How to Choose a LASIK Surgeon

NAVIGATING THROUGH THE LASIK LANDSCAPE

Everywhere you turn these days there are LASIK advertisements. It seems like each LASIK center claims it was the first or is the best, and that could certainly be confusing. With such an important decision as choosing where to go for your eye surgery you want to be sure that you’ve made an intelligent choice. It's simple to just price compare but this is not clothing or a household item you are shopping for, it's your vision. As with anything else you get what you pay for. Some discount LASIK centers would have you believe they also provide superior care but that is simply not true. Now the best in LASIK need not be the most expensive but it definitely shouldn't be the cheapest. So how do you navigate through the hype and find a LASIK team you can trust will provide the quality you deserve? Read on to learn how to navigate your way through the LASIK landscape.

FOUR FUNDAMENTALS OF A LASIK EXPERT

When evaluating a LASIK center know that the safety and accuracy of LASIK being performed at different centers is not equal. LASIK is not simply performed with the push of a laser button. A laser reshapes your cornea underneath a protective corneal flap. It is the flap that makes LASIK so convenient and fast. And it is the expert creation and handling of the flap by the LASIK surgeon that makes LASIK eye surgery a success; therefore a successful LASIK treatment will depend on four basic factors:

A well trained surgeon
An experienced surgeon
A surgeon that cares enough to pay very close attention to his or her patients before, during and after surgery and thereby screens out poor candidates and modifies unexpected outcomes to obtain an excellent result.
State of the art laser technology

WHAT TO LOOK FOR

Fellowship Training:
True sub-specialists in all fields of medicine do further training in their area of subspecialty. This is called a fellowship which usually lasts one to two years. For ophthalmology excellent fellowship programs have existed for many years for such areas as glaucoma, corneal disease and retinal disease. Several refractive surgery fellowships have recently begun to train young surgeons in LASIK in depth. Ask your surgeon if he or she is fellowship trained in LASIK (not to be confused with a fellowship in cornea that included no hands on training in LASIK). Whether the surgeon answers yes or no ask where and for how long they trained in LASIK.

Experience:
In addition to LASIK education ask how long the surgeon has been performing LASIK and how many cases he or she has performed. Despite the best education there is no substitute for experience. Look for a surgeon who has performed over about 5,000 cases.

Attention to Detail:
An extremely important clue to quality care is how carefully the surgeon evaluates your eyes prior to and after surgery. Some laser centers use a system where the surgeon does not examine the patients in the days before or after surgery. They delegate this all important task to a non-surgeon, an optometrist. As with any surgery you expect to receive the skill of the surgeon examining and evaluating you carefully before, during and after your procedure. So, look for a surgeon that will examine you before surgery, evaluate his or her findings and discuss with you the plan of action for your particular case. After the surgery the surgeon should again examine you and plan your postoperative care. Other technicians and doctors may be involved in your care as well, but there is no substitute for the in depth knowledge of the surgeon for your pre and postoperative care.

Technology:

Some laser centers can be misleading when it comes to describing the accuracy of the results from their laser (see Accuracy below). Let’s look at these three significant aspects of laser vision lasers so you won’t be so easily mislead.

CUSTOM LASIK Capability
With the approval by the FDA in 2003 of WaveScan technology enabling CUSTOM LASIK, the whole ballgame has changed. Two of the most commonly used wavefront guided custom treatments are the Visx CustomView and Ladar Vision Custom LASIK. In a FDA Custom LASIK clinical study it was found that with the VISX CustomView 98% of patients were corrected to 20/20 or better while with the Ladar Vision Custom LASIK only 79.7% were corrected to 20/20 or better. When comparing Conventional LASIK to CUSTOM LASIK a multicenter clinical study determined that with Conventional LASIK, 20/20 vision is attained during the the first treatment about 70% of the time. When Visx CustomView is used vision of 20/20 or better was attained 98% of the time. Some advertisments offering a very low price can be deceiving as they are usually not for CUSTOM LASIK. Make sure that while researching different LASIK centers you ask the price on their CUSTOM LASIK laser treatment; usually there will be a significant increase in the price for the custom treatment. Also since the workup (evaluation) for a custom treatment takes significantly more time such centers may be prone to recommending a conventional treatment even if they charge less for it. We highly recommend you have a wavefront guided custom treatment if it is available.
Tracking Lasers are Better
Eye tracking technology enables a laser to lock onto the center of a patient’s pupil and follow it even if the eye moves. This helps to guarantee a consistent delivery of laser energy to the center of one’s cornea and this allows a smoother and more accurate change in the corneal shape resulting in sharper vision with less chance of halos, glare and ghost images. With eye tracking technology both the patient and surgeon can relax and feel more assured that the treatment is taking place in the correctly centered location on the cornea.
VISX S4 versus Ladar Vision Tracking:
- Unlike Ladar Vision Tracking which was adapted from military tracking technology, VISX designed its tracker specifically for ocular laser surgery use.
- Visx does not require annoying dilated drops while Ladar Vision does.
- With VISX the laser automatically locates the center of the pupil and activates the tracker. With Ladar Vision a picture is taken of the undilated pupil. The pupil is then dilated and the center of the dilated pupil (which can dilate irregularly) is mathematically derived. This leaves some room for error in locating the pupil’s center with Ladar Vision.
- With both lasers, if the eye moves, the laser will follow it still locked onto the center of the pupil, but only with VISX will the laser immediately stop if the eye moves more than 1.5 mm. away. If the laser continued its treatment beyond this point the tracker would indeed keep it centered but the treatment would be at too great an angle for a good quality result. This "passive" tracking ability of the VISX tracker is another reassuring feature of VISX technology that is not present with Ladar Vision.
- Both trakers adjust for vertical and horizontal movement, but only VISX adjusts for a rotary movement of the eye by a sophisticated technology known as "Iris Registration". This ads further to the excellent results obtained by a VISX wavefront guided custom treatment.
Lasers Should Not Waste Precious Corneal Tissue
If the laser treatment goes too deep the cornea loses its structural stability and becomes irregularly shaped providing blurred vision even with eyeglasses. What you want is a laser that preserves the most corneal tissue. Of all the lasers VISX does this best. It takes about twice as long to perform a treatment with Ladar Vision and B&L lasers than with VISX, and in doing so over 4 times the volume of precious corneal tissue is removed with the B&L and up to 25% more with Ladar Vision.
Inralasik In 2002 the FDA approved the IntraLase Femtosecond Laser for customizing the creation of the flap in the first critical step of the LASIK procedure. Studies have shown that creating the flap with this computer controlled laser is 100 times more accurate, safer, and reduces the likelihood of post operative complications as opposed to the conventional approach where a surgeon uses a handheld bladed mechanical device called a microkeratome. Further studies have shown that patients receiving IntraLase enriched LASIK procedures reported fewer cases of dry eyes, and achieved better quality vision due to fewer incidences of glare and haloes.

Accuracy:
In the end always ask about outcomes. What percent of the laser center's patients see 20/20 or better without eyeglasses and what percent end up needing a repeat procedure to fine tune the result (an "enhancement", see Enhancement Rate below). Accuracy rates will vary depending on whether you are talking about nearsighted patients or farsighted patients and the amount of the prescription being treated as well as the amount of associated astigmatism. The national average for the attainment of 20/20 for the full range of nearsighted and astigmatic prescriptions is about 70% for Conventional LASIK. The VISX CUSTOM LASIK clinical study attained 20/20 vision an amazing 98% of the time.

Safety:
Be sure to ask for a center's safety rate. Serious complications leading to permanent and very blurred vision should be very rare (less than 0.1%). Mild complications leading to permanent but mild distorted vision occurs after LASIK about 1% of the time as a national average. With an excellent surgeon that carefully examines you before and after surgery and utilizes the latest technology this incidence should be even lower especially if Custom Excimer technology is available along with the use of the IntraLase laser.

Enhancement Rate:
Research the enhancement rate of the center (the percent of time the LASIK surgery needs to be repeated to eliminate a lingering prescription significant enough to cause blurred vision without eyeglasses). The enhancement rate reflects the accuracy of the LASIK performed at a center. It's nice that LASIK can be repeated, but it is also nice if the laser center can offer you their average enhancement rate. The national average is about 10% to 15% for the full range of prescriptions utilizing Conventional LASIK and it should be significantly lower with Custom LASIK.

WHAT TO IGNORE

Board Certification:
When reviewing the curriculum vitae of the surgeon be aware that some items can look good and help to fill up a page, but are meaningless as far as your LASIK outcome is concerned. For example, many surgeons will state that they are Board Certified. This is important but be aware that this Board Certification is not as distinguishing a qualification as you may think since 99% of the ophthalmic surgeons in Richmond are board certified in general ophthalmology. Some list that they are Diplomats of the American Board of Ophthalmology. All this means is that they are board certified ("diplomat" is the word used for board certified).

Professional Societies:
Some list the various professional societies they are members of (Va. Society of Ophthalmology, the International Society of Refractive Surgery, etc.). These are open societies to those willing to pay dues and are a poor clue to the skill of the surgeon.

Education:
Even a list of the general educational background of the surgeon may not be very helpful for the understanding of his or her skill level for the subspecialty of LASIK. Undergraduate school, medical school and even the Ophthalmology training programs are far removed from the practice of LASIK. Hands on LASIK training is not offered as part of Ophthalmology residency training. LASIK is usually learned in only a two or three day course after the surgeon is already in private practice (there are some fellowship trained LASIK surgeons but they are the exception to the rule). The surgeon then must go on to perfect the technique on patients as well as observing others operate and reading surgical journal reports and attending surgical conferences.

Experience:
Some corporate LASIK centers have setup a national network of Optometrists (non-surgeons) to examine the patients before and after surgery. These corporations have their surgeons flying or driving to different cities across the United States only showing up to perform LASIK surgery. These surgeons never examine the patients prior to surgery and leave immeditely after the surgery is completed. Such activity enables these surgeons to operate on huge numbers of patients, but don't be misled. Experience is very important, but when the surgeon is only involved in your case on the day of surgery other very important aspects of care then become much more of an issue.

Celebrity Testimonials:
We all are influenced one way or another by the powerful marketing technique of product endorsements by famous people. But in evaluating a surgeon this is another poor clue. In some large cities where sports superstars and movie stars live this has become a commonly used marketing technique by some laser centers. Influential? Yes. An intelligent way to pick a surgeon? No.

Optometric Referrals:
We certainly respect the invaluable role of optometrists (non-eye surgeons) in the delivery of eye care. And we respect the relationship you may have developed over the years with your local optometrist. But you must be aware of "co-management". In co-management Optometrists are paid for each referral to a LASIK surgeon and for examining the patients for the surgeon before and after the surgery. Co-management may be a reasonable option for you if your Optometrist is experienced at following LASIK patients and he or she works closely with an experienced and conscientious LASIK surgeon. However, what all too often happens with co-management is that the Optometrist and not the surgeon is the only one examining you before and after surgery. Co-management practiced in this way is of poor medical quality. In regards to Optometric Co-management we recommend 1) you are carefully examined before and after surgery by the surgeon, and 2) you evaluate for yourself the local LASIK surgeons available along with any LASIK surgeons your optometrist may refer you to, bearing in mind that your optometrist is being paid to work with the surgeon you are referred to.

A Very Cheap Price:
In Richmond when you see LASIK advertised for a very cheap price, expect that this will exclude being examined by the surgeon himself the days before and after the surgery, and it will be performed at a center that defines 20/40 and not 20/20 as success.

LASIK is an extremely safe and accurate procedure when performed by a well trained and skilled surgeon who is there for you when you need him or her. What you want to look for is a masterful surgical team that will make your LASIK experience seem like a few effortless minutes resulting in clear vision. Many may claim that they are such a center, but now you have the tools to better research who actually is. So find a great one, relax and enjoy the LASIK experience!

Why Choose Lipstock LASIK and Cataract Center?