“Most people have been thrilled with LASIK’s results, but it’s too early to see the long-term picture.”
Vision surgery has become trendier than the latest black-rimmed cat’s-eyeglasses from Paris.
Radio commercials and magazine ads trumpet so-called “flap and zap” laser eye surgery – one of the fastest-growing medical procedures in the United States – which last year helped lure about 1 million blurry-eyed Americans into doctors’ offices in the hope of throwing their glasses in the trash forever. But while laser eye surgery is about as hot as the NASDAQ index, where, in fact, some of the vision chains that perform the procedure are traded, it isn’t for everyone.
Experts caution people tempted to undergo LASIK – the name for the most up-to-date laser procedure – to be wary of seductive advertising and to choose a surgeon carefully; when done inexpertly, laser surgery can damage the eyes. During clinical trials for the Food and Drug Administration, researchers followed patients for only six months after the surgery. That means no one knows how a LASIK patient’s eyes will fare five or 10 years from now. LASIK has been available for several years. But it didn’t achieve its current level of popularity until the FDA gave its approval last October to the marketing of a new type of laser equipment designed to correct nearsightedness. For the most part, the new procedure results in markedly improved, sometimes 20/20, vision.
Although the FDA has not approved LASIK for correcting farsightedness, doctors use it to do so. Drugs and devices approved by the FDA for one purpose may be used by doctors for other purposes. The FDA was expected to consider formal approval for using LASIK for farsightedness (hyperopia) with astigmatism this month. So far, LASIK doesn’t have the capability to correct presbyopia, the aging-related eye condition that can cause reading difficulties in people over 40.
Meanwhile, the surgery is in demand, from posh Park Avenue offices to mall-based vision centers where shoppers watch the 15-minute LASIK procedure through glass windows. The acronym LASIK stands for laser in-situ keratomileusis, which refers to the process of cutting a flap in the cornea and reshaping it with an Excimer laser.
While LASIK is fast and painless for the most part – the perfect minimalist surgery for the 21st century – there can be complications for a small number of patients. The American Academy of Ophthalmology estimates that one to five percent of people who undergo LASIK end up with complications. Some doctors say their complication rate is lower, less than one percent. But patients are sometimes counted as successes even though they may require adjustments or a second LASIK surgery after the first one fails to achieve the desired degree of vision.
Post-surgery complications have ranged from eye infections to nighttime glare to permanently blurred vision in the small number of cases where something has gone seriously wrong. And a few patients have undergone corneal transplants to correct LASIK gone haywire. There is no single clearinghouse for post-surgical complaints, so the total number has not been determined. Still, the American Academy of Ophthalmologists estimates 1 million people underwent LASIK surgeries in 1999; by comparison, 310,000 Americans underwent laser resurfacing for various skin conditions.
But the possibility of eye damage at the hands of inexperienced doctors has experts like Dr. Douglas Koch, who is affiliated with the San Francisco-based American Academy of Ophthalmology, worried.
Koch recounts horror stories of ophthalmologists making mistakes such as worsening an astigmatism – an abnormal curvature of the cornea that causes distorted vision – instead of reducing it. Koch, an ophthalmologist who teaches at Baylor College of Medicine in Houston and performs LASIK in private practice, warns patients not to select a surgeon based on advertisements – specifically those that trumpet low prices. (The going rate in the New York City area ranges from $2,000 to about $5,500.)
“There is concern that patients can be fooled by ads, and that’s why we always encourage patients to get as informed as they can and to get the negative side of the surgery,” Koch said in an interview.
But assessing the competence of a LASIK surgeon isn’t easy. In New York, for instance, patients can call the state health or education departments to find out whether a physician has ever been disciplined for bad work. But no one tracks the outcome of LASIK procedures, most of which are done in doctors’ offices. It’s up to patients to find out where an eye surgeon went to school, the extent of a surgeon’s LASIK experience, and whether prior patients are pleased with the results.
But advertising abounds and many area doctors are relying on it to bring in patients.
Recently, Dr. Ken Moadel of Manhattan ran an ad in New York Magazine promoting his practice, experience, and the fact that he performed laser surgery on Yankees center fielder Bernie Williams.
Moadel, affiliated with Manhattan Eye, Ear & Throat Hospital, said he’s done more than 6,000 procedures. He charges $2,250 per eye. And, said Moadel, since most patients choose a laser surgeon on their own, rather than relying on a referral from a physician, advertising is key to attracting new customers. But he acknowledged that advertising medical services is “a fine wire to walk.” Another Manhattan LASIK surgeon, Dr. Eric Mandel, advertises his practice on local radio stations such as WCBS-AM, complete with testimonials from station employees who had Mandel perform LASIK surgery on them. Mandel, in an interview, urged caution in selecting an eye surgeon because “people need to realize this is their only pair of eyes. If you’re going to make one investment in this all-precious gift of sight, you want to be as sure as you can be.”
Nevertheless, Mandel, who charges $4,600 to do two eyes, said he doesn’t know how many LASIK procedures he’s done. And he declined to respond when asked whether he gave discounts to the radio station employees who provide on-air testimonials about his surgery on them.
While the higher-fee doctors caution against low-cost LASIK, one surgeon disputes their contentions that inexpensive surgery means bad surgery. Dr. Richard Koplin, director of LASER ONE in Manhattan, charges only $2,000 to perform LASIK on both eyes. Koplin said he does about 300 LASIK procedures a month now and that he did about 1,800 last year. He’s also a director of New York Eye and Ear Infirmary.
“The cost in this after leasing or paying for a LASIK machine, which costs $500,000 or more really becomes your marketing and advertising and some personnel,” said Koplin. “The rest is pure profit.” Koplin said he makes about $400 on each LASIK procedure; most doctors interviewed did not want to discuss their profits.
Dr. Joseph Dello Russo, one of the kings of LASIK radio advertising in the metropolitan area, said he did 7,000 LASIK surgeries last year in his Bergenfield, N.J., office. Dello Russo’s ads are a staple on WCBS and on WOR’s “Rambling With Gambling” morning show. Dello Russo admits he gives what he calls “small discounts” to local radio station employees to plug his business on the air.
Dello Russo, who had LASIK performed on his own eyes in 1999, draws patients from across the country and said the radio ads have helped. During the FDA’s clinical trials of the procedure, Dello Russo was an investigator, one of the doctors who observed the effects on patients for a set period of time. During the LASIK trial, the procedure was performed on 1,013 eyes, and patients were followed for six months afterward.
Wendy Gambling of Oyster Bay, whose husband, John Gambling, hosts the WOR radio show that bears his name, said she went to Dello Russo after hearing his ads on her husband’s program. She said Dello Russo gave her what she called a “major discount” because of her WOR affiliation. She also said he gave her attentive care.
Gambling, 47, said last year’s LASIK procedure cured her nearsightedness, but she found she needs reading glasses now – a common side effect of LASIK in patients experiencing presbyopia, a condition that necessitates reading glasses in middle age.
“I must admit when you’re shopping and trying to read something, it is a pain,” said Gambling. But that annoyance is minor compared to her ability to play golf the day after her surgery – and she didn’t need glasses for that. “It was unbelievable,” she said. “I think it was worthwhile.” Even Dello Russo, with years of experience, admits he receives complaints from patients from time to time. On occasion, he said, a patient will complain about a corneal flap that doesn’t sit right on the eye, or an eye that has been undercorrected or overcorrected. In such cases, he said, he treats the eye or redoes the procedure after an appropriate waiting time. And he said it’s important to inform the patient, in advance, that problems can crop up.
“We tell them that – they know about it,” Dello Russo said. “LASIK is not risk-free.”
One of Dello Russo’s patients, Chris Lubin, 35, tells a cautionary tale about selecting an eye surgeon.
Lubin sought a consultation with Dello Russo after another doctor told him he needed the LASIK procedure in both eyes. That puzzled Lubin because “my left eye was always fine,” he said. “I just wanted the right eye done, but he said, ‘Your left eye has an astigmatism.’” Lubin chose to have Dello Russo perform the procedure only on the right eye. And Mary Ann McGee of Rego Park also had a bad experience elsewhere. McGee, who works for a Manhattan advertising firm and was nearsighted, said she had her first LASIK procedure in July, and the doctor who performed it had a problem cutting the corneal flap.
McGee was left with blurry vision and was told to let her eye heal for several weeks before a second attempt. She sought a second opinion from Dello Russo, decided to have him perform the second procedure, and said “so far they’ve [her eyes] been great.”
But individual doctors make up only part of the LASIK story. LASIK eye-surgery chains have cropped up across the country: they buy or rent offices and equipment and then lease them to doctors who don’t want to invest in costly machinery. A LASIK unit can cost $500,000 or more. One company, TLC (The Laser Center), with Canadian owners, has LASIK centers across the United States and Canada. Dr. Mark Speaker, an ophthalmologist with a private practice, works as medical director of the Manhattan TLC center on East 57th Street. About 10 doctors use the center’s equipment and pay a fee to TLC. Speaker, for instance, charges patients $5,500 to do two eyes; $1,250 of that goes to TLC.
Speaker has hired a public relations firm and has scheduled a LASIK “event” to which members of the media are expected to be invited. But he, too, concedes that advertising poses a problem because patients shouldn’t be choosing a surgeon based on commercials that give only the rosy view of laser surgery. “If you listen to the radio or open a newspaper, everybody is an expert. Anybody can make up whatever they want,” he said. “This is serious surgery; it’s not driving your car into a carwash.”
It’s become tempting for some eyeglasses-wearers to walk into the nearest eye surgery office and have their eyes zapped.
For example, at the Visual Freedom Center at a mall in Columbia, Md., shoppers can walk out of Nordstrom’s and into the eye center, where they can peer through panoramic windows to watch doctors aiming lasers at patients’ eyes. Or they can decide to have the surgery themselves.
But Dr. Sandra Belmont, a spokeswoman for the San Francisco-based American Academy of Ophthalmology, suggests that people eschew convenience and look for a doctor who’s done at least 300 to 500 LASIK procedures. Belmont runs the laser vision center at New York Presbyterian Weill Cornell Center in Manhattan and has a private cornea transplant practice as well.
Belmont also advocates having LASIK surgery in a hospital. She insists that the sterile hospital atmosphere is well worth the extra effort. “I feel it’s important because of the standards we have to uphold because of the instruments,” she said.
Belmont, like Dello Russo, was an FDA investigator for clinical trials and estimates there are complications one percent of the time or less. All eye surgeons should receive approximately the same training in operating the equipment used to perform LASIK surgery. Christine Oliver, vice-president for marketing for Summit Technology of Waltham, Mass., said the company directly trains doctors who buy its machines. Doctors go through a 6-hour training session on the technical aspects of LASIK, the software that drives the machinery and restrictions on its use. Then there are proctoring sessions in which company representatives observe the doctors performing three to five surgeries in their own offices. After the training sessions, the doctor is certified.
LASIK is considered a replacement for a similar but sometimes less effective surgery for vision correction called PRK, which uses a laser to reshape the cornea but doesn’t involve cutting a flap.
Most insurance plans don’t cover LASIK; so many people simply can’t afford to have their eyes fixed even at discount prices.
However, some vision plans provide discounts for LASIK. For instance, Vision Service Plan of Rancho Cordova, Calif., offers a 20 to 25 percent discount to members who patronize ophthalmologists in the VSP network – and more coverage for customers willing to pay a higher premium.
With increasing competition and equipment that’s constantly being refined, prices for LASIK surgery may begin to go down this year. Bausch & Lomb has developed new laser equipment that is expected to make the market more competitive. And the competition may drive down prices. Still, cost is just one factor to be considered. However, a patient chooses to pay for LASIK, respected eye surgeons urge one thing above all others: caution when selecting an ophthalmologist to do the job.
WHO’S ELIGIBLE FOR LASIK?
The best candidates for LASIK are people who need relatively little vision correction, according to Dr. Joseph Dello Russo of Bergenfield, N.J. Those with more severe near- or farsightedness may have to continue wearing glasses – although ones with much weaker prescriptions – even after LASIK surgery. And clearly, not everyone is a candidate.
People with eye abrasions, very bad vision, or a long history of wearing contact lenses, which may have left scratches on the eyes, may not qualify. Pregnant women and those with auto-immune diseases also are considered poor candidates, as are people younger than 18.
People with very large pupils also may be ruled out because the laser machines currently in use have a limited range and cannot cover the entire area. This could produce a halo or glare effect, caused by light passing through both the corrected and uncorrected areas of the cornea when the pupil enlarges in darkness.
Most people with normal pupil sizes who undergo LASIK can expect to experience some glare or halo effect around lights at night, but that problem usually goes away in about six months. However, about five percent of people who undergo the procedure have reported a lasting effect. – Kathleen Kerr
”I CAN SEE CLEARLY”
Kevin Morrow has already taken some Valium and now he wants a cigarette. His face is flushed and his hands clenched.
Morrow, 40, is about to have his eyes sliced open with a high-tech cutting machine and then reshaped with an Excimer laser. Small wonder he is nervous. An ex-carpenter from Closter, N.J., who says he now studies international trade at the Fashion Institute of Technology in Manhattan; Morrow is extremely nearsighted and has astigmatism. He has worn glasses constantly for about 30 years. Now, with a gift of $5,600 from his grandmother Marie Iko of Boca Raton, Fla., he is about to undergo the increasingly popular LASIK procedure. He hopes to throw away his glasses forever.
“I’m sick and tired of them,” says Morrow. “It’s a big pain.” An assistant to Dr. Joseph Dello Russo, the Bergenfield, NJ ophthalmologist who is to perform Morrow’s surgery, escorts him to a small room containing an examining table with laser equipment attached. Morrow lies on the table, and two more assistants enter, measure his eyes, do computer calculations, and calibrate the laser equipment.
Now Morrow is ready.
With a Mozart CD playing in the background, Dello Russo enters, kicks off his black Prada loafers, and puts on a mask and surgical cap. A metal ring isolates Morrow’s eyeballs, and his eyelids are taped up. On a monitor, his eyeballs appear almost as large as the screen. Eye drops are used for an anesthetic, suddenly giving him the look of a raccoon. Then Dello Russo swings into action. He starts operating the equipment and he’s gliding, gliding, and gliding the microkeratome over the first eye, telling Morrow he’s going to feel some pressure as he cuts a three-sided flap from his cornea. Dello Russo hums as he works.
Now it’s time to use the laser to resculpt Morrow’s cornea. “Red light, red light,” Dello Russo says, instructing Morrow to stare at the tiny light above his head as the laser does its work, sizzling and emitting a slight burning smell. “Find the red light, Kevin.”
Then Dello Russo uses a cellulose swab and eye drops to ease the corneal flap back to its original position. Temporary contact lenses will keep the flap in place. Dello Russo repeats the procedure for Morrow’s other eye. Then the procedure is over – no more than 15 minutes from start to finish. Morrow says he felt no pain and now feels woozy from the tension. But he says he thinks he sees better already. He hands his glasses to an aide, who will replace the old prescription lenses with nonprescription sunglass lenses. He’s given a pair of large black eyeshields to wear temporarily and sits down until his eyes can be checked in about an hour.
A few minutes later, it’s Robin Bonner’s turn. Bonner, 37, from Bridgewater, N.J., has a myopic astigmatism in her right eye.
Again, Dello Russo cuts the flap and zaps the eye slowly with the laser, then tells Bonner that there will be some pressure on the eyeball. Minutes later, it’s all over.
Back in the waiting room, Bonner says: “I can see clearly.” Several weeks later, Morrow and Bonner both report they’re seeing clearly, the only side effect being a little night glare experienced by Bonner. And neither is using glasses anymore. – Kathleen Kerr