A Sight for Poor Eyes : Glasses? Contacts? Surgery? People with vision problems now have a broader range of corrective options than ever before.
Admit it. You’ve always hated your glasses--from the time your parents first bought you the tortoise-shell number and you became known at school as Four Eyes.
And you contacts users. You may love being glasses-free but how many of you really clean those $300 babies every night just as the doctor told you?
Well, no wonder so many people with refractive vision problems--such as the farsightedness and nearsightedness experienced by 35% of all Americans--are turning to eye surgery to free them from glasses and contacts.
The option is clearly gaining in popularity as various types of vision correction surgeries emerge and as studies attest to their safety and effectiveness.
Two recent events, in particular, have generated a high degree of enthusiasm for vision surgery:
* In October, a 10-year study on the controversial eye surgery radial keratotomy found that 70% of the RK patients still did not need glasses to correct their nearsightedness. The procedure was also found to be safe.
* Also in October, a government advisory committee recommended that the Food and Drug Administration approve the first laser device--the excimer laser--to correct nearsightedness, a procedure called photorefractive keratectomy. The excimer laser may prove to be more precise than RK, but is still experimental until final FDA approval.
Since the correction of vision via glasses and contact lenses is a “multibillion-dollar industry,” the advent of surgical correction could throw the marketplace into a frenzy as each sector lobbies to attract consumers, says Dr. Daniel Sigband, a Huntington Beach ophthalmologist and contact lens expert.
Adds Dr. Efraim Duzman, an associate clinical professor of ophthalmology at UC Irvine: “It’s a hot topic.” At a recent meeting of ophthalmologists, he says, close to 40% of the information had to do with refractive surgery.
Glasses, contact lenses or surgery? Consumers can expect their choices to widen in 1995. Here’s a look at some of the latest advances.
Radial Keratotomy (RK)
Developed in Russia, RK began generating equal amounts of excitement and criticism in the United States in the early 1980s. The procedure corrects mild to moderate myopia--nearsightedness--by making tiny incisions in the cornea in a spokelike, or radial, pattern. The cuts change the curvature of the cornea by flattening it and vision is corrected.
Critics of RK--and there were many--predicted complications and poor results. But those dire warnings simply haven’t panned out, says Dr. Robert Maloney, an ophthalmologist at UCLA’s Jules Stein Eye Institute.
“The study was very reassuring,” he says. “RK involves incisions in the eye, and that’s a frightening thing for people. But this study shows us the risks are very slight.”
The 10-year study showed that after surgery, 85% of patients had 20/40 vision without glasses--the requirement for a driver’s license--and at least 70% did not wear glasses or contacts for distance vision. Only 3% had poor distance vision and none had catastrophic problems.
The study did show, however, that RK patients may need reading glasses sooner than they would have without surgery. Most people find they need reading glasses about the age of 40. But RK may speed up this progression to farsightedness.
“That is a trade-off that people need to understand: They can see in the distance but need reading glasses sooner,” Duzman says.
But this shift to farsightedness has made some eye doctors reluctant to endorse RK.
“This is a significant problem that occurs in about 40% of patients,” says Dr. Lawrence J. Schwartz, an ophthalmologist with Cedars-Sinai Medical Center.
Still, because of rapidly improving results, Schwartz says he will start doing RK.
“There is a learning curve with both RK and the excimer (laser), which I, personally, didn’t want to be involved in. I think now people have reasonably good expectations.”
Anyone considering RK, however, should be counseled on possible side effects and complications.
Vision sometimes fluctuates from morning to evening, even long after surgery. A minority of patients also see a glare or “halo” around lights at night. And, if the surgery is not precise enough, additional surgery may be needed to sharpen vision.
RK takes about 30 minutes per eye. Patients are given eye drops to anesthetize the cornea and can usually return to their usual routines in two days. The second eye is corrected about two weeks after the first.
Like other refractive eye surgeries, RK is not covered by insurance. It costs about $1,500 per eye.
Patricia Webber of Brentwood underwent RK in 1992 because she was leaving for a European vacation, and “the thought of leaving without glasses and contacts was wonderful.”
Like most RK patients, Webber, 46, is pleased with the results.
“In the earthquake, I would have been panicked trying to run around and find my glasses. Everything was thrown on the floor.”
Automated Lamellar Keratotomy (ALK)
Less well-known than any of the other refractive eye surgeries, ALK is also gaining converts.
The surgery is for people with higher levels of nearsightedness, beyond what is recommended with RK. This is noteworthy because these people cannot see even a few feet without glasses or contacts.
In ALK, a layer of the top segment of the cornea, only 1/200 of an inch thick, is lifted up as a machine called a microkeratome glides across the cornea. To treat nearsightedness, a precise amount of corneal tissue is removed. The cap is then placed back on without stitches. Because some tissue has been removed, the cornea is flattened, reducing or eliminating nearsightedness.
The technique can also be used to make the cornea steeper and correct low levels of farsightedness.
“ALK is correcting farsightedness beautifully, but only in small amounts,” says UC Irvine’s Duzman, who adds that ALK is “taking off like a rocket in popularity.”
ALK was tried decades ago by hand but was too imprecise, says UCLA’s Maloney. But the recent invention of the microkeratome has made it much more accurate and safe.
“So there has been a resurgence in this procedure,” he says.
Most ALK patients improve enough to function without glasses or contacts, Maloney says. Glasses may still be needed for driving or watching TV.
As with all refractive eye surgeries, “The major limitation of ALK is that it is not possible to promise you perfect vision after the procedure,” he says.
Patients may also see halos, and vision may change over time, resulting in the need for more surgery or reading glasses.
The costs are similar to other refractive eye surgeries.
Photorefractive Keratectomy (PRK)
The long-awaited excimer laser that is used in PRK may receive FDA approval within two years to correct nearsightedness. And, while highly touted, it, too, has its pros and cons, says Maloney, who began testing the laser in 1989 with government approval.
According to the government panel that recommended approval, 78% of the patients gave up glasses or contacts despite vision that wasn’t perfect. The panel estimated that 3% to 7% of patients still had vision problems after surgery.
The panel said that doctors must be specially trained, and that patients must be warned that only moderate to mild conditions can be helped and that certain risks are involved, such as some vision loss and glare problems.
“It was the great hope. People thought it would allow precision in the correction of vision. But the main limitation of these surgeries is that we can’t guarantee people perfect vision. We almost always make people see better, but it may not be perfect,” Maloney says.
Patients with less-than-satisfactory results may need enhancement surgery three months later, he says.
PRK flattens the cornea using a mixture of argon and fluorine gases to produce a thin uniform beam of invisible ultraviolet light energy. When focused through a lens system, it vaporizes corneal tissue.
“The advantage of the excimer is that it’s less surgeon-dependent,” Schwartz, of Cedars-Sinai, says. “It’s computerized and more predictable, so many ophthalmologists have advised patients that this might be a better alternative.”
Possible side effects include scarring that can cause blurry vision or haze that cannot be corrected with glasses or contacts. About 3% of patients may experience this problem, Maloney says.
Moreover, vision may not stabilize for about six months. As with RK, about 5% of patients may experience a glare or halos around lights.
“It almost always improves with time. But it can be difficult to live with,” Maloney says.
“The haze issue is difficult,” Duzman says. “When you are dealing with a totally elective procedure on eyes that are normal, that is unacceptable. Each problem is not very common. But in combination, it will create problems in the FDA before it is approved.”
One advantage of PRK over radial keratotomy is that patients may not need reading glasses any sooner than normal, Maloney says.
Joyce Puckett, 42, has no regrets about plunking down $3,000 for PRK. It freed her from eyeglasses, which affected her self image; she found contact lenses to be too inconvenient.
“This has changed my entire outlook on life,” the Eagle Rock woman says. “I have lost 57 pounds, and my self-confidence has improved immensely. You think back to your days as a child, when everyone teased you because of your glasses. Even as an adult, I never wore my glasses to job interviews because I viewed that as a handicap.”
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Surgery to Correct Vision Problems
Two recent reports have lauded the safety ad effectiveness of eye surgery t correct vision problems, such as nearsightedness. Although some procedures are still under investigation, many ophthalmologists predict more patients will eventually toss out their glasses and contacts in favor of surgical correction.
How They Work
Radial Keratotomy
The cornea is resculpted by several small slits, similar to the spokes of a wheel. The procedure takes 30 minutes per eye; each procedure is done about two weeks apart.
*
Automated Lamellar Keratotomy
The cornea is reshaped using an instrument called a microkeratome. A layer of the cornea--the cornea cap--is lifted up as the microkeratome gently glides across the cornea. This procedure is now used only for myopia and for low levels of farsightedness.
*
Photorefractive Keratectomy
First, the outer layer of the cornea is removed by surgery. The excimer laser beam is then set to vaporize a certain about of tissue, usually very tiny, to reshape the cornea.
*
Sources: Dr. Robert Maloney; Summit Technology Inc.
