Laser Eye Surgery

Dr. Roy Rubinfeld has performed more than 15,000 laser eye surgeries since 1990. He was online Tuesday, Dec. 5 at 1 p.m. to answer your questions about the latest procedures and how laser eye surgery has changed over the years.

A transcript follows.

Read more: Maturity Becomes Lasik.

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Dr. Roy Rubinfeld: Thank you for inviting me onto WashingtonPost.com to follow up on today's excellent Health Section article. I'm glad to answer questions now. Answers to many common questions can be found on http://www.washingtoneye.com/.

-Roy Rubinfeld, MD

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Baltimore: Dr. Rubinfeld -- I'm planning on getting Lasik in the next few months and am currently trying to navigate through the myriad of different Lasik providers and technologies. A friend who is also getting the procedure said that her doctor told her that he prefers to use a blade rather than Intralase to make the incision, because he is concerned about reports of complications about Intralase. Is there any merit to this? It's confusing to me, since it seems like everyone is touting the superiority of the Intralase method. Thanks!

Dr. Roy Rubinfeld: You are absolutely correct that it is difficult to navigate between the hype and reality of different technologies and methods. It seems to make sense that a laser would be better for making a flap prior to Lasik than a conventional microkeratome.

I, too, have not had as good results with the Intralase device for creating a flap as compared to mechanical techniques. The key to navigating this maze is finding a doctor you can trust.

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Silver Spring, Md.: What is known about the long-term effects of the procedure? 20 years? 30 years? More?

Dr. Roy Rubinfeld: Lasik is a laser and computer refinement of a procedure that has been performed since the 1960s. Several recent studies internationally have reported on the long term results of Lasik and PRK.

I had my vision corrected in 1995 and still see well. I performed my wife's vision correction in 1998 and we are still married.

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Arlington, Va.: If corrective surgery does not produce 20/20 vision, can one still wear contacts post-operatively?

Dr. Roy Rubinfeld: In general, the answer to that question is yes.

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Olney, Md.: I am in front of a computer for at least eight hours a day; is Lasik right for me?

Dr. Roy Rubinfeld: In general most people can have Lasik who work in front of a computer. Sometimes, however, computers can cause temporarily dry eyes and this can usually be treated easily with artificial tears.

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Washington, D.C.: Is pupil size still a limiting factor for people wanting Lasik? Is the likelihood of suffering an adverse side effect higher for those with large pupils? Thanks!

Dr. Roy Rubinfeld: One of the major advances in Lasik over the last several years is the ability to safely treat people who may not have been good candidates in the past, such as those with large pupils or thin corneas. In general most patients find that Lasik (as it is currently performed) can often improve as opposed to degrade night vision even in patients with larger pupils. However, only a Lasik surgeon can determine whether you are a candidate and what your risks are.

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Washington, D.C.: I am noticing rapid loss of vision as I approach my mid-20s, however I still have neglected to get glasses. Do you feel glasses are the best first remedy or should I pursue laser surgery right off the bat?

Dr. Roy Rubinfeld: I think the first step is seeing an eye doctor to determine why your vision is changing. If it's simply nearsightedness and your prescription is relatively stable then Lasik might be a reasonable option. This is a good question to ask your eye doctor when you make your appointment.

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McLean, Va.: I'm interested in obtaining Lasik surgery, but my prescription keeps changing every year and therefore, I was told I'm not a good candidate. Is this true?

Dr. Roy Rubinfeld: If your prescription is changing only a little bit Lasik may be a good option. If, however, it is truly unstable then glasses and contacts may be a better option.

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Washington, D.C.: Is LASIK available and appropriate for extreme near-sightedness? My contact lenses are -9 and -10, and since I turned 30 a few years ago, my vision has finally stabilized. Does this make me a better candidate for surgery?

Dr. Roy Rubinfeld: Your prescription is within the FDA guidelines and results are generally very good for patients with similar prescriptions, but you must be carefully evaluated to determine if you really are a good candidate.

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Southern Maryland: I am very nearsighted (20/400) with astigmatism. I heard years ago Lasik eye surgery couldn't help me. Has it improved enough to correct my problem? I'm tired of wearing glasses and don't want to bother with the solutions and fiddling around with contacts -- you know the drill.

Dr. Roy Rubinfeld: With the availability of new custom Lasik technologies we can now treat more patients more safely than ever before. I often see patients now and find they are good candidates even though I told them not to have Lasik years ago.

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Johannesburg, South Africa: What is the prudent, youngest-age for Lasik? In other words, when does the eye finish growing/changing enough for the surgery to be most effective?

Dr. Roy Rubinfeld: Everyone's eyes are different but in general 18 is a reasonable time to start thinking about Lasik. As I noted above if the prescription is rapidly changing then it's best to wait until it's relatively stable.

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Washington, D.C.: My main concern is the possibility of being permanently blinded. I don't mind the procedure or the cost, but how likely is it to have worse vision than before the surgery?

Dr. Roy Rubinfeld: One way to answer this question is to refer to the most recent FDA trials for the new lasers. In general the majority of patients saw better after Lasik than they did in their contact lenses or glasses. Temporary dryness and irritation for a few weeks after Lasik is not uncommon and serious problems are rare and often can be resolved.

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Washington, D.C.: What is the best option for someone who wears one contact for distance and no contact for reading in the other eye?

Dr. Roy Rubinfeld: It sounds like Lasik in one eye to provide the same vision as you have with your contact might be a good option, but of course you would need to be examined and evaluated. Be sure you will have the opportunity to ask your surgeon any questions you may have. Answers to our FAQ's can be found at www. washingtoneye.com.

Only a Lasik surgeon can make the final decision as to whether this would be a good option in your case.

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Amman, Jordan: Could you comment on opening a flap in the cornea versus the original method of completely opening the cornea, please? Is there a difference in the post-op strength of the cornea between the two methods?

Dr. Roy Rubinfeld: Very good question. When I perform vision correction on active duty military personnel I generally offer them a surface procedure such as Epi-Lasik or PRK instead of Lasik. For most people Lasik is a good choice and provides very rapid vision correction so that they can return to work the next day. Surface procedures which do not make a flap require longer recovery time such as four or five days. If your risk of serious eye trauma is high then surface procedures can be safer.

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Washington, D.C.: I've been thinking about getting this surgery for at least 15 years. I would love to be able to see the alarm clock in the morning. But I'm not willing to go under the knife (or laser) until I have more data. Are there any large studies tracking the long-term effects? And are doctors reporting their results? I know there are several possible problems with the surgery, but I can't find information on how likely they are.

Dr. Roy Rubinfeld: I had laser vision correction in 1995 after working with laser patients for nearly five years and doing my own research. We now have performed over 10 million procedures in the U.S. starting in early 1990s. A recent study by Jorge Alio was the subject of a press release from the American Academy of Ophthalmology describing good long term results and safety of Lasik.

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Arlington, Va.: What should I look for in a lasik eye surgeon? What are the important questions to ask before I go under the proverbial knife?

Dr. Roy Rubinfeld: This is the hard part of vision correction in my opinion. Finding a surgeon should not be based on discount or advertising but on reputation in the community, recommendations from friends and doing your homework. The Internet is a good place to start as well and don't be afraid of getting a second opinion.

Asking about the surgeon's experience and getting to meet them will often help determine whether you feel comfortable under their care.

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McLean, Va.:"In general the majority of patients saw better after Lasik than they did in their contact lenses or glasses." Could you be more specific here? For someone thinking about spending $4k on laser eye surgery, this isn't a comforting thought...How many of your 15,000 patients still wear contacts or glasses after the surgery?

Dr. Roy Rubinfeld: With a single procedure, in recent trials, more than 95 percent of the patients who had custom Lasik with new technology saw well enough to drive without contacts. A second procedure (included in the fee) may be required in about 5 percent of patients. Wearing contacts with astigmatism in them can cost roughly $5,000 over 10 years. Lasik is generally a permanent correction and makes economic sense.

We do no advertising and rely on word of mouth. Of those tens of thousands of patients the overwhelming majority would have the procedure again and would recommend it to their friends. Recommendations from other patients is the number one way that patients come to Washington Eye Physicians & Surgeons.

Hope that helps answer your question.

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Rockville, Md.: In researching and selecting a doctor to perform Lasik surgery, what do you consider to be the top five qualifications a surgeon should possess?

Dr. Roy Rubinfeld: Experience.

The ability to handle any potential post-operative problems.

Does the doctor routinely lecture to other doctors about these procedures?

Does the doctor provide several different procedures or do they only do Lasik? The doctor needs to be able to find the best procedure for your eyes and your needs. Trying to put a square peg into a round hole is not a good idea.

Where do I fall in terms of being a candidate from one to five, with five being the most difficult patient the surgeon would still consider performing surgery on and one being the most plain vanilla patient around.

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Arlington, Va.: Is it a problem to perform Lasik on someone who is very squeamish touching his or her eye? I'd like to have the surgery done, but I can't even wear contact lenses because I can't touch my eye to insert or remove them.

Dr. Roy Rubinfeld: This is why g-d invented Valium.

We have many patients who are squeamish and do our best to make what is a potentially scary procedure comfortable and easy. Sedation and reassurance help a lot. We also play music of your preference in the laser suite.

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Washington, D.C.: Would it be possible to have the procedure done in the morning and be able to be active and see reasonably well later that afternoon or evening?

Dr. Roy Rubinfeld: Most of our patients are able to watch television the night of the surgery. Most return to work the next day.

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Pricing: I know there are a variety of different procedures and therefore prices, but what is a reasonable price range for lasik (with a fairly "normal" candidate with no complications)? I never know if these deals I hear on the radio are too good to be true.

Dr. Roy Rubinfeld: In general if something sounds too good to be true it often is. The FTC has investigated several of these offers and ads. Some of these links are on our Web site.

When choosing a brain surgeon or heart surgeon would you look for the one with a coupon?

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Seattle: Hi, I need glasses for distance not reading, but I understand that corrective surgery means I would then need glasses for reading but not distance. Is this correct?

Thanks.

Dr. Roy Rubinfeld: In general people with good distance vision start to need reading glasses in their forties. Lasik generally can provide freedom from glasses or contacts for most patients until they enter their fifth decade.

For people over forty monovision Lasik can be a good option to reduce or eliminate the need for distance or reading glasses.

For patients in their sixties the new advanced technology lens implants can often provide distance and near vision (see Restore, Rezoom/Crystalens tab at www.washingtoneye.com).

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Washington, D.C.: Hi Dr. Rubinfeld, thanks for chatting. I know you're one of the best cornea specialists in the business. I have a question on cataract surgery, it seems that many different ophthalmologists will do this surgery, but who is the best? Cornea specialist? Retina specialist? Glaucoma specialist? What should a potential patient look for in a surgeon?

Dr. Roy Rubinfeld: Thank you for your kind words.

I think my partners at Washington Eye are terrific and I sent my father to them but I am biased.

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washingtonpost.com: LASIK Surgery Boosts Vision Long Term (WebMD.com)

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Lynchburg, Va.: What are the key factors in determining if someone's eyesight can be restored to perfect via laser surgery? And what's the "poorest" level of eyesight that can be restored? (in terms of a prescription). Thanks.

Dr. Roy Rubinfeld: Even patients with extremely high prescriptions (up to

-15.00 and +5.00) can often now be treated. Lasik is the most popular procedure but for some people the ICL may be a better option for those with extremely high corrections.

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Falls Church, Va.: Can you explain the difference between LASIK and LASEK?

Dr. Roy Rubinfeld: LASEK is very similar to Epi-Lasik or PRK and is a surface procedure. Lasik involves a flap and provides rapid vision correction.

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Dr. Roy Rubinfeld: Thank you all for your excellent questions and thank you to the Washington Post for their continued excellent coverage of developments in medicine and for inviting me onto Washingtonpost.com. Roy S. Rubinfeld, MD.

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