See Clearly Now

By staff July 1, 2006

Freedom has many definitions. To someone who's been wearing glasses since elementary school, it may have little to do with the land of the free and the home of the brave.

Susan Haggard, 43, began wearing glasses when she was nine years old. At 15, she got contact lenses. "Remember the hard kind, the ones that would always pop out of your eye?" Haggard says. "Then I wore the soft kind that you had to boil."

She laughs remembering that, but a few years later it wasn't funny anymore. Haggard developed astigmatism. "I had to wear weighted glasses and couldn't wear contacts more than about six hours at a time," she says. After a while, "All I wanted was to be able to wake up in the morning and see."

With Lasik (Laser in Situ Keratomileusis) surgery, she got her wish, but it wasn't without agony. No, the procedure didn't hurt-the suffering was all in the decision making.

"I investigate everything," Haggard says. She interviewed several doctors in Tampa and more doctors closer to home in Sarasota. In fact, she'd had the file open on this particular case for about 10 years, ever since vision-correction surgery first hit her radar.

Although she doesn't remember which one it was, likely the technique at that time was one of the first, radial keratotomy. RK is not used often anymore, but the procedure involved incisions made with a diamond blade in a spokelike, circular pattern in the cornea. The number and exact placement of the incisions depended on the degree of nearsightedness to be corrected. It worked because the cornea bulged out on the sides, where the incisions were made, and flattened in the center, thereby changing the patient's visual acuity. The first RK surgeries were performed in the United States in 1978 and were based on a procedure invented by Russian ophthalmologists earlier in the decade.

How well a person sees depends on where the eye's focus point is in relationship to the retina. If the eye is shaped normally, the curve of the cornea is matched to its length, and a person is neither nearsighted nor farsighted (at least until about age 40, when a new factor comes into play: The lens simply loses its ability to focus at a close range, a condition known as presbyopia).

In a nearsighted person, the cornea is curved too much, or the eyeball is too long, either of which makes the eye's focus point in front of the retina, rather than directly on it. When light rays reach the focus point, they spread out but still have a distance to travel before reaching the retina. Spread-out light rays mean blurry vision.

In a farsighted person, either the cornea is not curved enough, or the eyeball is too short, making the eye's focus point behind the retina. Since the rays aren't yet in focus when they hit the retina, near vision is blurry.

Astigmatism occurs when the cornea is not round in shape. It has focus points in various places, which combine to appear as one blurred image. Both nearsighted and farsighted people may also have astigmatism. Contact lenses sit on top of the cornea and change its curvature, which results in vision correction.

A SHORT ANATOMY LESSON The pupil is the opening in the eye through which light passes. It's in the center of the iris, or colored part. In the dark, the iris opens up to allow more light to pass through the pupil. In bright light, it constricts, to take in less light.

The eye's lens-the one you're born with, which is right behind the iris-changes shape to allow fine focus by the eye, for reading or seeing street signs, for example, in the distance. The retina functions like film in a camera: It lines the inside of the eyeball and brings images into focus. It's also connected to the part of the brain that processes visual signals.

The strange part of this is related to that last sentence. Even though one of the side effects of eye surgeries, whether Lasik or RK or lens implantation, can be a starburst quality to the vision, it often ceases to be much of a problem a few months after surgery. That's because the brain begins to filter it out as useless information.

That's enough to make you wonder what could be right in front of you that you don't see, because the brain somehow considers it useless. Reality may not be what we think it is.

But it's best we stick with the more measurable aspects of vision here.

CATCHING UP WITH SUSAN Likely what made Susan Haggard finally decide to have vision correction surgery was the person who said, "Well, you can just wait until you get cataracts."

Although cataract surgery and lens implantation certainly improve vision and are a blessing to anyone in need, Haggard had no intention of waiting until she was 65-the age at which about half of Americans have the distinctive clouding of the lens marking cataract in at least one eye-to wake up in the morning and be able to see.

So she consulted an ophthalmologist to see if she were a candidate for Lasik (see accompanying story). She was.

"I thought about doing one eye in case I went blind," says the self-employed owner of a real estate Web business and mother of two boys, six and nine. "And then I thought, I'm being ridiculous."

Now, after having the painless procedure in January, "I can't believe I waited that long," Haggard says. She can read the newspaper classifieds unassisted, and yes, she can wake up, look around and see. She has one occasional side effect. "It happens very rarely, but when I'm really tired, and really should go to bed," she says, she notices that starburst effect.

Although Lasik patients nearly always experience some hazy vision at night or dryness immediately following surgery, these problems are gone by three months in most people, and six months in nearly all.

Dr. Murray Friedberg of the Manatee/Sarasota Eye Clinic is a fellowship-trained cornea specialist who has been doing Lasik surgery since 1999. He says that for people who are good candidates, Lasik is the best method of vision correction. The procedure starts with anesthetic eye drops. The eye is held open with a speculum. The surgeon then uses a microkeratome (a tiny blade) to cut a hinged flap of the superficial layer of the cornea, exposing the business part of the cornea. He then uses a laser to remove tiny amounts of tissue. Removal of tissue by laser changes the shape of the cornea and results in a change in vision. When surgery is complete, the flap is repositioned, stays in place without sutures and heals quickly.

The fear factor for some people considering Lasik is that a blade is used to make the flap-and it's hard to deny that a blade means cutting. The laser may be slightly more precise and somewhat less worrisome to patients, but either way, tissue is removed, and in the hands of an experienced surgeon, there's little difference in risk.

The very latest development in Lasik uses a laser to make the flap, too. Dr. William J. Lahners of the Center for Sight in Sarasota is among the earliest users of this blade-free method.

Lens implants are another option. Two categories of people might opt for lens implants over Lasik: those whose corneal thickness, curvature or pupil size vary greatly from the average, making Lasik more difficult, and those who need progressive bifocals and want to completely shed glasses, reading and otherwise.

Implants have long been used for cataract patients, whose natural lenses become cloudy and are removed and replaced with artificial ones. A recent breakthrough in artificial lenses benefited both the cataract patient and the over-40 patient simply seeking vision correction: multifocal lenses.

Dr. David W. Shoemaker, also of the Center for Sight, specializes in implanted lenses-whether a patient has cataracts or not. Until last year, Shoemaker says, the only implantable lens was a monofocal. It offered the patient the chance to see well in the distance and often at intermediate range, but did not correct near vision.

But last year, the Food and Drug Administration approved three other types. Shoemaker believes the best two are the ReStor lens made by Alcon Surgical and the ReZoom lens made by Advanced Medical Optics. Both are multifocal lenses, meaning they offer correction of near vision, intermediate vision and far vision at once.

The ReStor lens works by focusing light through many rings in the lens, which improve vision at varying distances. With the ReZoom lens, light is focused simultaneously through three zones for far, arm's length and near vision. ReStor may be slightly better for near vision, at the expense of intermediate vision. ReZoom may correct distant and intermediate vision better than near, according to patient comments on several online forums.

Although ReStor and ReZoom are relatively new on the market, says Dr. David Campbell of Sarasota Ophthalmology Associates, neither their manufacturers nor the procedures used to implant them are new. Alcon and AMO have an established history as contact lens manufacturers; in fact, the soft plastic implanted lenses are only slightly thicker than contacts. The procedure also is basically the same as what's used for cataract patients, says Campbell.

What's involved in this type of lens implantation? "No stitch, no shot, no patch, no pain," says Shoemaker. As is so often the refrain in the most recent surgical developments, the reason for such progress in both comfort and recovery in surgery is the laser. Used with the latest generation intraocular lenses, such as ReStor and ReZoom, it's used to make a hole that's 2.8 to 3.5 micrometers in size (for comparison, a human hair is about 50 micrometers wide), allowing the surgeon to extract the natural lens and insert the folded implant, which is then unfolded and spread into place.

In patients with healthy eyes, few side effects have been reported after lens implantation. At first, blurred vision, glare and rings around lights may be present, but those complications nearly always disappear within weeks. Occasionally, a person's ability to see in dim light or fog is slightly less sharp after surgery, and that condition remains. As lens implantation to correct vision in a person without cataracts is relatively new, long-term side effects aren't expected but cannot be completely ruled out, either.

What makes a Lasik candidate?

Three factors determine whether or not a person is a good candidate for Laser in Situ Keratomileusis, or whether another option should be taken, such as photorefractive keratectomy (similar to Lasik, in that the shape of the cornea is changed by laser, but different in that the top corneal layer is removed, rather than moved out of the way by making a flap that is repositioned after surgery).

Although recovery from Lasik is much easier (recovery from PRK can mean eight days of discomfort or blurry vision or both), it can't be done on everyone. Among people seeking vision-correction surgery, says Dr. Murray Friedberg, a Sarasota-Bradenton ophthalmologist, about three-fourths are good candidates for Lasik. That means:

  • A person's corneas are not too thin;

  • The corneas are not too flat and are not irregularly shaped;

  • The pupils are not too big.

Having problems with both near and far vision doesn't necessarily rule out Lasik, Friedberg says. Often the solution is something familiar to contact-lens wearers: monovision. One eye is corrected for near vision, and one for distance.

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