LASEK

This is a blog post about something which took place six months ago, so it could be considered somewhat belated. On the other hand, that gives me the opportunity to give the full story in one go, rather than just posting “well, I had the operation two hours ago and they didn’t actually blow up my eyeball, so I guess it could have been worse, but I’m not really supposed to be staring at a computer screen just now and anyway I am doped up on painkillers so I’m leaving now, okthxbye.”

I have been wearing glasses since I was ten years old or so. My vision has been fairly constant over the years: around -4 in the left eye, -0.75 in the right. Because of the right eye being only mildly myopic, I was able to function without glasses when necessary (just don’t ask me to catch a ball) but I would get a headache after a while. Never tried contacts. I had been playing with the idea of getting laser eye surgery for some years already, but it took me a long time to work up the courage to go ahead and do it. It’s a pretty routine thing nowadays, but it is still very easy to find horror stories of people ending up with vision problems worse than they started out with, although complete blindness is fortunately very rare. I’m rather attached to my ability to see, and it was not an easy decision to risk that in exchange for the rather minor inconvenience of wearing glasses.

So, why did I eventually decide to go under the laser? Largely for convenience. In a lot of outdoor activities, needing glasses can be a hassle. You’re constantly swapping between regular glasses and sunglasses. They are fragile, they fog up, fall off and get scratched. Your options for finding good-quality sunglasses are greatly reduced when you need them to be prescription glasses. Snow goggles for glacier use, in particular, are almost impossible to get in combination with prescription lenses. The best I have been able to find are the Elevation and Evil Eye series from Adidas, which have room for a little clip-in set of prescription lenses. However, that clip-in tended to fog up easily and also it was not quite wide enough for my face, resulting in headaches after a while.

I would be lying if I did not admit that vanity also played a part. Until just a few years ago, I was your stereotypical non-athletic flabby nerd; the beard and glasses served nicely to complete that picture. Over the last couple of years, however, I have been running and working out a bit, and while I will never have a movie star physique I am actually fairly pleased with what I see in the mirror nowadays. Hence, the aesthetic aspect of displaying my face to the world unobscured by the ophthalmic equivalent of a pair of crutches, started to play a role in a way which had never been relevant to me before.

I did have one big advantage over most other people considering a laser operation: because the vision in my right eye was pretty good already, I only needed the surgery in one eye. This not only meant that even in the worst-case scenario I would still have a spare eye to see through, but it was a lot cheaper as well. Without a single exception that I could find, all laser clinics seem to charge on a per-eye basis. This has always seemed a bit strange to me, because most of the procedure takes up just as much time for one eye as for two; the actual operation is only a small portion, time-wise, of the whole process. But apparently a large part of the clinic’s cost goes to the provider of the hardware, and they charge per eye lasered.

Prices vary a lot; typical costs in the Netherlands are between €1,000 and €2000 per eye. You can go a little below €1,000 if you go outside the country or if you really hunt for the best possible bargain, but I didn’t mind paying a little extra for peace-of-mind, so I did not even consider the foreign options. Please note, I’m not saying that foreign clinics are less competent or reliable; I have not reason to suspect that. It’s just that the whole idea of having a guy scrape away my cornea and start cutting into my iris with a laser beam, was stressful enough without the added inconveniences of travelling to another country. Eventually I selected EyeScan in Utrecht, mostly because they scored very high in a test done by the Dutch Consumer’s Organization, and also because they offered a pretty complete set of techniques: LASEK, LASIK and IntraLASIK, which gave me some extra confidence that they would honestly advise me on which option was best for me.

Before contacting a clinic, I did my homework pretty thoroughly. The main options for laser surgery are the three I listed in the previous paragraph. All three are identical in so far as they use a laser to reshape and thereby correct the imperfections in the lens of the eye; the difference between them lies in how part of the cornea is removed to give the laser access to the inner parts of the eye. LASIK is the most popular form used today. Basically, a cheesegrater-like microkeratome knife is used to create a little doggy-door flap in the cornea; this is then folded aside so that the laser can do its thing. IntraLASIK works the same way, except that the creation of the flap is done using a femtolaser (which is different from the laser used for the lens-correction operation itself) instead of a microkeratome blade. IntraLASIK is typically a few hundred Euros more expensive than regular LASIK. Opinions vary about its added value; clinics which have the hardware needed to offer it tend to claim that it greatly improves the quality of the result and the risk of the dreaded ‘halo effects’ afterwards, while clinics which have not yet invested in a femtolaser will assure you that there is no proven difference and it’s the skill of the surgeon that matters.

The main reason for the popularity of LASIK is, I think, the “instant satisfaction” aspect of it. If all goes well, you can be enjoying your new and improved vision within a few hours of the operation, and it only gets better from there. When everything goes well there is also supposed to be very little discomfort, other than dry eyes. However, the big disadvantage of LASIK, which scared me away from it, is that the “doggy door” flap remains a weak spot on the eyeball for years afterwards. Getting hit in the eye by a blunt object is never a good idea, but when that eye has been the recipient of a LASIK operation in the past, the consequences can be really nasty. Also, from what I learned most of the unwanted side-effects of a LASIK operation did not come from the actual laser surgery, but from the flap not falling nicely back into place or otherwise causing trouble. The main problem seems to be that, unlike most parts of the human body, the cornea does not really have the ability to heal damage sustained as an adult. The flap eventually gets fixed into place because the epithelium grows back over it, but the cuts that were made into the cornea itself may never fully heal, and neither will the nerves that ran through it.

Therefore, I decided to go with LASEK instead. LASEK, also called PRK, is the older approach to giving the laser access to the lens. Instead of cutting into the cornea, the surgeon scrapes away the epithelium. The epithelium is the uppermost layer of the cornea and it does have the ability to regenerate cleanly after being damaged. The main disadvantage of LASEK over LASIK, and probably the reason why the latter is more popular nowadays, is that the initial recovery period is a lot longer and more painful. With LASEK, the patient is recommended to take a week off in order to recover; with LASIK if all goes well you can be back in the office after a day or two. However, the risk of side effects is lower and after the initial recovery period the eye should heal so completely that after some months, even an ophthalmologist may have trouble seeing evidence that an operation ever took place. An illustrative incident is that when I had made the appointment for the operation with EyeScan, I was sent home with the legal forms for both types of operation; the list of potential complications for LASIK was three times as long as the one for LASEK!

There is also Epi-LASIK, which is the obvious combination of the two ideas: as with LASIK, the surgeon uses a ‘cheesegrater’ microkeratome or a femto-laser to cut a flap out of the cornea, but as with LASEK he only cuts as deep as the epithelium and does not cut into the deeper layers of the cornea that do not have the ability to regenerate. However, EyeScan did not offer that option (yet) when I had the operation.

One other choice to be made was between regular and wavefront-guided laser correction. EyeScan calls this “Superior / CustomVue”, other laser clinics have their own marketing terms, and all of them try to suggest that they have some extra-special technique for giving you a better result than you’d get from their competitors. What it comes down to is that instead of just re-shaping your lens from e.g. -4 to approximately 0, the laser is programmed to apply specific corrections to carefully measured local aberrations in the lens, thereby achieving the optimal result for your eye instead of applying a one-size-fits-all approach. Most clinics offer something like this next to their standard offer nowadays, at a higher price of course, and they all suggest that it will give you a more perfect vision, although at the same time they also keep their standard disclaimer that the results can vary and you are not even guaranteed not to need glasses anymore. To be honest, it seems a bit fishy to me: the way I envision it is that there is a little switch on the laser machine, with settings labeled “decent quality” and “extra good quality”, and the surgeon charges several hundred € for putting the switch to the “extra quality” setting, even though it’s the same machine! It’s a textbook case of market segmentation, of course: charging more money to people who can afford it, for basically the same service, by putting some extra features only in the more expensive version of the product, even though they cost you nothing extra to produce. How much did I really get for that extra money? I will never know for sure, but I would rather live with the vague feeling that maybe I got ripped off just a little bit, than spend the rest of my life wondering if my vision would have been better if I had checked the “wavefront-guided” box. So I paid up, and would pay up again if I had to, even though there is that niggling feeling that I am being played. Hopefully, in the future wavefront-guided will just be the standard, and the inferior option won’t even be offered anymore.

I had the operation on July 9, 2009. My parents drove me to the clinic and there was a brief, last check-up to make sure that my eyes still matched the measurements that were taken a few weeks earlier. Then there was a brief conversation with the eye surgeon, I was dressed in sterile clothing, and walked into the operation room. As is the case with most private clinics as I understand it, EyeScan is not connected to a hospital, so the operation room is simply a converted room in an otherwise ordinary office building. I was told to lie down, and a variety of different kinds of eye-drops were applied. One of them was a topical anaesthetic; other than that no anaesthesia was used so I was fully conscious during the operation. Then, the surgeon used a scalpel to move aside the epithelium, which looks really weird when you’re looking up at it from underneath!

After that preparation, the actual laser surgery was pretty much an anti-climax: all I had to do was stare at a blinking yellow light for a minute or so. There was no feeling, no way to confirm that anything was happening. Afterwards, a temporary lens was placed onto my eye to protect the lens while the epithelium was growing back, to be removed three days later. Then, I got up and was given a cocktail of painkillers with instructions on how to use them, plus a set of protective goggles to wear at night to keep myself from subconsciously rubbing my eyes. The surgeon and his two assistants were very professional and businesslike during the whole process, except that during the surgery they were having a conversation about some minor problem which worried me a bit, but which I was told afterwards was not about my case. Apparently, the surgeon is not employed full-time by the clinic but works at a hospital or something and is hired by EyeScan for a couple of days per week.

Immediately after the operation, my vision was already noticeably improved! Unfortunately that didn’t last, as things got blurry during the week after the operation. In hindsight, this was not surprising: at that point there was basically no epithelium at all obstructing my vision, so I had a very clear view but was at a hightened risk of UV damage from the sun. For the first two months or so after the operation, I was instructed to wear dark sunglasses whenever I went outside, even on cloudy days. I was also somewhat extra light-sensitive during the first weeks, but it wasn’t very bad — apparently some people can be very affected by this, to the point where they have to live in a completely darkened room for the first several days. Anyway, that period of clear vision immediately after the operation did not last; as the epithelium was growing back it formed some ‘scar tissue’ which took a while to clear up again, so for a week or so my vision got worse than it was before, after which it slowly got better again.

Next to the painkillers, I was also given a large collection of eye-drops: a large amount of ‘comfort drops’ to keep the eye moistened, which I had to use for the first two months and then gradually wean myself off, and some antibiotics to prevent inflammation during the healing process. Unfortunately, I turned out to be allergic to the preservative used in those eye-drops, and that allergy caused extra inflammation of my eyes and the skin around it. This is apparently a fairly common problem, but it was not noticed on my first check-up visit four days after the operation. So during the first week, whenever I used those drops I was actually making the situation worse! Fortunately, once the problem was diagnosed and I was given a preservative-free alternative, things started to improve quickly. I had taken a week of vacation following the operation; after that week I was able to go back to work, although the vision in my left eye was still far from perfect. I am glad that I still had my untreated right eye to look through, otherwise I would have been unable to work for another week or so.

Somewhere between two and three weeks after the operation, the vision in my left eye was roughly comparable to that in my right: hardly perfect, but good enough to get around without needing glasses. From there on, it slowly but gradually kept improving. I had several check-up meetings with EyeScan during the first half year, at increasing intervals, and was surprised to notice that even between the three-month and six-month check-up there was still a noticeable improvement. I think part of it was not so much the healing of my eye, but had more to do with my brain having to learn to deal with the changed situation. For example, initially it often happened that when I tried to make out some fine detail in the distance, I could improve the clarity by closing my right eye — apparently my brain was not yet used to the fact that suddenly, after more than 30 years, my left eye was now the better one for distance use! But I don’t seem to have that problem anymore.

So, how did I end up? Very well! On my last check-up, I scored a very pleasing 150% acuity in my left eye, with 100% apparently being a somewhat arbitrary reference point meaning “normal sight”. And indeed, I get around perfectly well without glasses, for close-up reading and computer work as well as making out small details in the distance. The fact that my right eye is still less than perfect, does not seem to hinder me in any way that I have noticed.

The only remaining side effect is that my eye is still sometimes more dry than it should be, especially when waking up in the morning. This can be painful when there is a piece of dirt in my eye but I am not producing enough tear fluid to get rid of it. I knew in advance that this was the most common side effect of laser surgery; it can take a long time to go away and can even be permanent to some degree. Fortunately, at its current level it is a fairly minor annoyance rather than a problem. Apart from that, I am very happy that I took the plunge, and if I had to make the same decision again I would definitely go with LASEK again.