March 1997

Vision Quest
  
Laser surgery takes the blur out of nearsightedness.
By Leslie Schwartz

Dale Noelle could not believe her eyes. Literally. For most of her life, Noelle was so nearsighted that she couldn't even see the clock she kept next to her bed. She used to joke that she went through so many pairs of contact lenses and glasses that she could have opened her own eye-wear shop.
  
Then, moments after undergoing laser surgery, she did something she never believed she'd be able to do: read the fine print on the eye chart in her ophthalmologist's office without the aid of glasses or lenses. "It was unbelievable," says the model. "It was like magic. I sat up and I could see.  Magic is how many people describe the clear vision provided by photorefractive keratectomy, or PRK, the first surgical procedure for correcting nearsightedness (myopia) that employs the use of a laser instead of a knife. The laser emits an invisible beam that vaporizes a computer-determined amount of corneal tissue.
  
About 70 million Americans suffer from nearsightedness, which occurs when the center of the cornea is more curved than it should be. Distant light focuses slightly in front of the retina instead of directly on it. The result is blurred vision for faraway objects.
 
PRK removes microscopic layers from the surface of the cornea, making it focus light like an eye with normal vision, explains J. James Rowsy, M.D., chairman of the department of ophthalmology at the University of South Florida Eye Institute.
  
In 1988, the FDA allowed limited use of the procedure for testing. Full approval was granted in October 1995. However, doctors in other countries have been performing the procedure since 1987, and to date, more than 1 million operations have been performed worldwide. While laser surgery may one day be used to correct farsightedness and other vision problems, for now its use in eye surgery is limited to myopia.
  
More than 1,000 ophthalmologists now perform PRK in the United States. To be certified, they must complete a one-day course provided by the makers of the laser.
  
Though PRK is hailed as safe and effective, it is not the right procedure for everyone. People looking for 20/20 vision without glasses should think twice about having PRK because no type of surgery can guarantee perfect vision, says Andrew I. Caster, M.D., medical director of The Caster Eye Centers in Beverly Hills and Culver City, Calif. Similarly, people who like wearing glasses (or contact lenses) or those under 21 whose nearsightedness might still be increasing should delay laser surgery until their eyes have stabilized. Pregnant women shouldn't undergo vision correction surgery because fluctuating hormone levels may cause temporary changes in their eyes, which could affect PRK efficacy. Also, patients with vascular or autoimmune diseases may experience difficulty in corneal healing. And PRK isn't recommended for people with herpes simplex virus in the eye because flare-ups have been reported during recovery.

Seeing is believing
Noelle, like most patients, had surgery on each eye a few weeks apart, and the entire process took less than 20 minutes each time. As with other surgical procedures, she signed an informed consent that detailed the possible risks and results of PRK. Then her doctor performed several tests to determine her exact vision before the laser treatment and numbed her eyes with anesthetic eye drops.
  
"I lay down on a table and the doctor looked in the monitor to make sure the cornea of my left eye was focused in the laser beam," she recalls. "I focused on a target light, and a few seconds later I heard a zapping sound and it was over."
  
She felt no pain during the procedure and within moments was able to read the eye chart through her left eye. A contact lens was put on the treated eye for protection, and she went home with antibiotic drops and mild pain killers.
   
"I did have pain after the [anesthetic] drops wore off and I took the pills for three days." During this time, she was unable to work as a model; she could not wear eye makeup because her eye was irritated. "But a few weeks later, when I did my right eye, I went to a job the next day like I had nothing done."

Before the days of laser rays
Prior to PRK's approval, Americans seeking a surgical remedy to their nearsightedness either went to a country that permitted PRK or relied on the more controversial procedure known as radial keratotomy, or RK. In RK, the surgeon uses a diamond blade to make a series of deep incisions from the center to the outer edges of the cornea. This causes the cornea to flatten, refocusing distant images on the retina.
   
RK is known to be highly effective in treating low levels of nearsightedness. Research indicates that up to 38 percent of patients achieve 20/40 vision or better without glasses after surgery. Although a 10-year study of RK found it to be safe and effective, some doctors believe that under certain conditions, incisions on the cornea can weaken eye structure.
 
"Radial keratotomy is a good procedure for the right patient," says Steven E. Wilson, M.D., medical director of the Cleveland Clinic's Eye Laser Center who performs both procedures. Like PRK, RK surgery isn't recommended for patients who are pregnant, under age 18 or who have suffered from autoimmune diseases. In addition, because incisions may weaken the eye, if you're very active -- say you're out playing racquetball and get hit in the eye -- you risk rupturing the incisions. That's why Wilson and a growing chorus of ophthalmologists prefer PRK, because it does not require making incisions in the cornea. It does, however, cost about $1,850 per eye, compared with $1,250 for RK.
      
About 70 percent of patients will have 20/20 vision without glasses after PRK, according to Caster, and 95 percent will have vision good enough to drive without glasses.
  
"People with mild nearsightedness will have the best results," says Caster, adding that some patients will be over-corrected, resulting in farsightedness. A study published in Archives of Ophthalmology (March 1996) found that for 22 percent of subjects who had PRK to correct nearsightedness, overcorrection occurred after a month. After a year the figure dropped to 2.2 percent: The eyes  adjusted themselves.
  
Doctors correlate the high incidence of farsightedness shortly after surgery to the use of bandage contact lens, anti-inflammatory drugs and the normal healing process. But after about three months, these factors are no longer at play, which sharply reduces the number of cases of farsightedness.
   
Nevertheless, for those 2.2 percent who still show signs of overcorrection, the only remedy is td wear reading glasses. However, the number of PRK patients who end up having to use reading glasses earlier than if they hadn't had the procedure is much smaller than among RK patients.
  
In rare cases, hazy or blurry vision can exist after PRK. "The haziness can last up to three months after the procedure, and in the worst possible case, up to a year," says Wilson. But research indicates that this occurs in fewer than 2 percent of patients, who might benefit from follow-up enhancement surgery.
  
For Noelle, the benefits far outweighed the risks. "Life is so much easier now. I can scuba dive and ride on a motorcycle without having to worry about dust. And no more looking for my glasses in the middle of the night so I can read the clock."
  
According to doctors who see PRK patients every day, the decision to undergo laser correction for nearsightedness is often a lifestyle issue. PRK is perfect for people with active lifestyles, where sports or regular exercise are an integral part of their lives and glasses can be a hindrance. And anyone who wears corrective lenses and travels knows the hazards of breaking glasses while away from home or the hassles of carrying around bottles of contact lens solution.
 
Noelle, who had no pre-existing conditions to limit her ability to undergo PRK, is grateful that advances in technology have made it possible for people like her to safely correct their vision through surgery. "I got my eyes back," she says. "I haven't had this experience since I was a little girl."
  
For more information on photorefractive keratectomy, write the American Academy of Ophthalmology at 655 Beach St., San Francisco, CA 34103-1336.

Leslie Schwartz is a free-lance writer in Los Angeles whose work has appeared in the Los Angeles Times, Mademoiselle and many other publications.

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