1997-12-03|Excimer Laser Eye Surgery (LASIK)

Introduction

• This is my personal account of the Excimer Laser Eye Surgery (LASIK). The information herein is provided without any warranty of any kind. For general information and testimonials on the Excimer Laser Eye Surgery, it is recommended that you find the web sites of laser eye clinics via Internet Search Engines.

• I started wearing eyeglasses at the age of 8 or so. The refractive power was increasing by -1 diopter every 2 years, until it stabilised at about -9 diopters when I was 25 years old. I started wearing hard contact lenses at the age of 14 or so. In 1983, I switched to oxygen-permeable hard contact lenses (Boston IV), which I was wearing exclusively for all day and night, sometimes 18 hours a day. I was not able to wear soft contact lenses because of the high refractive power requirement for myopia and astigmatism.

• The contact lenses had served me well. A few months after I turned 38, however, I failed to remove my contact lenses before going to bed, partly because of the influence of alcohol. So, I finally decided to have an excimer-laser eye surgery to correct myopia and astigmatism. My situation was high myopia, high astigmatism, large pupil size, and a long-time use of hard contact lenses.

• Being a professional engineer and a webmaster, I conducted an extensive research on the Internet on both PRK (Photo Refractive Keratectomy) and LASIK (Laser Assisted in Situ Keratomielusis). I visited numerous web sites of clinics offering PRK and/or LASIK. I also analysed quite a few postings in the sci.med.vision newsgroup over a 1-month period.

Pre-Script

• Miopia
  • approximately -9 diopter

• Astigmatism
  • approximately -2 diopter

• Pupil Size
  • approximately 8 millimetre

• Corneal Depth
  • approximately 540 micrometre

Clinic

• Laser MedCare (LMC)
  • Dr. Dennis R. Conrad, M.D., F.R.C.S.(C.)

  • 2430-6, Bank Street
  • Ottawa (Ontario)
  • CANADA K1V 0T7

  • World-Wide Web ......... http://www.lasermedcare.com/
  • Telephone .............. +1-613-739-3044
  • Facsimile .............. +1-613-739-4995

• Aesculap MediTec Mel 60 unit
  • Scanning Slit type

Free Consultation

• Because I was wearing hard contact lenses for a very long time, the doctor recommended that the corneal topography mapping be taken once a week for a few weeks to confirm that the cornea had stabilised prior to the operation.

• 1997-10-22 (Week -6)
  • 1st consultation with Dr. Conrad
  • Corneal topography mapping
  • Refraction test
  • Pupil measurement

• 1997-10-29 (Week -5)
  • Corneal topography mapping

• 1997-11-06 (Week -4)
  • Corneal topography mapping

• 1997-11-12 (Week -3)
  • 2nd consultation with Dr. Conrad
  • Corneal topography mapping
  • Refraction test

• 1997-11-20 (Week -2)
  • Corneal topography mapping

• 1997-11-28 (Week -1)
  • 3rd consultation with Dr. Conrad
  • Corneal topography mapping
  • Refraction test

Excimer Laser Eye Surgery

• I was first exposed to the excimer laser eye surgery when I attended a free seminar given by Dr. Michel Popp in 1994. Dr. Popp is one of the pioneers of the excimer laser eye surgery in Canada. At the time, he was doing PRK with a broad-beam laser at his clinic in Hull (Québec). He had just introduced the bandage contact lenses to be worn after the surgery. I went to a free consultation at his clinic, and was told that I was an excellent candidate for the surgery. However, I decided against the operation because of the concern regarding large pupil size.

• 4 years later, Dr. Popp, by then a king of late-night infomercial promoting his own clinics, operated LASIK, but only in Montréal, which made it very difficult for me because of the 3 young children. Fortunately, I found the only clinic in Ottawa (Ontario)-Hull (Québec) that was offering LASIK. I felt very comfortable with the Laser MedCare (LMC) clinic because Dr. Conrad had himself experienced excimer laser eye surgery (PRK).

PRK versus LASIK

• I value long-term optical integrity, so I could have tolerated significant short-term pain associated with PRK. One doctor said that with LASIK I would have to live with a weakened cornea for the rest of my life, without mentioning that PRK would permanently destroy the Bowman's layer. Another doctor said that he would not recognise the difference between a PRK'd eye and a LASIK'd eye after 6 months. I even found a web site which claimed that the complication rate with LASIK was 10 %, although in reality it was less than 1 %, according to more recent statistics.

• Despite obvious merits of LASIK, I was still struggling to decide between PRK and LASIK, because I had thought that LASIK was more invasive than PRK. So, I borrowed a video of the actual surgery from the clinic. There were 2 PRK and 5 LASIK operations in 1 afternoon. To prepare for PRK, the doctor scrapes the cornea to remove the epithelium with ethanol on a Q-tip with many abrasive motions. For LASIK, the epithelium is clean-cut in 1 quick slice, so it looked much less messy. LASIK also requires only a 1-day immediate post-operation visit instead of 2 consecutive visits after PRK. Normally, bandage contact lenses are not required after LASIK.

• After reading many horror stories with PRK and advantages of LASIK in the sci.med.vision newsgroup, I was finally convinced of the merits of LASIK if done with a proper laser. As each surgery takes only a few minutes, the surgery is more like an assembly-line operation, so there is more uniformity than being a beta tester.

Broad-Beam Laser versus Scanning Slit Laser

• The pupil size was the major reason why I had waited 4 years since I first learned of the excimer laser eye surgery. For this, I was forever thankful to Dr. John G. Attridge of Hamilton (Ontario), who said to me "You have very large pupils" when he prescribed Boston IV contact lens in 1983.

• I determined that the 1st Generation broad-beam lasers (VISX Star, Summit Apex, etc.) were inadequate for a large pupil size. The 2nd Generation scanning slit lasers (MediTec, Nidek, etc.) were adequate enough. 3rd Generation flying spot (raster) lasers (Chiron Technolas, etc.) may eventually dominate the industry, but I would not wait that long for relatively minor benefits past the threshold.

• The diameter of the broad-beam laser is only 6 millimetre to 7 millimetre, depending on the laser, so I would definitely have had halos and starburst problems. The scanning slit lasers (approved in Canada) could treat diameters from 9 millimetre to 10 millimetre, so my 8 millimetre pupil would be completely covered, at least in theory.

• I was quite disappointed that none of the clinics I had consulted before volunteered to disclose the problems with the pupil size. They all said I was an excellent candidate for a laser eye surgery, even after I pointed out that my pupil size was quite large! My fears were confirmed when I started reading many horror stories in the sci.med.vision newsgroup.

• I learned that a central island would form after PRK or LASIK if a broad-beam laser was used because of the Gaussian distribution of the photon energy, although nomograms try to compensate for it. It would not be a problem after PRK or LASIK if a scanning slit laser was used.

Laser Software and Doctor's Skill

• My doctor said that the software on his scanning slit laser deliberately over-corrects in anticipation for regression. Another doctor that I had consulted, who does PRK with a broad-beam laser, said that he under-corrects.

• So, even if the immediate post-operation results seem perfect and the patients can proudly put up happy testimonials on various eye clinics's web sites and television commercials, regression would make it necessary to have an "enhancement" operation done later on. This seemed to be a significant factor to me, as much as the type of the laser.

• My doctor said that most American and a few German lasers leave it to an individual doctor to manually come up with the exact parameters for tissue removal, while his German scanning slit laser has coded many years of accumulated knowledge into the software itself. Thus, all he has to do is to punch in the numbers and the treatment algorithm in the software automatically takes care of the laser power, speed of rotation, etc.

• For a pupil of 6 millimetre diameter, the laser takes away 9 micrometre per diopter, but for a pupil of 8 millimetre, it is 11 micrometre per diopter. Since my myopia was about 9 diopter, the excimer laser would take away 99 micrometre of tissue, which is well within the corneal depth of 540 micrometre.

• I also learned that vacuum suction could cause a retina damage if left for more than 3 minutes, but the operation is much shorter. So I kind of agree with my doctor that the use of a suction ring fixation device is better than the eye-tracking which requires complicated extra hardware and software.

• The doctor said that the measurement of refractive power used to be set at the contact-lens level, but is now set at a 12 millimetre gap between the eye and the lens.

• The blade in the microkeratome that is used to cut the flap for LASIK must be changed for every patient. The laser must be calibrated for every patient as well.

Pre-Operation Hell

• The doctor recommended that I remove the hard contact lenses for a few weeks in order to have the eyes stabilised. In my case, the period of 3 weeks, as suggested by other doctors, was not enough. My corneal topography and refraction stabilised only after 4 weeks. Thus, for the first time in 20 years or so, I was not wearing contact lenses for 5 miserable weeks prior to the surgery.

• As I did not own any eyeglasses, the doctor kindly gave me a prescription for temporary eyeglasses. As a self-proclaimed "Cheapest Person on Earth", I salvaged 2 pairs of eyeglasses donated to the eye clinic by the patients who no longer required them. I was able to find a pair with about -6 diopter and another with about -3 diopter. I attached the 2 lenses together with a few pieces of Scotch Tape, making eyeglasses of combined power of about -9 diopter. However, the eyeglasses had no astigmatism correction, so I was seeing doubles and triples, and was feeling like a Hubble Telescope before the COSTAR (Corrective Optics Space Telescope Axial Replacement) was installed. The home-made eyeglasses were extremely heavy (more than 70 gramme) and frustrating as the Scotch Tape was falling off almost every day. However, they saved me at least $150 CAD for a new frame and lenses (plus sales taxes) which would have become useless after a few weeks. I think the pair of eyeglasses, which I consider an engineering masterpiece, should be exhibited at a museum.

• The short-term pain included fogged eyeglasses while building a toboggan hill in the front yard and a skating rink in the back yard for my 3 kids. I also noticed that my geek/nerd look with thick eyeglasses made some receptionists (who are paid to greet people) ignore me, a reaction that I had not experienced when I was wearing contact lenses. I also missed a television programme because I misread "06:16" for "05:16" on a digital clock. I also mistook a can of gravy for a can of meat balls, which ruined a supper.

  

Financing

• The clinic charges $3 800 CAD for PRK and $4 800 CAD for LASIK. I am by no means rich, but I avoided getting "Laser Eye Surgery Financing Plan", which only benefits blood-sucking banks.

• The cost of the laser eye surgery is not covered by any public or private insurance. However, it is tax deductible as a medical expense, which I can greatly benefit, given the very low salary that I make.

• I saved more than $150 CAD for not buying a temporary pair of eyeglasses. I also saved by not only making maximum use of coupons, sales, generic no-name and bulk products, but also buying expired foods and dented cans, eating Macaroni & Cheese at least 2 times a week, finishing kids's leftover food, doing haircut for my 3 kids and myself, and not eating out at restaurants or going out to movie theatres. Buying damaged and broken toys at 10 % of the regular price and fixing them (mostly the power supply) for my kids was a joy. I also begged a friend of mine to give me a pair of cross-country skiis instead of buying a new pair at $200 CAD.

Operation

• 1997-12-03 (Day 0)
  • Sign the consent form that states "LASIK is not an exact science...", and "There is no guarantee..."
  • Payment by VISA ($4 800 CAD)
  • Corneal depth measurement
  • Operation by Dr. Conrad
  • Wearing plastic eyeshields, but no bandage contact lenses

• I picked up my wife who works in downtown Ottawa (Ontario). The traffic was slow and some roads were closed because of the goddamn event called "A Global Ban on Landmines: Treaty Signing Conference and Mine Action Forum". They should hold these conferences in cyberspace on the Internet and use digital signature so that they would not disrupt other people's lives! The physical signing ceremony is only an expensive photo-opportunity.

• At the clinic, I received a sedative (Advil) after a long wait. The nurse gave me anti-biotics eyedrops, followed by a series of anesthetic eyedrops. The doctor first measured the corneal depth with an ultrasound device. They explained the operation every step of the way as it happened. I was in the operating room for about 20 minutes, but the operation itself took about 2 seconds each eye to cut the flaps, and 2 minutes each eye for about 100 pulses of excimer laser. Since I had watched a few operations on the video, I knew exactly what the doctor was doing throughout the operation. It was completely dark during the laser irradiation itself, but the pulses were loud. I felt no pain at all, just some pressure from the suction ring. After all was over, the doctor put plastic eyeshields around the eyes, gave me a souvenir coffee mug, and I was discharged almost immediately.

• Despite the clinic's claim of "almost no pain", I had a mild pain after the effect of the anesthetic wore off. I took 4 A.S.A. (aspirin) pills within 24 hours, but no eyedrops as the eyes were tightly covered by the plastic eyeshields. The fact that LASIK, unlike PRK, did not destroy my Bowman's layer only helped. The post-operation pain was much less than that of wisdom teeth removal or that of vasectomy.

• Everything looked fuzzy and foggy, and I had a lot of tears, which made it hard to keep my eyes open. I slept for 3 hours in the afternoon. I did not miss @discovery.ca and Star Trek: Voyager programmes on television in the evening on the day of the operation. I also read headlines of the newspaper through the plastic eyeshields which distorted the vision too much to read the text.

Post-Operation Heaven

• 1997-12-04 (Day +1)
  • 1st follow-up check
  • Removing plastic eyeshields
  • Start anti-biotic drops (3 times per day)
  • Refraction test

• 1997-12-04 | DIN 02216051
  • Bion Tears^TM Libricant Eye Drops

• 1997-12-04 | DIN 00778907
  • TOBRADEX (TOBRAMYCIN, DEXAMETHASONE)

• 1 day after the operation, the pain was completely gone. There was not even a little feeling of wearing contact lenses. The doctor observed that the flaps were healing very well, and the risky period of infection had already passed. The doctor said that I had just passed the driver's license test with a 20/30 vision. He said that I would not even have to worry about being in a smoky room. So, I cannot use the operation as a convenient excuse to stay home instead of visiting the in-laws :-(.

• As expected, the vision was unstable and fluctuating widely. There were halos, starbursts, night glare, light sensitivity and low contrast. The doctor explained that they were due to the swelling of the cornea, which would diminish over time. I started wearing my "Eagle Eye" sunglasses. As a precaution, I kept the plastic eyeshields at night so that I would not rub my eyes unconsciously during my sleep, which would lead to dislodging of the flaps. Because of the light diffusion, the night vision was still to be improved. I could feel that my left eye was stabilising faster than my right eye, and this asymmetric healing made me very nervous.

• The vision seemed to have been slightly over-corrected, as expected, in order to compensate for later regression towards myopia. I took the first shower after the operation. I was indeed able to drive a car 24 hours after the operation, as advertised. Even though I set aside 1 week for recovery, I was back to my daily routine 2 days later, doing grocery shopping with my kids, cooking supper, building a toboggan hill in the front yard and a skating rink in the back yard.

• 1997-12-13 (Week +1)
  • 2nd follow-up check
  • Corneal topography mapping
  • Continue anti-biotic drops (1 time per day)
  • Refraction test

• I was able to drive rather comfortably at 1-week post-operation, but reading a telephone directory was quite difficult due to blurry vision which made it unable for the eyes to focus well. I noticed that the vision was much clearer on a sunny day than on a cloudy day, and it changed widely during the day. I was very anxious because my left eye was getting better while my right eye, which used to be dominant, did not seem to be improving as much. Once in a while, the vision on my left eye deteriorated and that on my right eye improved, so they were just about equal. I was hoping that it was just my paranoia over symmetry, but I even suspected that my right eye was among the 1 % risk of irregular healing of the flap that could result in permanently reduced visual acuity, or my right eye experienced epithelial depletion during the surgery.

• I also felt pessimistic, that an "enhancement" operation would be required in order to correct residual astigmatism and/or regression. A second LASIK is inherently easier than a second PRK, but the video showed that the second operation is not as clean surgically as the first one, so the doctor would place bandage contact lenses, which are not required after the first operation.

• The first post-operation corneal topography showed that the residual astigmatism was 0 (zero). The optical zone on the map was all blue, while it was yellow with 2 red islands before the operation. The refraction test showed that the vision was 20/25 on the left eye and 20/40 on the right eye, but they still fluctuate widely. The doctor praised my realistic expectation for the short-term post-operation results.

• The doctor observed the flaps under the microscope. He found that they were healing very well without forming any wrinkles. He ordered the frequency of the eyedrops to be reduced to 1 per day. The steroid component of the eyedrops inhibits healing, so this change would accelerate the rate of healing. The doctor explained that the lack of focus on my right eye was due to the diffusion of light by some debris particles at the interface, which would be absorbed by the body over time. Now that I knew the mechanism of the condition, I was feeling much more optimistic about the prospect of improvement.

• There was still a possibility of regression, which would show up during 6 weeks post-operation.

• 1998-01-09 (Week +5)
  • 3rd follow-up check
  • Corneal topography mapping
  • Refraction test

• 1998-01-09 | DIN 02231289
  • GenTeal^TM Artificial Tears

• I drove to the clinic during a State of Emergency due to the "Ice Storm of the Century". Canada's Capital Region was a war zone with power outages and fallen tree branchs all over the place along the way.

• The doctor observed that the flaps were almost invisible under the microscope, with no sign of scar tissues. Therefore, if a retreatment were to be done, he would have to cut a new flap. I had run out of anti-biotic drops a couple of days before the visit. The doctor said they were no longer necessary, and gave me 2 bottles of artificial tears for lubrication. I also returned the eyeshields to the clinic. The corneal topography map showed further stabilisation. The refraction test revealed that my right eye was about 20/30, while my left eye was about 20/20. I was seeing 20/15 with both eyes, so the doctor said that he would prescribe plain glasses for correction! He also pointed out that there was very little chance of regression, so the "enhancement" operation would not be required.

• The reason for the poor vision on my right eye compared to the left eye was not the refractive error but the light scattering at the interface. It became very clear when the doctor took the photograph of the 2 eyes. The left pupil looked very dark, while the right pupil looked slightly white. This was the only remaining concern, and the doctor assured me that it would only get better. So, I would have to be patient. He showed me a photograph of a PRK'd eye with a haze problem. The pupil was literally covered with murky stuff beyond belief! This person was retreated to have clear pupils again, but I felt so glad to have gone for LASIK, which does not cause the haze problem. I also learned that the haze occurs due to agressive healing. Thus, the haze is not corrected with another laser treatment per se, but the controlled post-operation healing with steroid.

• The doctor was aware that Bausch & Lomb had recently purchased the eyecare business of Chiron, including the excimer laser technology. I mentioned that although the airline pilots in the U.S.A. can now have the laser eye surgery, the U.S. Air Force do not authorise the laser eye surgery. He pointed out that the U.S. Navy have lasers to treat their own jet pilots. He also raised a point that the humidity control in the operating room is very important for the broad-beam laser, but not so much for the scanning slit laser. Also, the operating room would not have to be completely sterilised because the laser emits ultraviolet light, which disinfects the most sensitive treatment zone. Stopping the laser periodically during the surgery may not be necessary for the scanning slit laser.

• I was satisfied with the results at this point. I received a tax receipt for the operation. It was very unlikely that I would regret the operation.

• There was still so-called "starburst". Interestingly, however, I discovered that real stars do not burst at all. Instead, they look quite sharp, so I could still launch a career as an astronomer even if the effect continues. The halo effect is observed around the moon and city lights. The halos do not have ring-shaped interference pattern, which were quite annoying when I was wearing hard contact lenses even though they had maximum size possible.

• I started taking "Bilberry" capsules, as recommended by a LASIK'd police officer with whom I corresponded. This natural herb is supposed to enhance night vision. The colours look brighter and I can better observe the Scotch-Tape Luminescence in the dark. However, it might be just a psychological placebo effect...
  • Sunatori's Scotch-Tape Luminescence^TM <http://WWW.HyperInfo.CA/GS.Sunatori/1997-12-13.html>

• 1998-02-13 (Week +10)
  • 4th follow-up check
  • Corneal topography mapping
  • Refraction test

• The corneal topography map showed that the flaps were reaching the final stages of stability, and the effect of over-correction built into the LASIK nomogram was diminishing. This corresponded to my observation that the halo and starburst were getting smaller than before. In a high-myopia case like mine, the surface of the cornea becomes almost concave after the surgery, so it takes longer to heal than in a low-myopia case. The vision was 20/20 on the left eye, 20/25 on the right eye, and 20/15 with both eyes. Thus, a touch-up surgery would not be necessary.

• The doctor observed under the microscope that the right flap still had a loose spot filled with gel at the middle of the cornea, causing the light to diffuse. The unhealed zone, which might have been caused by epithelial depletion or dull microkeratome blade, had shrunk from the previous visit, so I was feeling more optimistic to reach perfect vision. I suggested that a gentle push or infrared radiation might stimulate the healing, but the doctor said that he would let only time to take its course. Apparently, some doctors in Europe were experimenting with a technique to have the patients wear hard contact lenses immediately after the surgery in order to make the flap better adhere to the cornea, which might have helped my right eye. I also raised some minor concerns about protein deposit and dryness, but they are normal in the winter.

• I mentined to the doctor about the new vertical flap cutting technique, which he said has some disadvantages, especially for patients with deep eye sockets. He said that a technique to use water-jet to cut the flap, instead of an oscillating blade, was under development. Any further refinement of LASIK, including a direct connection between the corneal topography machine and the laser, might be welcome, but most of them would be minor compared to the quantum leap from PRK to LASIK. I felt happy to be a pioneer rather than waiting for another 10 years for the technique to mature. The doctor envisions a machine to take a credit card and do a LASIK operation on the spot, eventually. He would lose his job, however.

• My request to the medical insurance company for consideration resulted in a reply stating "Cosmetic Surgery is not covered by the plan (LASIK TX OD/OS/OU)".

• I went swimming for the first time after the operation. I thoroughly enjoyed the freedom. However, but my right eye, which had been making gradual progress, suddenly deteriorated. I was not sure if it was due to the chlorine in the pool or the water pressure.

• 1998-03-25 (Week +16)
  • 5th follow-up check
  • Corneal topography mapping
  • Refraction test

• 1998-04-08 | DIN 02131625
  • Livostin^TM Levocabastine Hydrochloride Ophthalmic Suspension

• 1998-04-08 | DIN 02233143
  • Patanol^TM Olopatadine Hydrochloride Ophthalmic Solution

• The vision was now almost perfect, i.e., 20/20 on each eye and 20/15 with both eyes. However, these numbers do not tell the whole story...

• There was a gradual but marked improvement in my right eye starting 12 weeks post-operation. The vision stayed okay in the morning but deteriorated in the evening. Halos at night around intense light were noticeably much smaller. The microphotograph showed that the irregular healing zone had further shrunk from the previous visit. I did not have an unreasonable expectation of an instant gratification, so I was happy that my patience eventually was paying off. I just wished that both eyes had exhibited similar healing responses, which would have considerably reduced my anxiety.

• I always had the problem of lipid or protein deposit to the contact lens. When I mentioned that the problem of oily eyes may worsen because of the allergy season, the doctor gave me samples of Topical Antihistamine and Anti-Allergy Agent.

• I mentioned that VISX was now introducing VISX SmoothScan, which is a scanning slit laser with 7 beams. The doctor said that the amortisation period of his current laser would be over when the new laser becomes available, so he would certainly consider the new laser.

• 1998-05-06 (Week +22)
  • 6th follow-up check
  • Corneal topography mapping
  • Refraction test

• By 20 weeks post-operation, the fuzziness on the right eye due to irregular flap healing was almost gone, so I started to enjoy symmetrical 20/20 vision at last. The corneal topography map showed further smoothing of the surface, although there was still a small sign of residual irregularity. The doctor confirmed under the microscope that the irregular healing zone had disappeared. I was ecstatic that my long-term attitude had finally paid off, instead of seeking instant gratification.

• In spite of achieving near-perfection and my insistence of not wasting his valuable time any longer, the doctor made yet another appointment in 3 months. This shows how much he cares about his patients!

• I still had small halos. This meant that I really have an exceptionally large pupils. However, I heard that the pupil size will shrink as one gets older, so I am optimistic. However, I intend to live past 100 and possibly much longer, as I expect Telomeres Therapy to be developed before long.

• The doctor said that Implantable Contact Lens (ICL) or Intrastromal Corneal Ring (ICR), was no good because it is a foreign object that the body tends to reject. He had some concern about the new VISX SmoothScan because of the apparent lack of tight fixation method. He prefers vacuum suction as the most secure way to fix the eyes during the surgery.

• My vision deteriorated a little bit when the allergy season hit. Despite the anti-histamine drops that the doctor had given me, I had very itchy eyes. Rubbing my eyes hard probably affected the flap adhesion. I was seeing a distinct ghost image on my right eye under intense light. The cause might be a reaction to the vapour from the paint cleaner because I did a lot of painting of the house in the spring. It was very nice not to worry about sticky fingers too much because I no longer had to clean contact lenses.

• As the free supply of artificial tears eyedrops ran out, I hit upon an idea of using the Boston^TM Conditioning Solution For Rigid Gas Permeable Contact Lenses for eye librication. My wife, who was also using Boston contact lenses, had recently stopped using the contact lenses after losing 2 expensive lenses within only months apart. So, I now had 2 bottles of eye lubricant!

• I experienced a complete lack of focus, just like the spectral blur that I used to experience after I removed hard contact lenses. I had a couple of glasses of wine at lunch, then fell asleep in the passenger seat of the car while my wife was driving. When I woke up after 1 hour or so, my eyes could not focus anywhere. Luckily, it was a temporary phenomenon which went away after good night sleep, but I would like to know the exact mechanism of this interesting but disturbing phenomenon, which may or may not related to LASIK.

• 1998-08-07 (Week +35)
  • 7th follow-up check
  • Corneal topography mapping
  • Refraction test

• 1998-08-07 | DIN 02231289
  • GenTeal^TM Artificial Tears

• The doctor explained that the temporary loss of focus after drinking was solely due to dehydration by alcohol, and it has nothing to do with LASIK or vibration from the car. He told me that while he was in a medical school, he used to wear a portable injector to avoid dehydration while partying. He gave me a bottle of eyedrops to use when drinking alcohol, and told me to drink a lot of water.

• The vision had stabilised to 20/20 on each eye and 20/15 with both eyes. I was even seeing dots at the 20/10 line, which used to look blank. The doctor observed that the irregular zone of the flap on my right eye still existed but was barely visible under the microscope, corresponding with my observation of less and less fuzziness and fluctuation during a day. I told him that he was welcome to use my experience as a case study in a paper in a medical journal if he writes one.

• When I mentioned a real case of flap dislocation, the doctor said that he now puts temporary contact lenses on every patient after the surgery to minimise those flap problems.

• The doctor said that the MediTec laser was down for a day a few weeks back, and he had to reschedule some operations. The laser was functioning, but the optics did not calibrate well, so he had the optics replaced. He could easily have done surgeries in that state, but the patients would have required "enhancement" operation later.

• 1998-12-04 (Week +52)
  • 8th follow-up check
  • Corneal topography mapping
  • Refraction test

• 1998-12-04 | DIN 80101302
  • ONE SOFLENS^TM (Polymacron) CONTACT LENS
  • PWR 0.00
  • DIA 14.5

• 1998-12-04 | DIN 02006995
  • Alcon OPTI-FREE^TM Multi-Action Solution

• 1998-12-04 | DIN 02231289
  • GenTeal^TM Artificial Tears

• Ever since my Cable TV company (Vidéotron) added the Space Channel in 1998-10, I was falling asleep almost every night in front of the television set watching endless reruns of Star Trek and X-Files. I had not been able to do that before the operation in fear of having hard contact lenses stuck to my eyes. Also, I was proud to declare on my driver's license renewal form that I require no visual aid. I was anxious to apply for the astronaut programme when the Canadian Space Agency starts the next recruitment campaign, rumoured to be 18 months away.

• On the 1-year anniversary of the operation, the doctor observed that the Hudson-Stahli line, which is an iron-oxide deposit, was back on the cornea. He said it was a good sign, whatever it is. The vision was still 20/20 on each eye and 20/15 with both eyes. The irregular zone of the flap on my right eye had completely disappeared. However, the microscope observation revealed V-shaped wrinkles on my right eye. The distortion was responsible for the sharp fuzziness, which I was able to correct by applying very slight pressure. So, I suggested that I wear a hard contact lens for a while to smooth it out. The doctor said that such a distortion occurs in 1 % of the patients, and that a soft contact lens was better. Besides, he had free samples of therapeutic soft contact lenses with plano power (0.00), which are designed to be worn for 6 months without removal. The doctor takes an European approach of a 2-year horizon, instead of North American pursuit of an instant gratification.

• The doctor stunned me by suggesting that I come back for another appointment in a few weeks. His passion for excellent patient care was noted and appreciated yet again. He showed me a photograph of so-called Sands of the Sahara (SOS), in which dust during the LASIK operation had remained in the flap! This illustrates the superiority of the vacuum suction method where there is little chance of dust falling into the flap in hermetic seal, as opposed to relying on the laser tracking by software. The doctor is now a media star, appearing in television commercials and newspaper advertisements. He said that he was wearing a heavy makeup, and that it took 2 hours to film a 30-second segment.

• The doctor started to do ultrasound measurements of cornea thickness during consultation, instead of just before the surgery. He said that there is now a machine to measure the pupil size in complete darkness by infrared. I showed the doctor a LASIK-VISION CANADA advertisement offering a Grand Opening Special of $999 CAD/both eyes for the first 1 000 customers, which he said was made possible because the manufacturer did not charge for a new laser equipment during the first 60 days. The clinic was advertising the flying spot (raster) laser (Chiron 217) as a "4th Generation laser", even though it is universally regarded as a "3rd Generation laser" in the industry. The clinic also claimed to have an "automated keratome", when few clinics use "manual keratome", if any. I also learned that LASER EYE TECH could offer $1 999 CAD/both eyes because the clinic had purchased a used second-hand VISX laser.

• I was pleasantly shocked by the crystal-clear 20/10 vision when I put on the therapeutic soft contact lens on my right eye. A few hours later, however, the vision became clouded because of the protein deposit, etc. Moreover, my vision drastically deteriorated when I forgot to remove the lens before going to bed. This temporary effect was probably caused by dehydration, so I decided to wear it only during the daytime.

• I stopped wearing the therapeutic soft contact lens after 2 1/2 weeks, as instructed by the doctor. The results are that the daytime vision improved, while the halo effect indoors got worse. My guess was that the contact lens flattened out the V-shaped wrinkle on the cornea all right, but it also flattened the outer edge of the ablation zone. This finding may be publishable in a medical journal. 2 weeks after I stopped wearing the contact lens, the very annoying halo effect disappeared, and the vision was slightly better than the state prior to wearing the contact lens. Every time the vision fluctuated, I was almost feeling the displacement of wrinkles.

• While visiting the Journal of Refractive Surgery website, I found a report in 1995 of a patient who was seriously harmed by a home-made excimer laser which created a 1- to 2-millimetre optical zone with an estimated ablation depth of 400 micrometre, creating a pit on the cornea. After undergoing simultaneous bilateral LASIK with a custom-made excimer laser, the patient was functionally blind, and was capable only of finger counting 3 months after the LASIK. It may be an ancient history, but any doctor who claims that there has been "no case of blindness because of a laser eye surgery" is lying!

• 1999-01-22 (Week +59)
  • 9th follow-up check
  • Corneal topography mapping

• I showed a pre-draft of a paper for the Journal of Refractive Surgery to describe my experience with the therapeutic soft contact lens. The flattening of the cornea on my right eye was detected by the topography map. The doctor observed that the constant cell regeneration of the cornea had restored my left eye almost to its natural state. The V-shaped wrinkle of the cornea was now I-shaped under the microscope. He addressed my concern of ageing on the healing rate, now that I hit 40, by saying that one's age has little to do with cornea because it gets oxygen and nutrients not from blood vessels but from tears. Since the refraction was nothing but perfect, he did not even bother with a refraction test.

• I gave a photocopy of an article from the IEEE Spectrum (1999-01) showing the research on Microwave Thermokeratoplasy (MTK). The doctor was familiar with another technique called Laser Thermokeratoplasy (LTK). When confronted with my finding of a case of blindness due to a home-made excimer laser, he said he would qualify the statement to be "no case of blindness because of a laser eye surgery when an approved laser was used". I proposed that the corneal topography mapping system, which now maps only 8 000 points, be made more accurate with much more points so that the wrinkles on the cornea could be detected. I also gave him a couple of articles from the latest issue of Journal of Refractive Surgery.

• I was glad to hear that Laser MedCare (LMC) was undergoing an expansion. The clinic was in a mess because of the construction, but the waiting area was to become a second operating room with a new German flying-spot laser (MediTec). I was also pleased that the clinic had finally computerised the appointment system.

• The so-called Sands of the Sahara (SOS) syndrome was a big news on the Canadian Broadcasting Corporation (CBC) television and radio when an ophthalmologist in Vancouver (British Columbia) reported that 18 % of the patients had flap complication keratitis. My guess was that methylcellulose sponge in the microkeratome may be the cause of the syndrome, as reported in the Journal of Refractive Surgery. The SOS is classified into 4 grades (Grade I, Grade II, Grade III, Grade IV), according to the severity.

• 1999-03-10 (Week +66)
  • 10th follow-up check
  • Corneal topography mapping
  • Refraction test

• 1999-03-10 | DIN 02233143
  • Patanol^TM Olopatadine Hydrochloride Ophthalmic Solution

• 1999-03-10 | DIN 02233143
  • Emadine^TM Emedastine Difumarate Ophthalmic Solution

• The doctor observed that the wrinkle on the cornea on my right eye had disappeared, confirming my observation that the vision was nearly symmetrical at 20/15 on both eyes. There was a chance that the pre-operation dominance of the right eye was about to be restored. Although the vision was now "perfect", the doctor still wanted to see me in 3 months to check the halo situation, which is supposed to improve with age. The doctor gave me a couple of eyedrops since the allergy season was coming up. The Emadine^TM is a new medication, and is supposed to be more effective.

• The print advertisement of Laser MedCare (LMC) was showing full-colour face of a young woman, resorting to sex appeal. It indicated how competitive the refractive surgery industry had become. I felt it was much better than misleading advertisements of other clinics, such as the one showing a visible red laser pointer! Laser MedCare (LMC) now offers several plans. The high-cost comprehensive plan includes all pre- and post-operative consultations, while the low-cost plan at $850 CAD/eye undercuts every other clinic in town except for Lasik Vision Canada, but the plan requires the patients to pay $100 CAD/consultation and $25 CAD/topography map, extra charges for the eyedrops, etc. Since I had had 17 consultations with total satisfaction and counting, the high price that I paid ($4 800 CAD) was well worth it.

• The price war on refractive surgery was heating up. I noticed that a newspaper advertisement of Lasik Vision Canada said "OUR EVERYDAY LOW PRICE ONLY... $999. BOTH EYES, SURGICAL FEE". However, the asterisk reveals the following small print.
  • In-house pre-operative evaluation, post-operative follow-up and lifetime enhancement commitment provided for an additional compulsory fee of $499. Total procedure fee is $749 per eye.

  Even with this extra fee, it is still the lowest price in town. Although completely legal, this remarkable advertising tactic may catch the attention of Better Business Bureau.

• I promised the doctor to find out more about the mid-infrared pulse laser, patented by Dr. William B. Telfair, among others (U.S. 5,782,822). An article in EyeWorld Week claims that the mid-infrared pulse laser developed by IR Vision, Inc. promises to replace the excimer laser. However, its advantage turned out to be in lower cost only, not in optics.

• In the hyperlinks on the Council for Refractive Surgery Quality Assurance website, I found Advanced Corneal Systems, which is said to be developing a technique called corneaplasty of using drops to soften the cornea and rigid lenses to reshape. I also found The Refractec Corneal Shaping (RCS) system developed by Refractec, Inc. to support the Radio Frequency Keratoplasty procedure (RFK), which is said to treat over/under correction of LASIK. Also, a new technique named LASEK (laser epithelial keratomileusis), is claimed to combine the advantages and eliminate the disadvantages of PRK and LASIK.

• 1999-09-02 (Week +91)
  • 11th follow-up check
  • Corneal topography mapping
  • Refraction test

• The doctor observed that there was still a very fine line on the cornea on my right eye, which explained a occasional vision irregularity. I was able to read all characters on the 20/15 line correctly with both eyes. The doctor insisted that the halo situation would improve as I age, when the pupil size becomes smaller. The oily film on the eye was a major factor for the slight fuzziness, and the doctor mentioned an eye bath to rinse the eyes and also some kind of eyedrops to shrink the pupil.

• I told the doctor about a renowned LASIK physician in California whose technician in the operating room entered wrong numbers into the computer, doubling the patient's prior astigmatism. My doctor does all data entry himself, but he also heard from a Mexican doctor, who operates a LASIK factory assembly line, that he has 4 or 5 cases a year of programming errors, i.e., entering somebody else's data into the computer!

• 2000-03-02 (Week +117)
  • 12th follow-up check
  • Corneal topography mapping

• Knowing that the refraction was plano-perfect, there was no refraction test. To my surprise, the corneal map showed continuing change in the topography, after more than 2 years post-operation. The flattened surface of the cornea was still returning to a rounder shape like lava on a volcano, resulting in diminishing irregularities which I was still experiencing on my right eye. The doctor explained contact inhibition of the cornea underneath the Bowman's layer using an analogy of bone healing where new cells regenerate and slowly but constantly replace old cells.

• By this time, I was experiencing less and less starburst at night. The doctor confirmed that the shrinking of pupil size is more or less linear with age, to about 2 millimetre in diameter at age 70. He clarified that the sympathetic effect of pupil dilation is caused by adrenaline.

• When I told the doctor that LASIK patients could not donate cornea for transplant, he begged to differ because the integrity of the cornea returns to normal after LASIK. However, he said that the recipient of a replacement lens in a cataract surgery would have to forewarn of LASIK so that a subtraction formula would be used in order to correctly calculate the corneal axial length.

• In the laser industry, the doctor noted that the companies using the per-patient royalty scheme, i.e., VISX and Summit, are falling out of favour. The VISX S2 is actually a broad-beam laser with a single beam split into 7 beams, so it is only a pseudo-scanning laser. He prefers the new MediTec flying spot (raster) laser with a spot diameter of 0.8 to 2.0 millimetre.

• 2000-05-26 | DIN 02231462
  • allegra (antihistamine, fexofenadine hydrochloride 60 mg)

• I responded to a newspaper advertisement asking for volunteers in a clinical trial of an allergy medication, mostly because it would pay me to be a guinea pig. I went to Ottawa Allergy and Asthma Research Centre in Ottawa (Ontario) and had a patch test on the skin of a forearm with 6 tree and grass pollens and 2 controls. After 15 minutes, one patch with oak tree pollen had grown slightly, but a patch with birch tree pollen had grown tremendously. The nurse told me that she had never seen such a drastic reaction to an allergen. Unfortunately, the birch tree season was over, so I was declared unfit for the clinical trial, and I lost the chance to earn up to $125 CAD :-(.

• 2000-09-07 (Week +144)
  • 13th follow-up check
  • Corneal topography mapping
  • Refraction test

• 2000-09-07 | DIN 02231289
  • GenTeal^TM Artificial Tears

• I mentioned to the doctor about my allergy test, and that my vision deteriorated slightly after I scratched my eyes the previous week when they became itchy probably because of a light allergic reaction from an untested allergen. The topography map showed continuing improvement in cornea smoothness. The refraction test showed a very slight hyperopia of somewhere between 0 and +0.25 dioptor on my right eye, which is not correctable because the highest resolution for correction is 0.25 dioptor. To counter the occassional problem of cornea surface dehydration, he gave me a bottle of artificial tears.

• The clinic was getting a Wave Front Sensing machine. The aberrometry diagnostic tool makes use of adaptive optics from astrophysics, and it analyses not only the surface curvature of the cornea but also the light reflected back from the retina through the lens at 1 000 points. The doctor said that I would be a good candidate for such a diagnosis because of the pattern of recovery, even though it may be a little too late.

• I gave him a couple of articles about the scandal at Lasik Vision Canada. The doctor mentioned an article in a British medical journal about the night vision problem after LASIK by Dr. William Jory in which he cites "Lies, Outright Lies, and Statistics".

• I also noted an article about femptosecond laser in Scientific American. The doctor said that such lasers are used to cut a flap just as the water jet system is instead of a microkeratome, but it takes too long, i.e., as much as 45 seconds.

• 2001-02-08 (Week +166)
  • Appointment cancelled

• My condition had really stabilised. I noticed that my right eye was better than the left eye on more and more days, but the slight irregularity and the oily film on my right eye to distort and cloud the vision, respectively, were also permanent.

• I had a severe case of flu on the day of the appointment, so it had to be cancelled. Besides, the doctor did not seem to have purchased the aberrometer. Instead, he probably installed a piece of equipment to properly measure the pupil size because of the well-publicised controversy about poor night vision for driving after LASIK. Competent doctors would have honestly pointed out before the operation that a large pupil would cause halos and starbursts.

• Beside this controversy, Bausch & Lomb Inc. cut jobs, and industry consolidation was taking place as Icon Laser Eye Centers Inc. and Lasik Vision Corp. were merging to better compete with TLC Laser Centre Inc. They were all losing money due to a slower economy, confusion among consumers caused by competing claims among rivals, and a lack of repeat business.

• Although I would not be seeing the doctor, with whom I had many enlightening discussions on Excimer Laser Eye Surgery, I remain one of his very happy customers. I do not regret the operation at all. It was one of the best decisions that I made in my life, and it has been a dream come true for me!

• I noticed that Laser MedCare (LMC) started to advertise Customised Laser Ablation as "The future of Laser Eye Surgery". The doctor's dream of total automation is one step closer.
  • LMC's custom treatment uses digital imaging to create a blueprint of your eye, linked to state of the art laser technology for unparalleled correction.

Post-Script

• Like beauty, perfect vision is in the eyes of the beholder (pun intended). I hereby declare, 15 months after the surgery, that the result of my Excimer Laser Eye Surgery (LASIK) is "perfect". I definitely do not have to join the "Post Refractive Surgery Support Group".

• Now that I wear no eyeglasses or contact lenses, the distortion that was giving me frequent headaches is gone. Everything looks slightly larger, and things that looked curved now look flat. The Trinitron computer screen, which looked convex with the eyeglasses now looks even concave. I am sure it will eventually look flat. I can not only use hand cream but also use paint and glue without worrying about damaging contact lenses.

• My childhood dream of living in space was destroyed by the unaided vision requirement. I am now ready to apply for the Canadian Astronaut Programme when the next round of competition is announced.

• Even though I was not quite comfortable with the association with "Cosmetic Surgery", I highly recommend Laser MedCare (LMC) in Ottawa (Ontario) CANADA with its very informed and competent staff. Now, the challenge is how to convince my wife to have the operation. As a sideline, I might also organise LASIK tours to Canada from technology-deprived U.S.A. thanks to F.D.A. bureaucracy and politics. Canada is a lot closer and safer than Columbia, you know :-).

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