Qualifications Before Surgery The Procedure Benefits and Risks: LASIK vs. PRK Post-Op Enhancement

LASIK Laser in-situ keratomileusis, or LASIK, is a surgical procedure that is able to correct a wide range of nearsightedness (myopia), farsightedness (hyperopia) and astigmatism.

LASIK has been performed internationally for approximately 15 years. It was first performed in clinical trials in the U.S. in 1991. The FDA approved it in the US in 1999. As a relatively new procedure in the US, it is important to note that most the major components of the procedure have a long history. Ophthalmologists have been reshaping the cornea for over 50 years, creating a protective layer of tissue for over 35 years, and using the excimer laser since the 1980s. While West Virginia Laser Eye Center is a relatively new company, Dr. Moore are among some of the most experienced providers of refractive surgery care anywhere. In 2001 alone they have provided over 2500 procedures.

Do you Qualify for LASIK Surgery?
The are many components of a comprehensive eye examination that are evaluated in determining if you are a good candidate for LASIK surgery. There are a vast array of parameters that the FDA regulations govern in recommending which particular excimer laser may be used to correct which particular type and degree of refractive error. It would be impossible to determine if you are a good candidate without having a comprehensive exam.

At the West Virginia Laser Eye Center we feel that everyone is a good candidate unless they have been ruled out by a comprehensive eye exam. Conversely, we turn down a little over 20% of those who come to us for an evaluation. That's because we are driven by one goal, excellent results.

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Before Your Surgery
The first step is having a comprehensive eye examination to determine if you are a candidate for laser vision correction. During your examination Dr. Moore will discuss the various procedures to correct nearsightedness, farsightedness, astigmatism, and presbyopia. In addition, he will explain what outcomes you can expect, the recovery process, risks and other considerations.

During this comprehensive examination you will undergo a series of preoperative tests, in order to make certain that you get the most accurate correction possible. Some of the preoperative tests that may be done during your comprehensive evaluation are as follows:

• Computerized Topographical Analysis (Computerized Video Keratography)
  This is a very sophisticated, computerized, high-tech analysis machine that will record in detail the corneal topography (over approximately 6,000 points on the corneal surface), so that we may be able to see exactly what the corneal shape is prior to surgery and be able to follow that corneal shape after surgery to determine the impact of LASIK on the cornea.
• Pachymetry
  Pachymetry will be measured to determine the thickness of the cornea. This measurement will also be followed postoperatively.
• Tonometry
  Tonometry is taken to determine the intraocular pressure both preoperatively and postoperatively.
• Endothelial Cell Count (ECC)
  This is a technique employed to determine the number of endothelial cells present on the back of the cornea, as well as the health of the endothelial cells. These measurements will be followed periodically after LASIK. Endothelial cells are responsible for corneal clarity and appropriate hydration of the cornea.
• Contrast Sensitivity Analysis
  This is a contrast sensitivity test that will be done prior to and following the Excimer Laser surgery. Contrast sensitivity measures the ability of the eye to distinguish images under varying degrees of lighting.
• Glare Testing The BAT (Brightness Acuity Tester)
  Will be used to determine preoperative glare versus postoperative glare at various post-op intervals.
• Tear Assay Assessment
  One of the most frequent complications after LASIK is dry eye. This is because the procedure compromises the long posterior corneal nerves that help stimulate the brain to initiate the production of tears. The results of this test rarely rule out LASIK but can assist the doctor in determining the proper treatment plan post operatively.
• Keratometry
  Automated keratometry will be done to measure the curvature of the central 3 mm of the cornea.
• Slit lamp photographs
  Slit lamp photographs may be taken of the cornea both pre-op and post-op.

If you wear contact lenses you will need to stop wearing them prior to your comprehensive exam. At West Virginia Laser Eye Center we require two weeks for soft lenses and four weeks for hard or gas perm lenses.

It is not uncommon for Dr. Moore to request that some of the tests be repeated. Repeating these tests, in some cases, help ensure accuracy and predictability. If Dr. Moore requests repeating any tests or orders additional tests not discussed here, don't be concerned. Some of the tests may even be repeated several times preoperatively. Once your testing is completed you will be scheduled for your procedure. You should arrive for your procedure prepared to sign the consent forms that were given to you during your initial visit. You will be given many opportunities to ask any questions throughout your initial exam and prior to the procedure.

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The LASIK Procedure

Once your procedure is scheduled

• Eat a light meal prior to arriving for your procedure.
• There are a variety of Hotels to choose from in our area. Hotel accommodations are available for out of town patients at a special rate of $65 per night at the Ramada Inn. The Ramada has a restaurant, complimentary breakfast, swimming pool and an exercise room. Transportation to and from our office is available.
• Restrictions on the day of your procedure are as follows: No alcohol or recreational drugs but take your prescription drugs as usual. Wear comfortable/warm clothing, no eye make-up for 2-3 days prior to your procedure and no face make-up on the day of your procedure.
• Abstain from wearing perfume, cologne, hair sprays or after-shave as their vapors can affect your vision results.
• Contact lenses must be removed from the operative eye(s) prior to the day of your consultation and cannot be put back in the eyes before the procedure: 4 weeks for gas permeable or hard contacts and 2 weeks for soft contacts.
• On the day of your procedure you should arrange to be here at the clinic for a minimum of 2-3 hours. Please arrive ½ hour before the time of your scheduled procedure.
• Please feel free to call us before coming to the center for your procedure to confirm that everything is running on schedule. This will reduce the chance of your wait being longer than estimated.
• At the time of your exam Dr. Moore will prescribe any medication necessary to maximize the postoperative results. These medications may vary from patient to patient. Some patients may need to start medications as much as three days prior to surgery. Others will only need to start their medication the day of the surgery. You should have all pre-op prescriptions filled prior to the day of surgery.

When you arrive

• Check in and inform the front desk receptionist that you are here for laser surgery.
• Please bring all of your paperwork with you on the day of your procedure.
• You will be asked to read and sign the consent form. You will be required to sign the consent in the presence of one of our staff employees.
• You will be given a set appointment for the one-day and one-week appointments on the day of your procedure. These are important and need to be kept as scheduled.
• You may wish to pay in advance. Final payment is due on the day of your surgery. You will be asked to take care of any outstanding financial matters at this time. Accepted methods of payment are Visa, MasterCard, American Express, Discover, Certified checks or cash. We will request this information when your surgery is scheduled.

In the pre-op area

• You will be given the opportunity to request some medication to relieve any anxiety you may have. This is optional.

Inside the laser room

• Laser Vision Correction is performed in a few small steps. Most procedures take less than 10-15 minutes for each eye even though the actual laser treatment may only be seconds.
• The laser is calibrated and programmed with your customized treatment plan before you even enter the Laser room.
• It will take a few minutes to position you properly under the microscope.
• There will be drops applied for both lubrication and numbing of your operative eye(s).
• One eye will be covered during the procedure to help you focus with the operative eye.
• You will be instructed to look at a flashing, greenish light most of the time and then a larger red light during the actual laser treatments. Your cooperation is very important, as your fixation on the red light will determine your vision results.
• You will hear a buzzing sound when the flap is being created; for safety, suction is put onto the eye causing the vision in that eye to go dim then dark; this is normal, for safety, and vision returns in a few seconds so you can see the blinking light.
  

		Step 1 Using an instrument called a microkeratome, a thin layer created at the top of your cornea, which is lifted away, but still remains attached at one side.
		Step 2 The excimer laser, programmed to correct your degree of error, evaporates a microscopic layer of tissue. This part of the procedure takes approximately one minute.
		Step 3 Then a gently placed thin corneal layer back to its original position; healing starts immediately.

• Expect to hear a harmless clicking sound from the laser as the correction is performed.
• You may smell a scent similar to burning hair while the laser performs the correction; this is normal. The larger your correction the more the scent may be present.
• The laser room normally will be cool and noisy, but the staff will talk loud enough for you to hear and follow instructions.
• The first post-operative exam is in the Laser room.
• After surgery, you will be placed in a reclining chair and instructed to keep your eyes closed for at least half an hour.
• Then, Dr. Moore will do your second post-operative exam, place medications and bandage contact lens, if necessary, before you go home.

After the procedure

• Moments after your procedure, your vision maybe relatively blurry like looking through tears, this is normal.
• You should not drive or operate any machinery until given permission by Dr. Moore. Most patients are comfortable driving after their one-day post-operative appointment.
• You will be given a sleeping medication to be taken as soon as you arrive home; between the time of your procedure and the time you go to sleep you may experience some discomfort.
• You may experience such symptoms as itching, excessive tearing, and a scratchy sensation. This is more common with EPI-LASEK and PRK than with LASIK. Your prescription medications and moisturizing drop will alleviate these symptoms.
• Your eyes may be sensitive to bright light and may burn or itch when attempting to open them. Do not be alarmed; these symptoms are normal, temporary, and usually relieved with artificial tears. The remedy for this is sleep, or keeping your eyes closed as much as possible for the remainder of the day, and artificial tears every hour. Cold compresses may help.
• You will be given a post-operative kit containing medicated drops, goggles, sunglasses and artificial tears along with instruction for using each. It is very important to follow these directions and to ask question before you leave the center if you do not understand any of the instructions.
• Do not rub/touch your eyes for two weeks following your procedure.
• No swimming or hot tubs for two weeks. Heavy lifting and contact sports should be avoided for four weeks following your procedure. Safety glasses should be worn appropriately at work or while cutting grass. Uuse common sense.
• If you wish to shower, wear the white goggles that are supplied and turn your back to the shower for a least one-week. Do not let the shower spray hit you in the face.
• No eye make-up for two weeks and no face makeup for three days following your procedure.
• Be careful when attempting stairs due to your depth perception being affected following the procedures.

Expectations

There are a number of key features about the way your eyes will feel and how your vision will behave that are normal and temporary.

• Typically, eyes require several months for the vision to stabilize. Your vision can fluctuate for the first 1 to 2 months. This is part of the healing process.
• Your up close vision may be blurry for a week to ten days after your procedure as well as the fluctuations in your distance vision for the first few weeks after your procedure.
• If you are in the forty and over age group please understand that you may still need reading glasses following the corrections. During your initial exam Dr. Moore will discuss options for correcting Presbyopia with refractive surgery.
• If your vision is blurry beyond 20/40, temporary glasses may be required.
• Later, if our doctors feels you could benefit from an additional treatment, plans will be made to perform an enhancement if your vision is not at least 20/40.The vision must be stabilized first which is determined after two stable dilation exams.
• Driving at night may be difficult due to glare and/or blur. This is an expected, temporary, side effect. This usually resolves within 2 to 4 months.
• You should avoid driving and operating hazardous equipment if you are not comfortable with your vision.
• For many months to follow, artificial tears will be comforting. If your eyes are normally dry, your comfort and vision may be increased by closing your tear drains, e.g. punctual occlusion
• You are required to maintain your proper post-operative care as per our doctors' instructions. Should you fail to keep appointments or use your medications and lubricants as instructed, it will void our enhancement guarantee.
• West Virginia Laser Eye Center has co-management agreements with many area doctors. If you have arranged to have your surgery co-managed with one of those doctors you will be billed accordingly by each office. If, however, those arrangements have not been established prior to your surgery and you decide to maintain post-operative care at a clinic other than ours it is at your expense and it will void your lifetime guarantee for and enhancement .

To treat nearsightedness with LASIK Laser Vision Correction, the cornea must be made flatter. This is accomplished by removing tissue from the center of the cornea.

To treat farsightedness with LASIK Laser Vision Correction, the central cornea must be made steeper. This is accomplished by directing the laser beam to remove tissue from around this area.

To treat astigmatism with LASIK Laser Vision Correction, the cornea must be made more spherical. By changing the pattern of the beam, tissue is removed in one direction more than the other.
The technology associated with laser vision correction is such as to build in safety measures. Throughout the procedure, the surgeon is observing your eye and tracking your eye movements through the microscope. With any large deviations, the surgeon will simply stop the laser ablation and restart the process when the eye is perfectly aligned. Although eye movement is a concern of many patients, those who have experienced the LASIK laser vision correction procedure rarely note a problem-maintaining fixation throughout the short laser ablation.

To treat presbyopia with LASIK Laser vision correction we are changing the focal point of the eye. This has no affect on presbyopia since presbyopia affects the accommodative system of your eyes. If you have presbyopia we, in some cases, can set the focal point of one eye for distance and the other eye for near. We will try this with contacts to make sure it works before proceeding with this type of procedure.

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Comparison of Benefits and Risks of LASIK to PRK & EPI-LASIK
(PRK - Photo Refractive Keratectomy / EPI-LASIK the flap is made using only the epithelial tissue (outer layer) of the cornea.)

Benefits of LASIK:

• Bowman's layer is spared.
• No removal of the corneal surface tissue is necessary and therefore post-operative pain is substantially reduced.
• Post-operative visual acuity is restored within a few days rather than weeks.
• Less change due to healing (regression) and thus greater stability of the correction.

When comparing only the benefits of LASIK over PRK the first impression is that LASIK has the potential to be a superior procedure. There is however, a very significant list of potential complications or risks and these include:

• Failure of automated instrument to leave a hinge on the corneal flap, with the first incision.
• Loss of the corneal flap during the operation.
• Loss of the corneal flap after the operation.
• Slipping of the flap and healing off center.
• First incision too deep (perforation of the eye) or too shallow, causing a hole in the flap.
• Invasion of the surface tissue into the central tissue of the cornea.
• Infection of the cornea.
• Loss of visual acuity - from scarring or from decentration of the PRK.
• Technical problems with complex and finicky automated diamond cutting devices.
• The procedure is much more dependent upon surgeon's operating skills, than the computerized precision of the PRK procedure.

The overall complication rate for the ALK-E or LASIK in February 1995 was still in the order of 10% in the hands of the world leading innovators in the technique, although recent improvements in the technology have reduced that rate substantially.

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Post-Operative Enhancement
Every patient and surgeon wants to achieve perfect vision correction with one surgical procedure. Unfortunately it is more difficult to accurately predict results with a large refractive change than with a small refractive change. Most of the required refractive change was completed with the first surgery, but because the first surgery did not achieved the desire result, you now need a small amount of additional change.

It is not unusual to follow with a second procedure after the first has healed. This additional procedure is called an enhancement With LASIK and PRK, most surgeons wait three to six months after the first surgery before performing an enhancement procedure, however there are exceptions.

Intrastromal Corneal Ring Segments (Permanent Contacts) require significantly less waiting time. If your surgeon wants to perform an enhancement, ask why he wants to do the enhancement in the timeframe suggested.

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