LASIK Refractive Surgery Experience

My Experience with LASIK: Observations, Comments, and Thoughts

Legal Notice: I am an engineer, not a physician or other health care professional. What you see here should not be construed as medical advice and should not replace consultation with a qualified physician. I have attempted to provide a reasonably objective account of my own individual experience with LASIK. I have also made an attempt to separate my own opinions from more quantitative observations. My purpose in providing these materials is to provide others who are considering the LASIK procedure more complete information than I was able to obtain when I decided on my own procedure.

My procedure was done at:    LCA Vision Center (now known as Lasik Plus)
                                              Dr. George V. Simon
                                              1390 Willow Pass Road, Suite 540
                                              Concord, CA 94520
                                              925-688-0400

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I wish to note that Dr. Simon is distinguished from his colleagues by a number of factors, but some of the most notable factors were his high level of experience in terms of the number of procedures performed, his willingness to perform a comprehensive eye exam without cost or obligation, and having an unusually knowledgable non-OD/MD staff.
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The equipment used was a VISX Star S2 Excimer Laser.

I started at about -9 diopters in one eye and -8 in the other with mild astigmatism(~1.25 cylinder) in both.

My procedure was done on 8/24/99.

The Actual Procedure(posted 10/22/99, procedure done 8/24/99)
I arrived at LCA Vision Center at about 9:30 A.M. on 8/24/99, about a half hour before my appointment time. I signed the financial documents and legal disclaimer forms and then was given a 5mg. dose of Valium. I didn't notice much effect from the Valium though I suppose I might have felt slightly calmer. One of the staff members administered a series of eye drops which were described as antibiotics. After waiting for about 45 minutes for the medications to work, I went into the laser room and a technician explained the details of how the procedure would be run, but I had removed my glasses at this point and everything was very fuzzy and out of focus. I did see the flashing red light that I was supposed to try to fixate on during the procedure. After the explanation, Dr. Simon administered a topical anesthetic drop in my right eye. The first drop caused a moderate stinging effect, the next drop stung very slightly, and the final drop felt no different than ordinary eye drops. A few other drops were then administered. I wasn't sure what they were, but didn't feel anything from them. A metal device was then inserted to keep my eyelid open. It was uncomfortable for a few seconds, but the discomfort quickly passed. A suction ring was then put on my eye. As the suction was increased, I felt pressure on my eye just to the edge of where it would be painful instead of just uncomfortable. My vision blurred and then went dark as this was happening and the microkeratome was attached. I heard a sound resembling that from a small stepper motor as the microkeratome blade made the cut to produce the flap. It was slightly unnerving to know that a very sharp razor blade was essentially slicing open the top 160 microns of my eyeball. It was probably just as well that I couldn't see it until I watched the video afterwards. After the cutting was completed, Dr. Simon removed the microkeratome and suction ring. My vision was very blurry at this point, but I could make out a small tool being used to pick up the flap and lift it to one side. After the flap was lifted, my vision became even more blurry. I tried very hard to fixate on the red light previously described and the laser started firing with a soft crackling sound. Despite my efforts, I would lose sight of the red dot after 10-20 seconds and then it would suddenly reappear. The doctor and his team were also counting off the seconds while the laser was firing. I also noticed a very dim blue area becoming apparent around the red dot after the laser started firing. I wondered if I was actually seeing the UV light of the laser, but it was more likely to be fluorescence of the tissue being bombarded by the UV light. It is also interesting to note that the blue light persisted briefly even after the laser stopped firing. During the course of the laser activity(which lasted about 60 seconds), I felt quite anxious each time the red light disappeared from view, but, from viewing the video afterwards, it appeared that my eye did not move that much during those times. After the laser firing was done, Dr. Simon irrigated my eye presumably with saline and then repositioned the flap and smoothed the edges. I kept my eyes closed for a short time and Dr. Simon proceeded to my left eye. That procedure was essentially identical so I will not bother to repeat myself. After the procedure had been completed for both eyes, some additional drops were administered and I was told to keep my eyes closed for a few minutes. I then moved out to the waiting area outside the laser room and put on a pair of dark sunglasses. Everything appeared uncomfortably bright. After about 15 minutes, I started to feel a slight soreness in both eyes. This increased in intensity until I felt moderate pain after about an hour. The doctor then administered some eye drops which immediately relieved the pain. (I think they were topical NSAID drops.) A quick eye test also showed me at a slightly hazy 20/30 with both eyes at this point. I left the doctor's office at about 12:15 P.M. and had lunch with a friend. About half an hour after I left the office, my eyes were feeling sore again so I took 800 mg. of Ibuprofen which effectively relieved the discomfort. I arrived home at about 1:15 P.M. and decided to take a nap. My eyes were feeling OK after taking the Ibuprofen, but I felt quite tired for some reason. After a two hour nap, my eyes felt fine, but my vision was still somewhat hazy and I could just barely make out the small clock display on my VCR. In the evening, my eyes become very mildly uncomfortable though it more resembled just being tired than actual pain. I took some more Ibuprofen and felt normal enough that I went to dinner with a friend and his family that evening. I noticed that the halo effect was moderate to severe that evening. Light sources, particularly oncoming headlights and streetlamps, produced such a severe halo effect that I would not have felt safe driving that evening. After getting home, I took some Vicodin(Hydrocodone/Acetaminophen) before going to sleep. I found it impossible to keep the plastic eye shields in place. In fact, I felt it was more likely for them to become displaced and possibly have the edges make contact with my eyes. So, I ended up just wearing sunglasses in bed during my nap and I didn't wear anything to sleep at night. I woke up at about 7:30 A.M. the following morning and was pleasantly surprised to see my vision had improved significantly such that small text(10 pt. I think) on a 13.3" laptop computer screen was easily readable from a comfortable distance. But, there was still a mild to moderate halo effect around light sources, particularly LED's and the vacuum fluorescent display of my VCR clock. My general vision was very slightly hazy, but not significantly enough to impair any of my normal activities. I should also emphasize that I used the Tobradex(topical corticosteroid/antibiotic combination) eye drops religiously for five days following the procedure. The instructions on how long to use the drops were not overly specific so I opted for five days. The main purpose of the Tobradex drops would appear to be as an anti-inflammatory agent and as an antibiotic. I'm unsure as to the benefit or detriment of using them for a few more days, but corticosteroids typically inhibit or slow wound healing so I suppose it would be a tradeoff of preventing infection and slowing the healing process. Corticosteroids serve as potent anti-inflammatory agents, but they also have the side effect of elevating intraocular(internal eye) pressure which can have the effect increasing the risk of glaucoma. I was unable to find studies addressing the long term risk of glaucoma from short term use of topical corticosteroids such as Dexamethasone in this case. But, I believe this risk to be minimal.

8/26/99
My night vision remains significantly impaired though it is possibly improved from the second evening after the procedure. I still see moderate to moderately severe halos around light sources, particularly street lighting(mercury lamps) and oncoming headlights. It is quite distracting and my night vision is definitely significantly impaired. I tried yellow polarized sunglasses, but found they offered minimal improvement.

9/1/99
As of now(9/1/99), I still continue to see mild to moderate halo effects around light sources, particularly at night. But, it is also noticeable around indoor lights and particularly around near point source lights such as LEDs. At this point, my night vision is significantly degraded compared to my night vision with glasses(or soft contacts) prior to the procedure. I would consider my indoor and daytime vision to be good at this time and generally comparable to my vision with glasses(or contacts) in similar circumstances.

I was told that I was seeing 20/30 24 hours post procedure according to the big "E" Snellen eye chart. However, I now consider the Snellen eye chart to be a less than comprehensive assessment of refractive surgery results. For instance, it does not quantify visual distortion such as the halo effect or measure visual acuity under different lighting conditions. In my view, it is only a very rough estimation tool at best. Despite this, it remains the primary assessment tool and most, if not all, the LASIK and other refractive surgery statistics are based on measurements made using it.

I have concerns about the possibility of off center ablation. From the videos, it is apparent that the laser was generally centered on my pupil during the ablation process, but it is also apparent that there was noticeable jitter or movement. I am uncertain as to the significance of this at this time as I have to yet to find research and/or studies addressing this issue.

From my research, the VISX Star S2 Excimer Laser currently provides the smoothest and most uniform surface post-ablation. Though it seems logical that a smoother surface would yield superior optical and healing qualities, that remains, to my knowledge, unproven by reputable studies. The lack of a computerized eye tracking system in the VISX Star S2 system may be a limitation, but I think that the multi-beamed nature of this system somewhat mitigates the lack of a computerized eye tracking system. Note that the only computerized eye tracking Excimer Laser for refractive procedures I am aware of is not currently FDA approved and is currently undergoing human trials. However, I believe the laser(a small spot raster scan type) used in this experimental system is different and possibly inferior to that used in the VISX Star S2.

For the curious, the lasers used in LASIK and PRK are called Excimer Lasers because the gas inside the laser tube is generally a compound known as ArF, a substance that is in a class of chemical compounds known as excimers. Lasers with excimer gases, particularly ArF, emit a relatively short wavelength UV(ultraviolet) light which contains sufficient energy to vaporize certain materials(such as corneal tissue) without significantly heating the surrounding areas. UV light at these wavelengths is generally not visible however.

9/9/99
The halo effect has not significantly diminished since the first day post procedure. My last eye exam on 9/7/99 indicated I was near 20/20 according to the Snellen eye chart. I spoke with the ophthalmologist who performed my procedure and questioned him in detail about several issues. Among them, I was told that the entire laser ablation zone is about 6.25mm with the inner 5mm being corrected fully. But, the remaining area is a "transition" zone between the uncorrected area of the cornea and the corrected center 5mm. If the pupil were to expand past the inner 5mm fully corrected zone, visual distortion would occur. That would be consistent with the halo effect I notice particularly at night and in dim light, as the pupils dilate(expand) with lower light levels. My pupils were determined to be in the 4mm range, fully dilated. The measurement technique consisted of comparing my dilated pupils with different sized dots printed on a plastic card to find the closest match in terms of size. This would seem to be a less than exacting method of measurement to say the least. Despite my 4mm fully dilated pupil size, I still experience visual distortions(halo effects) around light sources in low light and at night. In my individual case, these effects may diminish over a period of months. But, from my conversation with my doctor this week, I believe it more likely that I will become accustomed to the distortion in low light rather than have them actually subside.

9/23/99
It has now been about a month after my procedure was done. My general vision remains good with the exception of night and low light vision. The halo effect remains essentially unchanged since my last entry on 9/9/99. The effect is distracting and somewhat disconcerting indoors, but I would not consider it debilitating at this time. It is most noticeable around near point source light sources such as LEDs. For instance, I can see a distinct halo around the red LEDs on my telephone as well as around the warning lights in my car when it is parked in the garage or at night outside. Increasing the light level causes the effect to diminish until it is no longer noticeable in bright light. I believe the effect is dependent on pupil dilation because the effect varies with ambient light levels. At night, I would consider the effect to be mildly debilitating though I believe I can still drive safely at night. Outdoor vision during the day is generally excellent. For comparison, I can still read the small vacuum fluorescent time display on my VCR as I could after the first day. I would characterize my vision as essentially the same as one week post procedure, possibly very slightly, almost imperceptibly worse. I continue to use the artificial tear eye drops occasionally whenever my eyes feel dry. My next routine checkup is scheduled for 10/5/99. In a nutshell, I consider the results to be generally positive at this time though I am becoming much less confident that the halo effect will diminish further with time since it appears to be unchanged since about a week post procedure.

10/8/99
I went in for my post one month checkup on 10/5/99. The only finding of note was that my left eye had become very slightly nearsighted. (about -0.25 diopters) But, my right eye was unchanged. I had not noticed the change since it is only noticeable if I cover my right eye. My vision with both eyes remains at about 20/20. The halo effect remains noticeable in low light, but seems unchanged. The only other thing of note is that the name of the laser center I went to has changed from LCA Vision Center to Lasik Plus. I'm uncertain as to all the implications of this change. But, one immediate effect is the cost of treatment being reduced by a third. There were also many more people in the waiting room than on my previous visits and I waited for about 25 minutes before being seen. (I was 10 minutes late to my appointment however.)
My next checkup is scheduled in January 2000.

10/22/99
I have added a detailed narrative of my LASIK experience before, during, and immediately after the procedure. Though I have no major complaints about my procedure at this time, it is interesting to note that my outcome was considered optimal. By my standards, I would characterize my outcome as acceptable, but not optimal or perfect. However, since since my outcome is considered optimal, it is clear that the accepted standard of "optimal" for LASIK procedures is significantly lower than one might be led to believe based on the common LASIK literature and patient information. In a nutshell, obtaining 20/20 or better vision in each eye with no side effects(such as halos in low light conditions) is not a probable outcome though achieving an acceptable result with some minor tradeoffs is highly probable. My own individual experience, at least to date, is the latter.

10/31/99
I noticed that my distance vision seems to have degraded slightly so I went for an unscheduled checkup on 10/29/99. The optometrist found that my combined vision with both eyes remained at 20/20, but the vision in my left eye had worsened slightly to a prescription of about -0.5 diopters while my right eye remained at 20/20. Thus, my left eye would seem to have gotten 0.25 diopters worse than on my previous checkup a few weeks earlier. It is difficult to be entirely certain of this as the measurement technique has a substantial systematic error. But, based on more subjective day-to-day observations, I think my overall vision is essentially unchanged, but the vision in my left eye is indeed slightly worse than several weeks earlier. A mild halo effect remains and is unchanged from several weeks ago.

1/15/00
It has been more than four months since my procedure was done. My vision with both eyes remains at 20/20 and appears to be stable, but I still see mild, though clearly noticeable, halos around light sources in low light conditions. The condition is not what I would consider to be debilitating, but I notice it often and it remains a frequent reminder of the limitations of the LASIK procedure. My current vision is generally comparable to my vision corrected by glasses except in very low light and/or night conditions. At night, I can still drive and function without significant restriction, but the visual distortion(halos) remain noticeable. The effect is distracting and represents what I would consider to be a significant degradation in my night vision compared to my night vision corrected with glasses before the procedure. In general, I would say that I am reasonably satisfied with my results to date. But, I want to emphasize that I do not consider my results to be perfect, but I think the tradeoff to be a reasonable one.

I also wish to note that this LCA Vision is now Lasik Plus. This facility located in Concord(CA) is now flooded with new patients and prospective patients, presumably as a consequence of the massive advertising of the new $2995 pricing. As a consequence, I would have significant reservations about having a procedure done at this facility without thoroughly investigating their quality control procedures and standards. Having this volume of procedures often entails significant degradations in quality control unless extremely stringent quality control standards and procedures are enacted. Even with strict QC standards, the doctor and other personnel operating the equipment may become tired and produce less optimal results. (You may recall that the doctor manually operates the microkeratome and lifts the flaps, as well as manually aiming the laser.) For my most recent checkup, I waited about 45 minutes before I was seen by an optometrist even though I arrived well in advance of my scheduled time. This is a significant departure from previous visits prior to their name change.

6/16/00
My vision continues to be good about 10 months after the procedure. It is now about 2 months before my scheduled 1 year checkup and my vision remains very good at 20/20 or near 20/20 vision with both eyes. My left eye, judging from the small display on my VCR, appears to be slightly worse than my right eye, but still very good. This slight degradation in the vision in my left eye was first noticed about 6 month ago and appears unchanged since then. The halo effect however is still present and unchanged since at least 6 months ago. It is mildly distracting at night and occasionally indoors, but is not debilitating. I would regard it as a minor annoyance at this point and a worthwhile tradeoff in exchange for the overall improvement.

8/31/00
I had my one year checkup today and the results are generally good though I do have some concerns since my vision apparently has degraded slightly according to the eye tests. I have not noticed any difference in visual acuity during my normal activities however. My right eye is still considered to be 20/20, my left eye is 20/25, and my combined vision is 20/20. However, those numbers may be deceptive as I am now -0.75 diopter with +0.25 cylinder astigmatism in my right eye and -0.50 diopter with +0.5 cylinder of astigmatism in my left eye. For reading text at a distance, I have noticeably better acuity in my right eye. At this exam, the optometrist also noticed a trace of haze in the laser ablated area of my right eye though I do not notice any visual distortion or other effects from it at this time. While I am unable to see this haze in a mirror, this is a change that concerns me and that I will monitor very closely. But, all indications are that it is not and will not become a significant problem. At this appointment, the waiting room was empty and I was seen quite promptly despite arriving about 10 minutes early. (The center has also hired additional staff though their physician staff remains unchanged.)

I should also mention that there are a number of new and/or improved LASIK variants being developed and some currently in clinical trials at this time. There is at least one variant that incorporates a computerized eye tracking/aiming system and another that has an extended laser ablation area. The old version corrected only a 5.0 mm area, the successor corrected 6.5 mm which is the one I had, and the latest version is supposed to be in the 10 mm range. This should reduce the halo and visual distortion problems experienced when/if the pupils dilate to beyond the corrected area. However, there may be significant consequences of ablating such a large area. In comparison, the area of a 10 mm circle is about 2.4 times that of a 6.5 mm circle. And, since the area in question is actually a sphere instead of a circle, the difference is actually even larger. I believe it would be prudent to closely scrutinize data about the effects of these changes before making any decision as the fairly solid collection of evidence recommending LASIK is only directly applicable only to the 5.0 mm ablation sized variant and may not necessarily apply to the 10 mm version. In addition, other effects, which may not be significant at 5.0 mm or even 6.5 mm size, may become significant when the ablation zone is enlarged to 10 mm.

Finally, contrary to what some developers of the LASIK equipment may claim, I believe that the skill of the ophthalmologist performing the procedure remains a significant factor in determining the outcome. The procedure is not as automated nor as repeatable as some may wish us all to believe. At this time, LASIK is still not something to be done casually though the majority of outcomes is good and will likely continue to improve in the future with better technology. It is unfortunate that some of the recent LASIK advertising could be considered deceptive. With pricing now advertised in the $2000 range for both eyes, the message I have seen advertised is that LASIK is just a more economical and convenient alternative to glasses or contacts. What is left unmentioned is that the results are permanent and typically imperfect. With our current technology, there is no way to reverse the procedure. As of now, I am one of the many who enjoy the benefits of a generally successfully procedure, but there are a significant number of patients that did not fare so well. Though the probability of an undesirable outcome is relatively low, I think it high enough to justify careful consideration before deciding on this procedure. If, for example, your work or daily activities require a high level of visual acuity which you presumably have before the procedure with the aid of corrective lenses, you may wish to carefully consider the possible consequences of having reduced visual acuity or the introduction of visual artifacts, particularly at night or in low light conditions. These post-LASIK conditions may not be correctable, are usually permanent, and you may have to restructure your work and activities to accomodate them. I do not intend to unduly frighten those interested in the LASIK procedure, but wish to bring attention to these important considerations. To temper these warnings, I should emphasize that these problems occur relatively rarely, perhaps in the range of a few tenths of a percent. But, these problem cases are not typically well documented in studies or literature as the "20/20" visual acuity numbers typically quoted do not directly address these issues.

I have scheduled an appointment with my regular optometrist and will provide the data and conclusions from that examination when it is completed in approximately 1 week.

9/9/00
I had my eyes examined by Dr. Richard Chong(my regular optometrist for the past 20 years) on 9/7/00. He confirmed that there was some clouding noticeable in the laser ablated area of my right eye. But, I do not currently notice any effects or visual artifacts from this clouding. Dr. Chong feels that the clouding was likely present shortly after my LASIK procedure and is not a developing condition. There was also some scarring evident around the edges of the flaps of corneal tissue that were cut, lifted, and replaced during the LASIK procedure. This does not cause any symptoms at this time and I believe it is not likely to cause problems in the future however. It does indicate that anyone considering a LASIK enhancement operation, particularly if it requires cutting a new flap, should thoroughly research the effects and likelihood of complications from a second flap cutting operation, lifting of the existing flap, or a second laser ablation procedure. Also, the fact that it is often possible to lift flaps that were cut several years earlier suggests the flaps do not re-adhere as well as suggested.

The comparison of visual acuity measurements is as follows:

LEFT EYE RIGHT EYE

Lasik Plus 0.00 Diopter -0.50 Cylinder * -0.25 Diopter -0.25 Cylinder *
20/25 20/20

Dr. Chong -1.00 Diopter -0.75 Cylinder -0.50 Diopter -0.50 Cylinder
(9/7/00) 20/30 20/25

Dr. Chong -1.00 Diopter –0.50 Cylinder 0.00 Diopter –0.50 Cylinder

(2/16/02) 20/30 20/25

(*The LASIK Plus measurements have been converted to the notation used by Dr. Chong for easier comparison and is from my last exam at Lasik Plus on 8/31/00.)

As may be evident from this data, the Lasik Plus Data is significantly different from Dr. Chong's measurements. The difference is entirely unfavorable though I would also emphasize that I consider my vision to be good at this time and I do not have any need to wear glasses or contacts. My most significant problem has been and continues to be mildly to moderately impaired night vision.

4/2/02

I have not noticed any change in my visual acuity. A routine checkup by Dr. Richard Chong on 2/16/02 found some slight differences that could be accounted for by systematic measurements errors. My vision continues to be good with overall vision with both eyes near 20/20. A mild halo effect continues to be noticeable around point source lights at night.

10/26/04

I have not had a regular eye exam for about 2.5 years, but my vision appears to have deteriorated slightly though it still remains good overall. I would estimate my current overall visual acuity with both eyes at somewhere between 20/25 and 20/30. While I could read the VCR display from my sofa 2.5 years ago, the small digits are now blurry enough to be nearly unreadable (at least without guessing.) As before, vision in my right eye is noticeably better than in my left eye. I have not noticed any additional visual artifacts though the mild halo effect about point source lights remains.

12/22/05

My vision is unchanged and remains good overall. I did notice that I can read small print/type more easily with my left eye than my right. This is probably due to my left eye being farther from 20/20 than my right eye. (I have better distance vision from my right eye.) This outcome was not planned or intended at the time my procedure was done, but perhaps it will work out well when I get older. Maybe I’ll even be fortunate enough to not need reading glasses in 10-15 years. (I turned 35 this year.)

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