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Laser Vision Correction
Wednesday, September 13, 2000

Refractive surgery is designed to reduce a patient's dependence on glasses and contact lenses. It is performed for the correction of nearsightedness, farsightedness, and astigmatism using laser vision correction procedures such as LASIK and PRK or Intacs, the non-laser approach for treating mild nearsightedness. LASIK, the most commonly performed laser vision correction procedure, treats low to severe amounts of nearsightedness, farsightedness, and astigmatism by removing molecules of tissue just beneath the surface of the cornea.

Rajesh K. Rajpal, M.D. is a board certified ophthalmologist who was the first surgeon in the Washington, D.C. area to perform excimer laser refractive surgery as a principal investigator in the clinical trials for FDA approval. He has trained more than 2,000 ophthalmologists around the country in excimer laser surgery techniques and has treated thousands of patients for nearsightedness and astigmatism. As a specialist in cornea and refractive surgery, Dr. Rajpal has many publications to his credit and has lectured extensively on laser vision correction. He has established a reputation as an expert in the field of laser vision correction and has previously served as President of the Washington, D.C. Ophthalmological Society.

Moderator: Welcome to Viewpoint with our guest, Dr. Rajesh Rajpal. Doctor, thank you for joining us today, and let's begin.

Alexandria, VA: Who makes a good candidate for these types of vision correction?

Dr. Rajesh Rajpal: Patients who are nearsighted, farsighted, or have astigmatism are eligible for the treatment. It is important to have a complete examination to determine the range of correction a patient is in and then understand all of the issues related to the treatment.

Washington, DC: Do you wear glasses or contacts?

Dr. Rajesh Rajpal: I used to wear glasses for my astigmatism. I have had LASIK also a few years ago.

Boston, MA: RK is an automatic disqualifier for many police jobs. Why does that older procedure prevent an individual from holding a law enforcement position, and does PRK and/or LASIK pose the same restrictions?

Dr. Rajesh Rajpal: The older procedure (RK or Radial Keratotomy) was done by making incisions in the cornea. This can weaken the eye and therefore was not allowed for many occupations. PRK or LASIK are laser-based. Most occupations do allow for this type of correction but there are some that do not yet. So, it is important to check into that prior to making a decision. Often we can provide much of this information as well. Most laser centers should be aware of some of the criteria.

Washington, DC: I'm interested in laser vision correction but have heard that lasers that track the eyes' movements are better. What is your opinion about that?

Dr. Rajesh Rajpal: There is marketing that directs patients towards a type of laser that offers tracking. In the vast majority of patients, tracking is not necessary nor does it provide any improvement in results. There are multiple lasers that provide tracking and offer it in different ways. Some of the current lasers that provide tracking require the eyes to be dilated. Often this is not as convenient or comfortable for patients. Again, the most important factor is whether there is any better outcome based on using a tracking system or not. There is no difference in results in the vast majority of patients.

Washington, DC: Dr. Rajpal, Is there any research that studies the long-term effects of this procedure? When were the first operations done? How are those patients doing?

Dr. Rajesh Rajpal: The procedure began in clinical trials in the late 1980s. Fortunately, after the first three months, the vast majority patients have achieved stable correction and their eyes do not continue to change. So, those patients who have had the procedures done many years ago are stable.

Churchton, MD: How is nearsighted, astigmatic vision that is corrected by LASIK affected by the natural aging process? When that 14 font begins to look like six font, does the corrected vision mask or intensify (or not impact) the effect?
Thirty five years of nearsightedness whose arms are apparently getting shorter.

Dr. Rajesh Rajpal: LASIK is done to correct for distance vision. Reading glasses may be necessary for those people who wear bifocals. One of the options for this is monovision treatment which allows one eye to be focused for distance and the other eye for near vision. This is important to try first and see if it can be tolerated. Many people do this with contact lenses and do not have to wear glasses very much. It is one of the important issues reviewed during a consultation.

Bethesda, Maryland: I have visited many centers in the area and have heard conflicting things. Can pregnant women have LASIK?

Dr. Rajesh Rajpal: Women that are pregnant should not have LASIK. This is partly because the prescription can vary during pregnancy.

New York, NY: Is there a degree of myopia combined with astigmatism beyond which a reasonable correction is unobtainable? Being realistic, I am not necessarily seeking to be corrected to 20/20 or even 20/40, but I would like to wear thinner, more light-weight lenses.

Dr. Rajesh Rajpal: The FDA regulations have approved treatment to 14 Diopters of nearsightedness or up to five Diopters of astigmatism. It is important, however, to make sure that all other aspects of the eye exam are appropriate for doing a treatment at higher levels.

Alexadnria, VA: I'm 24 years old, and my nearsightedness is still getting worse (i.e., I need a new prescription every six months to one year). Do I have to wait until my sight stabilizes before becoming a candidate for surgical vision correction?

Dr. Rajesh Rajpal: It is important for the prescription to be stable. If you have old glasses or prescriptions to compare, that helps in making the decision on whether stability has occurred or not.

Hartford, CT: Doctor,
If someone is in their 50s and has had a lot of exposure to the sun would they be better off waiting to have their vision permanently corrected by using the cataract lens replacement process which almost all cataract patients get? Or would they benefit from refractive surgery now, assuming a minor astigmatism and near-sightedness.

Dr. Rajesh Rajpal: Choosing to perform LASIK before cataract surgery is dependant on how important it is to you to decrease the need for glasses or contact lenses now rather than waiting potentially many years for the cataracts to develop. Neither surgery interferes with the other. However, cataract surgery is not done until the vision is limited due to the cataract. This has no relationship to correction of nearsightedness, farsightedness, or astigmatism with LASIK.

Cleveland, Ohio: Prescriptions for glasses are constantly in need of renewal as eye vision appears to naturally deteriorate over time. Why do you think that this eye vision deterioration will not also occur with LASIK correction?

Dr. Rajesh Rajpal: Changes in vision are not prevented by LASIK. LASIK is treating the current prescription and it is important that it is stable. Fortunately, when the eyes are stable enough to have LASIK, our eyes do not change significantally enough to require enhancements years later.

Alexandria, VA: Are patients awake during the procedures? Do they have the option of being asleep?

Dr. Rajesh Rajpal: Fortunately, numbing drops are the only anesthetic necessary for the treatment. Patients are awake but can choose to have a medication to help them relax some during the treatment.

Alexandria, VA: I have relatively severe myopia (-8.5) and am considering LASIK surgery. However, my greatest concern is the lack of long-term results, since the procedure is so new. What are the likely long-term effects from this surgery? Should I wait five years, 10 years, or more to feel that the known long-term risks are understood?

Dr. Rajesh Rajpal: The long-term results are known from the perspective of stability of the eyes after treatment. The earliest procedures with the laser technology were begun in the late 1980s. There are no substantial changes in technology that would influence clinical outcomes in development.

Potomac, Maryland: Is it true that any kind of doctor can do corrective eye surgery? How important is the doctor in terms of the outcome?

Dr. Rajesh Rajpal: Surgical experience is certainly one of the critical elements in success of the treatment. Ophthalmologists (MD's) are the ones performing the surgery. After completing training in ophthalmology, many of us complete corneal fellowships as well to become cornea specialists and then perform the surgery.

Washington, D.C.: Hello, Dr.:
A little over a month ago I went to a discount LASIK center to have the procedure done. The doctor started with my right eye, but stopped about five minutes into the procedure. He said that a corneal wrinkle had developed during the cutting of the flap, so he closed me up and scrubbed the operation. Today my right eye is still not back to normal. My vision (I still wear glasses) is cloudy, as if I'm looking through a bottle. Needless to say, I'm annoyed and frustrated. Can this condition be fixed? I'm still interested in getting vision correction, but I'm worried. Does this experience reflect more on the doctor than on my eligibility for the procedure (the preliminary tests indicated that I'm a perfect candidate)? HELP!

Dr. Rajesh Rajpal: There are methods of performing the treatment if the first procedure did not go as expected. As a specialty practice in cornea and refractive surgery, we do see many patients in this type of situation who may have had treatment elsewhere. It is important to have a complete evaluation including topography (mapping of the eye) and corneal thickness measurements to determine what approaches may be possible.

Washington,DC: I went to a consultation to determine if I could have the LASIK procedure done and was told that my pupils were too large for LASIK. I was told that LASIK is ideal for candidates with maximum 7mm pupils, and mine are 8mm. Is there a new laser procedure that will allow people with larger pupils to have laser surgery? If so, what is it called, and when will it be available in the U.S.? Thank you.

Dr. Rajesh Rajpal: The level of correction (prescription) that a patient has helps determine whether a certain pupil size may be too large. There is not any significant change in the laser technology that would affect this. Most lasers do have a blending of treatment zones for the larger pupil ranges. Again, specifics of determining whether a pupil size is too large for a treatment at a given prescription would need to be evaluated at an examination.

Bowie, MD: I am very nearsighted (-8.5 dioptry with soft contact lenses). In the early 90s I had a surgery for a detached retina. Am I a candidate for this procedure? If yes, can I do close work (reading books, writing memos, etc.) or would I need glasses?

Dr. Rajesh Rajpal: Patients who have had a detached retina repaired or other surgical conditions need to have a complete consultation and may need to see a specialist in that condition to confirm that their eyes are stable and appropriate for treatment.

Parma, Ohio: Dr. Rajpal, it appears that enhancements of equipment are continuing regarding vision correction, and thus the cost for the consumer remains high to cover technical R&D. Do you perceive that the cost will ever be substantially reduced (under $500 per eye) so that the vast majority can afford the procedure? Will there ever be a strong enough lobby to have this covered under insurance?

Dr. Rajesh Rajpal: Technology enhancements or changes are not changing the clinical outcomes. Most of the changes in technology improve maintenance and efficiency of the lasers. There are some insurance companies that do cover the treatment usually by specific arrangement with certain employers.

Rockville, MD: Doctor, I have three problems. I am myopic with a -5.00 diopter. I have glaucoma and slight astigmatism in my left eye. I also do not want to wear glasses in my 50s, having done it since my mid-teens. I am now 37. Are there any procedures out there now that can take care of all my problems?

Dr. Rajesh Rajpal: First, the glaucoma needs to be evaluated to determine whether treatment can be performed or not.

Myopia and astigmatism can be treated.

Reading glasses are necessary for most people after the age of 40-45. One of the options of decreasing the need for reading glasses is monovision.

Rockville, MD: Do your eyes hurt during and after surgery? Is one brand of laser less painful than another?

Dr. Rajesh Rajpal: During the surgery, numbing drops are used. There is the feeling of pressure but not usually severe pain. After the treatment, the vast majority of patients experience only scratchiness and tearing. For some people who may have more sensitive eyes, pain medications or mild sedatives can help with the comfort. The type of laser does not affect the sensation of the treatment.

Des Moines, Iowa: How do you cut my eye and what happens if my eye moves during that?

Dr. Rajesh Rajpal: The flap is created with an instrument called a microkeratome. During the creation of the flap, the eye is held still and there is the feeling of pressure. The eye cannot move during this time. After that, the laser smooths and sculpts the surface of the cornea to perform the correction.

Rosslyn, VA: Dr. Rajpal,
My vision has recently changed in that I need reading glasses now. My distance vision is fine. Can LASIK correct my need for reading glasses? And if not, do you know of a procedure that can?

Dr. Rajesh Rajpal: If you had your vision corrected for not needing reading glasses, your distance vision would no longer be as good. So, most people prefer not to end up with worse distance vision in order to improve reading vision.

Delaware: I have heard that if I have the surgery that I will have good days of vision and bad days of vision. Is this true?

Dr. Rajesh Rajpal: The vision may vary some at the beginning. It typically stabilizes quickly but in most everyone by the three month period.

Elk Grove, CA: I wear trifocal lenses and have six different prescriptive strengths. I am nearsighted, farsighted and have astigmatism. Can this type of eye problem be corrected with LASIK?

Dr. Rajesh Rajpal: The specific prescription would have to be evaluated.

Germantown, MD: I have very bad eyes. I've been told that my prescription is -13.75 in both eyes. Am I at a high risk of halos or can the surgery even be performed on my eyes?

Dr. Rajesh Rajpal: Since treatment at higher levels of correction requires removing more corneal tissue, there is a greater chance of glare or halos (usually noticed in dim light situations). This is something that should be reviewed at the time of evaluating your eyes and you should get a sense of how likely it is to occur. Sometimes, this can be simulated with contact lenses to allow you to have a better idea of what to expect. Then, you would need to make the judgement of whether the treatment seems appropriate for you.

Albany, NY: How soon can I throw away my glasses?

Dr. Rajesh Rajpal: The improvement in vision occurrs right away but is generally dramatically noticeable by the next day. Again, there may be some fluctuation while it stabilizes.

Denver, CO: How soon after having the procedure can you fly or do any type of scuba diving?

Dr. Rajesh Rajpal: Typically, most patients can fly within days after the treatment. It is important to make sure artificial tears are used to keep the eyes moist since the air can be dry in a plane. For scuba diving, it is better to wait a little longer - typically a few weeks to a month. In all situations, it is important to determine how the healing has occurred during the visits after the treatment.

Towson, MD: I was told by another center that I have a slightly flat cornea. Is this a something that I should be concerned about?

Dr. Rajesh Rajpal: It is important to make sure this is taken into account in determining whether treatment can be performed. In performing the procedure on patients in this situation, certain types of keratomes can create better flaps for the treatment. Having topography and corneal thickness measurements is part of determining this.

Dr. Rajesh Rajpal: Thank you for sending so many interesting questions. Unfortunately, due to the time limitations, I will not be able to answer all of your questions. You can go to our website www.seeclearly.com and send questions to our "Ask the Doctor" area and your questions will be addressed. If it is easier, you can call us at 1-877-234-2020.

Many of your questions require evaluation to determine what you can have done. We are happy to help with this process.

It is important as you go through the process of deciding on laser vision correction that you feel confident in the information and care you receive. Our centers and all of our staff and doctors are dedicated to providing the education and the personal care necessary to allow you to achieve your visual goals. Please feel free to contact us if we can assist you in any way.

Moderator: Our thanks to Dr. Rajpal, seeclearly.com, Washington & Baltimore Laser Eye Centers and all who participated.

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