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    Refractive eye surgery
    What's the latest?

    If you're tired of glasses or contact lenses, advertisements for eye surgery to correct nearsightedness may sound appealing. Could 20/20 vision be just a few laser zaps away? What would life be like if you didn't need corrective eye-wear to do everyday things: see a movie, drive, play sports?

    Refractive eye surgery radial keratotomy (RK), photorefractive keratotomy (PRK) and laser in-situ keratomileusis (LASIK) can offer the right candidate improved vision. But these procedures are not without risk; not everyone can expect the same results. And while these procedures may correct one vision problem, they can create others. If you're cautious by nature, your best bet may be to wait. If your desire to reduce your dependency on glasses or contact lenses is strong and you don't wish to wait, it's important to do your homework especially when it comes to surgery involving your eyes.

    Not for everyone

    RK, PRK and LASIK are for people who are nearsighted (myopic), for whom objects at a distance are blurry while close-up objects are clear.

    In a perfect eye, the image is focused on the retina at the back of the eye, providing a crisp image. But in nearsighted people, the image focuses in front of the retina, hence the blurring. RK, PRK and LASIK attempt to change the shape of the cornea to focus the image entering the eye so that it strikes the retina more precisely.

    The best candidates for RK, PRK and LASIK are healthy people between the ages of 18 and 40 who have mild-to-moderate nearsightedness and mild-to-moderate astigmatism (an unequal curvature of the cornea). The more nearsighted you are, the greater the chance you'll encounter problems with refractive eye surgery. Refractive eye surgery is currently under investigation to correct farsightedness when close-up objects are blurry while objects at a distance are clear.

    The best candidates also have realistic expectations. Refractive eye surgery can't guarantee 20/20 vision, and even if you gain 20/20 vision, you may still have a less-than-satisfactory result. You may see "halos" around lights at night as a side effect. You may still have to depend on glasses or contact lenses to achieve your best vision. And there is a chance your vision could end up worse than it was with glasses or contact lenses before surgery. More than one procedure may be required to achieve optimal results. And you can't simply "start over" if you're dissatisfied with the results. The effects of these procedures are irreversible.

    The lasers used in PRK and LASIK cost hundreds of thousands of dollars. Those who offer refractive eye surgery need a steady stream of clients to make a profit. Be wary of anyone who tries to rush your decision or who promises that you will be able to discard glasses or contacts. Look for an experienced eye surgeon (ophthalmologist) who has performed many such procedures and who uses approved equipment. He or she should be willing to discuss in detail the potential benefits and risks of refractive eye surgery. Thorough follow-up care is also important.

    What are the different procedures?

    There are pros and cons with each procedure. PRK is "hot" these days, because "laser" surgery in general is perceived to be more high-tech and sophisticated than RK. But that doesn't mean it's without risk. LASIK is being heavily promoted although little is known about long-term results.

    Radial keratotomy (RK) has been available since 1978 and is considered by many ophthalmologists to be the riskiest of corrective eye surgery. RK is not regulated by the FDA because it's a surgical procedure, not a medical device.

    In RK, the surgeon uses a delicate diamond-tipped blade to make several spoke-like slits in the nonviewing portion of your cornea. The slits alter the curve of the cornea, which may improve the focus of images on your retina. The procedure takes less than 10 minutes.

    Photorefractive keratotomy (PRK) involves use of an excimer laser, which is controlled by a computer that measures the shape of the eye and sets the power of the laser. With the laser which emits high-energy pulses lasting only billionths of a second the ophthalmologist theoretically can make extremely accurate and specific modifications to the cornea. The FDA has approved two lasers for use in PRK.

    The 1- to 2-minute procedure flattens your cornea by vaporizing microscopic slivers from the cornea's surface. The procedure itself is pain-free, but for approximately 10 percent to 20 percent of people the healing process may be painful for weeks.

    Laser in-situ keratomileusis (LASIK), the newest procedure (dubbed flap-and-zap), is under evaluation in clinical trials in the United States. It's recommended for moderate-to-severe nearsightedness. It may cause less post-operative pain than RK or PRK but it's not without risk.

    LASIK is a variation on PRK. It involves a laser and a cutting tool called a microkeratome. An ophthalmologist uses the microkeratome to form a circular flap on the cornea. The flap is flipped back, as if on a hinge, to expose the inner layers of the cornea, which are then treated with the laser. The effect is the same as with RK and PRK: changing the shape of the cornea to improve focus. The flap is repositioned to complete the procedure. If the flap is not correctly repositioned, it can lead to scarring and optical distortion.

    There is another procedure, automated lamellar keratoplasty (ALK), that is a cousin of LASIK. In ALK, the ophthalmologist uses the microkeratome to form a circular flap on the cornea, which is flipped back, just as with LASIK. The only difference is, the ophthalmologist then uses the microkeratome not the laser to reshape the inner layers of the cornea. Because ALK involves two cuts with the microkeratome, it is considered riskier than LASIK and is generally not recommended over LASIK.

    RK, PRK and LASIK are performed on an out-patient basis. The FDA recommends a 3-month wait before the second eye is done, to allow vision to stabilize.

    What can be expected

    Overall, refractive eye surgery for the right candidate offers good results. In a 10-year study of RK by the National Eye Institute, over half of the people studied who underwent RK gained 20/20 vision and 85 percent gained 20/40 vision (the requirement to be able to drive without corrective lenses). In studies supplied to the Food and Drug Administration by the manufacturers of PRK laser systems, approximately 95 percent of people achieved 20/40 or better vision with PRK. Early studies of LASIK indicate better results in vision than with either RK or PRK.

    Your chances of seeing 20/20 without the aid of glasses or contact lenses after having refractive eye surgery will vary depending on your age, degree of correction, degree of astigmatism and which procedure is used.
    Side effects

    There are side effects, although rare, associated with refractive eye surgery:

    May still need glasses With RK, approximately 10 percent to 30 percent of people who have the procedure require some use of corrective lenses; with PRK, between 5 percent and 15 percent. With LASIK, it's too soon to know. Also, everyone's eyes degenerate with age. Whether you have had refractive eye surgery or not, by about age 40, you may find yourself needing bifocals for sharp near vision.

    Night vision may be poor After refractive surgery, some may see "halos" around lights, which can make driving at night difficult if not impossible. For some, this side effect passes. For others, it can be permanent.

    May see variation in visual acuity For some, eyesight may be better in the morning and become less sharp at day's end. And some may experience some light sensitivity and glare.

    In very rare cases, there may be corneal scarring or rupturing Because the cornea is weakened in RK, there is a threat of corneal rupture at the incision site if the eye is hit. With PRK there can be scarring of the cornea. In a long-term safety study of PRK, researchers at Emory University noted a slight risk of corneal "scarring" developing 1 to 3 years after surgery. This scarring can cause permanently clouded vision.

    Should you wait?

    Is refractive eye surgery right for you? To aid in your decision, ask yourself the following:
    Are you a good candidate for refractive eye surgery?
    Are your expectations from surgery realistic?
    Does your lifestyle or work require you to have very precise vision?
    Is the benefit of a reduced dependency on glasses or contact lenses worth the surgical risk involved?

    If you decide that refractive eye surgery is for you, when is the "right" time to have it done? There is no one clear answer. RK, PRK and LASIK should undergo further improvement. There are new treatments for nearsightedness on the horizon, such as a corneal implant and permanent contact lenses that would be surgically placed. Whatever you decide, keep in mind one thing: If you don't take the time to learn everything you can about a procedure, hindsight may offer the only 20/20 vision you'll know.



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