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Up Front | Oct 2008

LASIK for Presbyopia

My experience on the other side of the laser.

As a cataract and refractive surgeon, I offer my patients a variety of corrective options. When presbyopia started to affect my day-to-day routine, I decided it was time to find a permanent solution that would simultaneously correct my moderate myopia and astigmatism and obviate my need for bifocal eyeglasses. After reviewing my options, I decided to undergo LASIK.

As I contemplated vision correction with LASIK, I was surprised by the questions that went through my mind. Was I ready to risk my vision? What if something went wrong during the procedure? What would I do if I could no longer practice medicine? Visualizing myself on the other end of the excimer laser made me realize how much time I spent every day reassuring patients about the safety of LASIK. I knew I would not recommend refractive surgery to my patients if I did not believe it was safe. Actually considering undergoing the procedure, however, gave me a new perspective on LASIK. After carefully evaluating my visual needs, I decided the best solution for my emerging presbyopia was modified monovision.

Trust is an integral part of any successful patient/surgeon relationship, especially if an adverse outcome can cause permanent disability. In my case, I was fortunate that my surgeon—Eric D. Donnenfeld, MD—was not only experienced and trustworthy, but he was also one of my closest friends.

To optimize my corneal surface, I used Restasis (cyclosporine ophthalmic emulsion 0.05; Allergan, Inc., Irvine, CA) b.i.d. for 2 weeks preoperatively and for 6 weeks postoperatively. Research has shown that patients who use Restasis achieve better quality vision and contrast sensitivity after LASIK than those who do not take this prophylactic step.1

Studies have also shown that, compared with other patients, healthcare workers have an elevated risk of developing methicillin-resistant Staphylococcus aureus keratitis after refractive surgery.2,3 To reduce my risk of postoperative infection, I cleaned my eyelid margins with SteriLid Eyelid Cleanser (Advanced Vision Research, Woburn, MA) once a day for 1 week preoperatively. My experience with Restasis and SteriLid was so positive that I now have all of my patients use these products preoperatively.

Dr. Donnenfeld and I planned my surgery to coincide with a business trip I was taking to New York. When I arrived at his office, his staff prepared me for surgery in the customary manner. After some good-natured teasing, Dr. Donnenfeld used the IntraLase FS laser (Advanced Medical Optics, Inc., Santa Ana, CA) to create flaps in both of my corneas. Next, he performed the ablations with the Visx Star S4 excimer laser (Advanced Medical Optics, Inc.). The treatment, which was guided by iris registration, targeted a plano refraction in my left (distance) eye and-0.50 D in my right (near) eye.

During my surgery, I made several observations that changed how I describe the ablative process to my patients. For example, I always used to tell them to look directly at the flashing orange light while they were under the laser. As soon as Dr. Donnenfeld lifted my corneal flap, I realized that my directions were not very accurate. Instead of a crisp, orange light, I saw a diffuse, blurry glow. I also noticed that it was hard to see the orange glow until Dr. Donnenfeld dimmed the lights and switched on the iris tracking system. Based on this experience, I now warn my patients that their vision will be blurry after I lift their flaps, and I encourage them to choose a point that they think is in the middle of the orange glow. I add that the orange light may be difficult to see at first but that it will be easier to make out after I turn down the lights.

The morning after my surgery, I played my usual erratic round of golf with Dr. Donnenfeld before heading to an all-day ophthalmologic conference. Three days after undergoing LASIK, I was back in the OR treating my own patients.

One year after undergoing LASIK, my visual acuity for distance is 20/20 OS and approximately 20/30 OD. The reading vision in my right eye is 20/20. Although I saw some ghost images and halos in the early postoperative period, these visual disturbances never prevented me from driving at night or affected my ability to view slides and attend lectures in dark rooms. Because the symptoms eventually disappeared, I suspect they were part of the healing process.

I am pleased with the improvement in my vision after LASIK, because I no longer need reading glasses to see patients' charts. My monovision correction has not affected my ability to operate with a surgical microscope, either. I just compensate for the disparity between my eyes by adjusting the eyepieces separately. I will probably need to wear reading glasses as my presbyopia progresses. For now, however, I am satisfied with my functional vision at all distances.

My decision to have LASIK was purely personal, and my goal was only to reduce my dependence on reading glasses. Some people have suggested that a surgeon who offers LASIK to his patients should also be willing to undergo the procedure. I do not believe this is true, and I would question any surgeon who thinks that having LASIK will make the procedure more appealing to his patients.

LASIK did not make me a better doctor. It did, however, help me to understand the procedure from the patient's perspective. I do not tell my patients that I underwent LASIK unless they specifically ask me. In these cases, I am happy to share my firsthand impressions. I describe what they can expect before, during, and after the procedure, but I always stress that their experience may be different.

My goal as a surgeon who underwent LASIK is no different from when I wore contact lenses: it is to help my patients make an informed decision about refractive surgery. I have always been comfortable discussing the benefits and risks of LASIK. Although I do not believe it was necessary for me to have LASIK to understand the procedure fully, I was pleased to discover that my experience provided me with additional insight into the process that I can share with my patients to help them set reasonable expectations for their outcome.

Kerry D. Solomon, MD, is the Arturo and Holly Melosi Professor of Ophthalmology, Medical Director of the Magill Vision Center, and Director of the Magill Research Center, all at the Storm Eye Institute, Medical University of South Carolina, Charleston. He is a consultant to Advanced Medical Optics, Inc., Advanced Vision Research, and Allergan, Inc. Dr. Solomon may be reached at (843) 792-8854; solomonk@musc.edu.

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