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A Guide to Laser Vision Correction

Dr. Robert Maloney believes that a well-informed patient is key to successful vision correction surgery. He wants to be sure that you fully understand what you can expect from your procedure you choose.

He wants to help you care for and preserve your eyesight in the best way possible. Here, you can find the information that you need to help you make informed choices about health care for your eyes.

Contemplating Laser Eye Surgery

Questions to Ask Your Surgeon

Once you have the names of refractive surgeons, the next step is to find out more about their credentials, reputation, and practice. Don't be shy about asking penetrating questions. LASIK surgeons understand that patients have many questions about them and about the procedure, and they should be prepared to answer the questions for you. When you find a doctor with promising credentials, call the office and ask to speak with the LASIK coordinator or a staff member who can answer your questions.

What Are the Surgeon's Credentials?
Consider only surgeons who are board certified. What does this mean? In addition to the medical education, internship, and residency program mentioned earlier, ophthalmologists must pass a series of exams given by the National Board of Medical Examiners; they must also pass two additional examinations administered by the American Board of Ophthalmol ogy. After passing these final exams, physicians are certified by the American Board of Ophthalmology. About 90 percent of ophthalmologists eventually pass these exams, so the designation "board-certified" does not help you separate outstanding surgeons from merely good ones. However, lack of board certification is a warning sign-it means the doctor is in the bottom 10 percent of ophthalmologists in knowledge of the field.

Some ophthalmologists are fellowship-trained cornea or refractive surgeons. This means they have been offered one or two years of extra training in diseases and surgery of the cornea under the supervision of leading physicians in the field. Fellowship-trained surgeons will likely have a lower incidence of complications, because they can diagnose subtle findings prior to surgery.

How Many LASIK Procedures Has the Surgeon Performed?
Be specific in asking about a physician's experience with LASIK, be cause other laser procedures require skills different from those required for LASIK. Because there is a learning curve, surgeons should have performed a minimum of 1,000 LASIK procedures; research shows that the complication rate for surgeons is reduced even further after they have performed 3,000 procedures.

It generally takes that many LASIK procedures before a surgeon's nomogram is reasonably well developed. The nomogram refers to the formula the surgeon enters into the excimer laser computer for each procedure. Even though excimer lasers come from the manufacturer with recommended settings to correct the various refractive errors, the surgeon fine-tunes and customizes these settings with the nomogram. Based on a series of measurements the surgeon takes during the preoperative exam, the nomogram includes factors such as the degree of refractive error and the patient's age. It also takes into consideration the surgeon's own technique and the type of laser he or she will use. A well-developed and artful nomogram allows the surgeon to more accurately program the laser for each patient, increasing the likelihood of perfect vision.

How Many Procedures Has the Surgeon Performed on Patients with Your Refractive Error?
Perhaps as important as the total number of LASIK procedures a surgeon has completed is the number he or she has performed on patients with the same refractive error as yours, using the same laser equipment. The surgeon should have completed 100 or more such procedures. Even an experienced surgeon could have difficulty with certain less common refractive errors. And new equipment takes some getting used to as well. Additionally, the surgeon should have experience with patients of your age and race-relevant because the surgical techniques needed to correct refractive errors in these groups may differ slightly.

Ask to Speak with Former Patients
Ask a prospective surgeon for the names of two or three patients you can contact who had a refractive error similar to yours. This is not an unusual request. When you speak with them, ask how they felt about the surgeon, the staff, and the quality of their LASIK experience.

How Does the Surgeon Track LASIK Procedure Outcomes?
The surgeon's response to this question will reveal much. If the surgeon has readily available statistics in the form of charts and graphs, he or she is most likely benchmarking, or tracking, LASIK outcomes. In addition, if the surgeon presents his or her data to other surgeons at well-respected national or international conferences, or publishes in professional journals, you can be confident that he or she is tracking outcomes.

Benchmarking is very important, because it indicates the surgeon is concerned about achieving the best possible results over time. There is no mandatory central reporting database for tracking LASIK outcomes, unless a surgeon is participating in a sanctioned clinical trial. Therefore, a surgeon's doing so voluntarily indicates high personal standards of professionalism and performance.

It is important in tracking data that your surgeon has performed a statistically significant number of procedures. With data from 3,000 or more procedures, your surgeon would be able to predict outcomes fairly accurately.

What Are the Surgeon's Success and Complication Rates?
The surgeon should be able to give you the percentage of LASIK patients whose procedures result in 20/20 vision or better. It's normal for more than 80 percent of LASIK patients to achieve this level of vision. In fact, with wavefront-guided treatment, which uses newer diagnostic technology, most patients in a top practice today have a 95 percent chance of achieving 20/20 vision. (See more details on wavefront in chapter 5.) With data based on 1,000 or more procedures, your surgeon should be able to tell your chances of achieving a good result with LASIK and whether you will need an enhancement procedure. Ask what percentage of LASIK patients report significant complications. Less than 1 percent is acceptable. Keep in mind that most complications, if they do occur, can be managed by an experienced surgeon.

Has the Surgeon Participated in Research Activities, Lecturing, or Writing?
Doctors who have researched and written articles for peer-reviewed journals, been speakers at medical conferences, and/or published books are usually well respected among their peers. This is an indication of a physician's experience and competence. This level of professional involvement, above and beyond his or her ophthalmology practice, shows the doctor's mastery of, motivation in, and passion for the field.

Has the Surgeon Ever Participated in an FDA Clinical Trial?
The U.S. Food and Drug Administration (FDA) authorizes some ophthalmologists to participate as principal investigators in clinical trials sponsored by laser manufacturers. A clinical trial is a research study, conducted with patients, that is designed to evaluate the safety and effectiveness of a new procedure or device. Typically, FDA-authorized ophthalmologists are chosen because of their demonstrated skill and ability and their complete understanding of laser vision correction and the laser being used. These surgeons are subject to detailed analysis and reporting and are willing to endure extreme scrutiny.

Note that an ophthalmologist may have never been asked to participate in a clinical trial, yet may be very competent to perform LASIK. Still, if you've found a surgeon who has participated in a clinical trial, you're more likely to have found one of the best.

Has the Doctor Ever Been Sued for Malpractice?
Even the best surgeon may have had a malpractice suit brought against him or her, so be careful about passing judgment based on what might have been a frivolous lawsuit. The typical vision correction surgeon is sued roughly once for every 3000 surgeries performed. Statistics indicate that about 80 percent of these suits are either frivolous or without merit. If the doctor has been sued more frequently than this, or has multiple simultaneous lawsuits, you should ask for an explanation. If you are embarrassed to ask about malpractice suits against the doctor, there are alternative ways to obtain this information.

One organization, the Association of State Medical Board Executive Directors, is a group of participating state licensing authorities that provides malpractice and disciplinary action information about specific doctors. The association's information is free and available at its Web site, www.docboard.org. However, not every state in the nation participates.

The Federation of State Medical Boards is another organization that collects and disseminates information about doctors' malpractice histories. It takes five to seven days to get an answer to a request. Contact the organization at its Web site, www.fsmb.org, or write to it at the address listed in the resource section.

Has the Doctor Been Sanctioned by the State Medical Board?
All doctors must be licensed by the state medical board in any state in which they practice. Medical boards will discipline doctors for significant misbehavior, including gross or repeated acts of negligence. Contact your state medical board for information on the doctor you are considering. Many state medical boards now publish disciplinary actions against surgeons online.

How Many Patients Does the Surgeon Turn Away?
A conscientious surgeon will turn away about 10 percent of the patients he or she evaluates during the preoperative examination. Be wary of a doctor who rarely advises a patient against the procedure. Many factors can make a patient a poor candidate for LASIK. No doctor with high ethical standards will perform laser surgery on your eyes if you are not a good candidate.

Will the Doctor Be Personally Involved in Evaluating Me for Surgery?
Avoid the "shopping mall" approach to surgery, where patients are shuffled through to the surgical suite without first having met with the surgeon. Most doctors have knowledgeable and compassionate staff to help perform tests and answer questions. However, it is also important to meet the surgeon and receive his or her personal evaluation before you decide to have the surgery.

Some patients choose to see their regular eye doctor for their preoperative and postoperative care. If you plan to do this, be sure your surgeon is comfortable working with your primary eye doctor. While the majority of people have an uncomplicated postoperative course, you want to make sure your care provider will be able to recognize complications if they arise and can either treat you or refer you for treatment before more serious, long-term repercussions occur.

What Type of Laser Does the Surgeon Use?
Make sure your doctor uses a newest-generation excimer laser that is capable of performing wavefront-guided treatment. Laser technology has improved dramatically over past years. State-of-the-art lasers now have eye tracking, which further improves the safety of the procedure. If your eye moves accidentally during the treatment, the laser automatically tracks, or follows, it. Make sure your surgeon uses an eye-tracking laser. State-of-the-art lasers enable surgeons to treat larger areas, minimizing the risk of nighttime glare.

The FDA Web site, www.fda.gov, also has links to laser manufacturers' Web sites, where some maintain lists of doctors certified to use their machines. If your doctor is not listed, you may wish to contact the laser manufacturer directly. Verify that the doctor has been certified by the laser company to operate a particular machine, which means he or she took a required training course.

How Much Does LASIK Cost?
Cost should not be the main factor in choosing a LASIK surgeon. First and foremost, seek out a surgeon who has a good reputation in the medical community and plenty of experience. If you are swayed by low cost, this may signal trouble for you down the road. Find the best-qualified surgeon with high medical standards for patient care, compassionate staff to tend to your needs, comprehensive postoperative care, enhancement procedures if necessary, and availability if any problems or complications crop up after surgery.

The cost of LASIK varies from surgeon to surgeon. Generally, high-quality, wavefront-guided LASIK runs between $2,200 and $3,000 per eye. Be sure to ask whether the quoted per-eye cost includes preoperative and postoperative care, as well as enhancement procedures. Many practices can help you arrange low-interest or no-interest financing, which makes high-quality surgery affordable for almost everyone.

Making the Decision »

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