A. Unknown. For RK, more than a thousand patients have been legally blinded in at least 1 eye (based on a statistical analysis using a 5 year timeframe, 6,000,000 patient estimate, and a legal blindness rate of 1 per 5000 eyes); See EyeKnowWhy's definiton of 'legal blindness', 'functional blindness' and 'vision impairment'. There have been reports of severe visual impairment including legal blindness after PRK (infection, cataract, retina detachment, optic nerve damage), but the quantity is unknown; it appears to be less than 100 through 1996. The same is true for LASIK. The FDA is investigating a recent case where a woman undergoing LASIK was blinded by a 'homemade' excimer laser. Functional blindness is where one eye is 20/60 or worse best corrected (Snellen line read) and suffers moderate to severe optical aberrations and non-visual ocular disease symptoms - a Eyeknowwhy definition. Vision impairment definitions vary. Here'a an example of vision impairment to think about: The Journal of Refractive Surgery (JRS) reported on a case of RK rupture with 20/25 recovery JRS article access, Summary: (AJO article, 120(6):800-802, 1995 Dec.): Synopsis: A 29 year old police officer w/8 scar RK with 3.0&3.5mm optical zone was involved in an accident at 35mph. His airbag deployed causing cornea rupture. 7 of the 8 RK scars split open in addition to a full thickness corneal laceration. 31 10-0 sutures 'repaired' cornea. Five months later, vision was 20/25 with a 'comfortably' fitting hard contact lens.) Question: What kind of 20/25 vision do you think this policeman has?

A. Yes, you can sue. The issue is winning. Anyone who is dissatisfied will discover the 'informed consent' form is formidable. You will also need to find an attorney willing to take on a complex case. It can be difficult, but people have won. In the new laser environment, defendants may include not only the doctor performing the surgery, but also the referring optometrist/ophthalmologist (if applicable), the company providing the laser facility, the university or hospital that the laser center is affiliated with (if applicable), and the laser manufacturers themselves.

A. There is a difference. Wound stabilization is the point within wound healing and scar formation that the cornea's structure is 'fairly' stable, and refractive acuity has stabilized around some value with a slight refractive 'wobble'. This occurs in the majority of eyes between 12 and 24 months for all refractive surgery procedures.

Because wound healing or 'cornea remodeling' after 12 months occurs very slowly, the changes can be subtle. It is unknown if wound activity 'accelerates' at a later date, years, possibly many years, after the initial surgery. There have been reports of PRK 'catalysts' that reactivate wound healing causing changes more than a year after the cornea seems to have 'stabilized' Known catalysts are systemic disease, pregnancy, severe depression, and severe UV exposure. Until several thousand patients are followed for 10 or 20 years or more, with a high followup rate, the actual long term effects of any refractive surgery procedure are unknown.

A. If all else is 'normal', and the person reads the 20/20 line on a Snellen eye chart clearly, accurately, and crisply, it is meaningful. So what is 'all else'? To understand that, let's look at a Snellen eye test. It is a test at a fixed distance, uses only central vision, does not assess contrast sensitivity, glare, optical aberrations (glares, arcs, starbursts, halos), astigmatism problems (both regular and irregular), or photophobia. Now in a normal eye with a healthy clear cornea, most of these other attributes are 'normal'. But in a compromised cornea (like a RK, PRK or LASIK cornea) they may not be. What's more, a postop patient who 'reads the 20/20 line' at 10 a.m. may not be able to 'read' the 20/20 line that evening due to diurnal (daily, over a 24 hour period) changes in the cornea that cause a 'mild' change in the eye's visual acuity. This diurnal change in refraction is applicable to RK; for PRK and LASIK, the frequency and degree are unknown, but appears to be rare three months after surgery. It's complex, but you get the idea. You should be aware that many patients are happy with their visual acuity after refractive surgery, even if it does not last, is imperfect or changes slightly during the day.

A. Generally all studies are misleading to some extent unless you know the details. The longer the study's review period, the more misleading the results. Here are some things to think about. Elective surgery of any kind is controversial, especially one that involves surgically invading the cornea of an otherwise healthy eye. Patients who have poor results are generally despondent. Since they have no recourse for compensation (they signed a consent form) and almost always seek medical help (such as new glasses or surgical treatment) for their poor outcomes elsewhere, they are DROPPED from the clinical trials. Here's an example: 100 patients underwent PRK. At 1 year, 90 came back for followup. Of the 90, 80 were able to read the 20/40 line or better (albeit slowly in some cases). What percentage 'could see 20/40 line or better'? Was it 88% (80/90) or was it 80% (80/100)? Because the 10 who 'dropped out' are eliminated, the answer is 88%. The study noted there were no 'severe' complications. Did this include the 10 who dropped out? No. It is well known in medical research that 'bad outcome' patients drop out at a higher rate than 'good outcome' patients. How much worse off are 'drop outs' compared to 'stay ins'? That is a good question, and may be studied by someone someday. Of course, tracking down dropouts can be difficult.

Another reason for skewing in refractive surgery studies is prodding, i.e. the patient is pressured to "see 20/40 or better, although he/she may state the letters are 'fuzzy' or 'somewhat blurred'". Nevertheless, if he/she can read most of the letters on the smallest line possible, that is what their Snallen visual acuity is recorded as. Invalid observation recording is another problem, e.g., a patient may say glare 'hasn't been a major problem', and the recorder (technician or surgeon) records 'no glare'. Then, of course, you can have surgeons who just put down whatever they want. You never know.

As for surveys of patient satisfaction, they are subjective and must be worded carefully to avoid bias and false conclusions. Most surveys published are somewhat suspect. One survey that was done by mail with only a 40% return rate quoted a 91% 'satisfaction' rate for those surveys returned. Click here to go to that published survey page (if still on the web). and here's an Eyeworld article with a high return rate but does not state the timeframes since surgery. Other details such as optical zones, follow up timeframe, general credibiilty and possible conflicts of interests of the surveyors must be considered. Another question to ask is "Do 'bad outcome' patients return survey forms at a higher or lower rate than 'good outcome' patients?"

You should be aware that 'bad data' is always dismissed by refractive surgeons as using 'old technology, the results using new technology are much better'. You have to make your own decision.

A. You just never know the ethics and integrity of researchers performing elective and medically unnecessary (in some people's opinions) surgery where personal financial gain and conflicts of interest exist. You should look at the refractive surgery industry as you would look at any company you may invest. What is the past performance and trends of the industry (good and bad)? Then, what are the present and future performance and trends of the industry (good and bad). We know that radial keratotomy (RK) was the 'bread and butter' of the refractive industry throughout the 1980s and up to 1996, representing over 95% of the refractive surgery procedures in the U.S. We also know that RK was successfully marketed to over one million Americans between 1985 and 1995 as 'safe and effective' although journal studies prior to 1990 pointed out many disturbing and adverse trends such as prolonged wound healing, progressive hypeopia, and delayed infections. During this same period, cataract surgery, the other dominant surgery product of ophthalmologists, experienced severe cost containment due to Medicare regulation and health maintenance organizations. It is also known that the 1.5 million Americans who had RK made the wrong decision. Although the PRK and LASIK market is currently expanding, some refractive surgeons are 'moving on' to LASIK exclusively. It takes about three to five years for adverse trends to show up in the medical journals in substantial numbers, and about five to ten years for them to be disclosed to the public. New PRK and LASIK technologies (lasers, keratomes) and new refractive surgery techniques are being developed. For what reasons are the costs for these new developments being incurred? Why would refractive surgeons market inferior products? Obviously, PRK and LASIK are far better than RK given the long term trends of RK. How much better will be determined over time. You have to decide when the technology has evolved that YOU are comfortable with it for your eyes.

A. The Basic Common Sense Tips: 1) Don't smoke 2) Eat smart 3) Exercise! 4) Take a break from 'sharp focus' activities (reading, monitor work) frequently 5) Rest your eyes during the day 6) See Your Eye Doctor as Recommended by Optometric Associations and the AAO 7) Protect your eyes during 'risk' events - carpentry, certain sports, etc. 8) Don't touch your eyes without washing your hands first 9) If you wear eye makeup, practice good makeup product hygiene (i.e., keep makeup clean, throw out old makeup).

A. People with high myopia (>-6) and other disorders need them most. If you are going to wear contacts, here are some general guidelines: 1) Get a really comfortable and expert fitting 2) Take them out at night if at all possible. 3) If you can, give your eyes a rest on the weekend from lens wear. 4) If you develop an epithelial abrasion, take them out and wait for the abrasion to fully heal. 5) At the first sign of problems or recurring problem, see your optometrist or ophtalmologist. Infections and other complications from contacts can be serious, and some have argued that refractive surgery is safer than long term contact use. Contact Lens safety and effectiveness is not what this site is about.

A. A lot of refractive surgeons like to distinguish between 'haze' and 'scarring'. Generally, they point out that haze is 'thin', 'does not have heavy concentration of fibroblast cells (scar cells)', and 'diminishes' with time. Scarring is usually denser, and diminishes much more slowly, if at all. It doesn't sound too different, but a recent article in the American Journal of Ophthalmology "Late Onset of Corneal Scar After Excimer Laser Photorefractive Keratectomy", Stulting, Thompson and Durrie, May 1996 http://www.ajo.com does attempt to distinguish between them. 'Clouding' can be pervasive or 'spotty'. As the name suggests, the cornea can have a 'cloudy, translucent' appearance, which may or may not be discernible with the naked eye. Spot scars are small 'cloud(s)' with slowly thinning edges, they are also known as 'nebulas'.

A. It's impossible to have the perfect study. Some of the criteria of a superior study would be:
Minimum size - 1000 patients
Minimum timeframe from LAST patient to report date - 7 years
Maximum patient loss at 7 years - 5% (if at all possible)
Number of sites participating (minimum) - 4
Funding - Federal Government
Oversight - At least some outside review and Independent control
Details - All visual assessments reported (cycloplegic and high and low contrast sensitivity as well)
Endothelial Status - Thorough assessment of endothelial cell loss study
Report of attempted followup of dropouts (dead, committed suicide, killed in car wreck, if located, why refused to participate further, not just 'lost to followup')

The standards for safety and effectiveness are subjective, and you have to determine those for yourself. Such a report would be costly and tedious, but its the only report I would absolutely trust. Eyeknowwhy still wouldn't have surgery. But people with high myopia and astigmatism may find the risks acceptable.

A. Based on studies reviewed, central islands ('spot' areas of elevated stroma usually in the center or just off-center within the ablation area) do diminish with time. Apparently the cornea 'doesn't like' steep spots. The elevated stroma tissue of the central island tends to be reabsorbed as healing progresses. You should read the journal articles on central islands. As for ghost images, there are many reasons for them - rough ablation edges, large pupil dilation, offcenter ablations, 'spot' epithelial hyperplasia, uneven haze. All of these tend to cause what is called 'light scatter' and 'multifocal image effect' (especially at night). Like central islands, they tend to diminish with time as wound healing progresses and the cornea surface smooths and haze resolves. If your acuity is pretty good and this is your only problem, don't rush to have a second treatment to 'fix' these problems; instead, give yourself time to see if they resolve on their own. EyeKnowWhy is not a doctor so any individual case may have a different conclusion and recommendation.

A. One of the risks of having retreatment for mild regression is the risk of overcorrection. There are many factors that can cause this. The laser pulses may have removed slightly more per pulse than normal, the ablation amount may have been entered incorrectly (not likely), or your cornea may have poor epithelial healing resulting in less regression than expected (as you probably are aware, eyes are slightly overcorrected initially to compensate for 'normal' regression associated with wound healing). Wait a little longer, and see if your eye continues to regress bringing down the hyperopia. I am sure your doctor is doing everything he can to reduce your hyperopia. There are experimental surgeries (hyperopic PRK using the excimer, and Laser Thermal Keratoplasty (LTK) using holmium lasers to burn conical wounds around the PRK ablation wound. These thermal burns do not remove tissue but do 'cinch' the peripheral cornea.) to increase central cornea 'steepness' after PRK overcorrection. Their effectiveness, safety and stability are inadequately documented at this time.

A. That's easy. First, print out this site and make copies. The first time visitor section explains how to do this. Second, let your relatives, friends and neighbors know about this site's URL. Give them copies if you can. Third, contact your local newspaper and TV news reporters. Let them know this site's URL and give them copies of this site. Fourth, provide a copy of this site and the URL to your Health Insurance and Human Resources (Personnell) department at your employment for their review.

A. Most contact lens fitting after refractive surgery is by trial and error. Before discussing further, you should be aware that contacts present risks in unaltered corneas, and more so in surgically altered corneas. There are several postop contact lens fitting strategies that have evolved as this is an expanding market. Your best source of clinical study information would probably be the Contact lens Association of Ophthalmologists (CLAO) and the optometric journals. This is what we understand about fitting contact lens after refractive surgery. You must wait at least three months, preferably longer, before being fitted. Soft lenses do not generally work well. Because the cornea curvature is abnormal, these highly pliable lens tend to 'sag' over the central flattened cornea area reducing 'acuity performance' and they may not remain centered. However, there are reports that they can be fitted in some cases. Other contact types that have been tried are gas-permeable, toric, and plateau. Some lens are now made with a flattened interior surface to improve fitting over post-operative corneas. Several contact lens manufacturers are developing specialized contact lens designs for post operative fitting. This answer will be updated as this information becomes available. One fitting strategy is to use 'softperm' lenses. Softperm lenses are essentially hard lenses with a softlens 'envelope' to improve comfort.

For patients with moderate to severe irregular astigmatism and night vision problems, contact lens fitting may be the only solution that can provide significant 'relief.' Unfortunately, these specialized lens, requirements for custom fitting, the frequent contact lens change requirements due to continued cornea remodeling, and special lens care can be cost and time prohibitive. If possible, you should try to find a contact lens fitting specialist (optometrist or ophthalmologist) who works with refractive surgery postops, and is empathetic to your needs.

As I briefly mentioned, I am also considering lense replacement surgery for the correction of nearsightedness. As with Refractive surgery, I had hear "good stories" about the procedure, and have received only one comment from a surgeon that the procedure could increase the risk of corneal detachment, as well as requiring the use of reading glasses. Can you recommend a source of information on this procedure which would give me a more accurate perspective?

Thanks for any help you can give me, and thanks again for your website.

A. In regards to LASIK, it is an option for high myopia, but you need to be aware of the risks. If you decide to pursue, know your doctor, clinic and laser. There are issues regarding the amount of tissues to remove to fully correct a -16 (for a 5mm ablation, it is about 11 microns per diopter, or about 176 microns in your case). That's a good bit.

As regards to IOL implants, this is no different than cataract surgery with an IOL implant (IOL=intraocular lens implant) which is commonly practiced, but is generally associated with the elderly. You said 'cornea detachment', but I think you meant retinal detachment or hemorrhage. Although retinal detachment is a small risk after PRK or LASIK (due to the trauma of surgery), it is greater with IOL implants since you must cut into the cornea at the edge, then cut into the internal lens sack, shatter the lens with acoustics, vacuum out the lens fragments, and then insert a plastic IOL. (In corrective surgery cases, they may just place the IOL in front of the lens rather than removing it.)) Naturally, this is invasive, and has all the risks of cataract surgery. I would recommend going to Medgate (see the reference page) and doing a search there on intraocular lens surgery. Experiment with keywords such as intraocular , cataract, etc. The National Eye Instititute does sponsor government studies of cataract/IOL surgical results (large population, and long term). Contact them for information resources. Granted these don't discuss results in relation to having IOL surgery for refractive purposes only; they are for cataracts, and the population average age will be greater. However, it will give you an idea of complications.

The other IOL technique I have heard/read about is where they cut the cornea, and insert a IOL in front of the iris. It is imbedded into the iris with 'claws' or 'hooks' to hold into place. Like cataract/IOL, there can be complications including severe iritis (inflammation of the iris), irritation of the natural lens causing a cataract, mislocation causing diplopia, etc. Some of the trade journals have produced articles on this technique for severe myopia correction that you should try to obtain (mags - ophthalmolgy times, ocular surgery news, eyeworld). Finally, ask your ophthalmologist or refractive surgeon for specific titles and dates for published studies. You may be able to get copies from him or you may have to go to a med library to get xerox copies.

I have found your site to be very valuable and informative. I do, however, have 1 question relating to the Better Health and Medical Netowrk (AOL only) Vision board which you refer to in your information on LASIK surgery - where do I find this resource ? I've tried checking on AOL with no luck. I am very keen to find more case information on LASIK procedures where there have been flap/cap complications and the corrective and healing processes experienced. Any information or leads you can provide will be greatly appreciated.

A. If you select the Health and Fitness Channel on the initial AOL channel screen, then select the Better Health & Medical Network in the box in the lower right, this will bring up the Better Health and Medical Network menu. At the bottom of the BHMN menu, you will see message boards. Select that.

This will bring up a box with many health subjects; Select the Eye & Vision Disorders board. It will bring up a box listing eye subjects; one of the subjects is RK/PRK Surgery. Select that. That is where you want to go.

You can skip all of the above process by selecting KEYWORD at the top of the AOL screen and entering the following:

aol://5863:126/mB:107867

This is the cryptic keyword string to take you directly to the Eye & Vision Disorders Message Board. You can bookmark the Eye & Vision Disorders menu, but not the individual board RK/PRK Surgery so you don't have to go through all the above steps again.

A. You state that you are 6/6 implying you have little refractive error, so you may be slightly farsighted and are able to see 6/6 because of accomodation, or you only have a little bit of residual myopia. To really answer your question, I need to know your refractive error in diopters with your lens paralyzed to prevent accomodation masking (if you are slightly farsighted.) Do you have your error in prescription form (i.e., diopters - spherical and cylinder)? You are lucky not to have central islands or other irregularities. We get a signficant amount of mail related to these problems, and they are difficult to fix. It sounds like the ablation zone is slightly rough and/or the ablation zone/transition zone edges are not smooth. Are you sure your transition zone is 8mm? Most of the 217 LASIK ablations I have been hearing about are about 6mm diameter total (4 to 4.5 mm ablation, and a 1mm to .75mm (each side) transition ring. If your transition was done to 8mm or 9mm, then I would be skeptical about the improvement you would get from a 'touch up' ablation. Your flap is probably a 8mm max diameter. Really large ablation zones present all kinds of complications. It seems that 7mm is the max ablation+transition diameter.

A touchup would be another surgery, with all the risks of the original surgery and there is concern about manipulating/traumatizing the flap tissue, stroma bed and epithelium again. The other big risk is that even a very light ablation may result in you gaining 1 to 2 diopters of additional correction. If you are truly emmetropic (0 diopter), this would put you +1 or +2 farsighted, you definitely don't want that. If you have about -1 of residual myopia, this risk would not be as great, but would still be there.

There have been published reports in the journals (from Sweden and Canadian surgeons) about doing retreatments for halos, with mixed but mostly positive results (within the time limitations and patient pool size of the studies). Most of these studies were done on PRK patients with residual myopia and central islands as well. Search the JRS and JCRS journal sites. They are linked within the site on the sources page (http://members.aol.com/eyeknowwhy/sources.htm ) You can also use the Medgate web site and search the Medline and Healthstar databases for PRK or LASIK. That link is on the reference page (http://members.aol.com/eyeknowwhy/referenc.htm ) The search options are powerful and flexible. The abstracts will give you some idea of the study's contents, but full copies cost a good bit.

You can also go to the medical library (that maintains bound copies of the journals, such as the AJO, JRS, etc., in their stacks). Often when researching one article that discussed a particular topic, it will contain references to related articles. Start with the most recent journals, and work back. The JRS, JCRS and Cornea journals probably have these studies more so than the AJO. Be wary of conclusions. Still, this may be the best way to find out how well these 'halo elimination' touchups work. Most have been for PRK halos, but they would have significant applicability to LASIK ablations.

Finally, it's been about 5 months since your surgery. Has there been no decrease in the past month? Most patientssay the halos continue to diminish over the first 12 to 24 months. Maybe you can wait another month. You also need to be careful not to fall into the "mo' surgery, 'n mo' surgery" trap which I am sure you are aware of.

(1) In LASIK, Bowman's layer remains intact, whereas in PRK this layer is obliterated. Given that ophthalmologists can only agree that they do not understand Bowman's layer fully, I think it is prudent to leave it alone.

(2) Incidence of corneal hazing/scarring appears to be less. While hazing is not necessarily scaring, the ablation of the anterior cornea and surface certainly seems to have the potential for scarring long term, as opposed to the the scarring potential of the stroma (this due to differences betweek epithelial cells and stroma cells of the cornea). Hence the aggressive steriodal anti-inflammatories post-op in PRK. These have acknowledged complications, e.g. intraocular pressure increase, glaucoma, cataracts.

(3) Less post-op vision fluctuation. While both surgeries report vision fuctuations up to 1 year, as the corneal structure "resettles", it appears (from what I have been able to dig up) that this effect is larger in PRK, perhaps because it is complicated by the additional hazing.

(4) Improvements in microkeratomes. Current microkeratomes are producing better corneal flaps than those of 1 year ago. Improvements here are at least as important as the improvements in laser technology. (5) Experience. I have consulted with a number of physicians via letter, email, telephone, and in person, probably to the point of becoming an annoyance. It seems that only the more conservative physicians who are relatively new to the laser surgery arena are advocating PRK for moderate (approx. -5.0) myopia. Surgeons with whom I spoke in the US who have more experience are greatly in favor of LASIK, as are the vast majority of refractive surgeons in Canada and Europe. They report few complications with flap mechanics, and no permanant vision issues related solely to the flap (most correction issues are related to glare from scarring as a result of the laser, not the cutting of the cornea).

A. Your first four statements are reasonable. The fifth regarding flap complications is questionable. The site proves there are individuals who have flap complications. These complications can be troubling. Obviously, surgeon experience can help reduce the risk of flap complications, but there will always be some degree of complications in the experienced surgeon's hand. Keratomes are improving (i.e, disposable preset depth keratome blades, experimental 'water jet' keratomes) but it is still a manual cut. The point being that patients with flap complication MAY be able to see 20/40 (even 20/20) using a Snellen eye chart, but they have optical aberrations and other problems related to poor flap relay or damage to the flap.

Undergoing refractive surgery is a hard decision for anyone. You did not mention your degree of myopia or astigmatism. Most postops (even if they are happy with the results) will tell low to moderate myopes that they should make their decision very carefully.

In your conversations about the flap creation, you need to ask about 'induced irregular astigmatism", risk of flap wrinkle and crooked flaps. These all contribute to optical aberrations, and an ethical surgeon should be willing to truthfully discuss these problems.

There are people out there who are very happy with their results, and there are people out there who regret it deeply. You just have to make up your mind and if you decide to have the surgery, REALLY CHECK OUT THE LASER AND THE SURGEON. Avoid high pressure sales clinics. If you get the feeling the surgeon and staff isn't being up front with you, what does that say? DO NOT BE INTIMIDATED TO NOT ASK QUESTIONS AND DEMAND SOLID ANSWERS.

I still have problems with glare in the right eye, but Beacon says that the problem with glare will go away within another year and a half. I never heard about glare before having the surgery.

My left eye is still screwed up. I asked CLINICX to transfer responsibility for treatment to their Dallas/Ft. Worth center. They said no. I am going to complain to a lawyer, but haven't decided whether the goal should be to put them out of business, or to make them continue my treatments at their Dallas office.

Do you know if anyone has sued CLINICX, or if there are any class action suits against CLINICX?

A. There are concerns about undergoing additional surgery. Benefits dimiinish rapidly and risks escalate with each subsequent surgery. It sounds like CLINICX is not being straightforward with you.

As for attorneys, we do not maintain a list of attorneys. We do not know of any lawsuits against CLINICX although there may be one or more active lawsuits. Their Securities & Exchange Commission 10Q (financial/business condition disclosure) will usually state whether there are any lawsuits pending. As you are aware, an informed consent form is a significant barrier to a lawsuit. You may want to contact the law firm cited in the RK malpractice case, and see if those attorneys can direct you to an attorney in your area familiar with refractive surgery malpractice.

I am 43, very myopic (-12.50, -12.75), and can no longer wear contacts for any length of time or regularity. I have been mainly wearing glasses for several years, and it is certainly not the cosmetic aspect of spectacles that motivates me to consider Lasik, but their frustrating limitations (dust, rain, fogging, scratching, AR coat deterioration, etc.), as well as the sheer discomfort of wearing even optimally light lenses. Lens replacement for cataracts is a routine operation with a relatively well known outcome. If I am willing to give up the years of presbyopia-free vision I have left, is this a safer alternative than Lasik? Could you outline the pros and cons?

Also, I have been waiting and watching for over a year now, hoping to see more studies and improvements in technique for Lasik. I see that there are better lasers coming into use, as well as better flap-cutters, and obviously, more experience for surgeons. Given that I am one of the "motivated" candidates with less to lose and possibly more to gain, in your opinion are there any particularly compelling improvements that I should wait for, and what is the time frame of the wait?

A. Highly myopic individuals do need a solution,but there needs to be a somewhat hard edge to the discussion within the site to balance much of the hype surrounding refractive surgery. Approximately 75% of myopes are -3 diopters or less, and over 95% are -6 diopters or less. These are the individuals that the risks are serious in comparison to the possible benefits since these people can wear comfortable glasses or contacts in most cases. The issue of risk vs benefit is much more difficult for high myopes and astigmats.

In regard to your question about the ICL, this may not be a good idea. It is real invasive. There are two ICL types: the posterior type is inserted between the iris and the internal lens. What is scary about this besides the invasive nature of the surgery is that if the natural lens is touched during placement, or the ICL, over time, punctures the lens sac and touches the lens, a cataract will form. The second type is an anterior (forward) ICL. This ICL is actually placed on the front of the iris, and using small claws, it is imbedded into the iris to hold it in place. Again, this can cause severe iriitis and scarring of the iris. Both of these surgeries require a full depth incision, and like cataract surgery, almost always cause warping of the cornea resulting in induced regular astigmatims and irregular astigmatism. You may be surprised by how many people are dissatisfied with their cataract surgery, it is over 30% 5 years postop even though almost 90% can read the 20/40 line. And IOLs are known to deteriorate significantly and complications increase after 5 years. Everyone should avoid having cataract/IOL surgery until their best corrected vision has deteriorated to the point that it is necessary. Myopes greater than 15 may consider IOL, but there is one other issue to consider. These patients carry the greatest risk of developing retinal detachments from IOL/ICL surgery.

The procedure currently recommended for myopia in your range is LASIK. The timeframe and waiting for technology improvements are always issues you must decide. You may consider waiting for the new lasers from ATC or Chiron if you wish to stay in the US. I would stay away from the Summit machines especially, and any black box lasers. The VISX star is widely used in the US, but the ATC and Chiron are to be approved this year for PRK. Surgeons will then be using them for all degrees of myopia LASIK surgery of course. The issue then becomes an issue of refinement and experience. For that,you would want a surgeon who has done more than a 1000 LASIK procedures, and at least 300 of those on the machine that you are to be operated on. Always ask surgeon's hard questions - Have you been sued? Have any medical complaints been filed against you? You must develop a list of questions and bring those with you. There are surgeons out there who are 'high volume' AND highly notorious. Know the difference between a good high volume surgeon and a bad one.

Whether LASIK will ever be 'approved' by the FDA is unclear because of its nature. That is, outcome depends on a surgeon's skill in doing the flap correctly. If you wish to go out of state, there are surgeons in Canada that do LASIK on these newer machines. Machat is probably one of the most well known and experienced. He is at TLC. There are other Canadian surgeons who supposedly are equally at depth at LASIK with the newest laser mahcines. There are posters that are enthusiastic about Galvis in Columbia SA (he uses a Chiron machine), although testimonials should not be a major factor in selecting a surgeon.

A. All refractive surgery procedures are detectable although they rarely are with the naked unaided eye.

There are three ways to detect cornea alterations after refractive surgery:
1) Slit Lamp Microscope with and without fluorescein staining
Generally, RK scars can be detected without staining due to their density. Staining makes them very easy to see. This will always be true. In cases of severe scarring, you may be able to see RK scars with the naked eye and appropriate lighting. PRK is more difficult. During the hazing/scarring period (2mos to 6mos), the haze is easy to detect with the slit lamp, with or without staining. After haze subsides, it is more difficult after the first year in most eyes, but the ablation profile and ablation edge can usually be detected with oblique lighting angles. After LASIK, the flap edge is usually detectable for the first two months, and as the flap edge is sealed to the stroma bed by a ring of scar formation, the scar is detectable with staining, and often without.

2) Mire Projection Detection
After refractive surgery, a projection of narrow rings of light on the cornea will pick up surface abnormalities. RK produces the most abnormal mire projections, and the scars are elevated and produce 'bumps' on the mires. PRK tends to vary based on the quality of the PRK and wound healing. If its a good PRK, only the ablation edge will produce mire irregularities. Other PRK problems such as central islands, off center ablations, irregular wound healing will produce other mire abnormalities. LASIK mire distortions depend on the quality of the flap and relay. In a good LASIK, the flap edge and hinge may produce some mire irregularity. Other flap and wound healing abnormalities will produce other irregularities. Abnromalities include flap wrinkling, ragged edge, elevated and low spots on the flap.

3) Color Curvature Topography Mapping
This is the easiest way to detect RK, PRK or LASIK without a microscope inspection. Generally, RK produces the strangest topography maps with 'points' where the incisions were made. PRK looks like a central 'bull's eye' and LASIK produces a different less defined 'bull's eye' pattern. This site http://www.geocities.com/HotSprings/Spa/2001/topindex.html Basic Corneal Topography Interpretation contains examples of the typical topography profiles for a normal cornea, an astigmatic cornea, and RK, PRK and LASIK corneas.

The Novatec Laser Novatec Solid State Laser contains a series of topography maps showing corneas before and after surgery using the Novatec laser. These maps show how the cornea SHOULD look after surgery. You will need to select the Clinical Data to review the maps. The colors on a topography map are mapped to the dioptric power of the cornea using the scale to the right or left of the cornea picture. A spherical cornea, regardless of the degree of myopia, usually has a power of about 42D to 43D. You can see how astigmatism looks before surgery at this site as well. This site does not show postop topography maps for corneas that had complications such as uneven ablation or offcenter ablations which result in IRREGULAR astigmatism. Novatec Laser is a laser similar to the excimer lasers (VISX, ATC, Chrion, etc.) but uses a different wavelength and laser source (a crystal vs. a gas mixture). The Novatec is in Phase III clinical trials for myopia in the U.S.

Here's an example to help you understand: A person with myopia of -5 diopters undergoes surgery. The preop map should show a cornea with a fairly consistent color mapping that maps to a dioptric power of 42D to 43D on the color scale to the right or left of the cornea map.. After surgery, there should be a well centered circle of color where the ablation occurs. The COLOR for this central circle should map to the color for 37D to 38D (42D-5D to 43D-5D). Go look at the maps and you will see this.

A. The epithelium is removed by four ways:
1) scrape with a blade to a diameter approximately 1 to 1 1/2 mm wider than the expected total ablation zone. This is the predominant way done today
2) use a electric rotary brush (kinda like an electric toothbrush), same diameter clearance as above
3) use the excimer laser in phototherapeutic mode to ablate the epithelium to the Bowman's membrane layer. Then check that it is clear.
4) use an alcohol based solution to dissolve and wipe away the epithelium. This solution does not dissolve Bowman's.

The ideal is to get to Bowman's membrane which is very smooth.

After 1 of the 3 above, the laser ablates based on the degree of tissue to be removed.

After the ablation, the epithelium along the edge begins proliferating (dividing) rapidly to cover the wound area. Initially this is very thin, usually only about 1 to 2 cell layers tall (versus the normal 6 to 7 layer tall). The defect is closed within 3 days in the majority of eyes. This initial layer is not real stable since it is regenerating over the stroma versus the normal Bowman's membrane. (I have seen pictures of this proliferation of the epithelium across the stroma taken in 8 hour interval and its fascinating.) But it does stabilize over time, and begin to rebuild to its normal height. There has been a study or two about how does the basememt epithelium develop a 'cohesion' bond to the stroma.. The general consensus is that the basal epithelium cells change to 'hook' into the stroma. It is a different cohesion structure than that for basal epithelium to Bowman's Membrane but seems to work ok. A few patients will not develop a good basal/stroma matrix; these patients may experience epithelial defects and erosions from time to time.

There are issues regarding the missing Bowman's membrane, and the new basal epithelium-stroma complex. Some skeptics say that loss of Bowman's makes the cornea more likely to develop long term dystrophies such as keratoconus. One thing that has shown up is that corneas that no longer have Bowman's membrane (after prk) tend to react adversely to strong UV exposure, i.e., excessive exposure to intense UV, such as tanning or tropical vacations, which may cause the cornea to scar. One question to ask is "If I have PRK when I am 30, will my cornea develop problems when I am 50? 60? Will I be at greater risk of developing cataracts earlier in life and more commonly than the general population?". No one knows for sure what will happen. Refractive surgeons believe postops will not experience higher cornea disease and lens problems than the regular population.