Maturity Becomes Lasik

(Katherine Frey - Twp)
By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, December 5, 2006

Linette Hwu had been warned by doctors that she was not a candidate for laser eye surgery: Her corneas were too thin, her pupils too large, and she was extremely nearsighted. The 33-year-old lawyer for Discovery Communications said she had resigned herself to being permanently tethered to the glasses she had worn since third grade.

But four months ago, Hwu underwent one of several relatively new procedures, this one known as Epi-Lasik, which is designed for patients who can't have conventional laser surgery because it removes too much corneal tissue. An eye exam last month showed she could see 20/20 without glasses.

"It's pretty great," Hwu said of the elective surgery that cost her $5,900. "I never thought I'd be able to wake up and see the alarm clock or be able to learn to surf, which has been my dream."

Alice Corbett, 53, of Chevy Chase had been told a few years ago that the shape of her corneas made her a questionable surgical risk, but recently approved technology revealed otherwise. "I thought, 'What can I do to improve my life as I get older?' " recalled Corbett, an avid tennis player. "Then I thought, 'Boy, what if I could really see better? Wouldn't that be great?' "

On Oct. 11, Corbett underwent Lasik after years of juggling reading and distance glasses, which she often lost, and contact lenses, which she hated. Although she still needs reading glasses, Corbett is thrilled she can do everything else unencumbered by eyewear.

The experiences of both women are emblematic of the maturing market for procedures to correct common vision problems, especially nearsightedness, a condition that affects one in four Americans.

Six years ago, hype about Lasik, an acronym for laser-assisted in situ keratomileusis, which reshapes the cornea using staccato pulses from a laser, spawned frenzied growth. Surgery centers sprouted in suburban shopping malls, high-profile advertising campaigns featuring cut-rate procedures abounded, and some surgeons became multimillionaires who boasted about how many procedures they could do in a day -- or an hour.

But in recent years the frenzy has given way to a more measured approach. While some procedures such as Lasik and Epi-Lasik (a more painful operation that requires a much longer recovery time) are popular in patients younger than 50, newly approved intraocular lenses are more common among patients older than 55, ophthalmologists say.

Lasik remains by far the dominant procedure, according to David Harmon, president of the St. Louis research firm MarketScope, who said that the growth of the procedure had plateaued at about 1.4 million procedures annually. In the Washington area, an estimated 47,500 procedures were done last year, Harmon said. Cost varies from about $1,400 to $2,900 per eye, depending on the surgeon and technology; because it is considered elective, the surgery is rarely covered by insurance.

At the same time, improvements in technology have broadened the pool of patients, and new treatments have won federal approval. Surgeons have become more cautious, chastened by a spate of multimillion-dollar malpractice verdicts awarded to patients who suffered serious vision loss. The biggest so far: $7.25 million awarded by a jury last year to a former Manhattan investment banker for surgery performed in 2000.

"Doctors have gotten smarter about picking good candidates," noted Los Angeles eye surgeon David A. Wallace.

That's one reason Harmon, who has tracked vision-correction surgery since its inception in the 1990s, said he thinks today's results "are dramatically better than they were five years ago." Harmon estimates that 5.5 million Americans have had laser eye surgery -- but says that many more are potential candidates.

A World of Candidates

Lasik and the second most popular procedure -- PRK, or photorefractive keratectomy -- are designed to correct three refractive errors: myopia, or nearsightedness, an inability to see distant objects, which is the most common visual problem; farsightedness, also known as hyperopia, which is difficulty seeing close objects; and astigmatism, a visual distortion that causes blurred vision.

"Ten years ago we had two procedures -- Lasik and PRK -- and everyone got one of them," said Chevy Chase eye surgeon Roy Rubinfeld, a clinical expert for the American Academy of Ophthalmology who operated on Hwu. "Today we have many more tools in our bag of tricks."

James Salz, a clinical professor of ophthalmology at the University of Southern California, agreed. "We can correct almost anybody now -- about 90 percent of potential candidates. A few years ago it was maybe 60 to 70 percent."

In addition to Lasik, PRK and Epi-Lasik, there is IntraLase, which uses a laser rather than the special blade used in Lasik to cut a flap in the cornea; it may offer improved precision and reduce side effects such as dry eye, the one complication Hwu experienced.

Intraocular lenses approved in the past two years are implanted in the eye like a contact lens and are approved for use in extremely nearsighted or farsighted people, and those who can't have laser surgery.

One key question -- the long-term stability of results -- appears to have been answered, at least for now. A study presented last month at the annual meeting of the American Academy of Ophthalmology found that 10 years after 200 patients underwent either Lasik or PRK, their vision averaged 20/25; they had no long-term complications.

Salz and other surgeons say newer results are likely to be even better, in part because of the now-widespread use of so-called wavefront technology, approved in 2002 by the Food and Drug Administration. Conventional Lasik relies largely on the kind of simple measurements used to create an eyeglass prescription, but wavefront -- sometimes called custom treatment -- creates a kind of ocular fingerprint, mapping the terrain of the cornea in extremely precise, three-dimensional detail that is then used to program the laser.

The U.S. military, which formerly restricted laser surgery, has embraced it through a readiness program called Warfighter. Doctors at eye surgery centers around the country, including Walter Reed Army Medical Center and the National Naval Medical Center, are lasering the eyes of many troops bound for Iraq and Afghanistan, where battlefield conditions make wearing glasses or contact lenses difficult or impossible -- and where the ability to see can be a matter of life and death.

No Eliminating Risk

But not everyone is enamored of the new technology. David Hartzok, an optometrist in Chambersburg, Pa., specializes in treating people with complications from laser surgery. He also directs the Vision Surgery Rehab Network, an advocacy group for patients with post-operative problems.

"The people I see coming in today are the products of the new technology, and they're having the same problems," such as dry eye, glare, starbursts and blurred vision, Hartzok said. "I do think in general surgeons are more circumspect about the kinds of patients they do and lasers are better." But that, he said, is no guarantee of a good result.

The Internet abounds with blogs detailing disasters. One of the best known is an account titled "Lasik Nightmare" by comedian Kathy Griffin. Griffin has undergone four corrective -- and so far unsuccessful -- surgeries to fix a rare complication caused by epithelial ingrowth, or scarring under the flap, which results in visual distortion.

On her Web site Griffin said that her vision remains blurry in her right eye. She urges those contemplating surgery to think hard.

Wallace, the Los Angeles surgeon, thinks such advice is sage, even though he considers the risk of problems low. Consumers should remember, he said, "it's a buyer-beware world. This is not a commodity like electronics." ยท

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