Lasik Surgery

Welcome to the exciting world of laser vision correction!

LASIK( Laser-in-situ keratomileusis) is a surgical procedure that uses a laser to correct nearsightedness, farsightedness, and/or astigmatism, and with today’s advancement in laser surgery, even presbyopia, or age related far-sightedness-you may describe it as your arm having become too short!

Lasik can also be offered to patients who have had cataract surgery and are seeking either spectacle independence or better uncorrected distance vision.

In LASIK, a thin flap in the cornea is created using a microkeratome blade. Dr Joseph folds back the flap, then removes some corneal tissue underneath using an excimer laser. The flap is then gently replaced in its original position, covering the area where the corneal tissue was removed.

With nearsighted people, the goal of LASIK is to flatten the central cornea which is too steep; with farsighted people, a steeper cornea is desired, and so the laser ablation is done in the peripheral cornea. LASIK can also correct astigmatism by smoothing an irregular cornea into a more normal shape.

If you are not a candidate for LASIK, you may qualify for another laser eye surgery such as PRK (similar to LASIK but without the flap). Your prescription and eye structure will be considered to help determine which procedure is best for you.

Orbscan is used to detect corneal pathology and is essential in the work up of LASIK or PRK

LASIK is an outpatient procedure, so you don’t have to stay at the surgery center overnight. The LASIK surgeon uses a computer to adjust the laser for your particular prescription. You will be asked to look at a target light for a short time while the laser sends pulses of light to painlessly reshape your cornea. The actual LASIK surgery takes about 20 minutes.


Information

1. Your eyes must be healthy

If you have any condition that can affect how your eyes respond to surgery or heal afterwards, you must wait until that condition is resolved. Examples are dry eye syndrome, conjunctivitis (pink eye), infection and any injury to the eye.

If you have persistent dry eyes, where you do not produce enough tears to keep your eyes lubricated and healthy, LASIK surgery may aggravate this condition. Common symptoms of dry eyes include burning or stinging, a “gritty” sensation in the eye, reduced tolerance to wind, intermittent blurry vision, and even excessive tears in some cases.

Your eye doctor can detect whether you have dry eyes during your pre-operative exam and successfully treat dry eye before proceeding with laser eye surgery. Possible treatments include artificial tears, punctal plugs, medicated eye drops, flaxseed or fish oil supplements, or a combination of these approaches.

Cataracts that interfere with your vision and uncontrolled glaucoma also will typically prevent you from undergoing LASIK or PRK(Photo-refractive keratectomy) procedures.

2. Your cornea must have sufficient thickness

Most refractive procedures improve visual acuity by reshaping the front surface of the eye (cornea). Laser surgery removes some corneal tissue.

Performing laser eye surgery on a cornea that is too thin or has a surface that is extremely irregular, and possibly even too steep (for example, if you suffer from keratoconus) will compromise results and can impair your vision.

Dr Joseph will therefore perform a test to determine whether you have a sufficient amount of corneal tissue for ablation and secondly that your corneal shape is adequate for laser surgery.

3. Your pupils must not be overly large

If your pupils are naturally large, you may be at increased risk of side effects such as halos, glares and starbursts in low light, especially when driving at night. This will also be evaluated at your initial consultation.

4. Your prescription must be within certain limits

If your prescription is very high — whether due to nearsightedness, farsightedness or astigmatism — Dr Joseph may advise you against the LASIK procedure.

Results of LASIK surgery for the treatment of very high refractive errors are less predictable and may not be worth the cost and potential risks.

In addition, very high amounts of myopia(short-sightendness), for example, would require removal of too much corneal tissue and put you at increased risk of vision complications.

If you have a very high refractive error, another type of vision correction surgery may be a better option, such as phakic IOL(intra-ocular lenses. Please ask Dr Joseph about this if you are not a candidate.

5. You must be over a certain age

Generally you must be over the age of 21 to be considered as a candidate. There generally is no upper age limit to laser eye surgery. However, it is important to note that once you hit your 40s, you may still need reading glasses to correct near vision due to a normal, age-related condition called presbyopia

6. You must have stable vision for at least 2 years

Teenagers and many young adults often experience changes in their contact lens prescription and eyeglass prescription from year to year. It’s important for refractive errors to be stable for at least 24 months before undergoing LASIK or other refractive surgery.

Usually it is nearsightedness that gradually becomes worse, but there may be other changes as well.

Younger people are not good candidates until their eyes have “settled down” into one prescription. It is always a great idea to bring along your current script from your optometrist, and to find out from him/her when last your refraction changed.

7. You must generally be in good health

Contraindications to laser eye surgery may include certain uncontrolled degenerative or autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, type 1 diabetes, HIV and AIDS.

Basically, if your body has any trouble with healing, your LASIK surgery outcome may be unsatisfactory.

Also, certain medications can exacerbate the risks of laser eye surgery. Steroids and immunosuppressants may interfere with post-operative healing, and some medications such as isotretinoin (Accutane) may increase the chance and/or severity of dry eye syndrome.

8. If you are pregnant, you should delay surgery

The LASIK procedure is not suitable if you are pregnant or nursing. Hormonal changes can alter the shape of your cornea, leading to temporary changes in your vision.

Surgery should not be performed until your hormones and vision have returned to normal after pregnancy. This could take a few months.

Pregnant women often have dry eyes, which is another reason you may need to postpone LASIK until a few months after pregnancy. In addition, some medications that would normally be used before or after surgery to promote healing (such as antibiotics and steroids) may be risky for your baby, whether unborn or nursing.

9. Do you have realistic expectations?

While the vast majority of LASIK surgery results are excellent, you should be fully aware of the side effects, risks and potential LASIK complications before you choose to undergo the procedure.

Dr Joseph will advise you whether you are a good candidate for laser eye surgery, or if another type of refractive surgery may be more appropriate.

What to expect prior to LASIK Surgery

Dr Joseph will perform a thorough eye exam to ensure your eyes are healthy enough for the procedure. The shape and thickness of your cornea; pupil size; refractive errors (myopia, hyperopia and astigmatism); as well as any other eye conditions will be evaluated.

The moistness of your eyes will also be evaluated, and a precautionary treatment may be recommended to reduce your risk of developing dry eyes after LASIK.

A corneal topographer is used to measure the curvature of the front and back surfaces of your eye and create a “map” of your cornea.

Dr Joseph will also note your general health history and any medications you are taking to determine if you are a suitable candidate for LASIK.

Please note that you need to stop wearing soft contact lenses at least a week prior to your initial evaluation. If you wear hard contact lenses, they will need to be removed for 2 weeks prior to seeing Dr Joseph.

How is LASIK surgery performed?

On the day of your surgery, you will come to the office about an hour prior to the procedure to fill in and discuss the consent forms.

You will then lie back and relax in the pre-operative room and if you have no contra-indications for taking a mild tranquilizer, we will give you an Ativan tablet. Topical anaesthetic eye drops will be instilled in your eyes at this time.

Dr Joseph wiil then run through the procedure with you and discuss the most important points that you need to follow during the procedure.

Once you are relaxed, you will be taken through to the theatre where you will lie on a bed and placed under the laser. Your single focus during the procedure is to concentrate on a red flashing light. If you can remember that, it will make the procedure as accurate as possible.

Dr Joseph will then place a speculum in your eye that will be lasered which will keep it open. You are free to either close or open your other eye, which ever is comfortable. He will then mark your eye with a marking pen to use as a orientation reference of the flap which will later be created in the cornea. Your vision will intermittently come and go during this process….just remember to focus on that red light!

He will then place a suction ring on your eye to increase the pressure prior to creating the flap with a hinge. To understand why this is necessary think of trying to skin a tomato-A hard tomato(higher pressure in the eye) is easier to peel with a knife than a soft one is. During this time which last about 30 seconds, your vision will disappear completely-do not panic!! A mechanical surgical tool called a microkeratome will then be used to create a thin, circular “flap” with a hinge in the cornea.

You will hear the keratome vibrating-once again Dr Joseph will inform you exactly when this will start vibrating so that you are prepared.

Dr Joseph then folds back the hinged flap to access the underlying cornea (called the stroma) and removes some corneal tissue using an excimer laser. During this phase you will hear a buzzing sound from the machine.

This highly specialized laser uses a cool ultraviolet light beam to remove (“ablate”) microscopic amounts of tissue from the cornea to reshape it, refocusing light entering the eye for improved vision.

After the laser reshapes the cornea, the flap is then laid back in place, covering the area where the corneal tissue was removed. The eye is irrigated and cleaned and antibiotic drops are instilled.

The other eye is then done using exactly the same procedure.

Laser eye surgery requires only topical anesthetic drops, and no bandages or stitches are required.

You will go home that day with both your eyes closed with hard eye shields protecting them. Your only compulsory activity is to sit back and relax, and designate someone to drive you home and be at your beck and call for a few hours prior to follow up.

Usually the eye patches are removed the same evening and antibiotic and steroid drops are initiated that evening.

LASIK surgery is done in our dedicated laser theatre. Relax prior to surgery with a view over the Knysna lagoon.

Procedures and expectations immediately after LASIK surgery

Your doctor will have you rest for a bit, and typically you can return home right away (you will need someone to drive you). You may feel a temporary burning or itching sensation in your eyes immediately after surgery.

You should expect some blurry vision and haziness immediately after surgery; however, clarity should improve by the very next morning, and usually to what we would expect after surgery by the end of the first week.

You may be able to go to work the next day, but many doctors advise a couple of days of rest instead.

Also, it is usually recommended that you refrain from any strenuous exercise for at least a week, since this can traumatize the eye and affect healing.

Pease avoid swimming and water contact with your eyes for the first 10 days post-operatively.

Do not rub your eyes!

Generally, you will return to see Dr Joseph the same, or following day after surgery.

At this initial check-up, Dr Joseph will test your vision and examine the flaps. You are then free to go home and initiate the drops mentioned earlier.

You will then be followed up a week, a month and 4 months after surgery.

Long-term results

Laser eye surgery offers numerous benefits and can dramatically improve your quality of life. Most people achieve 20/20 vision or better after the surgery, but LASIK results do vary. Some people may achieve only 20/40 vision or less.

You may still need to wear glasses or contact lenses following laser vision correction, though your prescription level typically will be much lower than before.

A small percentage of people have an enhancement, or “touch up,” LASIK procedure for further improvement in vision.

You also may still need reading glasses once you reach your 40s, due to a normal age-related loss of near vision called presbyopia.

While LASIK surgery has a high success rate, it is important that you discuss all facets of the procedure with your surgeon prior to consenting to the surgery.

Possible LASIK complications

Although a very safe procedure,LASIK carries a slight risk of short- and long-term complications. Most people respond well to treatment, but some cases are more difficult. Very rarely, permanent problems can result.

According to guidelines from the Eye Surgery Education Council (ESEC) founded by members of the American Society of Cataract and Refractive Surgery, fewer than 1 percent of LASIK patients experience serious, vision-threatening problems.

LASIK complications can include:

  1. Under and over correction. This implies ending up a little bit short-sighted or far sighted.This is by far the most common complication but is managed with an enhancement procedure after waiting at least 4 months for the eye to settle down. This happens because each of us react differently to absorption of the light rays from the laser. Take the analogy of sun tanning for instance. A heavily pigmented individual will require far more sun to tan or burn than a very lightly pigmented person. This principle applies too, to the cornea-we all react differently to the same amount of energy delivery from the laser. This percentage of under and over correction is in the magnitude of 15%, with 85% of cases ending up exactly where we targeted them.
  2. More serious problems such as eye infection, chronic dry eye and LASIK flap problems, which can be managed, mostly with excellent resolution.
  3. Less serious complications that generally clear up on their own as the eye heals, including halos, haze and glare.

The ESEC says most LASIK complications can be treated and usually clear up within several months.

It’s also important to remember that your general health and eye health both influence the risk of certain complications. For example, you may be at greater risk of LASIK complications if you have a disease such as diabetes that can interfere with your body’s normal healing responses. Of course, you will need to discuss your general health with Dr Joseph.

Also consider that, even under the most ideal circumstances with a technically flawless surgical procedure, each patient responds and heals differently after eye surgery.

Best-corrected vision after LASIK

The target values that the eye care community have established for LASIK vision outcomes say a lot about what you can expect from the procedure.

The most feared outcome of LASIK is a decrease in best possible vision, something doctors call best corrected visual acuity (BCVA), or sometimes best spectacle-corrected visual acuity (BSCVA).

In other words, if you can be corrected to 20/20 with glasses or contact lenses before undergoing LASIK, you’d like to be correctable to at least 20/20 after LASIK.

If you have 20/200 uncorrected vision before LASIK and see 20/20 with contact lenses or glasses, then see 20/40 uncorrected after LASIK but are correctable to only 20/25 with contacts or glasses, you have lost one line of BCVA (from 20/20 to 20/25) on a standard eye chart.

But even though you lost one line of best corrected visual acuity, you gained more than six lines of uncorrected vision (from 20/200 to 20/40).

The FDA expects laser manufacturers to show that no more than 5 percent of patients in clinical trials lose more than two lines of BCVA and that less than 1 percent of patients have BCVA worse than 20/40.

How well can you expect to see after LASIK? The nitty gritty academic detail.

In a major report discussed on the American Academy of Ophthalmology website, 64 LASIK studies published since 2000 were reviewed with these results reported:

  1. In a detailed analysis of all 64 studies, a median of 92 percent of eyes with myopia or myopic astigmatism achieved a correction within 2.0 diopters of target. Results were better for eyes with low or moderate myopia, compared with high myopia.
  2. In 22 studies of outcomes involving people with low to high levels of myopia, a median of 94 percent of eyes achieved 20/40 or better vision after surgery and did not require correction with glasses or contact lenses (uncorrected visual acuity or UCVA). A median of 99 percent of people with low to moderate levels of myopia had 20/40 or better UCVA, and a median of 89 percent of people with high myopia had the same result.
  3. In these same studies, outcomes for people with hyperopia also were examined. Results showed that a median of 88 percent of eyes with hyperopia and hyperopic astigmatism achieved correction within 1.0 diopter of target, resulting in at least 20/40 UCVA.

According to a major analysis of scientific literature by the American Society of Cataract and Refractive Surgery reported in 2008, worldwide satisfaction rates among LASIK patients is 95.4 percent.

Some studies, such as one reported in the October 2008 issue of Journal of Cataract and Refractive Surgery, continue to show a slight trend toward better LASIK outcomes if you don’t require a high degree of correction — for example, if you are moderately nearsighted as opposed to extremely nearsighted.

A special mention – how does LASIK cause dry eyes?

In certain cases, LASIK and other vision correction procedures can cause dry eyes after they penetrate the eye’s surface and reduce corneal nerve sensitivity. When your eye then fails to sense the need for lubrication, inadequate tear production results.

Dry eyes after LASIK can cause both discomfort and less than optimal visual outcomes. For this reason, many eye surgeons now recommend that you use lubricating eye drops or other therapies to help maintain eye moisture. This can be done either prior to or after LASIK surgery, and is usually temporary.

In some cases where dry eyes are of extra concern, corrective vision procedures that do not involve creating a thin flap on the eye’s surface — such as PRK(photo refractive keratectomy) — may be recommended instead of LASIK.

When is a LASIK enhancement needed?

When evaluating your vision after LASIK, it’s important to be patient. Although you should be able to see much better without glasses the day after surgery, it’s not unusual for vision to fluctuate for several weeks.

As part of your follow-up care after LASIK, your eye doctor will monitor your vision for several weeks.

Though not expected, it’s possible that you may feel uncomfortable driving or performing other visual tasks after LASIK.

If your vision is still noticeably blurred four months after LASIK, you may need an enhancement.

To determine whether you’re a good candidate for a LASIK enhancement, Dr Joseph will re-evaluate your corneas with the same methods used prior to your first LASIK procedure.

Among other evaluations, he will check to see whether you have enough corneal thickness for a second surgery.

How does a LASIK enhancement differ from the original procedure?

A LASIK enhancement is nearly identical to a primary LASIK procedure, except for one aspect. Rather than using a microkeratome or laser to create a corneal flap, the original flap is lifted using a special instrument. Re-lifting the flap is painless and typically takes only one or two minutes. Then your surgeon uses an excimer laser to reshape your cornea.

Typically, only minimal corneal reshaping is necessary during an enhancement. So this laser treatment takes just a few seconds.

After the enhancement, you will receive the same post-operative instructions that were given after your primary LASIK procedure.

In most LASIK enhancement cases, only one procedure is necessary to restore vision to an acceptable level. However, in difficult cases, more than one enhancement may be required.

 

Billing procedures

All accounts generated in the work up of the LASIK, including the procedure itself, are please to be settled prior to the surgery.