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Interviewer: When you think of vision correction surgery, most people think of Lasik. It's not the only option. We'll discuss what the other treatments might be next on The Scope.

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Interviewer: We are in the office of Dr. Amy Lin today. She's an ophthalmologist at the Moran Eye Center at the University of Utah. Dr. Lin, first of all, tell me why someone would even need to go get Lasik.

Dr. Lin: People get Lasik to get out of their glasses or contact lenses. They want to correct their nearsightedness or their farsightedness or their astigmatism. That's why someone would want to have Lasik.

Interviewer: That's not the only option, I'm hearing. There are other surgery options besides Lasik.

Dr. Lin: That's correct. The most common alternative to Lasik is something called PRK. PRK was actually the precursor to Lasik, but we still do a lot of PRK nowadays because there are certain advantages with PRK. And it does the same thing as Lasik, corrects nearsightedness and farsightedness and astigmatism. Instead of having a flap in the cornea like there is with Lasik. With PRK, there is no flap in the cornea, but your eye has to heal over naturally.

Interviewer: When a patient comes to the office and they ask you for suggestions of what treatments and what surgery they should do, how do you decide Lasik is better for you or PRK?

Dr. Lin: We do a whole variety of measurements in the office. We measure the steepness and the shape of the cornea. We measure the thickness. We measure the prescription in the eyes. And based off of that data, we decide is the cornea thick enough for Lasik and PRK because you do need a thicker cornea for Lasik. Is the prescription too high for Lasik and maybe still ok for PRK? That's kind of one objective measure that we have for choosing one or the other.

There are other parameters that we look at. We actually look at the patient and if they have a lot of dryness in their eyes, like they can't wear the contact lenses for a long time because their eyes become too dry, with Lasik, we know that you get a lot of dry eye afterwards than with PRK. If you have dry eye existing, it may be a better option to go with PRK rather than Lasik so you don't worsen your dry eye.

Interviewer: When your doctor tells you that they recommend PRK as your treatment, does that mean that you are not a candidate for Lasik? Can you not do Lasik if you are recommended PRK?

Dr. Lin: Usually, people are either candidates for both or candidates for just PRK. If a doctor recommends to you that they recommend PRK, usually, it means there's something that usually bothers them in Lasik and they think it might be too risky to do Lasik, but it would be safe to do PRK.

Interviewer: Now, are the outcomes of both of the surgeries the same?

Dr. Lin: Yes, the outcomes are the same. When they do the studies that compare PRK versus Lasik, the visual outcomes are the same. PRK takes a lot longer to heal whereas Lasik is a lot faster. Lasik people are saying well after a day or so. With PRK, it takes several weeks. That's not to say that you're blind for several weeks. It's just not to be quite as crisp and clear for several weeks, but the vision does get there. Interviewer: With gradual outcome.

Dr. Lin: Exactly.

Interviewer: With Lasik, from what I understand, there is a laser involved that corrects your eye vision for you. Tell me about PRK. Is that the same thing? Is there a laser involved or is it some totally different procedure?

Dr. Lin: Both Lasik and PRK have a laser involved. With Lasik, there are actually two lasers involved. There is one laser that cuts a flap and the cornea and then, there is a second laser that corrects for the vision. And with PRK, we just use the laser that corrects for the vision. After the laser procedure, with PRK, a bandage contact lens is actually put on the eye and that contact lens is kept in the eye for several days so that your eye can heal. Whereas with Lasik, there isn't any extra material put on your eye. Your eye kind of . . . it's fast and your eye is almost kind of healed at that point. There's really nothing to cover up.

Interviewer: Is there one that you would prefer over the other, in terms of their kind of better outcome long-term.

Dr. Lin: PRK could be a little bit safer and the reason is that with Lasik, there's kind of a long life risk of having additional damage to your eye if your eye gets hit really hard. We're talking hard injury like a car accident, baseball to the eye, a big fall, something like that because the cornea isn't that 100% strength. There could be additional injuries to the eye with whatever injury hits you in the eye, but if you have PRK and you get hit in your eye later on, any eye injury you would have wouldn't be any different than getting hit in your eye right now.

Interviewer: PRK is not a surgery that a patient could come into your office and say, "I want this surgery." It's something that you need to evaluate and it's a doctor-prescribed treatment?

Dr. Lin: Exactly. PRK is an elective surgery, but we still need to see if you are a candidate for it. But some people are not candidates for Lasik and some people are not candidates for Lasik or PRK. I think they're both great procedures and the only way to for you to determine that is to see a doctor, get all the testing to see if you're a candidate.

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Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Miller and I'm here with Dr. Mark Mifflin. He's the Professor of Ophthalmology and his practice includes refractive surgery, otherwise known as LASIK to many.

Now if we go to the operative day where they're going to have the procedure, is that a fairly involves surgery or is it fairly straightforward, done under local anesthetic, or do they have to be under general anesthesia? Just describe that procedure a little bit more.

Dr. Mifflin: Yeah, the actual procedure itself is outpatient and pretty user-friendly. I like to think of it that way. Amazingly, most modern eye surgery, at least on the anterior part of the eye, and this would include laser vision correction surgery, is done with what's called topical anesthesia which means we just actually numb the eye with several eye drops, maybe three or four sets of numbing drops. Amazingly, that can result in a pain-free surgery. And typically, for vision correction surgery there's no sedation, no IV, and it's done in kind of a clean setting in a laser room but the person doesn't have to change into a hospital gown or anything like that.

Dr. Miller: So patients coming in for the surgery might be anxious on the operative day. Some people are very concerned about having their eye touched, and I can understand that. That gives people a sense of squeamishness. How do you calm patients who are coming in for surgery? Obviously they're going to be awake. You mentioned that you're going to use a topical anesthetic so they're going to know pretty much what's going on during the surgery, and I would suspect a number of people would be anxious. How do you calm them and how do you get them through the surgery so that you have a really good outcome?

Dr. Mifflin: The day of surgery is actually a culmination of a long process of teaching the patient and kind of letting them know what the whole experience is going to be like, not only preoperatively, but during the surgery itself and then also the recovery phase. It's actually very easy for most people to go through. We literally handhold. We have a staff of about three or four people in the laser room. We have nurses and technicians who have been doing this for decades, some of them. So anything from gentle coaching by the surgeon in which there is constant verbal interaction. Some people even call it a vocal local, meaning kind of calming the patient by talking to the patient and coaching them and kind of telling them what to expect.

Dr. Miller: Vocal local. That's good. So I'm assuming that they've got to be completely still while that laser is performing the procedure, doing the changes, sculpting on the lens.

Dr. Mifflin: Interestingly and that . . . you're absolutely right. It's a great source of anxiety for patients. Not only, number one, we have really strong reflexes to keep things away from our eyes. That's just ingrained in us. The concept of somebody doing something to your eye is unpleasant, but again, through the educational process and also a very stepwise process where we kind of ease in to the surgery, it's amazing that pretty much anybody can tolerate it.

Part of that process again is the fact that it is pain-free and the laser technology actually tracks the eye just like a weapons technology laser or something would track a target. That's how the laser technology works, so even though the patient is a little bit worried about not looking in the right place . . .

Dr. Miller: The laser is sophisticated enough to be able to do that automatically.

Dr. Mifflin: That's absolutely right. The patient looks at a target. The surgeon is aligning the laser, and then the laser has a camera and/or lasers in it that is tracking the pupil. Between those things, I've never seen one of these laser tracker fail. It's very, very accurate. So if the patient should look away more than about a half a millimeter the laser automatically quits firing.

The actual sculpting or laser ablation typically would last between 5 and 20 seconds per eye, so it's very quick. In LASIK surgery the initial stage of the surgery is cutting a flap and that takes about maybe 30 seconds, so the actual time under the laser where they are really kind of critical things going on is really usually less than a minute per eye.

Dr. Miller: Do you usually do one eye per session or do you do them both?

Dr. Mifflin: Very early, we recognized that this was extremely reliable technology and by doing one eye at a time it was mostly just inconveniencing the patient. Rarely, we still see patients that are a little bit uncomfortable with the thought of doing both eyes and we offer that option. Most people are afraid to have this surgery, but by the time we have finished educating them and get them to the day of surgery they are very comfortable.

The other fear that patients have is that they are able to do something to cause a bad outcome, and that is actually not true. It is such a safe surgery and we have such a low tolerance for risk in an elective eye surgery like this that we have literally made it risk-free in terms of anything the patient can do to cause a bad outcome.

The patient can put themselves at risk by being non-compliant with postoperative care. There are medications, prescription eye drops that are necessary. There are certain protective and common sense things that are required during the healing period. Barring that, it's almost risk-free and that really boils down to having a good conservative screening process that steers away people who are better served by wearing glasses or contact lenses.

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Dr. Miller: You don't want to wear your glasses and you don't want to use contacts. Are there other options? We're going to talk about that next on Scope Radio. I'm Dr. Tom Miller.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Today I'm here with Bala Ambati and he is a professor of ophthalmology here at the University of Utah. Bala, what's the story? If you don't want to wear glasses and you're sick of even trying contacts or you can't wear them for whatever reason are there other options?

Dr. Ambati: We now have options for patients at almost any age to get rid of the need for glasses or contact lenses. In the young adult population, I'd say between the ages of 20 and 45 the primary option of course is LASIK or laser vision correction. In patients that have very high near-sightedness we can do what's called and intraocular contact lens, placing a lens inside the eye between the iris and the lens.

Dr. Miller: Let's go back for a second. LASIK, so that's actually a laser that cuts into what, the cornea, the lens? What does it do?

Dr. Ambati: LASIK, laser vision correction relies on creating a flap within the front quarter of the cornea, laying that flap off to the side and then reshaping the remaining cornea, the bed of the cornea, and then putting the flap back on.

There are some patients who are very near-sighted who would not be candidates for LASIK because the amount of laser would be too much for their eye. And in that situation we can offer what's called the intraocular contact lens where you can actually go inside the eye and place a contact lens in between the iris, the colored part of the eye, and the lens, and that has also been around for several years and works very nicely for the very high near-sighted population.

Dr. Miller: Well, it sounds great that we can use Lasik in some people to relieve them of the need of glasses or contacts but are there any downsides to the LASIKs procedure?

Dr. Ambati: I would say that any time you consider doing surgery you should get a careful screening. You want to make sure you don't have something called keratoconus. We do cornea scans to look at the shape and thickness of the cornea. We'd want to see if you have any other eye problems inside the eye.

Dr. Miller: If you had keratoconus I'd suppose LASIKs would not be a procedure you would prefer.

Dr. Ambati: Yeah, I would definitely not do laser vision correction on a patient with keratoconus. It is important to remember that after age 40 the lens in the eye weakens just due to increasing wisdom and maturity and when that happens

Dr. Miller: What a nice way of putting that.

Dr. Ambati: When that happens, you start needing reading glasses. And so, if you have Lasik at age 22 or 23 you would need reading glasses at age 40. But if you never had LASIK, at age 40 you would need bifocals.

Dr. Miller: I see. That makes sense.

Dr. Ambati: Exactly. And then, as I mentioned, in the older population, in patients over 55 or 60, the options at that point to get rid of glasses or contacts would be what are called multifocal or accommodating lens implants. Lens implants that can be placed inside of the eye that can give both distance vision and near vision. That usually happens at the time of cataract surgery. And that's a wonderful technology that's come out in the last five or six years.

Dr. Miller: It sounds like we can customize vision internally now almost.

Dr. Ambati: Absolutely. Anything in the front of the eye, the cornea, the lens, we can reshape or replace and customize it based on the person's eyes and visual goals and lifestyle.

Dr. Miller: One question I had from a patient not too long ago was if you had LASIK surgery, does that prevent you from having cataract surgery later in life? Is that a problem?

Dr. Ambati: It doesn't prevent cataracts or any other eye condition. So if you have LASIK at 25 and you're going to get cataracts when you're 70 or macular degeneration when you're 90, those things are still going to happen. And you can still undergo the usual procedures for those.

Dr. Miller: What you mentioned is that LASIK is not for everybody. There are some patients that couldn't receive LASIK, you mentioned keratoconus was one of those conditions. You mentioned this intraocular lens implant. How often are you using that lens implant now as compared to LASIK surgery? Is that becoming more popular?

Dr. Ambati: I would say that in patients with more than eight or nine diopters of near-sightedness, the intraocular contact lens is probably a better option.

Dr. Miller: Are there more risks with intraocular lens implantation than with LASIK? And if not, do you expect the lens implantations to become more popular than LASIK at some point?

Dr. Ambati: Every surgery has risks. Because the intraocular contact lens involves going inside the eye, there is a higher risk of bleeding or infection inside the eye than laser vision correction which stays just on the surface of the eye. But that said, the risks are extremely low, less than 1%.

Dr. Miller: It sounds like the first you would recommend would be LASIK surgery and if the measurements for the cornea weren't quite right for that the next step would be recommending intraocular lens implants.

Dr. Ambati: First, I would talk to the patient and see what phase of their life they're in and what their visual goals and needs are. Somebody who is 70 years old is probably going to be better served with removing an early cataract and putting in a lens implant at that time. But in a patient who is between 21 and age 45 the best thing for their eyes would be LASIK, assuming they're a good candidate. And that's what we would screen for.

If they're not a good candidate because their cornea's too thin or their cornea's not the right shape then there are all of these options like PRK, lasers without the flap, intacs if they have keratoconus, or the ICL, the intraocular contact lens if they're a very high near-sighted or a stigmatism patient.

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