Question for the Eye Surgeons...

[DrRobert]

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Gaspasser here... so if you were a candidate for LASIK and cost was not an issue... would you get LASIK?

Why or why not?

 

[USCTrojan11]

always wanted to know why most ophthos don't get lasik

 

[Visionary]

I'm an emmetrope, so no need for LASIK. However, my wife has had it, as have other docs in my practice (they also perform LASIK, Trojan). The key is to go to someone who is very experienced, preferably someone recommended by someone you trust. Don't go for the buy-one get-one places. You don't want any sort of bargain eye surgery! With good patient selection and a good surgeon, LASIK has a really good safety record. It is effective, but not permanent. Even in perfect circumstances, there can be regression over time. My wife is more than 10 years out with stable vision, though. I'd say the optimal time to have LASIK is early to mid 20s. That will give you the longest potential glasses-free interval, as presbyopia sets in once you hit the early 40s.

FYI, I suspect the reason for the perceived lack of ophthalmologists having LASIK is the relative preponderance of high myopes in the field. They seem to gravitate to ophthalmology, perhaps because of their experiences with eye care. I am one of the rare emmetropic ophthalmologists! High myopes are often not candidates for LASIK, due to risk of post-op ectasia from corneal thinning.

 

[Slide]

FYI, I suspect the reason for the perceived lack of ophthalmologists having LASIK is the relative preponderance of high myopes in the field. They seem to gravitate to ophthalmology, perhaps because of their experiences with eye care. I am one of the rare emmetropic ophthalmologists! High myopes are often not candidates for LASIK, due to risk of post-op ectasia from corneal thinning.

I'm such a myope, and though I'd like to have LASIK, I don't think I'd be a good candidate either. I suspect the other reason is an issue of time as well; lots of residents are broke and if on their own, they can't really afford it until a few years into their residency. By then, the typical resident is 30? 32? I think at that point, it's just not worth it to some residents because of the hyperopic shift. My n=12 and is based on my experience, but just my thoughts. I have had met residents in other fields that had LASIK and were overall very happy to get it.

 

[tm12]

The key is to go to someone who is very experienced, preferably someone recommended by someone you trust. Don't go for the buy-one get-one places. You don't want any sort of bargain eye surgery! With good patient selection and a good surgeon, LASIK has a really good safety record.

I've met very few ophthalmologists or optometrists myself who have undergone LASIK, many of them who are not high myopes. I suspect we have a much lower tolerance for risk.

Experience is an important but interesting point. Everybody here knows the residents and fellows are just as good at pressing the button as the attending. Patient selection is important but the most experienced surgeons are the ones most willing to do the riskier cases.

 

[Dusn]

I'm pretty sure that, at the end of the day, LASIK is much safer than wearing contact lenses. I see a contact lens related corneal ulcer every week. I think LASIK or PRK would be safer even if you are using the contact lenses properly and cleaning them daily.

I think the biggest downside to refractive surgery is that you'll eventually need reading glasses if you get LASIK.

Assumed in the OPs question, is the premise that ophthalmologists who are not getting LASIK/PRK are doing so for a logical reason related to safety and outcomes. They usually aren't. Especially if they're wearing contact lenses instead of getting LASIK. Also, ophthalmology training can make you somewhat odd and paranoid regarding your eyes. My wife will make fun of me because I'll wear glasses while cooking, doing yard work, mechanical work, etc just for eye protection

 

[Shnurek]

I'm pretty sure that, at the end of the day, LASIK is much safer than wearing contact lenses.

lol? Surgery being safer than a medical device that does the same thing but in the different way, right. Only 80% get to 20/20 and there is a 0.2%-0.3% chance of vision loss (>2 lines) with refractive surgery. Guess what the numbers are for contact lenses? Post-refractive surgery ectasia is devastating for example.

 

[OphthoQuestions]

lol? Surgery being safer than a medical device that does the same thing but in the different way, right. Only 80% get to 20/20 and there is a 0.2%-0.3% chance of vision loss (>2 lines) with refractive surgery. Guess what the numbers are for contact lenses? Post-refractive surgery ectasia is devastating for example.

Here we go again... 😍

 

[Visionary]

Everybody here knows the residents and fellows are just as good at pressing the button as the attending. Patient selection is important but the most experienced surgeons are the ones most willing to do the riskier cases.

This is the key statement. Is LASIK difficult to perform? No. The most important thing is patient selection and pre-op evaluation. As to the riskier patient comment, that's not been my experience. Some of the best LASIK surgeons I've seen will actually steer the riskier patients away from LASIK, toward PRK or no surgery at all. They will take on patients who have received poor care elsewhere. In that sense, there is more risk.

 

[DrRobert]

I think the biggest downside to refractive surgery is that you'll eventually need reading glasses if you get LASIK.

So if you get LASIK, there is a 100% chance you will need reading glasses in the future?

Does LASIK cause people to need reading glasses sooner than if they hadn't gotten the procedure?

 

[Shnurek]

So if you get LASIK, there is a 100% chance you will need reading glasses in the future?

Does LASIK cause people to need reading glasses sooner than if they hadn't gotten the procedure?

Does this fall under medical advice or cosmetic advice 🙂 Everyone loses their ability to accommodate their eyes with age, yes 100% of people. Accommodation is the ability to change the shape of your lens to see things both at far and at near. If you are around a -2 myope then I personally wouldn't do laser surgery because you will never need reading glasses but if you correct that myopia to see in the distance then you will need reading glasses after around age 40-45.

 

[east]

This is the key statement. Is LASIK difficult to perform? No. The most important thing is patient selection and pre-op evaluation. As to the riskier patient comment, that's not been my experience. Some of the best LASIK surgeons I've seen will actually steer the riskier patients away from LASIK, toward PRK or no surgery at all. They will take on patients who have received poor care elsewhere. In that sense, there is more risk.

Disclaimer: OD here not wanting surgery, but a serious question for you visionary(you have always seemed very reasonable).

I do all pre-op and post-op myself in my office. Can you maybe see why some ODs feel they could "press the button"? If the argument is managing complications post op, I do that now.

 

[Shnurek]

Disclaimer: OD here not wanting surgery, but a serious question for you visionary(you have always seemed very reasonable).

I do all pre-op and post-op myself in my office. Can you maybe see why some ODs feel they could "press the button"? If the argument is managing complications post op, I do that now.

Its OK, ODs can do LASEK in Kentucky and PRK in Oklahoma and any new laser refractive surgeries that come out in both states. Its just a matter of time for the other 48 states.

 

[tm12]

This is the key statement. Is LASIK difficult to perform? No. The most important thing is patient selection and pre-op evaluation. As to the riskier patient comment, that's not been my experience. Some of the best LASIK surgeons I've seen will actually steer the riskier patients away from LASIK, toward PRK or no surgery at all. They will take on patients who have received poor care elsewhere. In that sense, there is more risk.

The younger attendings I know are very reluctant to take on cases where there is any doubt about getting an excellent outcome. They have a reputation they are still trying to nurture. On the other hand, many of the higher volume refractive surgeons seem willing to do anything. If the patient is not a candidate for LASIK, they may steer them towards PRK. If they aren't a candidate for PRK, they may steer them towards ICLs. Of course the vast majority of cases turn out successful anyway.

 

[OphthoQuestions]

Its OK, ODs can do LASEK in Kentucky and PRK in Oklahoma and any new laser refractive surgeries that come out in both states. Its just a matter of time for the other 48 states.

 

[guttata]

lol? Surgery being safer than a medical device that does the same thing but in the different way, right. Only 80% get to 20/20 and there is a 0.2%-0.3% chance of vision loss (>2 lines) with refractive surgery. Guess what the numbers are for contact lenses? Post-refractive surgery ectasia is devastating for example.

Some studies mention the risk of severe vision loss is about 1 in 2000 from contact lens versus 1 in 10000 from LASIK. Btw, CL endophthalmitis is devastating too.

 

[Shnurek]

Show me the study please. You mean advertisements like this one: http://www.ohsu.edu/xd/health/servi...s/laser-vision-correction/lasikvscontacts.cfm

Where they show statistics for infections and vision loss by using contact lenses for the past 30 years whereas excimer lasers only gained FDA approval in 1995 so that is 17 years of use or less compared to 30 years of use.

I'm continually amazed at the poor quality of research that gets published in our journals. It's embarrassing, really. We receive little training in statistics and research design in med school, . . . and it shows.

This one too compares 30 years of use vs. 11 years or less (article published in 2006). Published in WebMD no less: http://www.webmd.com/eye-health/news/20061010/lasik-surgery-safer-than-contacts

 

[guttata]

Show me the study please. You mean advertisements like this one: http://www.ohsu.edu/xd/health/servi...s/laser-vision-correction/lasikvscontacts.cfm

Where they show statistics for infections and vision loss by using contact lenses for the past 30 years whereas excimer lasers only gained FDA approval in 1995 so that is 17 years of use or less compared to 30 years of use.


This one too compares 30 years of use vs. 11 years or less (article published in 2006). Published in WebMD no less: http://www.webmd.com/eye-health/news/20061010/lasik-surgery-safer-than-contacts

Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008;115:1655–1662. [PubMed]

Schein OD, Glynn RJ, Poggio EC, Seddon JM, Kenyon KR. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. A case-control study. N Engl J Med. 1989;321:773–778. [PubMed]

Poggio EC, Glynn RJ, Schein OD, et al. The incidence of ulcercerative keratitis among users of daily-wear and extended-wear soft contact lenses. N Engl J Med. 1989;321:779–783. [PubMed]

Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999;354:181–185. [PubMed]

You have access to a library. Find the other ones yourself.

I am not a refractive surgeon, but most causes of severe vision loss from LASIK present intraoperatively or within the first few years postoperatively, so it can be a reasonable comparison. Obviously, lens are improving, but so is laser vision surgery. You can argue both ways and statistics can be manipulated, but it is not as black and white as your initial smug response. There are risks with both contact lens and with LASIK. If you don't want risk, wear spectacles.

Nice to bring in the quote from another thread - in that manner, I am sure you will also argue that Oklahoma optometrist surgical complication rates is zero, right?

I'm not going to continue this back and forth. I believe (from reading your other posts) that you should perhaps think more and talk less; but, we can all believe what we want to believe.

 

[Shnurek]

None of the above compare the incidence of contact lens wear complications to refractive surgery complications. But I will look around. One ophthalmologist told me in the past that refractive surgery complications are highly underreported but here is what I found:

"The most common complications were
overcorrection (30.4%), irregular astigmatism (29.8%),
dry eyes (29.8%), glare (26.1%), difficulty with night
driving (16.7%), and corneal haze (16.7%)."

http://www.dovepress.com/getfile.php?fileID=11359 (2011)

 

[Visionary]

Disclaimer: OD here not wanting surgery, but a serious question for you visionary(you have always seemed very reasonable).

I do all pre-op and post-op myself in my office. Can you maybe see why some ODs feel they could "press the button"? If the argument is managing complications post op, I do that now.

I can completely see where you're coming from, but I still feel there is a need for a surgical foundation to perform surgical procedures. Things can happen intra-op that would have you pooping your pants, if you didn't have anterior segment surgical experience. Do they happen often? No, but they do happen.

 

[Visionary]

Its OK, ODs can do LASEK in Kentucky and PRK in Oklahoma and any new laser refractive surgeries that come out in both states. Its just a matter of time for the other 48 states.

Incorrect. While poorly worded, in a way that leaves a loophole for such, the KOA came forward with a statement that they have no plans to perform any sort of refractive surgery. That would sort of be biting the hand that feeds them. Some of the biggest ophthalmology support for the bill actually came from high-volume refractive surgeons who utilize large optometry referral networks.

 

[Shnurek]

Incorrect. While poorly worded, in a way that leaves a loophole for such, the KOA came forward with a statement that they have no plans to perform any sort of refractive surgery. That would sort of be biting the hand that feeds them. Some of the biggest ophthalmology support for the bill actually came from high-volume refractive surgeons who utilize large optometry referral networks.

I see, so the loophole exists but the KOA will not certify ODs to perform it. Its probably for the better until a surgical residency is or may be in place.

 

[orbitsurgMD]

I am nearly -4.00 O.D. and O.S. with little astigmatism, and my birthday cakes are candle-laden enough that bifocals are useful.

I like having very sharp near vision that doesn't require glasses. With LASIK, I would lose that. I also have a fairly large pupil diameter, so flap interface might be a consideration. If I were 20 and had the money, I might think differently.



When the time comes, I will definitely seek a multifocal solution to cataract, whatever that solution might be down the road.

 

[PBEA]

I am nearly -4.00 O.D. and O.S. with little astigmatism, and my birthday cakes are candle-laden enough that bifocals are useful.

I like having very sharp near vision that doesn't require glasses. With LASIK, I would lose that. I also have a fairly large pupil diameter, so flap interface might be a consideration. If I were 20 and had the money, I might think differently.



When the time comes, I will definitely seek a multifocal solution to cataract, whatever that solution might be down the road.

I'm surprised you'd get a multifocal IOL, the optics are pretty hairy in any multifocal modality, and most multifocal IOL's I've seen still need reading glasses at least some of the time.

Regarding "laser corrective surgery", I think it is absolutely true that many surgeons dont opt for it because of the risk. Sure, maybe they aren't concerned about serious vision loss because yeah those numbers are low, but the minor side effects which are common. Glare, haloes, dry eye, reduced bcva, etc, not exactly something an ophtho wants to jeapordize their careers with.

My bias is that I'm emmetropic and havent needed specs yet (prsesbyopia here I come), but even if I had to wear glasses for a lifetime, knowing what I know, I would NEVER risk my eyes to laser correction.

 

[dantt]

d

 

[Shnurek]

Regarding "laser corrective surgery", I think it is absolutely true that many surgeons dont opt for it because of the risk.

Personally, I have not met one ophthalmologist that has had laser refractive surgery. One comprehensive ophtho even stated that she doesn't recommend it to patients because she wouldn't have it done herself. But this is anecdotal.

 

[golfman]

I got LASIK before medical school (and before I decided to go into Ophthalmology).

I haven't regretted it for a second.

Now that I've matched into Ophtho, in hindsight I would have laser correction surgery again in a heartbeat, by a trusted provider. If I had to do it over again, though, I would probably choose PRK over LASIK due not having to cut a flap.

 

[palehose]

Personally, I have not met one ophthalmologist that has had laser refractive surgery. One comprehensive ophtho even stated that she doesn't recommend it to patients because she wouldn't have it done herself. But this is anecdotal.

Perhaps it depends on who you ask. If you are talking to older ophthalmologists in their 40s or 50s, it makes sense they would not have had refractive surgery done in the past. At the time in their lives where they would have been prime surgical candidates (15-25 years ago), laser keratorefractive surgery was in its infant stage and therefore it's very plausible that ophthalmologists at the time would be reluctant to have surgery done on themselves.

Today however, new technology including femtosecond laser flap creation, wavefront guided ablations, the sophistication of today's corneal topographers, etc all help reduce the complication rate and help achieve more predictable results.

This is just one example, but at my program, about 1/3 of our current residents have had refractive surgery done during their residency. This is probably an anomaly and may be related to the fact we get an excellent discount and have great refractive surgeons here, but I felt I should share this as an attempt to dispense the misconception that ophthalmologists do not get refractive surgery. In fact, one of our refractive attendings had PRK done on himself just a couple of years ago.

 

[TheLesPaul]

Personally, I have not met one ophthalmologist that has had laser refractive surgery. One comprehensive ophtho even stated that she doesn't recommend it to patients because she wouldn't have it done herself. But this is anecdotal.

Exactly, this is anecdotal. I know several surgeons who have.

 

[Andrew_Doan]

Several of my colleagues have had LASIK and love it. In the Navy, pilots get it all the time to keep them in flight status (no cost to service member). The safety is good and outcomes are predictable with modern technology.

 

[Shnurek]

Several of my colleagues have had LASIK and love it. In the Navy, pilots get it all the time to keep them in flight status (no cost to service member). The safety is good and outcomes are predictable with modern technology.

I'm not knowledgeable about this but I heard somewhere that flap creation is contraindicated in pilots because of the risks of flap lifting/detachment during excessively high G forces. Therefore PRK would be more preferable for pilots?

 

[odieoh]

They can have LASIK with a flap, especially with a femtosecond laser "manhole cover" type of cut. And think about it, "G's" have an effect on something based on its weight. . . how much does the corneal flap weigh? Not much. So the risk of it peeling off due to high G's is pretty slim.

 

[Cooperd0g]

Several of my colleagues have had LASIK and love it. In the Navy, pilots get it all the time to keep them in flight status (no cost to service member). The safety is good and outcomes are predictable with modern technology.

I was one of those Navy pilots who had PRK, 20/15 for nine years since surgery. Then a retina surgeon was the only one willing to take "an over qualified, no experience, guy who is going to leave in a year for med school" so that I could get some actual medical and patient care experience as a tech to really make sure I was making the right choice. That retina surgeon has become a mentor of mine and one of my biggest supporters in this massive career change. So between my own needs and my experience working with him I am leaning towards ophthalmology.

They can have LASIK with a flap, especially with a femtosecond laser "manhole cover" type of cut. And think about it, "G's" have an effect on something based on its weight. . . how much does the corneal flap weigh? Not much. So the risk of it peeling off due to high G's is pretty slim.

The Navy is looking at LASIK, but it isn't fully approved to my knowledge. It isn't the G forces that are the problem, it is the structural integrity of the eye with a small scar at low pressure that is the problem. A LASIK eye can alter shape distorting vision in a low pressure environment whereas a PRK eye is less likely to have that problem. This is as it was explained to me so someone correct me if I'm wrong.