeglasses, contact lenses or refractive laser surgery (such as LASIK). Disease or injury is the usual culprit for the vision loss.

Keratoconus is a common reason for needing a corneal transplant. In this degenerative condition, the cornea thins and bulges forward in an irregular cone shape. Rigid gas permeable (GP) contact lenses can treat mild cases by flattening the cornea, yet contacts are not effective when it comes to advanced stages of keratoconus. The National Keratoconus Foundation reports that 20% to 25% of people with keratoconus will require corneal transplant surgery to restore vision. Other corneal degenerative conditions will also result in a need for keratoplasty.

Corneal ectasia is a thinning and bulging of the cornea that sometimes occurs after LASIK or other refractive vision correction procedures. In the event that this happens, a corneal transplant may be needed to restore vision.

Corneal scarring, due to chemical burns, infections and other causes, is an additional reason that a corneal transplant may be indicated. Traumatic injuries to the eye are also commonly responsible.

Corneal Transplant Procedure

Keratoplasty is generally done on an outpatient basis, with no need for overnight hospitalization. Depending upon age, health condition and patient preference, local or general anesthesia is used.

Using a laser or a trephine, this is an instrument similar to a cookie cutter, the surgeon cuts and removes a round section of damaged corneal tissue and then replaces it with the clear donor tissue.

Extremely fine sutures are used to attach the donor button to the remaining cornea. The sutures remain in place for months (sometimes years) until the eye has recuperated, healed fully and is stable.

Recovery from a Corneal Transplant

The total healing time from keratoplasty may last up to a year or longer. At first, vision will be blurred and the site of the corneal transplant may be inflamed. In comparison to the rest of the cornea, the transplanted portion may be slightly thicker. For a few months, eye drops are applied to promote healing and encourage the body to accept the new corneal graft.

A shield or eyeglasses must be worn constantly after surgery in order to protect the healing eye from any bumps. As vision improves, patients may gradually return to normal daily activities.

What happens to vision post-keratoplasty?

Some patients report noticeable improvement as soon as the day after surgery. Yet a great deal of astigmatism is common after a corneal transplant. A patient’s prescription for vision correction tends to fluctuate for a few months after the surgery, and significant vision changes may continue for up to a year.

Hard, gas permeable contact lenses generally provide the sharpest vision after a corneal transplant. This is due to a residual irregularity of the corneal surface. Even with rigid contact lenses, eyeglasses with polycarbonate lenses must be worn in order to provide adequate protection for the eye.

Once the sutures are removed and healing is complete, a laser procedure such as LASIK may be possible and advised. Refractive laser surgery can reduce astigmatism and upgrade quality of vision, sometimes to the point that no eyeglasses or contact lenses are needed.