Laser Eye Surgery For Sailors: A Personal View

Created by doina. Last modified on 2006-09-25 10:11:19
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Topic: Medical

Having now reached the age where I have to look for glasses anytime I want to read a chart or look at a small part number on some piece of equipment I sympathize even more with the poor blokes who have to wear their glasses above decks in a gale. To be able to see in the distance without glasses is a great asset for sailors, even if we must wear them to read. For that reason I relate my experience with laser eye surgery.

First off, I have not had the surgery for the reason many sailors should not. 1) It does not help with age related poor focusing close up. 2) I have only a very small amount of myopia (nearsightedness) and mild astigmatism. This combination only makes the distance a little blurry but gives me the ability to read up close a bit better than if I had no prescription. A good trade off as far as I am concerned. My wife chose not to have it done either. She is nearsighted enough to be able to read for long periods without her glasses and prefers that to having to wear bifocals all the time, another reason not to get laser correction. There are medical reasons not to have it done, principally keratoconus, which can result in terrible vision and even the need for a corneal transplant so a thorough evaluation by a qualified doctor is critical. There are any number of websites to educate yourself on the details of laser surgery and I will not do that here.

I am now retired and only practice optometry as a volunteer with medical brigades to underdeveloped countries. I have no current connection to any of the doctors I mention. However, over the past 15 or more years I have provided post surgery management of hundreds of patients including many friends, several office staff and my brother. I live in a smaller community with no laser surgeon closer than an hours drive and the surgeons sought out our office as a convenience for their patients to have post surgical checks without the long drive. Having my own private optometry office gave me the opportunity to see the work of a number of different surgeons. Because I became known in the community patients sought me out for a second opinion when problems arose even though I was not their regular eye doctor. I speak from the experience of dealing with patients weeks and months after their surgeries.

First off, Laser surgery, particularly LASIK is a modern marvel. With a properly selected patient and a skilled surgeon who has all the necessary data, the results were nothing short of amazing. I had patients who were incapacitated without their glasses who were better than 20/20 without any glasses 2 weeks after surgery. For those doubting doctors reading this, my brother had 5.25 diopters of astigmatism in each eye. He now has RE 0.00 20/15 LE 0.00-0.75 x 090 20/15 and 20/20 without the correction. No night glare, halos or other visual disturbance. He sees as good as I was ever able to get him to see with glasses or contacts. He was so ecstatic that for 2 years after he commented how great his vision was every time we got together. There is risk with any surgery but as I explained to my patients the risk in laser surgery was about the level of walking out in the street and getting hit by a truck, which was low enough for me to recommend it. I have only seen one very poor outcome where the best vision the woman could get was 20/40 with any glasses and it was absolutely the result of a poor job by the surgeon on someone who, in my opinion, should not have had it done in the first place. The eye journals bear out that bad outcomes were the result of poor work or poor patient selection on the part of the doctor. Having now said how great laser surgery is, I will, as I did many of my patients, convince some of you not to have it done.

I have learned the attention and skill of the surgeon is critical to a good result. In spite of representation to the contrary, laser surgery, particularly LASIK is a precision operation. The quality of the flap cuts by different surgeons was obvious when viewed under a microscope. The microtomes used to cut the flaps were very expensive and my impression was sometimes a surgeon would use one that was not the best available. For a time there was talk that surgeons were using the blades too many times and rough cuts were the result with slowed healing and less than the best possible outcome. Even with all things the same I felt some surgeons were consistently better than others at flap cuts. Low cost laser centers often have doctors doing the surgery that are learning on you. Not a good thing. If you want to find out who is good ask an optometrist who has an independent practice as they get to deal with the failures.

Another important factor is, what prescription the surgeon dials into the laser is the one you get. If it is wrong you will still be a bit blurry. It was too frequently obvious the surgeon did not accurately determine the prescription and dialled one into the laser that was off, sometimes only a bit, but enough the patient was not able to have sharp distance vision without glasses. A quick check just before surgery is not adequate to get the best possible vision. The surgeons I preferred wanted to know what the persons prescription was several years before, a year before, 2 weeks before surgery, what it was before drops to dilate the eye and after the eye was dilated, all of which we did in our office and sent to them ahead of time. And then they checked one last time before surgery and did a corneal topography (evaluation of the shape of the cornea) and microscopic exam of the eye. They wanted us to confirm the patient had not been wearing contacts for a period of time before the surgery and if there were any changes after the patient quit wearing contacts. They wanted from us a full eye evaluation including checks for corneal disease, glaucoma, cataracts or retinal disease. My experience was the laser centers advertising cheap prices did not take the time to do the in depth review that was needed to be accurate and rule out patients it was not appropriate for.

Lastly, it is important to get good follow-up after the surgery, especially in the 2 weeks immediately after. Fortunately complications are not common but they do occur. Almost every complication can be dealt with with no vision loss if addressed quickly. I recall a lecture by a surgeon who had a woman scrape the edge of a cardboard box across her eye a few days after surgery and fold back the flap. Even then the surgeon was able to smooth the corneal back into shape without any loss of vision after it healed. When my patients were to have surgery I gave my personal cell number and firmly instructed them to call me day or night if they had pain or decreased vision. I had emergency contacts for the surgeons I agreed to work with and have gotten them out of the shower to address questions when I needed advice. If you do not have an assured emergency contact method 24 hours a day, 7 days a week for the 2 weeks after surgery occur don’t use that surgeon. The hospital emergency room is no answer as they will not recognize some of the subtle signs of impending vision loss and will send you home without the correct treatment. Plan at least 2 months before setting sail away from medical care if you have the surgery.

I saw enough bad results over the years that in the US where malpractice suits are much more common than other countries I declined to do follow up for some surgeons who did not get consistently good results. I had the good fortune to never have been sued during my career. None of these patients who were poor outcomes were blind, just their vision should have been better. Of the two most common types, PRK (photorefractive keratometry) and LASIK I generally prefer the result of LASIK. I saw a number of patients who got PRK, especially in the early years, who had mild hazing in their corneas, sometimes symptomatic and sometimes not. This hazing often did not occur until 2 or 3 months after the surgery. There are very appropriate cases for PRK though usually only for milder prescriptions. I am always asked names so I will give a few I am comfortable with. I am certain there are many other excellent surgeons out there, I just never had a chance to see their work. None of the doctors I liked were cheap sometimes they were triple the cheapest advertised prices I saw in larger cities but they were definitely worth the extra cost. In Vancouver Canada I saw many patients from Dr. David Lin. His flap cuts were consistently excellent. Also in Vancouver, Dr. Simon Holland has a very good reputation. In Seattle USA I often recommended Dr. William Hancock. I was able to be present at one of his surgeries and he is a skilled and precise surgeon. Also in Seattle, Dr. Audrey Talley and Robert Ford.

Laser surgery has some risk and cost but the life changing testimony of my patients after laser surgery convinced me it was worth the risk and cost for many people.

Fair winds and following seas.

Ken Henderson, SV Panta Rei