Which procedure is best for me?

[NINnerd]

Hi there. I'm new and I don't know what most of the abbreviations mean, so some of the past threads don't make sense to me. So I'm posting a new one. If there is a thread that answers these questions, just point me to it. :D

So, here's my profile:
Female
26 years old this April
Near-sighted (not too much...but I don't have my prescription)
Slight dry-eye due to outside forces (makeup, allergies) and not something wrong with my eyeball

I kept a "Dry-Eye Journal" for my optamologist, basically reporting when I had dry eyes, how severe, what was different (e.g. Was I wearing eye makup?), and all that for about two weeks. He saw it and said I would be fine for Lasik.

My question is - which procedure causes the least amount of dry-eye? I already have some problems and I don't want to make it worse. I know all procedures have a risk of causing dry-eye, but which is least likely to do so? (I think I read on here that any of the non-flap procedures are better for reducing the risk of dry-eye.)

Also, what about other complications like ghosts, halos, etc.? Is there any one procedure that has less of a risk for those things?

Thanks so much in advance! :D :D

[6502programmer]

I can only speak from my own experience and research, so consider this simply as a data point, not a complete opinion.

Regarding dry eye, yes, your research and mine line up that the more shallow the procedure in the cornea, the less the risk of dry eye. Additionally, dry eye seems reduced with surface ablation.

GASH is always a risk, but from what I was able to find, wavefront-guided ablation not only has a lower risk of inducing higher order aberrations, but also may be able to correct them.

For me, with high nearsightedness (-6.5,-7.0), moderate astigmatism, and moderate HOA's, wavefront-guided was the best approach. The first provider I saw was gung ho on LASIK. The second provider said I was not a good candidate because of the amount of correction and low-normal corneal thickness. After finding out about the PRK surgery, as well as the lasers at the provider, I started doing my research.

They use a VISX Star S4 for wavefront-guided patients. The process starts when they do the scan. The eye is scanned and mapped relative to the iris. This is transmitted to the laser for the treatment plan. During the surgery, the position of the iris is used to guide the ablation. It's tracked 4000 times per second, allowing it to compensate for minute movements.

Often, the visual complications of refractive surgery are due to one of two things: flap complications and decentered ablation. The former, something goes wrong, whether during flap creation or healing, that disturbs the optical properties of the cornea. In the latter, the surgery is done "off center". From what I could find, the laser used for my surgery minimized that possibility.

I chose PRK, though one provider was willing to do LASIK, to eliminate the first case's complications, and went with wavefront-guided to reduce the possibility of the latter. There is some research out there that indicates the clinical results achieved with wavefront-guided correction are better, both in terms of straight acuity (how many letters can you read on this line), as well as quality of vision, particularly at night. There is some research that PRK is mildly better, from a clinical results perspective, than LASIK as well.

I never suffered dry eye before (even with regular constant contact usage), and now, 6.5 weeks post op, do so only from time to time. My vision is outstanding, both in acuity (20/20) and quality (no signs of GASH at all).

I can say that unless you're ready for about a week of "bad contact days", approach PRK with trepidation. That first week was NOT fun, with the first four days being spent doped up with Tylenol III and the next week and a half after that putting artificial tears in every twenty minutes. Add to that I suffered a couple of (extremely painful) epithelial tears that required more visits with the doctor, it was not a pain-free affair.

[NINnerd]

Thanks for the reply!!

So is Wavefront just for Lasik? Or for PRK? Lasik is the one with the flap, right?

Sorry...I know very little, so a lot of that went over my head.

Thanks for your help, though. :)

[LasikExpert]

Wavefront is a mapping system to determine where and how much tissue the laser should remove. Wavefront-guided laser is possible for Lasik, All-Laser Lasik, PRK, LASEK, or Epi-Lasik.

In Lasik, the first step is to make a cut across the cornea, creating a flap of corneal tissue. The flap is moved aside, the laser energy is applied, and then the flap is repositioned over the treatment area.

By removing tissue underneath the flap in the deeper area of the cornea, the eye is "fooled" into not realizing it has had surgery. This is why Lasik has a relatively fast recovery and virtually no pain.

PRK is exactly like Lasik, but without the Lasik flap. The laser removes tissue at the surface of the cornea. The advantage of PRK is that it leaves more cornea untouched and with no Lasik flap, there is no possibility of a Lasik flap complication (no matter how remove, there is always a risk). A disadvantage of PRK is a much slower vision recovery and discomfort.

[NINnerd]

Oh ok! Thanks!

I guess my main concerns are not what is going to happen immediately after, but more long-term.

Which procedure is best for people that have occassional dry-eye already or that just want to avoid it? Thinking long-term, btw.

Thanks again!

[LasikExpert]

As a general rule the surface ablation techniques of PRK, LASEK, and EPi-Lasik are considered less likely to induce dry eye than Lasik or All-Laser Lasik.

[NINnerd]

Thanks!

I just want to get some general info so that I can present that to my Dr. should I decide to go through with it.

:)

[6502programmer]

Sorry if it was too techie.. Essentially, PRK (and cousins LASEK and epi-LASIK) have a longer healing time, more discomfort, and cost more.

The ONE thing I think I was misled on was why PRK costs as much as all-laser LASIK. The initial consultant I talked to said it was because of a drug they use. Afterward, I came to the conclusion it's the post-op clinical management. When I shared that with the optometrist, he said PRK requires 3x the visits of LASIK, on average, which is why it's $1000 more than LASIK with the same laser. It wouldn't have dissuaded me, knowing it would need more followups than LASIK.

Honestly, if you suffer from dry eye, and are looking to avoid it, I would probably suggest you not go through with any surgery. Anything you do to disturb your corneas has dry eyes as a possible outcome. Nothing currently available can guarantee you won't suffer from them.

I was looking long-term as well, which was what led me to PRK. It is more painful initially, has a longer "functional" recovery time (it took five days for me to be able to drive in the daytime), and has a longer time for the eye to fully heal and yield optimal results. There is also the problem of haze developing, though taking Vitamin C before and after surgery, as well as the common use of Mitomycin C during the surgery, minimize the chances.

In exchange, I have a better shot at "good" vision (20/30), a much better chance of "better than good" vision(better than 20/20), a much lower chance of poor vision, a lower chance of dry eye, and an eye that, aside from minor physiological changes, is essentially the same eye I started out with.

[NINnerd]

See, I thought I had too much dry-eye, too. But when I created my dry-eye journal (which I was really honest about), my Dr. said I would be ok. This is the same guy that turned me down the first time because I told him I had occassional dry-eye. He sends his patients to an eye surgeon he works with, and they do NOT take just anyone. They turn down lots of people, and the surgeons are not just performing vision-correction surgery. They do all sorts of surgeries. So I was comfortable knowing this.

I'll mention all of this to my Dr. and see what he says.

Thanks, guys!

[NINnerd]

Ok, I have a consultation set up with my Dr. for next Wednesday.

His Lasik person there (for lack of a better title), told me that vision-correction surgery and dry-eye kind of go hand-in-hand. I told her that I know people that didn't experience long-term dry-eye after surgery, and she said it's more common in women, but that everyone is different (the people I know are both men).

So I'm really hesitant. On a scale of 1-10, with 1 being no dry-eye ever, and 10 being constant dry-eye, I would say MOST people are about a 1, and I'm maybe a 2-3. So we'll see what my Dr. says.

I'll keep you updated. :)

[LasikExpert]

When I shared that with the optometrist, he said PRK requires 3x the visits of LASIK, on average, which is why it's $1000 more than LASIK with the same laser.

Your optometrist is correct that a PRK patient will likely require more postoperative care, but this is the first time I've heard of a doctor charging more for PRK than for Lasik - a lot more. I do not actively monitor pricing throughout the country (and doctors can charge whatever and however they want), but this is new to me.

[6502programmer]

The conversation went like this (during the fifth or sixth visit in three weeks):

me: When I asked [consultant] about why PRK costs as much as Intralase (bladeless), he told me it was because the mitomycin is so expensive, requires special handling, etc. Now, I understand, with all these followup visits!
optometrist: Yes. PRK usually requires three times the clinical management that LASIK does.
me: And I'm assuming you don't work here for free!
both: laugh

Initially, I was taken aback by the idea that the PRK package cost $1000 more, or the same pricing as Intralase, than the same ablation with LASIK. I didn't understand why something that is ostensibly more simple, no flap versus flap, cost more. I did some research about the cost of MMC, and determined, based on pricing provided by my prescription coverage company, that the MMC used in my procedure could cost no more than $100, and that's at a MUCH higher concentration that I found is typically used intraocularly. I had already committed myself to spending more for wavefront-guided versus traditional, and I already had a strong preference for this provider over the others because of their candidness regarding corneal depth, correction required, and PRK vs LASIK.

All things considered, I'm glad I went with the provider I did. The optometrist, based in the facility, provided me far better care than I think a co-managing optometrist would have provided. He took a lot of time with me when I needed it, had ready answers to all of my questions, was perfectly candid, and seemed very professional. He is the type of doctor that makes people believe most doctors are all-knowing and infallible.

In fact, even from my first interaction with him, I was impressed. During my initial clinical consultation, I was told I would have my eyes dilated and that my focusing would be affected for up to 48 hours. Needless to say, I was somewhat concerned by this, and had questions. Within five minutes, I was speaking to the doctor. He took the time to explain to me what was being used, how it was different from the usual dilating drops, and why it was necessary. While I'm sure he can "dumb it down" for most people, I appreciated that he didn't for me.

For most people and in most cases, I'm sure that co-management works out great. I don't have a primary optometrist I see regularly, so it wasn't important. The office was only about thirty minutes away for me, so it wasn't too burdensome to go there. While he's "only" an optometrist, postop management is what he does day in and day out. He's likely to be more able to manage things early on by himself than an optometrist in private practice.

[LasikExpert]

In reality, your care was comanaged by an ophthalmologist and an optometrist. The difference was that it was in the same office.

With the exception of easy access to the surgeon, you would undoubtedly have received the same level of care from that optometrist if he had been in an independent practice that comanaged with the same surgeon.

With the right people comanagment can be an asset. With the wrong people poor care is poor care no matter what the environment.

[NINnerd]

I'm not too worried about the co-managing because my Optometrist only works with two surgery centers. And he always has. So he's very familiar with the people there.

[NINnerd]

Well, I had my consultation and here's what we found out. :D

*The day I went in, I hadn't slept well so I had a bit of irritation. The doctor wants to make sure I have NO irritation before surgery, so he put me on Restasis eye drops for a month (and gave me all free samples!!). So this will serve two purposes: 1. To get my eyes ready, and 2. To see if these drops help my eyes so that if I have dry-eyes post-surgery for the short OR long-term, I'll know if these drops can fix that (he is checking for irritation in a month and also for tears produced).

*I metioned how PRK might be better for me cause of dryness. He said that he doesn't think the difference for me will be that great because I need such little correction and they won't be removing that many microns. So he would still recommend Lasik (but the surgeons do both).

*The surgeons do Wavefront. I'll talk more with them about using it, cause it sounds like a great advantage from what I've heard. But they will know if it's right for me.

*They measured my eyes at the consultation, they'll measure them again in a month, and then again at the pre-op meeting, and I *think* on the surgery day (they should on surgery day, right??). If the last two or three times are the same, they will do the surgery.

So yah, He said that in a month, if my eyes look good, he could see starting everything rolling. I'll be bringing the "50 Tough Questions..." lst with me when meeting with the surgeons. ;) How does it all sound to you guys?

Thanks for reading this!