From latest Barron's.....
May 17, 1999
Should You Have Your Eyes Lasered?
Here's the story of a guy who did
By Jay Palmer
My wife jolted awake from a deep sleep as I shouted in sheer surprise: "I can
see birds flying outside the window!"
Truth be told, the view wasn't all that great, mostly because my eyes were
covered with thick protective plastic shields. They were also rather blurry, full of
tears and feeling about as sore as if I'd been out on the town the night before. But
I hadn't. The afternoon before I'd had laser surgery to correct my incredible
shortsightedness. The operation was a munificent birthday present from my
parents, who pointed out that my lack of perfect vision was mostly their fault,
genetically speaking.
The results of the procedure were beyond all expectations. For the first time in my
life, I could open my eyes first thing in the morning and see, really see, without
fumbling around the bedstand for my glasses or hopping out to the bathroom to
put in contact lenses.
I can hardly call what I did
pioneering. There were more
than 400,000 such operations
last year, most of them in the
U.S., and there will be at least
800,000 this year. That's not
enough to more than dent the
current potential market of
150 million
"visually-challenged"
Americans, who spend an
estimated $13 billion a year on
vision care. But the writing is
on the wall.
By the year 2003, the number
of laser surgeries is expected
to run at an annual pace of
two million, and even that estimate might prove conservative. What is clear is that
as the price of an operation comes down from the current $2,000-$2,500 per eye,
more and more people will opt for surgery, in effect shutting down the vision-care
business as we know it.
United Nations studies estimate that at least one-quarter of the world's population
have less than perfect vision, and the U.S. numbers, where testing is more
widespread, suggest that the real percentage may be more than double that.
Sometimes the problems are caused by injury or disease, but more commonly it's
because of lousy genetics. For centuries, the only way to correct the most
common vision deficiencies was to put corrective lenses in front of the eyes,
initially magnifying glasses and spectacles, but more recently contact lenses.
No one of these solutions is
ideal. As any wearer knows,
glasses often fog up and
have an infuriating habit of
slipping off the nose at the
most awkward moments.
They break, get lost and,
when they're on, sit there
like some permanent
billboard atop the nose.
Moreover, as Dorothy
Parker quipped, "Men
seldom make passes at girls
who wear glasses."
Contact lenses also have
disadvantages. They're expensive, difficult to get used to, and the process of
wearing them involves a time-consuming routine of daily cleanings and morning
insertions. Eye infections are not uncommon, and the tiniest bit of grit in the eye
on a windy day can leave any contact lens wearer demobilized in agony. Worse,
the slightest jolt to the head or flick of the eyelid can dislodge a hard lens from the
center of the cornea, sometimes sending it spinning off into oblivion. Soft lenses,
for their part, offer less perfect vision-correction and have problems of their own,
including a tendency to tear easily.
Surgery to correct defective vision is not a new idea, having been first tried with
mixed results back in the late 1890s. A Colombian surgeon took matters further in
the 1940s, manually shaving the top of the cornea to get better vision while, in the
1970s, a Russian citizen invented a procedure called radial keratotomy, or RK,
using the finest of scalpels and mechanical knives to cut microscopic spokes in a
radial pattern around the cornea, causing the front of it to flatten and focus light
more directly on the retina.
Though RKs are still being performed successfully, lasers have all but taken over
since the mid-1980s, when medical researchers discovered that IBM's new
excimer laser, invented initially for etching computer chips, could cut tissue
without leaving any surrounding damage. So fine and exact is the excimer laser
light beam that it can cut with an accuracy of 0.25 microns, breaking the
molecular bonds between cells of the cornea and typically taking up to 200 beam
pulses to cut through tissue the width of a strand of human hair.
Two public companies share the U.S. market for the excimer laser (which is made
under license from IBM), and both have become market darlings in the latest mad
rush for technology stocks. Santa Clara, California-based VISX, which claims
roughly 75% of the U.S. market, has seen its stock soar from under 10 last year
to 121 3/4 last week. Summit Technology of Waltham, Massachusetts, holds the
remaining market share and has fared almost as well in the markets lately, with its
stock climbing from around 3 last year to a recent 15 7/16. Though neither stock
is cheap when valued based on current earnings, both seem to offer potential for
unusually fast growth.
My decision to opt for laser surgery had not been made easy by the fact that I
was one of the fortunate few who, despite the odd brief bad moment, found hard
contact lenses effective and comfortable. Against that, however, there was the
irritation of having to clean the darn things every night and fumble mindlessly to
reinsert them again every morning. And then there was the constant daytime threat
they might slip off-center or even out of the eye at any moment, engendering
agonizing chaos in the middle of an important meeting or whatever. Lastly, there
was the fact that with old age creeping up, my arms were getting too short to hold
a book far enough away for me to read easily, making glasses inevitable.
I didn't have to search
widely for an eye surgeon,
having been directed by
friends who'd had
successful laser surgery to
Dr. Wayne Grabowski, a
Princeton, New Jersey,
ophthalmologist with offices
not far from my home. An
appointment was quickly
made and preliminary eye
readings taken. Since I was
not, luckily, one of the
0.25% who are too
nearsighted for surgery, a
date was set for four weeks
away. The worst part was the nervous anticipation -- and the fact that I couldn't
wear my lenses for three weeks prior to surgery, making it the longest span since
the 1960s that I've had to wear thick, uncomfortable glasses all day.
Aside from incisional procedures like RK, where the corneal lens is re-shaped with
a knife, there are three longstanding eye procedures for which lasers are used.
The oldest of them is photo-refractive keratectomy (PRK), where the laser beam
is used to burn away and reshape the surface of the cornea, eliminating low to
moderate amounts of nearsightedness (see diagrams). A second procedure,
photo-astigmatic refractive keratectomy (PARK), works much the same way to
eliminate astigmatism. In each case, the amount of tissue removed is determined
by the amount of vision correction required.
But the laser operation of choice, especially for people like me who require higher
levels of vision correction, is laser in-situ keratomileusis (or LASIK). This means
to shape the cornea within using a laser.
Unlike PRK, which treats the surface of the cornea and is used almost entirely to
correct for shortsightedness, LASIK treats the inner eye tissue, and is now
approved by the Food and Drug Administration to correct farsightedness as well
as shortsightedness.
First, a mechanical knife called a microkeratome is used to cut a flap in the front
outer layer of the cornea. The doctor lifts that flap and folds it back out of the
way. At that point, the excimer laser is used to re-sculpt the internal corneal tissue
to the correct refractive power, a process that typically takes less than a minute.
The flap is then laid back in its original position and, most often, bonds back into
place within days.
There are risks to laser surgery, including the possibility the patient will end up
experiencing a slight halo effect at night around bright lights. The odds of serious
vision damage are reckoned to be less than 1 in 3,000, while the possibility of
post-operative infection can be effectively eliminated by proper use of eye drops.
Since PRK uses a laser to sculpt the outer surface of the cornea, it causes a higher
level of post-operative discomfort, typically lasting no more than a week or two.
LASIK, by contrast, involves a mechanical knife and penetration of the eyeball,
and the surgical risks are thus higher, though in practical terms hardly higher than
an operation for an ingrown toenail. The post-operative discomfort, however, is
small and doesn't last long.
The biggest risk, if you can call it a risk, is that the procedure ends up not
working as well as expected. The simple fact is that no laser eye surgeon can
guarantee achieving perfect 20/20 vision in both eyes, though there is reckoned to
be a better than 60% chance that this could happen when the final post-operative
blurring finally fades two or three months after surgery. Still, statistically, laser
operations are most often runaway successes, with close to 100% of Dr.
Grabowski's patients ending up with 20/20 in one eye and better than 20/30
overall, a common level of success in the industry.
The doctor more or less guaranteed me 20/40 or better, at least inasmuch as he
offered to redo the surgery three months later at a greatly reduced cost if that level
was not achieved.
When the day of my
operation dawned, I
nervously phoned to get
directions to the Somerset
Eye Center in nearby New
Brunswick, the site of the
surgery. "Oh, haven't you
been called?" replied the
chipper receptionist. "Your
appointment has been
canceled. A test showed
that the microkeratome
machine used to cut the flap
in your cornea is not
working properly. We're not
sure whether it would cut
properly." Three days later,
having spent much of the intervening period ducking a nighttime vision of some
demented mechanical Boris Karloff playing tic-tac-toe on my eyeball, I was all set.
The procedure started with sets of numbing eye drops, followed by an effort to
get comfortable in what felt like a fully reclining dentist's chair. With nowhere to
put my hands and arms, I was glad to take up an offer to hold a squeezy toy. As
my wife watched through a nearby window, first my eye lashes were taped back
and then a metal device was inserted in my eye to hold my lids open. By now
repaired, the microkeratome device was placed over my eye much like an
upturned eggcup, with the doctor pressing down hard to get a perfect vacuum
seal as the knife cut the corneal flap. When it was lifted off, my vision became
blurry as the doctor lifted up my flap. All I could see of the laser was dancing blue
lights, and I heard a soft zapping sound. The smell, the nurse insisted, was ozone.
To me, it seemed like burning flesh.
Fifteen minutes after lying
down, both of my eyes
were done. I sat up, tears
streaming down, and read
the time on a wall clock.
That evening, though, I
despaired. I couldn't read,
the TV was a blur, I
couldn't see much of
anything, and I figured I
never would. Then, the next
morning, I saw the birds.
Since then, my eyesight has
improved steadily, with
original blurring steadily
fading to the point that now,
six weeks after the surgery,
I'm better than 20/30 in each eye and still improving. The long-term hope is 20/25
or better in both.
But there is at least one catch. Ironically, I now wear glasses for much of the
working day -- reading glasses. As I was warned, re-shaping my eyeball to
near-perfect long-distance vision doesn't do anything to improve one's reading
vision, which deteriorates with age. And oh, yes, my wife, worrying that I can
now see her first thing in the morning without makeup, is threatening an
unnecessary facelift.
|
