Doctors Answers Questions About Eye Surgery

Almost everyone older than 45 will develop presbyopia, or the loss of close-up vision. Some cope by wearing reading glasses or contact lenses, but surgical options are becoming increasingly popular.

Are these surgeries safe? What is the recovery like? Who is a good candidate? Here, tackling a sampling of your questions is Dr. Barrie Soloway of the New York Eye and Ear Infirmary.

Kelm Brueschke of Urbandale, Iowa, asks: I am a type 2 diabetic and want to know if that precludes me from being a candidate for Lasic eye surgery?

Dr. Soloway: Diabetes in and of itself would not preclude you from having LASIK eye surgery, however, all the other caveats would apply such as the need for the prescription to be stable and the diabetes under control, including any retinal vascular problems.

H. Porter of Charlotte, N.C., asks: Is surgery to correct presbyopia recommended for someone who wears contacts for distance vision and astigmatism and wears glasses for reading?

Dr. Soloway: Most people who want their presbyopia corrected surgically are having it done in addition to getting their distance vision corrected as well. With current techniques for surgical presbyopia correction, one might find it difficult to use contact lenses afterwards. Some of the methods you might consider if you are found to be appropriate anatomically would be monovision lasik surgery which can be done in the United States as it is fully approved.

Angelo of Jersey City, N.J., asks: Without adequate lighting, I have to strain my eyes to read and I am only 39 (40 in March, 06). I am worried that if I even am a candidate for surgery, presently, how long before I would need another to correct my ever-changing eyes? I currently use my glasses two weeks at a time vs. my contacts (L-5.5, R-5.0) for one week at a time. I am very curious, please advise me, Thanks!

Dr. Soloway: It is unusual but not unheard of that someone in their 30s needs reading glasses. It is possible that your distance prescription is too strong as this would have the same effect. Surgery for the distance alone might be OK if that portion of your exam isn't changing. Unfortunately, the reading portion will deteriorate gradually over the next 25 years.

Kathy Duff of Gainesville, Fla., asks: I have been wearing glasses since I was 15 for myopia. The prescription has not changed much over the years, except for a little change causing me to wear bi-focals. I am 41. I have been wanting to see if surgery could fix my vision, as I hate wearing glasses and contacts. I want to wake up and see clearly and not have problems swimming. I also feel it interferes with some of the assignments I have been given at work. My husband says that it will not fix the presbyopia, and I will still need glasses. I'd rather wear glasses for when I am reading than wear glasses 24/7. May I have your opinion?

Dr. Soloway: The decision to have laser eye surgery when a patient is already using glasses for reading, on top of their contacts, can be a difficult one and each patient reaches their answer differently depending on their own personal desires and needs. Some patients, when made aware that they will need reading glasses, wonder why anyone would have the surgery. Others using contacts and readers over the contacts view it as a way to at least get rid of one of the two. I like to ask my patients what they are hoping to accomplish with the surgery. I get many different answers, but try to lump them into one of two categories: surgery for vision reasons such as fog, skiing, etc., and surgery for glasses reasons -- the "I hate glasses" sort of patient. The vision group tends to do best with distance correction in each eye and doesn't mind using reading glasses. The glasses group will typically make good monovision patients which will minimize their use of glasses the most. If you would rather wear glasses for reading instead of 24/7, then you have realistic expectations of what the surgery can do and should consider checking to see if your eyes are appropriate for surgery.

Nancy of Raleigh, N.C., asks: I am 54 years old and wear progressive, biofocal glasses. I have extreme dry eyes and tried plugs in my eyes. I also have tried contacts, but they make my eyes feel even drier. I have been told lasik surgery would make my eyes even drier. Would a lensectomy work for me? (I already have the beginning of a cataract in each eye, but it is the slow-growing kind).

Dr. Soloway: Most patients get drier after LASIK surgery and if you already have extreme dry eyes, you "have been told" correctly. Other methods of excimer laser (the laser used in LASIK) surgery such as surface treatments of PRK or EpiK might be considered. Lensectomy shouldn't make the dryness worse, but does have some risk due to the fact that it is intra-ocular surgery, so infections or bleeding, though rare, could cause the vision to end up worse. Depending on the level of your cataract (worse is better) it could however be an excellent choice.

"Kcpin" asks: I have presbyopia otherwise no problems with sight. I'm 52, female and I wear 2+ enlargers. Are they harmful? And would I benefit from lazer surgery?

Dr. Soloway: There is no harm in using the over-the-counter readers or magnifier glasses, and +2.00 is about right for your age. They shouldn't be used as a reason to not visit with an eye doctor from time to time (perhaps every 2 years) to be certain that you don't have any silent eye problems such as glaucoma.

Sherry Davis of Bristow, Va., asks: I am in my early 40's and recently went to the eye doctor. I was told that I wasn't a good candidate for laser eye surgery because my prescription hasn't stopped changing. My eyesight is slowly beginning to revert to far-sightedness instead of near-sightedness which I've been for many years. Is it true that I shouldn't get laser eye surgery? The Dr. instead is recommending a treatment using contacts to mold my eyes while I sleep at night, slowly correcting my vision. I would prefer to go the laser surgery route. What would you advise?

Dr. Soloway: One of the first prerequisites of laser eye surgery is that your prescription for distance (not the reading glass prescription) is reasonably stable. Slight changes of a quarter diopter (the measurement for glasses strength) are not typically reasons to not have surgery. The method that your doctor is referring to is called "orthokeratology" and is usually practiced by optometrists (who do not do laser surgery) and not by ophthalmologists (some of whom do perform laser surgery). Orthokeratology can work well depending on the practitioner and the original prescription (weaker prescriptions being easier to treat). Both groups of eye doctors might offer different options based on what is available to them. You might consider getting another local opinion, but be certain to bring as many pairs of old glasses in order to have an assessment of just how much your eyes have been changing.

Brad Dick of Lenexa, Kansas, asks: Are any of the new non-medical eye-focusing programs effective? One program claims a person can, through eye exercise, regain the ability to focus at both distant and close distances. Any truth to these claims?

Dr. Soloway: While there is a good deal of controversy over these non-surgical methods of vision correction, in my practice I have found them to be effective over only a very small range of mild prescriptions.

Frank Kitchen of Folsom, Calif., asks: I have been told that I am not a good candidate for Lasic surgery because I have keloid skin associated with scarring. That was 5 years ago. Have any developments been made that I could now have the surgery? I've told that there are some new procedures that may allow me to have the surgery. I would appreciate your comments on this matter. Thank you for your time and consideration.

Dr. Soloway: Keloid formation is primarily a risk of surface excimer surgery and currently it is not a contraindication for LASIK surgery.

Curt Benefield of San Antonio asks: I have had Lasik surgery about 8 years ago to correct my near-sightedness problem. I am now 56 and have lived with presbyopia for about the past 6 years with a correction of about -1.75. Am I a candidate for corrective surgery?

Dr. Soloway: In the U.S., only a re-treatment to make you nearsighted in one eye with the excimer laser of CK for monovision might help. The other surgical procedures for restoration of reading vision such as SSP (scleral spacing procedure) would not be able to be done as they are investigational and most protocols require no prior eye surgery. One presbyopia investigator's practice is in San Diego and you might contact him for an evaluation: Larry Lothringer, MD.

Carolyn of Brookland, Ark., asks: If you have Amphilophia (lazy eye) in the left eye only and wear bifocals would you be a candidate for laser surgery or would you consider it to dangerous to try? Thank you for your reply in advance.

Dr. Soloway: Monovision may not work well with amblyopia (lazy eye) as the second eye may not see well enough on its own. Depending on the level of weakness, laser surgery, while not more risky, might not be a good option on your only good eye.

Brian Williams of Lenoir City, Tenn., asks: I had RK surgery in 1992 to correct near-sightness. I could read fine without glasses then. Three years ago I had to start wearing glasses again for near-sightness and also for reading. Can surgery correct my near-sightness and allow me to be able to read without glasses?

Dr. Soloway: It would be unusual to be both nearsighted and need reading glasses at first, even more than 10 years after RK. More than likely you have had a farsighted shift. Either way, laser surgery can be performed in most patients that have had RK in the past to improve the distance vision without glasses. CK or conductive keratoplasty might not be advised after RK as it can have the adverse effect of re-opening the RK incisions and causing an unpredictable result. Monovision with the laser can also be considered.

Gennell Winkler of Scottsdale, Ariz., asks: Is eye surgery right for me? I am 75 years old and I (a) wear bifocals, (b) am in good health except I have COPD and bronchitis, and (c) walk approximately 1-2 miles a day. Thank you.

Dr. Soloway: I have performed laser eye surgery for vision correction in patients up to 84 years young but it was a very unique case. I have done surgery on people in their 70's as well but that too is rare. Usually lens-based surgery is advised as there are typically some lens changes toward cataracts and lens-based surgery can then actually improve a patient's resulting vision by removing any opacity in the patient's optical system (that is, the cataract).

Sara Abrams of Richmond, Va., asks: My vision deterioration started around age 42 (I am 53). Prior to that time, I had never needed glasses. As time has passed, my close-up vision has continued to decline and I now find that my distance vision is also affected. Night driving is almost impossible. Would surgery be a benefit for me? Is the cost reasonable? How do I find a competent vision specialist to make the decision?

Dr. Soloway: Most likely you are farsighted and were able to control the distance vision with the same focusing muscles used for reading by normal sighted people. I would venture to guess that when you were younger (in your teens for instance) you saw things far better than all your friends. Far sighted laser surgery is available but it is important that your prescription has stopped changing or at least you accept the strength of eyeglasses found to be needed on a dilated or focusing muscle paralyzed eyeglass examination. The parameters of pupil size are slightly more limited in farsighted surgery, but it is available, and the cost is usually the same as nearsighted surgery. Finding a competent surgeon can be challenging as you need to separate the hype from the reality. I suggest getting as many recommendations from friends that might have had the surgery, learning as much as possible in advance about the surgery, and visiting with a few specialists in your area to see who is experienced, and not trying to be too sales-y, will be seeing you after the surgery and practices in an office that you feel comfortable in. Since consultations for vision correction surgery are typically complementary, you can check a few offices without much financial impact (it might only cost you your time).

Bill Thomas of Jackson, Miss., asks: I am 56 and have better than average vision, 20-10 or 20-15, but suffer from presbyopia. The lens replacement seems quite invasive and I was wondering about the less invasive surgical options. What else is out there? I was particularly interested in an experimental surgery that tightened the muscles around the eye.

Dr. Soloway: Most surgeons that are using the lens replacement method would not consider you a candidate for that surgery because your distance uncorrected vision is so good. The surgery to increase the working distance of the muscles around the eye (tighten them so to speak) is currently under investigation in the United States. One of the advantages of this surgery is that so far during the clinical trials, distance vision has been unaffected. During the investigation time of this surgery prior to FDA approval it is imperative that the patient return at regularly defined intervals to collect information on how they are performing. The name of the company sponsoring these trials is Refocus group based in Dallas. I am the medical director of these trials and the nearest investigators to you would be Richard Yee, MD, in Houston and Larry Lothringer, MD in San Antonio.

Mark Smith of Saint Paul, Minn., asks: Is eye surgery available for those with keratoconus?

Dr. Soloway: Keratoconus is one of the true contraindications to excimer laser based vision correction surgery. I have used Intacs successfully in some patients with keratoconus and this is an accepted (but not approved) method of treatment (The FDA granted Addition Technology an HDE (humanitarian device exemption for this) for people with mild keratoconus. In advanced stages, such as when there is scarring, corneal transplant surgery is typically advised.

Denise of Queens, N.Y. asks: My question has to do with my grandmother. She is 90 years old and has been recommended for cataract removal surgery. She does not have severe loss of vision, so I'm thinking at her age she really doesn't need the surgery. What are your thoughts? Thanks.

Dr. Soloway: Because cataracts alone do not typically cause any permanent eye damage, cataract surgery is rarely mandatory and is typically performed when patients are not happy with the level of vision they have. Some of the other reasons that surgery might be indicated are if there are signs of other eye pathology that can't be diagnosed or treated, or rarely if the cataracts are causing other eye health problems. If your grandmother is driving, her vision might need to be improved to continue this. If she is happy with her vision, sees well enough to read and do the things she likes to do, then you may be thinking correctly. If her vision is impacted and she is in otherwise good health, you (and she) might reconsider and think towards having the surgery as it is safer to perform it earlier, better to do when the patient is in relatively good health, and the benefits can be substantial.

Jamie Noe of Alexandria, Minn., asks: Do these lasik/laser surgeries on the eyes create scar tissue as in regular surgeries and, if so, do they have potential to create problems as well later down the road?

Dr. Soloway: In almost all cases, there is minimal to no scarring in LASIK or other vision correction surgeries. LASIK has been performed regularly in the US for over a decade now without problems arising in those patients that have had it done years ago. Some of the problems that we are overcoming has to do with the calculation of lens power after cataract surgery on eyes that have had lasik, but this is improving and will continue to improve going forward.

Stewart Pomerantz of New York asks: What surgical options are available for "high myop" people who are now experiencing midlife presbyopia?

Dr. Soloway: Clear lens surgery is an option, but due to the higher risk of retinal detachment in highly nearsighted people, it is something that you should carefully consider. Approval within the last year or two of "Phakic Intraocular Lenses" specifically increases the options available for highly nearsighted people. Going forward, some of these implants are likely to be available (not yet, however) as multifocal lenses like those used in cataract or clear lens surgery.

Greg of Moorhead, Minn., asks: I have nystagmus due to multiple sclerosis. Am I a candidate for eye surgery?

Dr. Soloway: Patients with side-to-side nystagmus do very well on the Alcon LADARVision high speed tracking laser. I have reported my results with this in peer-reviewed medical literature and have heard of numerous successful cases performed with that laser.

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