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Dr. Barrie Soloway, Surgical Director of Vista Alliance Eye Care Associates and Director of the Autonomous LADARVision Center of Excellence at the New York Eye & Ear Infirmary's Vision Correction Center, appeared in the October 1999 issue of Health, a national magazine.  Here is the complete article.

Health, October 1999

A Clear-Eyed View

Surgery to Improve Vision is all the Rage. But are There Hidden Risks?

By Elizabeth Krieger

Michael Maxim's nervous voice floats up from beneath several layers of sterile plastic. "Yeah, I feel a little pressure now," he says quietly. His right eye is under the scalpel of Richard Abbott, co-director of cornea and refractive surgery at the University of California at San Francisco's Beckman Vision Center. Through a minuscule incision, Abbott digs two tiny tunnels around the outer edges of Maxim's cornea and inserts two slivers of plastic called Intacs. On a television monitor above the table, the 33-year-old engineer's bulging, anesthetized eye appears terrified and vulnerable.

Just 30 minutes later, Maxim feels well enough to join a friend for a plate of chow mein in the hospital cafeteria.  As he leaves the hospital, his bandaged eye is still sensitive to light and pressure, he says, but stray eyelashes have given him more trouble.

By the next morning, his vision in the treated eye was 20/40 and improving.  "For the record," he said of the procedure, "going to the dentist is worse."  Two months later, Maxim had the Intacs removed.

Having your eyes done used to mean surgically lifting droopy lids, but no longer.  In hopes of escaping the tyranny of spectacles and contact lenses, nearly half a million Americans have offered up their orbs for a more invasive form of vision correction: surgery.

Intacs are the newest form of surgical vision correction -- approved for general use just last spring --and the only procedure that's reversible if results aren't up to snuff. Even more popular is Laser In Situ Keratomuleusis, or LASIK, a stream-lined version of a surgical technique that's been around for a dozen years.

The allure of either operation is easy to understand: no more midnight fumbling for glasses when the phone rings or frantic scrambles for a lost contact on a busy sidewalk.  "Throw away your glasses," one splashy ad gushes.

But can you? Should you?  While many problems that dogged earlier techniques have indeed been ironed out, the Federal Trade Commission has called the fevered pitch of many ads misleading.  Even the Council for Refractive Surgery Quality Assurance  -- a consortium of experts who perform the techniques -- says that only about half of all patients end up with 20/20 vision six months out.  Harsher critics worry that amid the excitement, the risks of side effects are being underplayed. Before you let your own eyes go under the knife or laser, here are a few things to consider.

How Blind Are You?

The acuity of your vision depends largely on the shape of your cornea, a transparent cap that covers the iris and pupil.  As light enters the eye, the cornea helps focus the incoming image.  If your cornea's too steeply curved, you're nearsighted --- distant objects look blurry. Too flat and you're farsighted, unable to sharply focus on people or objects close at hand.  If you have astigmatism, your cornea is steep and flat by turns. In theory, at least, refractive surgery can eliminate all three flaws by slightly changing the cornea's shape. But take note: If you've suddenly found yourself struggling to read the phone book or thread a needle, chances are the lens of your eyes have started to stiffen, as happens in most adults by age 45. None of the surgical techniques introduced thus far can eliminate the need for reading glasses.

What Are the Risks?

In 1978, American doctors began to use a technique called Radial Keratonomy (RK), which is essentially a series of incisions made around the iris to flatten the cornea. That eased myopia, but the deep cuts were painful as they healed into scars that often clouded vision.  In 1987, Photorefractive Keratectomy  (PRK) produced better results by using a laser to more lightly sculpt the cornea, but haziness and discomfort often persisted.

The solution was LASIK, developed around 1990. LASIK skips scraping the top of the cornea in favor of sculpting beneath its surface; it's known as "flap and zap" in surgery circles. The doctor first numbs the eye, then carefully slices across the cornea a flap the thinness of an onion skin and holds it out of the way. Next, with the eye looking like a peeled grape, the laser goes to work shaving off less sensitive cells underneath.  After about a minute, the flap's replaced, and the procedure's over.  The flap re-adheres to the eye much as plastic wrap does to Jell-O.  Recovery time's quicker than with PRK, and there's little pain; most people return to work in a day or two.

LASIK'S success rate is impressive, too -- at least for some surgeons. Barrie Soloway, co-medical director of the New York Eye & Ear Infirmary's Vision Correction Center, says three-quarters of his patients end up with 20/20 vision; another 20 percent get at least 20/40. While initially just for nearsighted patients, LASIK can now help those who are mildly to moderately farsighted or who have astigmatism as well.

But every operation has a margin of error, and with LASIK, the trickiest part is creating the flap. "If it's not quite right -- too ragged, for instance -- and the surgeon goes ahead and does the lasering, the eye won't heal properly," Soloway says.  "There may be scarring." To reduce the chance of a mishap, he says, choose a highly experienced surgeon from a reputable center who has enough humility to know when to call off the procedure.  (It can be attempted again once the eye heals.)

Unfortunately, certain side effects aren't predictable and can never be undone.  If the calibration of the laser is off -- which experts say can happen in the hands of even the most skilled doctors -- you could go into the operating room nearsighted and end up a bit farsighted, or vice versa. From one to five percent of patients struggle with chronic glare after LASIK, or see halos around bright lights.  Such complications, especially noticeable at night or while driving, can be a nuisance for some people and a nightmare for others, says Walter Stark, a professor of ophthalmology at Johns Hopkins Medical Center's Wilmer Eye Institute who's seen some of the worst complications from botched jobs.

You shouldn't consider LASIK if you have diabetes or any other medical condition that threatens eyesight, or if your lens prescription has appreciably changed in the previous five years. The stronger your lens prescription, the higher the risk of side effects; there's simply more work to be done in the eye. It also helps to have a fat wallet: LASIK runs about $2,500 an eye, and insurance companies rarely cover the cost.

Joy Graziano, 60, of Overland Park, Kansas, was happy to pay that price, even though her distance vision after LASIK is less sharp than with contacts. "Before, if you were standing in front of me and I didn't have my lenses in, I couldn't tell who you were," Graziano says.  "Now I can."

If you're not quite so blind, Intacs may be a better choice. (So far, Intacs are an option only for the mildly nearsighted, though other groups are likely to be included eventually).   The crescents of plastic placed around the edges of the cornea subtly and precisely change its shape.  Because the center of the cornea is avoided, any scarring is usually out of the line of sight.  Tests suggest the results are on par with similarly priced LASIK, but with fewer side effects.

Intacs aren't perfect, however.  They, too, can cause glare and starburst halos around lights, particularly at night; in early tests about 4 percent of patients had the inserts removed because of these other side effects. Maxim had his taken out after being dogged by unrelenting double vision and light sensitivity.

Though disappointed the Intacs failed him, Maxim doesn't regret having tried the procedure. "I asked if I could keep them," he says. "I'll put them in my good-ideas-that-didn't-work box."  He still feels he's a walking advertisement for their strongest selling point: reversibility.  His uncorrected eyesight is now about what it was before.  With contacts, he has 20/20 vision.

What Are Your Goals?

In the end, how satisfied you're likely to be with either Intacs, or LASIK depends mostly on how poor your vision is beforehand and how bothersome your find contacts or glasses.  If even a mild improvement in vision would make you happy, you're less likely to be put off by the risks or common side effects.

"I prefer patients who tell me, "I want to be able to go to the beach and see my towel,' not perfectionists who say, "I don't want to ever wear glasses or contacts again," says Soloway.  "I can't guarantee that, and anyone who does is lying." Remember: Even at their most effective, Intacs and LASIK just buy a little lens-free time.  Surgery or not, nearly everyone eventually needs glasses to read.

If you don't want to be dependent on glasses or contact lenses call Vista Alliance Eye Care Associates, The New York LASIK doctors toll free at 1-888-NYLASIK (1-888-695-2745) for more information on any of our Vision Correction procedures (LASIK, INtacs, ICL or SRP), to schedule a personal evaluation to help you determine the right prodecure for you, or to register for one of our classes or  seminars