Seeing LASIK's risks clearly
By WES ALLISON
© St. Petersburg Times, published October 1, 2000
Paula Cofer had worn glasses or contact lenses since grade school and was tired of the hassle.
The ads for LASIK eye surgery she heard constantly on the radio intrigued her, and she was impressed by the testimonials from happy customers she read in the newspapers.
So this spring, after her sister had the surgery, Cofer decided to take advantage of a special offer.
"This is the one that got me," Cofer, 42, of Tampa, said recently, pulling a newspaper ad from a file by her desk.
It offered a deep, deep discount rate of $499 per eye to the first 1,000 patients who visited a new LASIK center in Tampa, and promised "tens of thousands of satisfied customers worldwide." The ad quoted a nurse and a firefighter who were thrilled. And Cofer could afford the price.
But that ad, like many for refractive eye surgery, made no mention of the risks. No mention of common side effects. No mention of the potential loss of contrast sensitivity, which makes it difficult to distinguish where one object stops and another starts.
A free informational seminar she attended was equally vapid, she said. Now Cofer says she suffers from all those problems, and she's saving money for experimental surgery in Canada that she hopes will repair some damage. She is bitter. And mostly she blames herself.
"People need to do their homework," said Cofer, the branch manager of a credit union. "I didn't do my homework, I didn't educate myself. I just listened to all the hype, I just listened to all the success stories."
LASIK, by far the most common type of refractive surgery, has blossomed into a $3.3-billion industry, and ophthalmologists are hawking it with all the aplomb of used-car dealers at a holiday sale.
Repeated studies have shown that LASIK has a complication rate of less than 5 percent, and most patients are happy with the results. But with an abundance of ads featuring costumed dogs, two-for-one specials, celebrity testimonials and free seminars, even some of the surgery's biggest advocates complain style often overshadows substance, that hype can hide reality.
"It's still surgery. It's still your eyes. We're not at the level of Wal-Mart," complains Dr. Anne Sumers, a New Jersey ophthalmologist who speaks about LASIK for the American Academy of Ophthalmology.
"When Wal-Mart sells you lawn furniture, it's the same lawn furniture they're selling everybody else," said Sumers, who offers LASIK along with traditional ophthalmologic services. "You need to know who's doing your surgery. It's an operation . . . with attendant risks, benefits and alternatives."
The growth has been phenomenal, with the number of procedures doubling every year from 1996 to 1999, to nearly 1-million. Another 1.65-million are expected this year, with 2.65-million forecast for 2001.
LASIK stands for laser in-situ keratomileusis, a surgery in which a laser reshapes the cornea so light is refracted at the proper angles. It is most commonly used to correct nearsightedness. During the procedure, the doctor cuts a flap in the top of the cornea, peels it back, and zaps the tissue below it with the laser. The flap is reattached, and the eye heals quickly.
Most people suffer from some blurred or distorted vision for up to a month or so, and doctors need to redo the operation to tweak their work in 10 to 15 percent of cases, the American Academy of Ophthalmology says. This should be included in the price.
Like tummy tucks and liposuction, LASIK is elective and most insurers won't pay for it. Doctors contend they must advertise aggressively to compete with vacations, new kayaks and football tickets for your discretionary income.
It's also lucrative. Although income from each flap-and-zap varies, a busy LASIK practice can net far more cash than a general practice. Some doctors buy their own lasers, which cost between $300,000 and $500,000, but most rent them or pay to perform surgery at laser centers.
The going rate is about $2,000 to $2,500 per eye, although deals can be had for half that. Some area ophthalmologists do one procedure almost every half-hour, three or four days a week.
"I can earn more with one LASIK than I can (earn) working three days in the office," Sumers said. "There's a powerful financial incentive."
But she and others complain that in the LASIK ads in the Yellow Pages or newspapers, you'll find more "pioneers" than at a Little House on the Prairie cast party. Around Tampa Bay, at least six doctors bill themselves as the area's "most experienced" laser surgeons. One, Dr. Scott C. Behler, boasts in ads that he also is a "talented concert pianist."
Many ads flirt with false advertising, and they don't always address the risks.
The pitch "Throw away your glasses" is misleading because you still might need reading glasses. Claims of permanent vision improvement are common, but the Federal Trade Commission says they haven't been substantiated.
Ask lots of questions
One recent evening, 14 people crowded into the waiting room at Updegraff Lasik Vision in St. Petersburg to hear Dr. Stephen Updegraff discuss the procedure, who makes a good candidate and some of the troubling things that can, rarely, go wrong.
"The last thing I want is a patient who is uneducated and has unrealistic expectations. That just turns out to be a bad situation for patients and doctors alike," said Updegraff, who was one of the first ophthalmologists to practice LASIK in the United States. His marketing tools include a long list of the professional athletes and local doctors who have entrusted their eyes to him.
Physicians say patients should ask lots of questions about a doctor's training and experience before choosing one. Increasingly, consumer and doctors' organizations are offering tips to help people make informed decisions.
The Surgical Eyes Foundation, a non-profit patients' group in New York, serves as a clearinghouse of information and complaints about LASIK.
The group is now building a database of patients who suffer from complications -- most involve decreased night vision -- and is pushing for more truth in advertising and patient education. About 2,000 are on the list so far, Executive Director Ron Link said. The group's Internet address is http://www.surgicaleyes.org.
Some have stories like Brenda Holmes, whose eyes were treated in March by a Sarasota doctor she will not name who apparently over-corrected her vision. Now she has to wear glasses all the time, to read and to see at a distance. She suffered blurred vision for months.
Like Cofer, she, too, answered an ad that offered LASIK for $499, although the price jumped to $999 an eye because she had astigmatism. And because the surgery made her astigmatism worse, now she can't be fitted with contacts.
"They told me the next day, you should be at least 20/40," said Holmes, a customer service representative at an insurance agency. "Well, the next day I couldn't even drive. I had to take off at least two weeks of work, because I couldn't even read, not even with glasses.
"Letters would jump out at me, and they'd move all around when I tried to read. I had tremendous headaches. It was terrible."
Her vision stabilized after about three months, then she was able to get new glasses. She has since gone to Updegraff, who hopes to reshape the cornea to make up for the over-correction. Still, she must wait at least two more months for her eyes to fully heal from the last surgery, and her night vision is terrible.
"Now, it's so bad, I'm not even comfortable driving with my glasses," she said. "I'm only 33."
'I was a sucker'
The American Academy of Ophthalmology has taken an interest in how LASIK is marketed and is warning members to avoid misleading statements. The Florida Board of Medicine also is looking at some edgy claims, said Dr. John Glotfelty, a board member and ophthalmologist from Lakeland.
"Some of the ads do not meet the requirements. We know that," said Glotfelty, who does not offer laser eye surgery. "We're just observing now. I think that (because) of some of the ads, the people will get notices that they're not meeting the requirements."
Only ophthalmologists, not optometrists, are allowed to do the procedure, but there are no state or federal requirements for training. Some doctors learn LASIK at weekend seminars sponsored by laser manufacturers, while others attend more courses or enroll in fellowships.
And the surgery takes skill. Certain functions are pre-set on the laser, but it's crucial that the patient's eyes are measured and examined thoroughly beforehand, and that the doctor expertly cut and replace the flap. The doctor also must decide how much of the cornea to zap, and over-corrections can be difficult to fix.
"When you select a surgeon, you're selecting the surgeon for how he or she handles the problems," said Dr. Lewis R. Groden, who heads the ophthalmology residency program at the University of South Florida College of Medicine and is also the medical director of LASIK Plus in Tampa.
"Most surgeons can handle uncomplicated cases very well. Where the skill of a surgeon comes into play is when things do not go well," he said. "And there is no surgery so simple that there cannot be complications."
Lt. Nick Reale, a Pinellas Park firefighter, learned the hard way his first go-round with refractive surgery. Three years ago, he picked the lowest price he could find -- $500 an eye -- for radial keratotomy, which has since been rendered all but obsolete.
"Relatively, it was cheap. But it didn't work, so it was expensive," Reale said. "And at that point I said, "If I ever get this done again, I am going to go with someone I can trust.' "
He and his wife attended one of Updegraff's seminars on the advice of a friend, and both had him do the surgery in March. This time, he's thrilled.
"I came out with 20/15 vision, and I was about as blind as you can get," Reale said. "I had been that way since I was about 10 years old. It was an amazing procedure."
Cofer, who was treated in early June, spoke with the Times on the condition that the name of her LASIK center not be used, because she is still trying to get her medical records and does not want to aggravate things. She also doesn't blame the doctor who performed the procedure, who has agreed to provide post-operative exams if she's treated in Canada, she said.
In her case, the original surgery in June went well, but a technician apparently erred in measuring the diameter of her pupil during a pre-operative exam. She said her doctor later told her that her pupil was actually much larger, putting her at the outer limits of the acceptable size for the surgery. The laser beam just wasn't large enough to cover it.
The result is near-constant blurred vision and very poor vision indoors or at night. She wears glasses to correct a laser-induced astigmatism, and she's ordered yellow-tinted Polarized glasses, akin to shooting glasses, to help bring back some of the contrast.
At night, streetlights, taillights and headlights loom large and blur together. To drive, she turns on the map light or props a flashlight on the console so it shines into her eyes. The light causes her pupil to constrict to the size of the treated area, easing the starburst effect.
"If I'm outdoors in the sunlight, things are fine. I can see really well," she said. "But if I'm inside, under like fluorescent lights, I call it my fuzzy vision. I see everything fuzzy. All the time.
"I have actually gotten lost in my own garage since this happened to me. Couldn't find the door into my own kitchen."
Ironically, based on the standard eye-chart test, Cofer's surgery was a success: A near perfect 20/30.
But there's a difference between being able to read the 20/20 or 20/30 line on the eye chart and being able to see well. Updegraff said this is a common misconception, and patients who are lured by promises such as "20/20 in 20 minutes" need to realize that.
"The notion of 20/20 can be very deceptive," Updegraff said. "What we want to achieve is vision as close to contact lenses or glasses as possible."
Cofer said she'd give anything to have her old vision back.
"I was a sucker," she said. "I just thought, "This is like a miracle procedure. You have glasses or contacts all your life, and in 10 minutes you can walk away and see perfectly.' "
Ask Your Doctor
Choosing an eye surgeon should depend on more than a catchy slogan and a good deal. Here are some questions -- and preferred answers -- you should ask before hiring a doctor to perform LASIK on your eyes.
Q: How long have you been performing LASIK?
A: Preferably, at least three years.
Q: How many procedures have you done?
A: Preferably, at least 500.
A: The norm is about 90 percent
Q: What percentage of your patients achieve 20/20 vision?
A: The norm is about half. If the doctor claims it's more, ask why and ask for proof.
Q: How many prospective patients have you turned down?
A: The only suspicious answer is none. Not everyone is a candidate for LASIK.
Q: What is the worst outcome that one of your patients has ever had? How did you handle it?
A: Complications are rare but inevitable. Be suspicious if the surgeon claims to never have had a bad case.
Q: Can you give me a list of patients I can speak with?
As with any surgery, you should ask if your doctor has ever lost hospital privileges, been disciplined by the state Board of Medicine, or been convicted of any crimes.
You can check the disciplinary records of Florida physicians on the Internet by logging onto the state Department of Health's Practitioner/Physician Profiling system at http://www.doh.state.fl.us.
The site also lists major malpractice suits.
Plenty of information about LASIK and other forms of refractive surgery is available on the Web. Here are some sites:
American Academy of Ophthalmology, http://www.eyenet.org
Surgical Eyes Foundation, http://www.surgicaleyes.org
Council for Refractive Surgery Quality Assurance, http://www.usaeyes.org
Source: Council for Refractive Surgery Quality Assurance, state Department of Health, Times research.
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