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© The Atlanta Journal - Constitution
Tuesday, 10/17/2000

LASIK: What you need to know before this vision surgery
HEALTHY LIVING: Your Tuesday Guide to Medicine and Health Care

Tami Mickle, 43, waited almost two years to undergo LASIK eye surgery to correct her nearsightedness. When she finally decided to go under the blade and laser, it was only after she had waded through the recent blitz of radio ads for free limousine rides and newspaper ads screaming about two-eyes-for-one specials and "bring a friend" discounts.

But Mickle, an east Cobb County ice skating teacher, didn't trust the hype. After reading up on the subject, she decided to go with Emory Vision Correction Center, the first facility in the Southeast to offer the procedure and a participant in the U.S. Food and Drug Administration's 1995 clinical trials of the surgery.

"I wanted cream-of-the-crop physicians and cream-of-the-crop equipment," Mickle said. "I wanted to pick the best to the best of my ability."

The selection process left her frustrated. Like many health consumers, before making a decision she tried to gather information from more than a dozen metro Atlanta facilities and surgeons offering LASIK, but most refused to provide meaningful information about their practices. In the end, she decided that paying more money --- $2,400 an eye --- was the best choice, in part simply because Emory answered her questions.

For an industry that touts clarity of vision as its goal, too many LASIK facilities are keeping patients in the dark, providing shaky or no information about credentials, outcomes and complication rates.

"There are no set standards in the industry," said Jenny Pomeroy, president of Prevent Blindness Georgia, a nonprofit patient advocacy organization devoted to eye health and safety. "You can't just go find a board-certified LASIK surgeon."

But how many people would undergo heart surgery based solely on cut-rate prices or a free limousine ride to the hospital? "I think most patients would be quite uncomfortable if there were ads for, say, 'free hysterectomy' or 'free tonsillectomy,' " said Dr. R. Doyle Stulting, managing director of the Emory Vision Correction Center. "And yet they don't seem to be startled at all by offers of 'free LASIK.' "

And how many patients would undergo any other serious elective procedure if their doctor rebuffed or ignored their requests to know more about his or her past performance?

"We don't see a lot of caution out there," said Ron Link, founder of Surgical Eyes Foundation, which manages an Internet site (www.surgicaleyes.com) that tracks LASIK procedures gone wrong. "And very few people seem prepared for a less-than-optimal outcome."

Many patients, of course, have had very good results from the surgery. In LASIK --- which stands for ''laser in situ keratomileusis'' --- a surgeon cuts a thin flap into the top of the cornea, folds it back, reshapes the inner tissue of the cornea with a laser and folds the flap back into place.

"I feel almost evangelistic about this," declared Mickle. "I'm in awe of the surgery."

But there can be complications. Link's Web site has registered 7,000 e-mails since May 1999 from patients seeking help after LASIK procedures went bad. National statistics indicate that up to 5 percent of patients experience such complications as blurred vision, poor night vision or halos and "ghost images" around lights. Up to 15 percent require follow-up surgery to reshape the cornea. Fewer than 1 percent, however, have vision that is poorer --- with glasses or contact lenses --- than before the surgery.

There is no meaningful oversight of the LASIK business, which has exploded to more than 1.5 million this year, according to David Harmon of Market Scope, which publishes the leading newsletter on the laser eye care industry. Although the FDA regulates the surgical equipment, it does not regulate facilities or doctors directly. The only guideline it issues is that doctors should give patients pamphlets, written by the laser manufacturers, about possible side effects and outcomes.

There is also no ''gold standard'' of training for doctors using LASIK. At a minimum, they must be ophthalmologists and be certified and trained by the manufacturers in how to use the laser and the microkeratome, the device that makes the initial slice into the cornea, according to the Lasik Institute of Boston, an academic organization that is working to set standards for training.

And although you can check for disciplinary orders against doctors through the Composite State Board of Medical Examiners, only the most egregious cases are typically caught. Dr. Jim McNatt, the board's medical director and an ophthalmologist, said he has seen only one complaint related to LASIK in the three years he has worked on the board. The complaint was closed without disciplinary action, he said.

Other areas of concern include:

Lack of peer review: When doctors perform other delicate operations, such as heart surgery, it's often in a hospital setting, with a committee of medical professionals reviewing procedure. With LASIK surgeries, as with many plastic surgery procedures, that rarely happens. And that means that doctors can practice bad medicine for a long time without being questioned or noticed by their peers.

Lack of information: In an effort to reassure patients, many facilities say they have done thousands of procedures But many offer no detailed information about complication rates or the percentage of cases that require follow-up reshaping procedures. Reshaping isn't necessarily a bad thing; it's a way for a surgeon to refine the work and give a patient's sight more precision. But if the numbers are unusually high, it could indicate a problem.

Also, it's worth noting that when asked for this information, two of six companies operating in metro Atlanta --- Laser Vision Institute and EyeSight Laser --- did not respond to telephone requests. Two companies --- LasikPlus and Clear Vision Laser Center --- responded to calls but couldn't provide data in time for publication. Only two facilities --- Emory Vision Correction Center and Woodhams Eye Clinic --- provided details about complication and reshaping rates, which were in line with national standards.

Lack of follow-up data: Offices and clinics rarely have mechanisms for checking back with patients to see how a procedure turned out. The simple fact is that, if there's no follow-up data, there's no way to determine whether a facility is doing a good job. If a facility provides information only about the number of procedures it has performed, it's like bragging about how many rounds of ammunition you've fired from a gun without saying how many times you hit the target.

Limited options: If a clinic performs only LASIK surgery, it's unlikely --- from a sheer common-sense perspective --- that its employees will discuss other, perhaps less radical, options with patients. As the saying goes, if the only tool you have is a hammer, everything starts to look like a nail.

Although higher cost doesn't necessarily translate into higher quality, it may be a factor in some cases.

Stulting, who charges about $2,500 an eye at Emory, says price does matter. "What are you paying for? You're paying for my experience --- not only with the procedure, but with the complications,'' he says. ''You're paying for the fact I sat on the FDA panel that reviewed these lasers."

He also points out that higher costs can result from an institution's using better equipment. For example, he recommends newer "scanning slit" or "flying spot" lasers over older "broad beam" lasers.

Stulting said his center was approached by a salesman selling cut-rate surgical blades. When Stulting checked the blades under a high-powered microscope, he found them nicked and uneven. He turned them down, but worries that other centers might not be so careful.

But Dr. Trevor Woodhams, whose ads offer LASIK for ''as little as $995 per eye," argues that the quality of care he offers equals those who charge more.

"We were one of the first to offer the low-price thing merely because a few corporations were trying to move in and steal our employees," he said. "We decided we needed to beat them to the punch. So it was a marketing decision --- and certainly doesn't indicate a lower standard of medical care."

But Woodhams has reservations about some competitors, noting that several LASIK operations around the nation have folded. He has inherited patient charts from two other eye clinics that went belly-up --- even though they gave patients a ''lifetime guarantee'' of care.

Woodhams also frets that many facilities don't do the pre-operative testing needed to determine whether a patient is a good candidate for surgery. "I turn away people every day because they're an unacceptable risk," Woodhams said. "But I'm not as hungry as some others."

Link, of surgicaleyes.com, agrees, saying that the e-mail he has received points to lack of pre-operative testing as the biggest problem with LASIK.

"I had my life shredded apart by this," said Link, 41, a former firefighter whose own surgery resulted in ghost imaging, halos and diminished night vision. "People need to realize that when they have this procedure done, there is no Plan B."

Our consumer health columnist
Call Diane Lore at 404-526-7590.
Write: P.O. Box 4689,
Atlanta, GA 30302
e-mail: dlore@ajc.com

Reprinted with permission from The Atlanta Journal and The Atlanta Constitution. Further reproduction, retransmission or distribution of these materials without prior written consent of The Atlanta Journal and The Atlanta Constitution, and any copyright holder identified in the material's copyright notice, is prohibited.

* The practice changed its name to InView in 2004. Emory trained surgeons Keith Thompson, MD and George Waring, MD, founded the practice in 1994.