How to evaluate whether or not you are working with the correct laser center for LASIK eye surgery

Not a day goes by where a patient of mine does not ask me about LASIK eye surgery. This life changing surgery has been available in the United States since 1999 and it is estimated that over 600,000 people have this procedure performed every year. Sadly not all LASIK centers are the same and it is important to know how to determine if the center you are working with is the best choice for you.

Your number one consideration is safety:

The shape of the front lens of the eye, the cornea, causes light to focus inside the eye. If light focuses properly on the retina then you will be glasses free. However if the cornea is too curved or too steep then you are nearsighted and need glasses or contact lenses. LASIK surgery changes the shape of the cornea by removing small amounts of tissue, which thins the cornea as it flattens it shape. There is a limit as to how much the cornea can be both safely thinned or flattened.

Recently I evaluated a patient at the UC Berkeley School of Optometry where I teach LASIK evaluation and post-operative care. I always inform my patients that to do LASIK safely they need thick enough corneas, curved enough corneas and cannot have any structural integrity issues and that if I see any of these issues come up I will tell them not to do LASIK in a heartbeat. I scanned her cornea on a device that measures corneal thickness, corneal curvature and corneal structural integrity to see if her corneas were suitable. Unfortunately her corneas were too thin for her prescription to qualify and they were also not curved properly to do the surgery safely. I had to sit her down and explain to her that she should never do this type of surgery. I explained that if she did LASIK she would have, at best, horribly distorted vision for life or, at worst, need a corneal transplant within 5 years. Oddly enough she just smiled at me and told me that she found that interesting since she had just seen another center in the Bay Area the day before and they said she was a perfect candidate and would offer her a $200 per eye discount if she did the surgery that week. I told her that one of us was lying. She figured out very quickly that is wasn't UC and opted not to do surgery.

This is how people get hurt with LASIK. Some doctors either does not know when or how to say "No" to a patient. My experience says that about 12-15% of the time a patient simply does not safely qualify for surgery. Sadly by not saying "no" they harm people for life. Only work with people who are willing to turn you away when necessary.

The second consideration is the equipment used:

LASIK is essentially a two-step process where a flap of the outer cornea is made to expose the inner cornea for surgery and then replaced when the surgery is done. The outer layers of the cornea act as a protective skin layer that is replaced every 7-10 days. Consequently if you need to make a permanent change to the corneal shape you need to work below this tissue. In LASIK a flap of the skin layer is made and folded back to allow the rest of the cornea to be worked on.

Hand held blade devices can make flaps also but the flap thickness they create can vary depending on the pressure and speed that the surgeon applies during the process. A flap that is made too thick can endanger the outcome of the procedure depending on the amount of treatment necessary.

However, the Intralase laser flap-making device makes a stable, predictable thickness flap every time. It is computer controlled and does not have the variability of pressure or speed like the hand held devices. Do to this fact Intralase is now considered the standard of care within the industry. Always look for this option when considering a center.

Secondly the type of laser matters also. The VISX Star 4 laser and the Allegretto lasers are considered the gold standard in the industry and would be the only lasers I would recommend for my patients. Both give outstanding outcomes with the highest degree of safety.

Your third area of consideration is your surgical team's experience and availability:

Practice does make perfect and you do not want to be anyone's test case. Only work with surgeons that not only have years of experience with this procedure but performs them regularly. A surgeon can have performed over 500 surgeries but if he has done so over a fifteen year time frame it means that they only do 2-3 of these a month. In all areas of medicine the surgeons that are the busiest with their particular surgery are the most fluid and competent and should be the ones you seek out.

The same goes for your post-operative care team. Work with people with extensive experience with this procedure that know it inside and out and are not learning on you as they go.

Also make sure that your team is accessible. LASIK follow-up requires several post-operative visits. Many centers offer a year's follow up but only perform a single visit but leave the option for you to return any time in that next year if needed. Do not be fooled by this tactic.

Your fourth and final area of consideration is retreatment policies:

Every surgeon attempts to give you perfect vision with his or her initial surgery. However, sometimes eyes have to be retreated to achieve this. Sadly many doctors have you sign a waiver that if you achieve 20/40 vision or better you will not qualify for a retreatment. This is a huge red flag!

LASIK surgery is very precise and even a residual correction of -0.50D can be treated in most cases. This small amount of nearsightedness would leave a patient with shaky 20/25 vision. Reputable surgeons and centers will retreat this amount. Do not sign on with a surgeon that requires you to give up your retreatment rights if you only achieve 20/40 vision.

In short the list below can be used to help you pick a good LASIK team to work with:

• Ask you team how many times they tell people "no" due to thickness or curvature. If they claim less than 12% of the time I would shop around.
• Look for a center that uses the Intralase flap making system and either a VISX star 4 laser or an Allegretto laser.
• Look for a team that has extensive knowledge in this arena and works with a surgeon that performs these dozens of times a month. Make sure they offer extensive postoperative care as a part of your surgical fees.
• Never work with a surgeon that requires you to sign a waiver giving up your rights to a retreatment if you only achieve 20/40 vision.

If you follow these guidelines you will end up with a final outcome you deserve.