Correcting Your Vision: Advice and Opinions from an Eye Surgeon Health Radio April 17, 2007 Mark Walker, M.D. Introduction

Transcription

1 Correcting Your Vision: Advice and Opinions from an Eye Surgeon Health Radio April 17, 2007 Mark Walker, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Hello, and thanks for being with us live on Health Radio. Andrew Schorr here. Some days we approach the program when we're very excited and upbeat. Obviously the whole country is kind of down today with the events at Virginia Tech yesterday, and as we learn more we'll kind of explore what happens to someone where they suddenly can become violent. We don't know much at all as I was watching the news about this student from South Korea who they say was the perpetrator of this terrible massacre, but we'll cover some mental health issues for sure as we continue on Patient Power live every weekday and begin to understand the more common things and also when there is some more extreme event like this an how could this be perpetrated. Fortunately, this is very, very rare, and so most of the time for us we go on with health issues that are right in front of our face, and one of them is how is our vision? So, you can't turn on the radio or watch TV or open the newspaper almost if your eyesight is good enough to read all the fine print and not hear about LASIK surgery with an "I" or LASEK surgery with an "EK" instead of "IK" or even another one, PRK, and everybody wants to say, 'Well, gee can I get rid of my glasses?' I wear glasses, and increasingly as I've gotten older I really depend upon them, so I've got those progressive lenses. My wife wears contacts, but when she takes those off she's got pretty thick glasses, etc. Wouldn't it be nice if you could throw your glasses away? That was always the idea that would be great, but how do you do that and go into it shall I say "with your eyes open" or go into it with all the facts, and that s what Patient Power is about, and also understand what are the technologies, how are they changing, what are the procedures, what are the qualifications you should be looking for in an eye surgeon, and where does price come into it because a lot of times you'll see ads, and I know where I am in Seattle, you know, the Canadian clinics up there started years ago, and they said, 'Oh it's so many hundreds of dollars per eye,' and I knew people who were just shopping price. Is that the way you should treat your vision? Today we're going sort of do an up close and personal with a refractive eye surgeon. That means he specializes in these areas of eye surgery. That's Dr. Mark Walker, and he is with 1

2 a private medical group called Restore Eye Centers, and we want to learn more about that. They're here in the Pacific Northwest where I am, but he's very well trained both from the University of Texas and the University of Washington. I want to understand more about what they do both at Restore Vision Centers and his window in the world of where we are with eye surgery and go into it clearly understanding how there are questions you need to ask as you pursue this, so let me welcome our guest, that's Dr. Mark Walker who's joining us also from near Seattle in Renton, Washington. Dr. Walker, welcome to Patient Power. Thank you, Andrew. Surgical Correction Techniques to Restore Distance Vision Dr. Walker, we hear these terms, LASIK, LASEK, PRK, but particularly LASIK with an "I", and you know, there's no shortage of ads around, and people say, 'Oh great idea.' You know, in and out, it's all done, and then I can see 20/20 or something like that. Put it in perspective. It is a, you know, an invasive procedure, and in the case of LASIK I know you're using a laser to cut a flap in the eye. Who is this right for generally, and then help us understand the procedure. Of course it has become fairly commercialized, and we need patients to understand that it is a real surgical procedure. We are operating on the eyes, and the results are permanent. Who is it for? It is for patients who want to improve their distance vision. The majority of patients we get are nearsighted. The FDA says that patients have to be over the age of 18. There's not a real upper limit in age. I've done patients even in their 70s. The majority of older patients in their 70s and even 60s sometimes aren't right for refractive surgery. Sometimes they would be better off served with cataract surgery as the lens inside their eye ages. The important thing to understand is this is a distance correction, and so people can have good distance vision after this procedure basically for the rest of their life, but as they get over 40 and begin losing their near vision, otherwise known as presbyopia, they will still for the most part be in reading glasses afterwards. So the idea is though, but let's take for driving or things like that. People who need glasses to drive, this would be a help for them? Absolutely. 2

3 Okay, so people look at this and say, 'Oh and I'm going to look better. I won't need to wear glasses all the time so I'll look more like I did when I was younger.' So that's attractive. Now this has gone on for 10 years or more now, but the lasers you use and the tools you use continue to evolve. Now there are terms like wavefront and maybe you can explain that. You're sort of using new tools, so it's evolving. Hopefully it's getting better. Yes, that is correct. We've been doing laser refractive surgery for almost 20 years now. They used to do PRK before LASIK came along, and basically the laser was the same. It just involved not making a flap, whereas with LASIK we make a flap, and both of these procedures are very good. Recently in the last two or three years something known as wavefront technology has been developed, and it's basically the same technology they used in the Hubble telescope that NASA has used to see really far away objects, and it's more of a customized correction based on each individual patient's eye, and it's able to correct the smaller imperfections in the cornea that regular LASIK and PRK just weren't able to correct. Okay, and then there are other terms I'm hearing about like Epi-LASIK? What does that mean? That is correct. The very first procedure that came along was called RK, and that was basically where they took a small scalpel and made tiny incisions in the cornea by hand. That was reasonably successful; however, it severely compromised the structure of the cornea, and nobody really does that anymore. It was perfected over in the old Soviet Union, and a few people had it in the United States. Then a vast leap in refractive surgery came with the invent of PRK, which was where the laser was done basically on the surface. You would scrape away a few surface cells known as epithelium, do the laser on the surface generally flattening the cornea, and this technology worked very, very well, and we still use it very often today probably one-quarter to 20% of our procedures are still PRK. The downside to PRK was that it's fairly uncomfortable for about 48 hours. We generally give patients Vicodin as well as visual recovery is fairly slow. You're in a soft contact lens for a week, and you vision is really lousy for a week down to a point where you can't drive, usually can't work depending on what you do, so they tried to find a way to not so much improve the visual results as improve the recovery time, and that's when LASIK was developed. It's a procedure where we make a flap at the front of the cornea, lift this flap, do the laser underneath it, and then put the flap back down so the patient is left with their original corneal surface and by doing that it's much more comfortable. You have about five hours or so of discomfort, and the next day you are seeing very, very well. 3

4 So people discuss PRK and the advance that was LASIK. It's not really a visual advance. The visual results between LASIK and PRK are very similar. It's more decreasing the recovery time is what LASIK adds. Now I did read somewhere though that the thought was, at least they cited some cases where while somebody had more of a recovery with PRK, their vision, they had PRK in one eye and I think they had LASIK in the other, in their case, and this is just anecdotally of course, the PRK eye did better over time. There have been many conflicting studies. Most refractive surgeons would say that in their hands final visual results are the same. Now, there is a subset who believe that just making the flap in general can cause some visual aberrations. In theory at least, the flap is supposed to be refractively neutral meaning it doesn't affect the vision one way or the other. Doctor we're going to take a break. Hold the thought. We're going to continue our understanding of the surgery, the flaps, possible complication, etc., as we continue our discussion with a refractive eye surgeon, Dr. Mark Walker, on Patient Power. We'll be right back. Welcome back to Patient Power live on Health Radio. I'll mention a couple of things coming up. One tonight, tonight at 7:00 p.m. Central, 8:00 Eastern, and 5:00 Pacific, that's right, I'm doing it, we have a special edition of Patient Power on complementary and alternative medicine with the folks from the M.D. Anderson Cancer Center in Houston, so if you know somebody going through chemotherapy or they've been treated with some of the more aggressive cancer treatments today, you wonder well is there anything that can help me through it, help me get well, or even cope with the side effects of cancer care, and the answer is yes, but you want credible information. We're going to have with us Dr. Lorenzo Cohen who runs a whole integrative medicine center there at the University of Texas M.D. Anderson Cancer Center, which is one of our very top cancer centers in the world. That's live tonight, 7:00 p.m. Central on Health Radio, so please give us a call, send us a question, and tell your friends and listen in. Let's go back to talking about refractive eye surgery today. These procedures that have different acronyms, LASIK with an "I", LASEK with an "E", PRK, wavefront, custom LASIK, all these. You can read up on it. If you look at a back issue of "U.S. News and World Report" the news magazine, the March 5th issue had a whole cover story called "The Eyes Have It" and certainly tens of thousands, hundreds of thousands of people have now had these surgeries, particularly the LASIK one now. With us on the line is Dr. Mark Walker who's in the Seattle area, who's with the Restore Vision Centers, and does all these procedures basically and has feelings about it, which we've been discussing. 4

5 Dr. Walker, before the break we were talking about sort of the debate between PRK and LASIK and that with LASIK you make a flap. So what are things, now not everybody can have LASIK, and maybe you can explain about the thickness of the cornea and where that comes in, but if people could have any procedure, what's the debate about the flap with LASIK and whether it's a good thing or not? Of course. With LASIK I mentioned that we make a flap at the front of the cornea. This flap is generally about a third of the thickness of your entire cornea, and there are people out there who have thin corneas, thin enough that it won't support having a flap cut in those, and those are generally people who are better off having PRK. There is a misconception out there that because PRK came before LASIK that LASIK is a much better procedure, that it's the more advanced technology, and that's not true. As I mentioned, visual results are basically identical, and PRK in general is you get the same eventual results without the flap. I mentioned the healing was a bit longer, and it takes longer for vision to come around. We, in our practice at Restore Vision Centers, we do about 20% to 25% PRK. About half of those are patients that have to have PRK simply because they're not a good candidate for LASIK usually because their corneas are too thin, but the other half are elective PRK, patients that generally just want PRK rather than LASIK because they don't want to have to deal with a flap. With LASIK, it's a very safe procedure, but you do have a flap on your cornea, and it never attains its original strength, and so months and even years down the line if you took a sharp enough trauma to your eye it is still possible to dislodge that flap. Now, it's very rare, but it is possible. Many of these elective PRKs that we see are people who are at somewhat greater risk for having that happen to them; firemen, police officers, athletes, generally people who are very outdoorsy, people that could certainly get some eye trauma at some point, and so they will in general have PRK and not have to deal with having a flap on their eye basically for the rest of their life. Dr. Walker, let's back up a minute. So explain a little bit about the physics of vision. What are you doing with any of these procedures that enables someone to have better distance vision? Is it the way the lightwaves are handled? Just explain that to us in sort of a basic way. Of course. About 80% of our patients come to us with nearsightedness, and all nearsightedness means is that your eyeball front to back is too long for what you want to see, and so light rays that come into your eye are actually focused in front of the retina rather than on the retina, which is what you need for good, clear distance vision. So all 5

6 we're doing with this laser is we're flattening the cornea, in other words, shortening the length of the eye so that it can focus light rays on the retina. For nearsightedness we are flattening the cornea. For farsightedness, which we do see a minority of but we do see them, we are actually steepening the cornea, and it basically stays that way theoretically forever, so you're able to maintain good distance vision basically for the rest of your life. Now what about that? Do some people need follow-up surgery because their vision changes or for any reason or to fine tune what the original surgery was? Where does that come in? Absolutely. There's a phenomenon known as regression, which is when the cornea somewhat attempts to fill in what we've taken out with the laser, and the more you start with, in other words, the higher your prescription is, the more likely this regression is, and so we measure nearsightedness and farsightedness in what we call diopters, and the average amount we correct is about three diopters, but it's approved for up to even diopters, which is really, really high. These are the types of patients what we would say, you're going to have a great result, but you are more likely to regress and thus to need an enhancement a few months down the road. In general if somebody's going to regress they do so once, and they get an enhancement at three to six months or so, and then they don't regress again, and they maintain good vision basically forever at that point. Choosing an Eye Surgeon Dr. Walker, let's talk about quality. So any doctor could invest in buying a laser or the latest equipment, and they could say, 'I've got the wavefront, the this, the that,' you know, but how would you advise people? Certainly you turn on the radio or TV, and there's price competition, but what it really comes down to isn't it the skill and the experience of the surgeon too? So help, if your mother or a relative were saying, and maybe they didn't live in your part of the country where you in fact would be the surgeon, what advice would you give them on how they find where to have this done? Right, Andrew, there's a big misconception about this procedure that it is, you know, it's just like going to the store and buying anything that the lowest price you can get you're better off, and it's so pervasive now that it's almost not looked at as what it really is, which is surgery, and you have to live with these results basically for the rest of your life, and you should look at it like any other surgery. If you're having open heart surgery, are you going to immediately go to the surgeon that's going to charge you least for it, or are you going to go to the one with the most experience and who gets the best results, and that's the way patients need to look at it, and the patients who basically will call around and only find the surgeon with the lowest price, as with anything else in life, you get what 6

7 you pay for. So, there are many patients out there that wish they hadn't shopped like that because like any other surgery, experience matters, and you really need an experienced surgeon for this type of surgery. Well I imagine there's a percentage of what you do where you have people who had the original surgery somewhere else and you're having to do some correction or follow-up. I'm sure that happens. Yes, it's a fairly high percentage, and especially for the older procedures. I mentioned they used to do RK, and RK worked well for some patients, not for others, and there are some patients that come to us saying I had RK 10 years ago, and my results aren't great, can you fix me? Many times we can, and we also, as you mentioned, we get patients from other surgery centers. Back before this was FDA approved I'm sorry Dr. Walker. Hold the thought. We'll continue after the break. We're talking with Dr. Mark Walker, who is a very experienced refractive eye surgeon who does LASIK and these other procedures to help people get back their distance vision. We'll be back with more about this on Patient Power right after this. Welcome back to Patient Power. Years ago I was a television consumer reporter, and really what I realized is so important to Patient Power is really you being a consumer, and Dr. Mark Walker, our eye surgeon is with us today, was just talking about it that you've got to apply your critical thinking to this purchase, and it's often not covered by insurance, of eye surgery just like you would anything else; buying a house, buying a sound system, buying a car, you know, it makes sense, and after all this is your vision. Now I want to give you some help. There are some websites to look at. Certainly there's the American Academy of Ophthalmology, and you can go there. There's something called the Council for Refractive Surgery Quality Assurance, and actually looking on a website now that was quoted in "U.S. News and World Report" and right there they have the Council for Refractive Surgery Quality Assurance's 50 tough questions for your doctor and some responses they think that would sort of make the grade but let's ask a surgeon himself. Dr. Walker, what are things that you think, and you welcome I'm sure the questions in your own practice, that people should ask when they're considering this sort of surgery? Well, the number one question, Andrew, is probably how experienced is the surgeon. This is a type of surgery where there is a learning curve, especially with LASIK where we are creating a flap in some very delicate tissue, and this is the type of thing where you know if it's your first 10 cases or so your complication rate is probably higher than it is once you 7

8 get in your thousands, and it's not just eye surgery. I'm sure it's that way with any surgery, and so you should be up front and ask the surgeon how many refractive surgeries he's done and what is his complication rate, and more importantly, what are the odds of your particular case having any complications. By the way, how many LASIK procedures have you done? I've done about 25,000. Oh wow. Okay. Now, Dr. Walker, So the experience, we think of technology all the time we think, well if somebody, and I think I mentioned this earlier, you have the latest, greatest, you know, model of the laser that's used, and so that takes the guesswork out for the surgeon, but some of it, and I know that's not true, and I'd like you to comment on that, but also you sit down with your patients to try to decide which procedure is right for them and what recommendation you'd make and what they're comfortable with, and you were talking about not just LASIK but variations on that. The older PRK procedure etc., what are the unique qualities of their eyes or their vision. So that's part of what you're paying a surgeon for too, right? That is correct. The very first thing we do when we see a patient is we ask them what do they hope to get out of this, and everybody's different. Some people, you know, you mentioned looking better without glasses. Vanity turns out to be fairly low on the totem pole as far as people's motivation to get this type of surgery. Often it's to get away from the annoyance of contact lenses, or their eyes have been too dry with contacts, and they want to get out of those. Some people are misinformed. Some people think that it will get them out of their reading glasses. They see just fine at distance, but they want to get out their reading glasses, and so they're not aware of the limitations of LASIK and PRK. So, we basically ask them or oftentimes it's a job limitation; they want to be able to see better at night when they're driving their ambulance or whatever. So the first thing is to pin down their motivation, see if it s realistic, and then pinpoint the best way to help them. I mentioned it's not always LASIK, sometimes it's PRK. Sometimes it's giving them perfect distance vision. Sometimes it's sacrificing a little bit of distance vision to give them a little bit more up close vision, so it's sort of customized, and again it all comes down to experience knowing what's in the patient's best interest as far as which procedure is right for them. 8

9 Potential Complications of Vision Correction Surgery So, we talked about the experience of the surgeon and certainly finding out which procedure is right. For instance, when we talk about LASIK though, there's the risk of complication. What are the complications you'd like to put on the table and then how likely, at least in your practice there with Restore Vision Centers, how likely are these? Of course. With LASIK probably the worst complication you could have would be an infection. Infection is the type of complication that could really decrease your final vision even from where you started, and that's, you know, when talking about patient's fears and why they're hesitant to have refractive surgery, that's the thing they're primarily worried about. They say, 'you know, with my glasses and my contacts, sure they're annoying, but you know what? I see really well in them, and the big thing I'm worried about is coming away from this not being able to see well even with contacts or glasses.' Unfortunately infection's the big thing that could really limit that. Fortunately, infection is very, very rare. Nationwide it's probably about 1 in 2000 incidence, and I've, as I mentioned, done over 25,000 of these, and I've never had one. In general, patients that get them tend to not follow the instructions, not use their antibiotics the way their supposed to, and things like that. So, there's infection. I mentioned with LASIK we are creating a flap usually with an instrument called a microkeratome. The flap has to be absolutely flawless in order for the laser itself to work well, and if for some reason, and it's made with a machine, if for some reason the machine doesn't make an absolutely flawless flap, the laser won't work well. In those cases we just basically put the flap back down, let it heal for a few months, and then we can come back and do the same thing later on or even do PRK later on on them. Okay. So any other ones you'd mention that you'd be concerned about? Sure, there's things that aren't really complications because they are expected. A biggie after LASIK and PRK is dry eye, and we go into this telling patients you are going to have much dryer eyes than usual for about 6 months, and so patients are using what we call artificial tears many times a day for a few months and then that goes away. So it's not really a complication, but we just let patients know up front it is a bit of an annoyance. I had LASIK myself about five years ago, and I thought the dryness was the most annoying part of the entire ordeal, was having to put those tears in. There are issues with glare at night, seeing halos around lights, and I tell patients you're going to have that for about six weeks. In general it doesn t keep you from doing anything. It doesn t keep you from driving at night or things like that, but they are 9

10 noticeable and eventually they end up going away. Now one of the big advances with this wavefront or custom technology that has come down the pike is that the odds for having any sort of long-term glare problems, especially in patients with larger pupils, are much reduced with this wavefront technology. What we'll do, Dr. Walker, is in the next section we'll kind of hear, it's an evolving field, where it's headed, and as you sort of fine tune these procedures and help more and more people benefit from it, lower the risk of complications. We'll hear about that when we continue on Patient Power. We're visiting with Dr. Mark Walker who's a refractive eye surgeon from Restore Vision Centers in the Seattle area in the Pacific Northwest. We'll be right back. Here we go with more of Patient Power. We re here every day usually live. As we go into the last section of our discussion today about LASIK surgery and PRK and all the different acronyms that try to help give people back their distance vision. We're visiting with Dr. Mark Walker, who as he said has done about 25,000 refractive surgeries. He is also from the Seattle area as I am, and he's at the Restore Vision Centers, which are around the Pacific Northwest. Advances in Laser Eye Surgery So Dr. Walker, you had, yourself, LASIK surgery 5 years ago. There are people listening to us today who have said, 'you know I thought about this, but you know I hear you're getting a better laser or you re making these flaps better. You have all these new tools and people like you continue to get more experience. Why don't I wait and see what the next big leap of technology and skill is so that it'll be better for me?' Sure, and it's a valid point, Andrew. I get asked about this all the time. Patients come in for consults and say, 'you know I've thought for a long time about having this, but I read on websites that this next technology is just around the corner.' And I say, that is true, but technology is always going to be advancing, and this is going to be a better procedure 100 years from now than it is right now, and if you always wait for the next big thing, you'll never end up having any procedure at all, and that was the case with myself five years ago. I knew exactly what was coming down the pike, and I just decided, you know, either have it now or don't have it. There's always something better coming along, and I had it before wavefront technology, and is it considerably better now than it was five years ago? Yes it is. There are other procedures coming down the pike. The big leap forward is going to be in lens technology when they actually insert a lens inside your eye surgically. Now it is a lot more invasive than what we're doing now. Right now we're not entering the eye with PRK 10

11 or LASIK. We're staying on the surface. These new lens technologies, where they're inserting a lens either just behind your cornea or even replacing your eye's natural lens are technologies that might even allow you to regain your ability to read, in other words, overcome this presbyopia that you get after 40, but these are technologies that are considerably more invasive, have a higher complication rate, but as technology advances and these procedures are perfected, eventually these might even replace what we're doing now. Now, when I think of older people, my in-laws and great aunts and great uncles, what I'm usually hearing about with them is cataract surgery. So if somebody has had cataract surgery, can they have LASIK or these other variations as well, and when you talk about lenses, is there something where it could sort of be an all-in-one kind of procedure? Right, yes. After LASIK, it does not prevent you from having cataract surgery in the future. A lot of people ask me, you know, if I have this LASIK surgery, does it mean I'll never get cataracts? No. Everybody on the planet, if they have enough birthdays, are going to eventually get a cataract. Now one thing people aren't aware of is that when they have cataract surgery, they replace the eye's natural lens, which has gotten cloudy, with an artificial lens. This artificial lens can be whatever power the surgeon chooses. In other words, it will replace the patient's glasses for distance, which makes LASIK or any other refractive surgery unnecessary. In other words, somebody goes in nearsighted, has cataract surgery, they replace their lens with a nearsighted lens inside their eye, and suddenly they come out not needing glasses except to read, and I'll see a lot of patients who come in for LASIK or PRK. We look in their eyes and say, oh, lucky you. You actually have a cataract, and so they go and will have cataract surgery, which insurance actually will pay for, and the lens inside their eye is replaced with a nearsighted lens, and they get out and suddenly don't need glasses any more. They're not quite as accurate with their lens selection as we are with LASIK, and so sometimes they'll even come out after cataract surgery and then we'll do LASIK or PRK on them just to fine tune it and get it exactly where they need to be. Well, it's a fascinating field, and it continues to evolve, but as you say, if people need that help with their vision now, I think the thing is to really be a smart healthcare consumer and research this and then have a discussion with one surgeon or more who's experienced to see what procedure is right for you and who would be a good healthcare provider for you. We'll get some final comments from Dr. Mark Walker, a refractive eye surgeon, right after this. 11

12 We're getting near the close of another live edition of Patient Power. It's all about being a smarter patient, and for all of us as we get old and want to have good distance vision, should we have surgery? Who should we have it with? Do we shop price? How do we get the best? It's all about being a smart consumer, so do you research. Let's hear just one more time from Dr. Mark Walker who's done about 25,000 of these refractive eye procedures and get his perspective, and it's even more from the Restore Vision Centers here in the Pacific Northwest. Mark, a final comment from you and your advice to our listeners. Sure, Andrew, I would just encourage patients to look at this surgery as they would any other surgery and treat it, how would you react if you were having heart surgery or an appendectomy, and would you solely base it on price. Do your research. Patients tend to have thousands of questions about this. I would encourage them to visit our website at ask questions; we like nothing more than a well-informed patient; and know what you want out of the procedure, know what to expect, and certainly go into it knowing that the decision that you make is going to affect your vision basically the rest of your life. That's so true. You know, I want people to understand as you said, this is not like getting your oil changed. This is your vision. God gave you hopefully two good eyes, now they're changing over time, you want to get back some of that vision quality, and so you're considering an invasive procedure. I know Mark you probably invite people to ask questions, and if they want to get a second opinion that's fine too. They need to feel comfortable with that decision. Absolutely. We like nothing more than a well-educated patient, and patients that go out and do their research and ask questions and aren't just looking for the best deal they can get are the type of patients that do really well with this. Right, well thank you. Thanks for spending time with us. So remember folks, tonight we'll be back with our alternative medicine show the M. D. Anderson, and then tomorrow, thyroid. As always with all these topics and vision for sure tonight, it's all about being a smarter patient because knowledge can be the best medicine of all. Andrew Schorr signing off. Have a great day. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 12