Sierra Tower Bldg.
El Paso, TX 79902
The Whole Magilla
Your Step by Step Laser Refractive Surgery
Thank you for choosing our office to perform your laser refractive surgery. I am certain you will have a number of questions, some quite technical and others more human in nature. I would like, therefore, in a step-by-step explanation, to walk you through the usual laser refractive surgery experience. This explanation, I hope, will prove to be both informative and reassuring.
First and foremost, I want you to have confidence in me, your surgeon, as well as in the equipment I use and in the dedicated people who will be helping me. I work in concert with TLC Vision, Inc.(Sightpath Medical) This company, which owns more VISX lasers than anyone in the United States. The operation of the VISX Star 4 Laser; has upgraded the five times since 1995 for us. A new laser may cost as much as $500,000, its yearly upkeep as much as $180,000.00 Such costs are prohibitive for most ophthalmic practices, even for those who belong to a group. Consequently, when improved lasers become available, TLC Vision, Inc., can better absorb the expense of all the technological advances. It can also underwrite the expense of laser operators and other equipment necessary to provide you with the utmost safety for your surgery.
The upshot, thus, is whenever I use the VISX laser, trained engineer/technicians are responsible for any adjustments or maintenance needed: they attend to the laser beam itself and its homogeneity, to the mirror system, which conveys the beam to the eyes and they oversee the computer which controls the machine. In the surgery I always work in conjunction with these engineer/technicians. Their presence frees me to concentrate on your particular surgery. They are qualified individuals who have spent many hours training with VISX, TLC Vision, Inc., and various microkeratome and laser manufacturers. They are certified by Refractive Surgical Services, a subsidiary of TLC Vision, Inc. For example, some are skilled in the handling of the microkeratome, the instrument that creates the flap, a thin layer of the cornea, for the LASIK procedure. Those who work with the lasers have had wide experience with refractive surgery cases in this country, with as many as 2,000 to 4,000 cases as a rule. Your surgery, obviously, is watched over by expert and concerned individuals. The instrumentation is their work. Your all-important surgery is mine. I do, however, encourage you to investigate other programs, in El Paso largely because I am certain ours is among the best.
Our lastes upgrade was in 2008 which included Wavefront Technology (Customvue ™ aberometer) measuring equipment and the upgraded VISX STAR 4 laser with its personalized custom treatment profile based on wavefront technology. The use of this complex instrument to make your procedure more precise than ever has been used at Schuster Eye Center since June of 2003. It measures all the distortions in the visual system to give a personalized fingerprint of your eye's corrective needs. In some circumstances, your treatment may be programmed to exactly correct even the slightest distortions, so that vision afterwards, when treatment is based on wavefront, can provide vision better than 20/20. In other words instead of just correcting nearsightedness, farsightedness, or astigmatism, which is based on the curve of your cornea, it will also correct the small distortions that everyone has within the eye itself to further enhance the visual result. We proudly offer this evaluation to every patient considering laser refractive surgery to better plan your procedure allowing the best results possible. Indeed, studies showed that 48% of the time, using the VISX STAR 4 and wavefront guided correction (ablation) patients will see 20/15, which is a line on the eye chart better than 20/20. This specialized treatment also greatly reduces the possibility of nighttime glare difficulties.
Even more exciting is our use of the Femtosecond Laser System (IntraLase FS Laser) developed by Intralase Corporation now apart of Abbot Medical Optics, for flap creation. Traditional flap preparation with a mechanical keratome as discussed above is made by creating pressure within the eye and using a razor type blade to prepare or cut the flap. This is extremely safe, but complications can occur. The keratome and / or blade may very rarely produce a less than perfect, torn or distorted flap. This can lead to postponement of the operation, and a recovery time of 3-6 months before the procedure can be safely repeated. Even more rarely this can lead to permanent visual distortions. But , with the Intralase, the flap is produced with much greater security. The intralase laser doesn't cut the cornea per say, but gently separates the lamellae of the cornea at exactly the right depth with precise laser spots to produce a more personalized non-meniscus flap than a traditional bladed keratome can. Indeed in over 100,000 Lasik procedures in the US , there have been no flap complications using our new Femtosecond Intralase Laser.
So, at Schuster Eye Center, with the combination of the upgraded VISX STAR 4 laser to produce the most perfect correction possible, plus wavefront guided treatment to create a true fingerprint of the eye and now more precise and safer flap production with the intralase laser, we offer a trilogy of safety, available only in very few selected locations in the US today.
I think we have accomplished with our newest upgrades the very best laser refractive surgery possible.
It just doesn't get better.
Let me now continue with the step-by-step account of the surgical procedure—or celebration—you have chosen. A date for the actual operation will be set. Then, in agreement with your schedule, a pre-operative appointment will be made to perform a series of measurements or tests, which will help determine exactly how your laser refractive surgery will be conducted. Your medical eye examination with me, which should already have been performed, will have ruled out evidence of any eye disease and cleared you for other tests. Ordinarily, these tests require about one hour and further establish your fitness for surgery. Since a number of these tests are similar to the actual surgery, they constitute a sort of “dry run” that will enable you to undergo the operation with greater ease. These tests may be scheduled either the day of your initial surgical evaluation or at a later date closer to your surgery, primarily depending on your schedule. If you have been wearing contact lenses or had your eyes dilated, all accurate testing will be difficult. For this reason, you should have removed your contact lenses—much depends on the type you have worn—three days to three weeks before the procedure. The shape and curve of your cornea, which can be altered (warped) by contact lenses, should be in their most normal state for pre-operative measurements.
Now for an explanation of the testing procedures you will undergo. First, you will recline in an examining chair for pachymetry measurements (thickness measurements) of your cornea. Depending on the corneal thickness measurements one can best determine whether the flap portion of the operation is to be made with the intralase laser or the mechanical keratome . Sometimes if the cornea is normal, but too thin, s urface ablation or PRK, (doing the treatment on the surface with the superficial skin layer removed), is safer than Lasik. Small wires will be positioned to hold your eyelids apart to prevent blinking. Since your eye will be numbed before this test, you will feel no discomfort aside from the pressure of the wires. The measurements are taken with a small, cone-shaped instrument about the size of a pencil. This instrument will be brought forward to touch various locations on your cornea while you are looking straight ahead. It then takes ultrasound measurements of the exact corneal thickness to an accuracy of ± ten microns. This test, which requires you to hold your eyes steady for less than two minutes, is similar to what you will experience in surgery, except in surgery you will be looking at a small blinking red light. The laser treatment, happily, takes even less time.
For the next measurement, called corneal topography , you will be placed in a comfortable chair and asked to look into a cone-like structure that presents a series of lighted rings. A photograph will then be taken. This photograph will be analyzed by a computer to present a color-coded map of your entire corneal surface. This is like a relief map in color, which shows any abnormal hills or valleys on your corneal surface. If there are any irregularities evident on the cornea, these can be noted and may again change the surgical plan. No wires are used in this entirely painless test. At Schuster Eye Center a second more specific topographc measurement always taken. The instrument is called the ORBSCAN. This measures not only the curve of the front of the cornea. It Also to measures the back surface of the cornea, the distance between, the depth of the eye from the cornea to the lens, the corneal width etc. All this helps predict the best flap diameter specific for each patient.
With your glasses in place, you will then be measured form the front surface of the eye to where your glasses sit. These measurements are factored into the formula for correction since the degrees of nearsightedness, farsightedness, and astigmatism that have been determined before surgery are measured with lenses placed at this location; and are not measured from the corneal surface itself. This procedure aids in the accuracy of your operation.
Next, you will undergo a five-minute measurement of your tear production (successful laser refractive surgery requires an adequate tear flow to promote healing). In this test, after your eyes have been numbed, a small strip of filter paper will be placed against the lower lid of each eye. You will then be asked to blink in a normal fashion and to look ahead for approximately five minutes. To qualify for surgery, a candidate should have a tear flow of over 6-10mm for the five-minute duration. This test, also, is painless.
Your pupil size in dim and bright light will now be measured. This test will predict whether or not you will experience nighttime starbursts and halos after the operation. Ideally, your pupil should be less than 6.5mm in diameter, in dim light, to prevent post-operative night vision problems. Although every patient will see halos at night at first, this problem generally clears up in one or two months. New software and refinements in the VISX STAR 4 laser treatment patterns plus wavefront treatment and intralase flap creation now often allows patients with larger pupils in dim light to be safely treated.
Either before or sometime after other tests the “ wavefront refraction ” (measurement of the intraocular defects, is taken. This most important measurement will feel very similar to the corneal topography. You will be looking into an eyepiece booth and seeing a tunnel-like area as the measurement is taken. As explained above, this test measures all the imperfections in the eye rather than just the topography of the cornea. With this information, distortion can be eliminated by etching onto the cornea, with the excimer laser, VISX STAR 4, a mirror image pattern of the defects, thus eliminating them. Wavefront ablation is not necessary in all cases, but has the potential when used properly to produce better night vision and sometimes vision better than 20/20 during the daytime.
Videotapes and CD's of the laser refractive surgery you will be undergoing will be shown to better help you understand the advantages, disadvantages, risks and expected gain from your surgery. They should add to your understanding and increase your confidence in the procedure. They require about twenty minutes to view. You may also, if this means of communication is possible for you, visit our web site at www.schustereyecenter.com . Another very helpful site is www.lasikinstitute.org , where even more detailed information can be obtained. Our site also provides links to more authoritative technical information on the internet for those who are interested.
By now I trust you are sufficiently well informed about the surgical procedure you will be undergoing. I hope, too, you are at ease with the idea of surgically correcting your vision. I think, though, you will find it helpful, even emotionally reinforcing, to speak with individuals who have already experienced the operation. You may, if you wish, speak with our refractive coordinator who will be happy to arrange such visits for you with previous patients. Many patients feel this is even more reassuring than a consultation with me, with the office personnel, with the surgical coordinator, or through educational materials presented in handouts or on videotapes. In addition, several of the individuals in our office have undergone radial keratotomy and laser refractive surgery as well. You can speak with them candidly about any concerns you have. I believe patients who have had surgery are among our truest celebrators.
After we have completed your measurements, the surgical coordinator will schedule an approximate time for your surgery as well as a time to report to our center,
Schuster Eye Center Sierra Tower Building 1700 Curie, Suite 2400
where the surgery will be performed. To be certain of success with decreased risk, we will often repeat some tests previously done as a double check. We will leave “no stone unturned” to prevent complications !
Once you are in our surgical center, you will be taken to an area near the laser room, where you will be given an oral sedative to relax you and make you feel comfortable for the operation. This sedative, which has the side effect of creating a mild drowsiness, will later help you to sleep for three or four hours after you go home. It will minimize any discomfort you may feel early on in the post-operative period. At this time, too, of course, you will recognize people form our office that will help you every step of the way. Soon, after numbing drops have been placed in your eyes, you will be taken to the laser room, which is a small room with a rather cozy atmosphere, one that suggests a friendly room of people rather than an operating room. Here you will recline in the laser chair, which will comfortably support your back and neck. You should be wearing loose and comfortable and warm clothing. The lasers all function best at 60°-70°, which often feels cold without warm clothing.
Important! On the night before surgery, certain special precautions are necessary. You should spend at least five to ten minutes to remove all makeup with a non-irritating shampoo (dilute baby shampoo works well). You should scrub your lashes and lids thoroughly. Your lashes and lids, depending on their appearance, may also require and antibiotic ointment at this time. Since oily debris can work its way under the flap after LASIK surgery, these safeguards are extremely important. Remember that fumes and oily debris from hairspray, perfume, and makeup—mascara, eyeliner, eye shadow—can either distort the laser beam or hinder the post operative healing process.
Now for the procedure itself. As we position your head slightly lower than your feet, you may have the feeling you are slightly tipping over. Nevertheless, this slight lowering of your head should not be unpleasant. Next, your head will be placed in a special pillow that will firm up to surround you. You will feel a light firmness, which should add to your comfort and sense of security. You will now be rotated into position beneath or near to the laser. For the first time you will see the blinking red lights and trios of ring lights as well. They are not painful to view. You will be asked to stare at various lights at certain times as the treatment is carried out. At no time during the surgery will your eyes be draped or your mouth or nose covered. You should not experience any claustrophobic sensations. During this phase of the surgery, a small piece of tape is used to hold your eyelashes out of the way. Small smooth rods will be used to separate the lids gently. Additional numbing drops will be administered but you will not feel anything other than the gentlest firmness.
Next, in order to create a perfect flap for LASIK, the pressure in your eye must be elevated so that as the keratome passes across your cornea or the femtosecond laser prepares the flap, your vision will fade out. How is this accomplished? A small smooth suction ring will be placed gently between your lids and suction applied to the white part of the eye. As this occurs, you will hear a vacuum-like whirring sound and also a small beeping noise if the conventional keratome is used. These sounds tell me that the suction is adequate and the pressure properly elevated. Now your vision will gray out momentarily. It is rather like a pilot pulling G's in an airplane. But after the keratome and suction are released, your vision will quickly return and you will see the blinking lights again. If the Intralase femtosecond laser is used to prepare the flap when suction is applied, it is not elevated as high as with the keratome so your vision will fade, but usually not go to complete darkness. To prepare the flap with the Intralase femtosecond laser , there is no feeling or sound associated with its production. Once the keratome or intralase flap is complete and suction released you will be rotated underneath the VISX STAR 4 laser for the remainder of the surgery. The production of the flap by either keratome or intralase takes about 45 seconds per eye.
Whether the flap is prepared with a keratome or the interalase, once under the VISX laser, the remainder of the surgery is identical.
The flap will now be carefully lifted and turned back. This will blur your view of the blinking red light, but you will still be able to concentrate on it. It will look like a fuzzy blinking red sun. The VISX STAR 4 laser will now be activated as you stare into the light and the cornea will be reshape (the sound of the laser firing resembles that of a coin being tapped on a metal table). Immediately after this procedure, the flap will be repositioned and you will see much more clearly again. The time for laser reshaping, you should know, takes between 10 to 60 seconds (the degree of correction needed determines the time). Remember the VISX STAR 4 laser has an eye tracker so if you look away it will still automatically follow. The latest upgrade assures the treatment will be perfectly centered no matter where you look . If you move, blink, or squeeze the laser shuts off automatically.
A wait of two or three minutes now begins. Marvelous things are happening. Chemical cascades and enzymatic reactions are taking place, which, with the help of surface tension hold the flap back down firmly. At the same time, an amazing set of cells on the underside of the cornea begin to work like a vacuum-pump sucking fluid from the flap and the area where the cornea was treated which further tightens the flap into position.
All this helps the flap to stay fixed and in place. Soon you will be able to blink forcefully, but you will have only the rewarding experience of seeing more clearly. Although all patients worry about this, it is almost impossible for the flap to come loose at this point. Also, there is very little you can do that will cause a poor result if you follow your postoperative instructions
If you have chosen, your other eye will now be treated in the same fashion. If not, then your surgery is complete. The chair will then be rotated outward from the lasers and raised to let you sit up. You should at this moment, be able to recognize relations or friends in the hallway, to read the clock on the wall, to see signs on the door, and view the city from windows in the laser suite. Initially, of course, your vision will not be perfect. But when you do get home you should be able to see around the room and recognize relatively large objects. You should be able to perform the usual tasks of daily living. You will not be able to read or perform other delicate visual tasks for the first four to twelve hours. Just after surgery, remember, your eyes will be red and your lids swollen. The most frequent experience, as the anesthesia wears off, is a sandy feeling in the eyes (as from an eye scratch or dirty contact lens.)
Before you do go home, however, you will be asked to wait in the holding area for five to twenty minutes. A second evaluation of the flap is then carried out. Occasionally, mucous will get underneath the flap as it is laid back in place. Sometimes, too, other debris can accumulate under the flap. So, careful evaluation is also carried out at this point to be certain no foreign material is present in the interface. Occasionally, this does happen. If it does, it is easy to return to the laser room to re-irrigate and reposition the flap. In the majority of cases, however, the flap will be well seated and free of debris. You will then be ready to go home.
You will be given careful instructions, verbal as well as written, to guide you through the next twelve to twenty-four hours. A clear shield will be placed over your eyes for protection. You will be issued eye drops both before discharge and afterwards to prevent infection, to reduce inflammation, and to allay any discomfort. Once home, the sedation and tranquilization you were given before surgery will help you to fall asleep. As you go home, you can look around or you may prefer to keep your eyes gently closed. They will be sensitive to light but dark glasses you will be given will reduce this problem. When you are actually at home, I would suggest you spend the next few hours in bed with your eyes closed. Although pain medicine will be available, Tylenol and aspirin should be sufficient for ordinary discomfort. As I indicated above— and this is worth repeating—you may go about the tasks of daily living. For example, you can wash your face, but its best not take a shower the night after the operation. You may walk around, watch TV, and carry on other activities on a limited basis.
AGAIN, THERE IS VERY LITTLE YOU CAN DO AT THIS POINT THAT WILL HARM THE RESULTS OF THE OPERATION.
As healing goes on, the most striking and disconcerting feature of the operation for most patients will be the difference between the two eyes when the are operated on together. Always, always, always , the eyes behave differently. Surgery can be performed identically on both eyes, but they never behave in the same way. One eye is always a bit redder. One eye is always slightly more irritated. Certainly, at first, one eye always sees better than the other does. This may vary from hour to hour and day to day in the early going. Small hemorrhages, an effect of the suction ring used at surgery, may show up on the white part of one eye but not on the other. Please understand this is all very normal and does not suggest that one eye experienced a complication. You will, certainly, compare one eye with the other. This action is human and natural. Please, however, do not be frightened if there are minor variations between the two.
In most cases the celebration of better vision begins twelve to twenty-four hours after surgery. By this time, the endothelial pump (the little cells lining the inner corneal surface) has sealed the flap into place even better, and the outer layer or epithelium (the cells making up the ‘skin' layer of the cornea) has firmed up. The next morning one usually arises to a clear view of the world. Joy can be overwhelming at this point!
A dose of reality is now necessary. Keep in mind that you have not seen well without correction for many, many years. Suddenly, your naked vision is better than ever. At this supreme moment, most patients experience a joy and happiness beyond belief. It is a celebration! It is truly glorious that you can now see clearly. You will, for example, be able to go to the supermarket and see cans on the shelves; you will recognize what is written above the aisles; you will be able to see your neighbor at the far end of the store. All this without correction! It is stimulating and exciting. But very critical activities, such as reading fine print in dim light or driving at night, may not be as good as they were with your glasses or contact lenses at first. This may hold for the first few weeks. The desired end result of laser refractive surgery is when you can tell me that everything is clearer than it was before your operation. That is, when, you had your best possible correction (glasses or contacts) in place. Such is our goal, one that is achievable ordinarily within two or three weeks after your surgery. Generally, the weaker the vision before the surgery, the longer it takes to reach our goal.
During the first few weeks following surgery, you will continue to use eyedrops to reduce inflammation and prevent infection. Remember that healing is two steps forward and one step back; your vision will not always be the same from moment to moment or day to day. One thing, however, is certain: you will notice progress form week to week. In every sense of the word.
This step-by-step account represents what usually happens. But do not be frightened if you do not experience exactly what I have described. Since nature allows for us all to be different, each of us heals at a different rate. Some of us always heal faster and see better sooner than others. Also, regrettably, not everyone achieves perfect results. From time to time, glasses or contacts will be necessary on a part-time basis— after surgery .
One positive result we hope you will realize from allowing me to perform your procedure, will be a close, intimate, and concerned personal relationship. This will be especially true after your surgery. There are laser centers around the world where patients are treated without meeting the doctor who will perform their operation until they are in surgery. They will never see their surgeons again after their operation. Any interaction between the patient and their surgeon has been pretty well removed. I have encountered many disenchanted patients who have suffered through this scenario. You and I, on the other hand, will become partners in realizing your total rehabilitation. Our goal is for you to be 100% satisfied. A part of this relationship will include my monitoring any concerns you may have during the healing period. I will see you as often as necessary to make sure all is progressing, as it should. Still, you may, if you so choose, go elsewhere—particularly to other countries—and pay less. But as in most endeavors, “You get what you pay for.”
As I have mentioned before, not every patient achieves perfect results. For this reason, our charge for surgery includes a complete package (a fixed agreement). There is no additional charge for you pre-operative measurements or time involved in your post-operative care.
Whether you have nearsightedness, farsightedness, astigmatism or a combination of the above because treatment times only vary from ten seconds to 1 minute, I feel it is unfair to charge higher fees for patients with need for more correction. The preoperative, operative, and postoperative care is equal whether, for instance, you have one unit of nearsightedness or ten. Charges based on degree of correction I feel are an unlawful “bail & switch” technique, I feel this technique is used by less than ethical centers to attract and then increase charges for unsuspecting patients. Be aware of this tactic when you see advertisements offering “Custom Lasik for $299". It never costs this little. It is a very unfair to bring in patients and switch them to higher fees. It is certainly never true custom treatment with a wavefront, so be careful of what terminology really means. Lastly, if a center suggests that you can truly have Lasik for a very low fee, ask to speak with patients they have performed surgery on for said price. Beware: there never are any!
As you see, I hope, we will maintain a close and intimate relationship until we both are completely satisfied. Since I frequently work with other ophthalmologists, if you live out of town and find it difficult to get back for your post-operative follow-up, I will whenever possible arrange for you to be monitored by a well-qualified doctor. In this circumstance, the three of us will work diligently together to make your pre and post-operative experiences satisfying. If a local or out-of-town ophthalmologist or optometrist refers you to me initially, I will expect them to see and monitor you as well. Such practice has been traditional in medicine and represents the best in successful patient care. We will also arrange these follow-up visits for you at no additional charge.
Thank you once again for choosing our practice for your surgery. We will not let you down.