Published on February 25, 2014
Olympia HSA Medical Series Laser Eye Surgery A COMPLETE GUIDE FOR CANADIANS 1
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INTRO Imagine vision improvements that could translate into driving without glasses or playing sports without contact lenses. That’s become a reality for many of the millions of people worldwide who have elected to have laser eye surgery. This popular surgery is seen as a safe and effective way to correct vision problems and enhance lifestyles. Basically, it all comes down to the shape of the eye. Any variations in shape, including length, can result in vision problems. By using a laser to change the shape of the cornea, surgeons can correct refractive errors and improve the eye’s ability to focus on objects. Laser eye surgery can correct vision problems such as near-sightedness, far-sightedness and astigmatism, providing candidacy requirements are met. And cuttingedge advancements in laser technology means a wider range of candidates can be treated. While the idea of improved vision is a compelling one, the wide range of procedures, associated costs and laser eye surgery providers can seem overwhelming. The purpose of this guide is to provide an overview of laser eye surgery and to shed some light on the options available. 3
TABLE OF CONTENTS Intro 3 Geting started 5 LASIK 7 PRK 9 Keratoconus Treatment 11 Laser Epithelial Keratomileusis 14 Epi LASIK 15 Cataract Surgery 16 Artificial Lens Procedures 18 Monovision, Laser Blended Vision Correction and Corneal Inlay for Presbyopia 21 Laser Eye Surgery Results and Recovery 23 Laser Eye Surgery Cost 27 Conclusion and Additional Resources 29 4
Getting started The first step in the process is an assessment that will help the surgery provider determine whether or not a patient is a candidate for laser eye surgery. It is also geared towards helping potential patients decide whether laser eye surgery is right for them. The preoperative assessment, which is normally complimentary, differs amongst providers. During this initial appointment, which can last between two and three hours, surgeons and clinic staff will gather patient information, including medical history, as well as answer questions and provide information through patient counseling. Eye testing is also a key component of the process. The eye specialists could be examining criteria such as current vision prescription, corneal thickness, pupil diameter, as well as both general and eye health. If a patient is deemed eligible for laser eye surgery, the provider will recommend and outline a surgical procedure and review pricing. Laser eye surgery is considered an elective surgery and is not covered by provincial health care plans. However, it is an eligible 5
expense under a health spending account. Clinics normally have a contact lens policy in place which means that contact lenses must be removed for a certain amount of time before appointments. This allows the cornea to return to its natural shape and ensures accurate test results. There are a few factors that will exclude a patient from having laser eye surgery: • • • • Certain medical diseases Certain eye injuries and diseases or disorders Candidates should be a minimum age of 18 Have a vision prescription that has been stable for at least a year and that falls within an admissible range • Pregnant or nursing women are not eligible for surgery Recent advancements in laser technology have opened doors so that a wider range of candidates can turn to laser eye surgery as a vision correction option. 6
Types of Laser Eye Surgery LASIK Laser-Assisted In Situ Keratomileusis LASIK can be used to correct nearsightedness (myopia) farsightedness (hyperopia) and astigmatism. Myopia and hyperopia are refractive errors that are caused by variations in the shape of the eyeball. Astigmatism is a result of an irregular-shaped cornea, which is the transparent outer portion of the eye surface. Surgeons can use the two-step LASIK procedure in different ways, specialized for each patient, to correct refractive errors. Generally, the process involves reshaping the cornea to improve the way that light rays focus on the retina (the light-sensitive, back portion of the eye). First, surgeons use either a bladed instrument called a microkeratome or a laser to create a precise flap of the cornea. This hinged flap, which is still attached to the cornea, is raised. Next, surgeons will use an excimer laser to reshape the cornea by accurately removing corneal tissue. The preoperative eye exam determines how much tissue should be removed for each patient. 7
An advanced technology, custom wavefront LASIK, is available that allows surgeons to further refine the standard LASIK procedure and enable more precise vision corrections. LASIK, which is an outpatient surgical procedure, takes place under local anesthetic. The surgery itself is considered painless and takes only a matter of minutes per eye. After surgery, the natural healing processes of the eye take over to help seal the flap of the cornea. Although LASIK surgery is considered safe, there are risks involved: • • • • • Poor night vision due to halos Bright light sensitivity Dry eyes Double vision and regression Rarely - infection or weakening of the cornea 8
Types of Laser Eye Surgery PRK Photorefractive Keratectomy In photorefractive keratectomy (PRK), surgeons remove the thin surface layer of the cornea (called the epithelium). Like LASIK, PRK can be used to correct nearsightedness, farsightedness or astigmatism. PRK differs from LASIK in that it doesn’t involve cutting a flap in the cornea. After the epithelium is removed, PRK surgeons will then use an excimer laser to reshape the cornea by removing a predetermined amount of tissue. Either standard PRK or custom wavefront PRK can be used at this stage of the process. Custom wavefront PRK is an enhanced version of standard PRK that allows surgeons to further customize the procedure for patients and can improve the outcome of laser vision correction. The actual treatment time, including preparing the eye and the laser process, is roughly 30 minutes. During that time, the laser is used for only a few minutes per eye. Healing time is longer with PRK than with LASIK since it takes about three to five days for the epithelium 9
to grow back. During this time, patients are fitted with contact lens ‘bandages’ to protect the cornea and help it heal. The surgical process itself is considered painless. However, patients can expect some pain during the healing process. PRK can be used on patients with high vision prescriptions or whose cornea is too thin or too soft to withstand the creation of a flap. It can also be recommended for people who participate in activities, such as boxing or martial arts, which put them at risk of getting hit in the eye. Although PRK surgery is considered safe, there are risks involved: • • • • • Poor night vision due to halos Increased bright light sensitivity Double vision and regression Hazy vision (normally clears up after healing) Rarely - infection or weakening of the cornea 10
Types of Laser Eye Surgery Keratoconus Treatment In recent years, laser eye surgery has been combined with a process called corneal collagen crosslinking or CXL, to treat a progressive eye disease known as keratoconus. This disease, which often emerges when people are in their late teens or early 20s, causes the normally dome-shaped cornea to bulge into a more conelike shape. The irregular shape results in blurred vision that, as the disease progresses, becomes increasingly difficult to correct with glasses or contact lenses. Traditionally, some people with keratoconus would have had to consider a corneal transplant to curb the effects. But recent advancements in keratoconus treatment are offering new hope for diagnosis and treatment of the disease. Using a technique called corneal collagen crosslinking, or CXL, surgeons are able to strengthen the cornea, helping it to retain its natural shape and resist bulging. 11
The CXL Process • • • • • Anesthetic drops applied to numb the eye Surface skin of the cornea is polished Riboflavin drops are applied to the eye 10 and 30 minutes of UV-A light Bandage contact lens worn for several days Riboflavin drops, combined with the UV-A light, act on the cornea to strengthen it. Recent advancements in corneal collagen cross-linking are reducing the riboflavin soak time as well as the UV-A light exposure time. CXL can be combined with laser eye surgery to improve vision quality with glasses or contact lenses for people with keratoconus. Before the CXL process, surgeons can use a standard laser vision correction process to reshape the cornea and help improve overall vision by reducing myopia, hyperopia or astigmatism. A more advanced laser eye surgery option, CXL combined with T-PRK, has also recently become available. 12
Using state-of-the-art imaging technology, surgeons are able map out and improve corneal irregularities in people with keratoconus prior to CXL treatment. Treatments for keratoconus, including laser eye surgery combined with CXL, will not normally eliminate the need for glasses or contacts in people with the disease. The goal of these procedures is to improve vision quality and to slow or prevent the progression of the disease. 13
Types of Laser Eye Surgery Laser Epithelial Keratomileusis Photorefractive Keratectomy (LASEK) LASEK is a newer procedure in which the surface layer of the cornea (epithelium) is cut with a fine blade and loosened with alcohol drops. This thin, hinged layer is raised and pushed to the side, allowing surgeons to use a laser to reshape the cornea. Once the procedure is complete, the epithelium is replaced and a bandage contact lens is inserted to help with healing. Risks of this surgery can include: • • • • • • • • Initial vision clouding or haze Night vision issues Bright light sensitivity Double vision Regression Overcorrection or undercorrection Rarely - infection, sores on the cornea Rarely - Glaucoma or pressure inside the eye 14
Types of Laser Eye Surgery Epi-LASIK In this procedure, the surface layer of the cornea is lifted with an epithelial separator or epi-keratome, which is a special machine with a blunt blade. Surgeons reshape the cornea and then replace the surface tissue. A bandage contact lens is worn to assist with healing. Depending on the results of the preoperative consultation, Epi-LASIK may be recommended for patients who are not suitable candidates for LASIK due to a higher risk of an eye injury due to certain careers or sports activities, or whose corneas are too thin for the creation of a LASIK flap. Custom wavefront techniques can be used with Epi-LASIK to customize the procedure. Risks of this surgery can include: • • • • • • • • Initial vision clouding or haze Night vision or bright light sensitivity Double vision Regression Overcorrection or undercorrection Rarely - infection and sores on the cornea Rarely - Glaucoma Rarely - Increased pressure inside the eye 15
Types of Laser Eye Surgery Cataract Surgery Cataracts can affect vision quality by causing cloudiness in the lens of one or both eyes. Although cataracts are often linked to aging and are most common in adults over 40, children can also be affected. Cataracts are painless and usually progress slowly. Glasses or contact lenses can often help with mild forms of cataracts, but they cannot correct vision when cataracts become more advanced. There is no cure for cataracts and surgical removal is the only option to help restore vision. Laser surgery is beginning to be offered as an alternative to traditional cataract surgery with lasers replacing some of the steps that are normally completed with a diamond blade. Advanced imaging technology, called optical coherence tomography (OCT,) is used to provide surgeons with a detailed ‘map’ of the eye. The resulting images and measurements are used in conjunction with laser surgery to customize the surgical procedure to each patient’s unique eye characteristics. 16
Based on results from the imaging part of the process, a femtosecond laser is used to make precise incisions, to reduce or control astigmatism, and to breakup the cataract. Then, ultrasound technology is used to further break down and remove the cataract. Finally, a clear, artificial lens, called an intraocular lens, is inserted into a tiny, laser-created pocket. The surgical procedure takes only a few minutes, with minimal or no patient discomfort. Antibiotic eye drops are given and recovery can take from about 48 hours up to a week. 17
Alternatives to Laser Eye Surgery Artificial Lens Procedures Artificial lens procedures were initially designed to replace natural lenses that had become clouded by cataracts. Since then, the technology has evolved to be used to correct refractive errors as well, offering an alternative vision correction solution for those who are not suitable candidates for laser eye surgery. • Refractive Lens Exchange (RLE) - This surgery is similar to traditional cataract surgery in that a natural lens is replaced with an artificial lens implant. The primary difference is that while cataract surgery is done for medical reasons, RLE is an elective surgery to correct refractive errors and improve vision. The procedure can be performed on patients whose extreme nearsightedness or farsightedness would affect the outcome of laser eye surgery. In the RLE process, the natural, crystalline lens is removed using either a laser or special ultrasound tool, called a phacoemulsifier. The artificial lens, which is chosen based on the amount of correction required, is inserted through a tiny incision in or near the cornea. Depending on a preoperative assessment, the surgeon may choose a foldable lens, which unfolds 18
once placed in the eye, or a more rigid lens. Anesthetic drops are used to numb the eye and minimize discomfort during the procedure, which takes about 15 minutes per eye. Stitches are not normally needed since the incision is designed to self-seal. • Phakic Intraocular Lenses - This procedure is similar to the RLE process, except the natural lens is not removed. The implantable lens is inserted into an incision and placed over the natural lens of the eye. The procedure takes roughly 20 minutes per eye and usually requires no stitches. Phakic Intraocular lenses can be used to correct extreme nearsightedness, farsightedness and can also be used to treat astigmatism. • Presbyopic Lens Exchange - Commonly referred to as PRELEXR, presbyopic lens exchange is used to correct presbyopia, which affects the eyes’ ability to focus on near objects. The natural lens of the eye is replaced with an artificial lens that will allow the eye to focus on objects that are both near and in the distance. The procedure is aimed at reducing 19
or eliminating the need for reading glasses. Also, since the natural lens, which can be prone to the development of cataracts, is removed and replaced by an artificial lens, the risk of cataracts is eliminated. • Cataract extraction - Cataracts can cause symptoms such as cloudy vision, reduced appearance of colours, reduced night vision or double vision in the affected eye. In this procedure, surgeons replace a natural lens that has been clouded by cataracts with a clear artificial lens. An ultrasound tool is commonly used to break up the natural lens, which is then removed. The artificial lens, which is normally a soft, foldable lens, is inserted into a small incision, replacing the natural lens. Once placed in the eye, the lens unfolds and the incision begins to heal naturally. Often patients can resume normal activities about 24 hours after the surgery. 20
Types of Laser Eye Surgery Monovision, Laser Blended Vision Correction and Corneal Inlay for Presbyopia • Monovision - Using LASIK or PRK laser eye surgery, one eye is corrected for distance vision.The other is undercorrected, leaving it slightly near-sighted, allowing for improved focus on near objects. Monovision can improve presbyopia and reduce the need for reading glasses. One of the challenges for people who undergo monovision is to become accustomed to relying on one eye for distance vision and the other for near vision. Monovision can also result in reductions in depth perception, distance vision clarity and quality of night vision. While reading glasses would still be required for activities such as reading for an extended time, monovision can help with scans of smaller print on things like price tags, restaurant menus or documents. • Laser Blended Vision Correction - With a special excimer laser, using a LASIK procedure, surgeons correct a dominant eye for distance vision, while near vision is improved in a non-dominant eye. The depth of field in both eyes is also increased. The brain is able to blend the two images together creating improved vision at near, intermediate and far distances without the need for glasses. The image appears to be in focus for both eyes, and, although there will be a variation in vision between 21
both eyes, patients are less likely to notice it with laser blended vision correction. This is different from monovision surgery, in which patients must adjust to relying on one eye to see near and the other to see distance. Laser blended vision correction also appears to have a higher acceptance rate among patients, compared to monovision, with a shorter adaptation time. • Corneal Inlay - Commonly called the KAMRATM Inlay, this process involves inserting a microscopic ring into only one eye. The black ring, which is much smaller than a contact lens, has a diameter of 3.8 mm with a tiny opening in the middle. If LASIK is done, the inlay is inserted into a LASIK flap, or it can also be inserted into a laser-created pocket if LASIK is not done. The outer ring part of the inlay prevents unfocused light from reaching the retina, while the tiny opening in the ring allows only focused light through. This procedure can improve presbyopia by bringing near objects into focus. The inlay is etched with thousands of microscopic openings to help the cornea stay healthy. The procedure is reversible and takes about 20 minutes. There are no stitches required and eye drops are given to help with the healing process. Recovery time varies from a few days up to months, depending on individual healing times. Most patients are able to return to work and resume normal activities within 24 hours. 22
Laser Eye Surgery Results and Recovery When it comes to laser eye surgery, it’s important to focus on realistic expectations. Before undergoing any procedure, a thorough consultation with a surgeon can help clarify expected results for patients. Follow-up care can include: • • • • Taking a number of days off work Taking prescribed medication Attending post-operative appointments Temporary break from sports activities Results and recovery time will vary from patient-topatient. Here’s a snapshot of possible results and recovery time after laser eye surgery. LASIK Recovery • Little or no pain after • Vision improvements often noticeable within a few days • Return to work within 24 hours (depdending on the level of eye trauma risk associated with a certain job) • Protective sunglasses during the initial healing process • Administration of eye drops • Follow-up visits to check on recovery and healing 23
A temporary condition called dry eyes can occur. Symptoms can include: • Temporary blurry vision • Excessive tearing • Burning, itchiness or redness of the eyes Dry eyes can be treated with artificial tear drops or comfort plugs. PRK Recovery PRK surgery takes slightly longer than recovery from LASIK. That’s because PRK surgery involves the removal of the epithelium (top layer) of the corneal, instead of the creation of a LASIK flap. It can take between three and five days for the body to regrow the epithelial layer that was removed during surgery. Patients will be fitted with a contact lens ‘bandage’ the will help the protect the cornea and help it heal. Patients who undergo PRK surgery can expect some level of pain for a few days following the procedure. 24
After PRK, vision can temporarily be reduced or can remain blurry for some time and it can also take longer for vision to stabilize. A schedule for follow-up surgery will be provided and surgeons will provide prescriptions for eyedrops and, if necessary, pain medication. The visual correction outcomes of PRK and LASIK are comparable. LASEK Recovery Recovery times for LASEK, a newer procedure, are normally longer compared to recovery from LASIK or PRK surgery. Bandage contact lenses or eye shields are applied and worn for a few days after surgery. They help protect the cornea so that the epithelial layer, which is loosened during this process, can reattach and heal. Vision can be temporarily reduced while the epithelial layer heals following LASEK surgery and there can be pain associated with the healing process. Prescription eye drops are used for up to several months after the surgery and follow-up visits are scheduled to monitor recovery. 25
Epi-LASIK Recovery Vision correction results from Epi-LASIK can be comparable to LASIK and PRK. After surgery, bandage contact lenses are inserted to help keep the epithelial flap in place and to protect it as it heals. There can be pain associated with the Epi-LASIK healing process. After EpiLASIK surgery, vision stabilization can take anywhere from a few days up to several months. An eye drop prescription and application schedule will be given and follow-up visits will be scheduled to monitor healing and recovery. Artificial Lens Implant Recovery Normally, incisions used in this process are selfsealing and do not require stitches. Although patients can notice vision improvements immediately following surgery, best results are often not realized until a day or two following the surgery. Recovery time and followup procedures can vary depending on the type of lens inserted. 26
Laser Eye Surgery Cost While the idea of improved vision is appealing, cost is a primary question for many people considering laser eye surgery. There is a wide range of pricing for the procedures, from a starting point of about $500 up to thousands of dollars per eye, but the average price falls around $2,000 per eye. Costs of refractive lens exchange tend to run higher than those of laser eye surgery. Vision prescription strength, surgeon experience, laser technology used and the surgical procedure itself can all have an influence on cost. And, since pricing packages vary amongst service providers, it’s important for prospective patients to ask questions about what’s included in order to avoid surprises. Pre-operative and post-operative consultations, including all eye testing, are commonly included. Other costs to consider: • • • • Post-surgery prescription medication Bandage contact lenses Protective glasses Possible laser vision enhancement surgeries in the future 27
Some clinics have options for surgery financing. Since laser eye surgery is considered an elective procedure, it is not normally covered under insurance policies. The procedure is an eligible expense under a Health Spending Account.That means, the entire cost of laser eye surgery can be deducted as a pretax expense. 28
Conclusion and Additional Resources 29
CONCLUSION Laser eye surgery can be a life-changing experience that opens doors to a world of vision improvements without the hassle of glasses or contact lenses. It is also a big decision that can be daunting. Anyone considering laser eye surgery can benefit from carefully researching and choosing their service provider to find the best fit. It is also a good idea to prepare a list of questions and concerns to review at the first appointment. Millions of people world wide have already benefited from having their vision improved with laser eye surgery. It’s considered safe and effective. Overall, the surgical procedures have had high success rates with minimal downtime. Plus, laser technology used for vision correction is constantly evolving, bringing new options to more patients who wish to enjoy the freedom of better vision without glasses or contact lenses. Since most health insurance plans don’t include laser eye surgery, it’s important to review costs in detail. Also, keep in mind that laser eye surgery is an eligible expense under a Health Spending Account, making this type of plan an effective tool to reduce costs. 30
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