Refractive surgery is an ophthalmic subspecialty that deals with surgically reducing or eliminating vision deficits and the need for glasses or contact lenses. Procedures are available to help patients with nearsightedness (myopia), farsightedness (hyperopia) and astigmatism. The doctors of Hines-Sight have many years of experience in refractive surgery.
Radial Keratotomy or RK is a surgical procedure in which the doctor makes a number of microscopic incisions on the cornea in a radial or wheel spoke pattern. This changes the shape of the cornea, making it flatter, and improves the way that light rays focus on the retina. RK is still performed for patients with mild nearsightedness (myopia).
Photo-Refractive Keratectomy or PRK is a surgical procedure where the doctor removes a thin layer of skin from the surface of the cornea. An excimer laser is then used to reshape the cornea. Removing tissue from the center of the cornea flattens the eye, correcting nearsightedness, while removing tissue from the edges of the cornea steepens the eye, correcting farsightedness. With PRK your vision will initially be blurry after the procedure and may take a week or two before clearing enough for normal functioning. Your vision will continue to gradually improve over the course of several months after the procedure. PRK may be the best procedure for patients that are highly nearsighted or have thin corneas.
Laser Assisted in situ Keratomileusis (LASIK)
Laser Assisted in situ Keratomileusis or LASIK is a surgical procedure that utilizes a microkeratome to cut a thin flap of tissue on the corneal surface. The doctor then lifts the flap and uses an excimer laser to reshape the internal cornea. Afterwards the flap is repositioned where it bonds back into place. LASIK is currently the procedure of choice for many refractive surgeons.
An epikeratome is a mechanical device used to separate the surface layer of “skin” of the cornea (the epithelium) from the layers below. This epithelial sheet is removed and an excimer laser is used to reshape the cornea. This procedure is similar to PRK and heals in the same fashion.
Phakic Intraocular Lens
A lens implanted within the eye can allow clearer vision just as a pair of glasses or contact lenses would. The word “phakic” means that the natural crystalline lens is left in the eye (it is removed in cataract surgery), thus allowing a patient to retain the normal focusing ability of the eye. There are currently 2 lenses approved for this type of refractive surgery, the Verisyse lens and the Visian lens. This is an outpatient treatment that usually takes 15-30 minutes, and only one eye is treated at a time. This procedure is ideal for very nearsighted patients and may be the best treatment for thin corneas or higher refractions.
Accommodative Intraocular Lens
Accommodation is the eyes ability to focus on near objects. As we age the eye gradually loses this ability resulting in the need for reading glasses around age 45. An accommodative intraocular lens is a lens that is implanted within the eye, just like cataract surgery the natural crystalline lens is removed from the eye. There are currently 3 lenses approved for this type of refractive surgery, the ReSTOR, ReZoom, and Crystalens. These lenses are used to correct both the distance vision and the near vision simultaneously, although there may be a small degree of blur at distance or near.
A complete eye exam will confirm whether the you are nearsighted, farsighted and/or have astigmatism. There must be no untreated ocular health problems, such as significant cataracts or untreated glaucoma. Additional measurements are needed, such as the thickness of the cornea and a corneal surface mapping, which will be done in the pre-operative evaluation. A qualified optometrist or ophthalmologist can ultimately determine whether you are a candidate for LASIK eye surgery. Please feel free to take our LASIK self-evaluation TEST and a patient coordinator will contact you to discuss your candidacy steps!
The success of any LASIK procedure depends more on the skills and experience of the surgeon than other surgical procedures. A qualified surgeon should be well trained in Ophthalmology and be board certification by the American Board of Ophthalmology and be trained in refractive surgery, and have experience with ophthalmic disease. The ideal surgeon should have performed many types of ocular surgeries and have performed many LASIK procedures, too. It is important to keep in mind that you are making a lifetime investment when choosing to have LASIK so you should take your time and select the right surgeon for you.
The procedure takes 5-7 minutes per eye. It is done under topical anesthetic drops and sedatives are given prior to the procedure. During LASIK, an instrument called a microkeratome is used to lift a thin layer (flap) of the cornea and a laser is used to remove a precise amount of the cornea to shape the surface of the eye so that objects are focused clearly on the retina. After the laser treatment, the flap is laid back into position and kept in place by natural adhesion with no sutures. Eye drops are used and plastic shields are placed over the eyes to protect them until the following day. Results are almost immediate, with minimal discomfort during the first 24-hour period.
Recovery is fast. The first couple of hours after surgery, the eye feels somewhat irritated, with a burning sensation and some tearing. Vision is typically smokey of hazy during this time. Most patients nap for a couple of hours due to the preoperative sedation. After several hours, the irritation goes away and the vision begins to clear. The day after surgery, most irritating sensations are completely gone and vision is remarkably clear.
A mild sedative will be administered prior to surgery to encourage relaxation to encourage sleep afterwards. The surgeons and operating room technicians will talk you through the procedure to keep you at ease.
Some patients may prefer to have each eye done on different days. In most cases, however, both eyes are done on the same day. This avoids the period of imbalance that occurs if one eye still needs correction while the other one doesn't. This is a discussion that you should have with the surgeon so that you can decide what is best for you.
With any medical procedure, there is not a guarantee of perfect vision. Almost everyone experiences improved vision, however, and most see well enough to pass a drivers' test without corrective lenses. It is important to know that LASIK does not always eliminate the need for glasses in all situations. Some may need glasses for best distance vision and some may need reading glasses of very small viewing. Beginning at around the age of 40, a condition called presbyopia usually appears, requiring reading glasses or bifocal correction when the eyes are properly corrected for far away viewing. For those desiring to see well near and far without the use of glasses or contact lenses, Monovision may be just right for you.
Active sports should be postponed for two weeks or until the eye is fully healed, unless protective eyewear is approved by the surgeon. Swimming, hot tubs and saunas should be avoided, as well. After full recovery, normal activity can resume, and the ability to play sports without glasses makes them more enjoyable for many patients.
LASIK is a permanent procedure. In some cases, however, an enhancement procedure may be required. Some patients' eyes may change throughout their lifetime, which can happen with glasses or contact lenses as well.
Fluctuation can occur, but visual improvement is almost immediate following the procedure. Most patients feel that major fluctuations have stopped after two weeks. At the same time, it may take additional time for all of the swelling in the eye to resolve and fluctuations to cease. Many patients do have healing that, in a minor sense, may continue to improve over six to nine months.
The procedure is very safe, and that is why it has been so readily accepted. With any surgical procedure, however, there may be complications. Vision-threatening complications do exist, but they are unusual, these include: infections (an incidence of 1 in 50,000), irregular healing that can lead to "irregular astigmatism" that glasses cannot correct fully and contact lenses or further surgery may be required to improve. There are also complications which may lead to temporary blurriness, temporary dependence on glasses or contact lenses or a need for additional surgery. In most cases, the patient can still do well and recover with good vision. It is for this reason that LASIK patients should confirm the experience of their surgeon to determine if he or she has specialized training in cornea surgery. Because LASIK is performed on the cornea, knowledge of the healing properties of the cornea and management of any complications are critical to the patient's well being. Knowing how to handle a complication, should one occur, can make a significant difference in the patient's outcome.
Success depends on several factors, the most important being the degree of nearsightedness, farsightedness or astigmatism. Depending on the prescription, the surgeon can help determine the likelihood of reaching 20/40 or greater vision. Approximately 98 percent of eyes treated with LASIK reach 20/40 or better vision with one procedure, which is the requirement for driving legally without correction. If a patient does not achieve his or her goal with one procedure, additional enhancement surgery often improves vision to a satisfactory level. Not all qualify for enhancement and may require contact lenses or spectacle correction.
Many patients who desire LASIK surgery have dry eyes. They have become intolerant of their contact lenses because the dryness makes them uncomfortable. LASIK occasionally worsens dry eyes, but typically, this is temporary and usually treated with frequent artificial tear lubrication. In special cases of severely dry eyes, special lacrimal punctal plugs are placed in the lower eyelid tear drainage ducts to allow the tears which are made naturally or are instilled into the eye to remain there longer, thus keeping the eye moist longer. These are easily removed in the office once the dryness resolves, or they can be left in place permanently.
LASIK can correct each eye for distance or each eye for better near vision or one for distance and one for near (monovision). If you are over 40-45 years of age and LASIK is performed such that distance glasses are not needed, it is likely that you will need to wear glasses to read. The exception to this is when patients opt to have monovision, when one eye is corrected fully for the distance and the other is left properly nearsighted. Monovision is great for about 90% of the population and is extremely versatile for allowing one to see both near and far.
As a rule, astigmatism can be corrected by a laser procedure at the same time as nearsightedness or farsightedness. The greater the amount of astigmatism corrected can increase the chances of needing an enhancement to “fine tune” your vision. There is currently not an intraocular lens that can correct for astigmatism. It may be necessary to have a laser procedure after the implant to correct your astigmatism.
The minimum age for refractive surgery is generally 21; however, on rare occasions a younger person may qualify. More important than age is how stable your prescription has been over the last several years. After the age of 21, the health of the eye is the primary limiting factor.
Technology has improved dramatically since RK (which could only treat low to moderate amounts of nearsightedness) was the only refractive procedure available. With a laser correction the amount of nearsightedness that can be corrected is limited by the thickness of the cornea. A phakic intraocular lens is able to treat very severely nearsighted individuals regardless of corneal thickness.
Although most people are candidates for refractive procedures, some are not. Situations that would make one a poor candidate for refractive surgery include, but are not limited to: the overall shape of the cornea, the health of the eye, your particular vision requirements, or your expectations.
Any surgical procedure carries a certain degree of risk. These risks are generally very minimal with refractive surgery. Relative to most surgical procedures, refractive surgery procedures are among the safest surgeries performed. Risks for refractive surgery include, but are not limited to: discomfort, light sensitivity, glare or halos around lights, corneal haze, infection, irregular astigmatism, and either over or under correction. The risk of serious vision threatening complications is less than 1%.
Laser surgery requires no shots or stitches. Intraocular lens implantation typically will not require any stitches. With a LASIK procedure, the flap of the cornea bonds back into place eliminating the need for stitches. The corneal flap is not visible to the human eye and does not interfere with vision. With a lens implant the incision is typically small enough that no stitches are needed.
The goal of refractive surgery is to provide the most functional vision possible. This means that you should be able to do most of the things you enjoy without glasses. Glasses with a small amount of correction are sometimes needed to fine tune your vision for certain situations such as driving at night. If you have presbyopia, you will require reading glasses or a monovision correction.
Presbyopia is the loss of the ability of the lens within the eye to focus on near objects. This generally occurs around age 40 and as it becomes more advanced will require the use of bifocals or reading glasses. Laser surgeries are not able to prevent this loss of focus. An accommodative intraocular lens can help overcome presbyopia. Myopic patients are typically able to remove their glasses and read well. After a laser procedure, if both eyes are corrected for distance, this advantage would be lost and you will need to wear reading glasses like most normally sighted people over the age of 40. Many patients are candidates for monovision, a technique used to help reduce the need for reading glasses.
Monovision corrects one eye for clear distance vision and the other eye for clear reading vision. It may take a few weeks for your brain to adjust to this correction, but most people adjust rather easily. Monovision allows people with presbyopia to function without having to always rely on reading glasses.
In numerous clinical studies throughout the world, excimer laser procedures have not produced any significant long-term effects on the integrity of the eye. Experts are confident that they will not discover any problems, however firsthand data is not yet available much beyond 15 years. Since the excimer laser removes only a small amount of tissue from the cornea, the integrity of the eye remains intact and no stability problems for the future are anticipated. The procedure is permanent, although in some cases it will need to be retreated to enhance the final outcome.
Obviously the goal of refractive surgery is to reduce the need for glasses or contact lenses. But should you require corrective lenses after surgery, contact lenses are typically still an option. On occasion, the cornea may be altered enough to prevent an easy fitting of contact lenses. The eye will be drier after LASIK potentially making contact lenses tougher to tolerate in the eye.
No surgeon can guarantee perfect vision after refractive surgery. Among experienced refractive surgeons, greater than 95% of the people undergoing refractive surgery achieve 20/40 vision or better without glasses or contact lenses. In Colorado, 20/40 vision will still allow you to obtain a driver’s license without a restriction. If improved natural sight is the indicator of success, then virtually 100% of refractive surgeries could be considered successful.
20/20 is considered normal vision. This means that from 20 feet you should be able to view an object that someone with normal vision should be able to make out from 20 feet. 20/40 means that from 20 feet you should be able to see an object that someone with normal vision should be able to identify at 40 feet. The larger the second number, the poorer that the vision is.
Refractive surgery procedures are considered permanent and are not intended or designed to be a temporary correction. Some eyes may continue to change with time. The more stable your prescription has been before surgery, the greater the likelihood that your vision will not change after surgery.
You must undergo a complete eye examination to ensure that your eyes are healthy and functioning normally. This detailed exam includes in-depth testing to measure your prescription, the health of the eye, the size of your pupils and the curvature and thickness of the cornea. These tests will determine if your prescription is stable. It will also determine if you are a good candidate for a refractive procedure, and which procedure would be best for you. Plenty of time is allowed for our technical and medical staff to answer all of your questions. This exam will take 2 to 3 hours. Your pupils will be dilated during this examination and the effects of these drops can take up to 72 hours to wear off. It is important that you have not been wearing contact lenses for a period of 5 days (for soft contact lenses) or 3 weeks (for hard or rigid gas permeable lenses) prior to this exam. Only by having not worn contact lenses can accurate measurements be obtained.
LASIK is one of a few procedures where both eyes can be done on the same day because the risk of infection is much less than with other refractive procedures. The choice to have both eyes done on the same day will be a decision both you and your doctor will make. PRK and epi-LASIK may also be done on both eyes the same day, although this is generally not recommended. In fact the FDA does not recommend that you have both eyes treated on the same day with any procedure. Any intraocular procedure will be done on one eye only at a time.
Driving a car immediately after refractive surgery is never advisable. You will have been sedated with medication prior to surgery, impairing your ability to safely drive. You will need a responsible adult with you on the day of surgery. If desired, they will be able to view the procedure from monitors in the waiting area. In most cases you should be able to drive yourself by the next morning.
You will be awake and alert throughout the entire procedure. Prior to the procedure, you will be given a mild sedative to relax and calm you. Anesthetic drops are used to numb the eye so that you will experience no pain or discomfort during the procedure. Although you are aware of what is going on, you will not actually see the procedure being performed. The staff at the laser center will talk you through the entire procedure to help alleviate your fears.
LASIK typically takes about 5-10 minutes per eye; however, with the pre- and post-operative instructions and monitoring you should expect to be at the laser center for 1 to 2 hours. Other refractive procedures will take a little longer for treatment.
LASIK is considered to be a painless procedure. You should feel nothing but a gentle pressure on the eye during the procedure. Some patients do experience some mild discomfort for 4-6 hours after surgery. Discomfort varies from patient to patient and may be controlled with pain medication that you are given at your procedure or by other methods. It is normal for the eyes to be fairly sensitive to light initially after surgery. It is also normal for the eye to tear profusely initially after surgery. Other procedures may have more discomfort associated with them.
Most people are able to go back to work within a day or two after their procedure. We advise you to take the day off following your surgery. Allowing your eyes to rest the day following your procedure is a way to aid in your recovery process.
You can begin normal activities as soon as you feel comfortable. Most people resume normal activities within 24 hours of their procedure. For 2 weeks after the surgery you should not wear any make-up around the eyes; no swimming, hot tubs or saunas for 2 weeks as well. Exercising the day after the procedure is fine. If you participate in contact sports or any activity where your eyes are prone to injury, please consult with your doctor regarding restrictions. Typically these activities are ok, with appropriate eye protection. There are no restrictions on flying after surgery.
Our doctors will continually monitor your eyes until they are satisfied with the health of your cornea and the quality of your vision. At a minimum you will have 3 follow-up visits in the year after your procedure. Typically you will be seen: one day, one week, one month, three months, and one year after surgery. These exams are essential and are necessary for any enhancements to be covered in the price of the procedure. Enhancements are included in the cost of the procedure for a period of 1 year if you have kept all your follow-up visits.
Common side effects reported by patients after LASIK include: fluctuating vision, light sensitivity, glare and halos at night, and dry eyes. These phenomena are due to the healing process of the cornea. As the cornea heals these problems are minimized, and in most cases, eliminated completely.
Some patients experience problems with glare or halos at night. This is a common side effect, most noticeable initially after surgery. It typically fades with time. If you have large pupils it could be more noticeable. In most cases, patients who have had refractive surgery have no more problems with their vision at night than they did prior to surgery. A small percentage of patients may have long-term problems. A pair of glasses can help overcome the glare and halos.
Dryness of the eyes is another side effect after surgery. It will be worse for several months following surgery, but should improve with time. This will require the use of artificial tear drops frequently initially after surgery. In rare cases, additional methods may be needed to help with the dryness.
Diabetes, glaucoma, hypertension, and other health problems are factors to consider in the decision to undergo refractive surgery. These conditions must be under treatment and in control at the time of surgery. If the cornea is healthy, most health problems will not impact the ultimate success of refractive surgery.
Since pregnancy brings about many changes in your body, it is not advisable to have a refractive procedure if you are pregnant. Refractive surgery may be performed 3 months after delivery, unless you are nursing. Nursing mothers may not have a refractive procedure until they have discontinued nursing for 6 weeks.
Laser refractive surgery is recognized as a safe and effective alternative to wearing glasses or contact lenses. Good vision without correction is usually an asset in many occupations such as police work, fire fighting, and flying. The FAA has approved LASIK for all classes of pilot licenses and air traffic controllers. Many military academies have strict vision requirements that do not include vision corrected by refractive procedures. If you plan to enter a specialty field, you should investigate the vision requirements as they relate to refractive surgery.
The fee for Lasik includes the initial consult and all pre-operative and post-operative measurements for a period of 1 year. The fee is due in full on the day of your procedure. Enhancements are included for a period of 1 year as long as all post-operative visits are completed. The fee for surgery is determined on what type of procedure you have and the equipment used for that procedure. Other refractive procedures will typically be more expensive than LASIK. If you have a traditional LASIK procedure initially and later have an enhancement with wavefront guided LASIK, there will be an upgrade fee of $400.00 charged at that time. For your convenience, we accept: Visa, MasterCard, Discover, American Express, cash and cashiers checks. Personal checks are not accepted for refractive surgery. We also offer financing through CareCredit. You can apply by accessing their websites or ask our Lasik Coordinator for assistance in applying . Financing must be approved prior to your procedure. LASIK is a qualifying medical expense for a flex plan offered through your insurance.
Traditional LASIK procedures have been performed with great success since the early 90’s. A traditional LASIK procedure can treat nearsightedness, farsightedness and astigmatism just like glasses or contact lenses. Wavefront guided procedures are capable of addressing other distortions that may be present in the human eye. At the examination prior to surgery a series of images are obtained of the eye, quantifying the relative amount of these distortions. In many cases these distortions are so minimal that they are visually insignificant. Patients that have significant levels of these distortions will obtain a crisper visual outcome with a wavefront guided procedure. Additionally, by correcting these other distortions, you may experience better vision at night; reducing the amount of glare and halos around lights. If you have a traditional LASIK procedure initially and later have an enhancement with wavefront guided LASIK, there will be an upgrade fee of $400.00.
Refractive surgery is considered to be an elective procedure and is not a covered expense under most insurance plans. Many companies offer cafeteria or medical flex plans that allow you to use tax-free money to pay for your surgery. We do not submit claims for insurance, but will provide you with the appropriate paperwork to submit it yourself.
Dr. Cushing is an optometrist who will perform most of the consultation visits for refractive surgery. Dr. Cushing has been practicing for over 25 years and is an expert at dealing with difficult corneal problems. Dr. Hines performs the majority of LASIK and other refractive procedures. He has been performing refractive surgery since 1983. He has currently performed over 40,000 LASIK procedures and is the ophthalmologist for many professional and amateur athletes including numerous Denver Bronco football players. The doctors and staff at Hines-Sight are always happy to answer any questions that you may have regarding refractive surgery.