Originally printed in the Tampa Tribune (9/24/00)
Consumers should see the risks as well as the benefits of this phenomenally popular way to improve vision.
For years, wearing contact lenses limited Brian Anderson's ability to water ski and scuba dive because the ocean's salt burned his eyes and disrupted his vision.
So last year, the 30-year-old former Palm Harbor resident decided to have Lasik corrective eye surgery, a treatment on course to become the most popular elective procedure in the nation's history.
Like millions of others, Anderson was drawn by Lasik's promise to reduce his reliance on contacts and glasses, which he has worn since age 12. Without aids, he can't see his hand's details in front of his face.
Anderson, who has a master's degree in business administration from the Wharton School of Business, researched the surgery for six months.
In December, he selected a Canadian Lasik center because it charged $1,000 for both eyes compared to the $4,800 cost at many U.S. centers at the time.
Anderson lay down, a laser homed in on his cornea, and ... zap ... the procedure was over quickly. He was sent home with goggles and eye drops.
"They pumped me in and out in five minutes,'' said Anderson, now a salesman at a technology firm in Baltimore. "It was an assembly line.''
It's common for Lasik patients to have blurry vision and see halos and star bursts at night for several days after the procedure. But Anderson's problems lasted several weeks.
A Tampa ophthalmologist discovered Anderson's cornea had been wrinkled, a problem Anderson attributed to the Canadian center's inadequate preoperative and follow-up care.
Without another corrective procedure, Anderson was told, he would suffer long-term damage, a condition one patient advocacy group estimates will affect at least 15,000 Americans this year, about 1 percent of all Lasik patients.
Anderson paid another $400 to repair his cornea and is now among the millions of Americans enjoying the fruits of successful Lasik surgery.
But his story is a cautionary tale about a wonder technology that many ophthalmologists say will yield more errors because of inexperienced doctors and insufficient training and oversight.
It also raises pointed questions for millions of Americans considering the surgery: What do you really know about Lasik? What should you know? How can you improve your chances for a successful outcome?
LASIK, short for laser in-situ keratomileusis, was approved in the United States in 1996. It has been available overseas since 1989, making early debuts in Greece, Brazil and Colombia.
The surgery is designed to make those with nearsightedness, farsightedness and astigmatism less dependent on glasses or contacts. The process improves vision by using a laser to vaporize cells to reshape the cornea so light hits the retina at a favorable angle.
Famous people including golfer Tiger Woods, supermodel Cindy Crawford and baseball great Wade Boggs have undergone Lasik knowing the surgery is safe and effective in the vast majority of cases. Odds are you, or someone you know, has had the procedure.
This year, Americans are expected to spend $2.8 billion on 1.5 million Lasik procedures, according to Market Scope, a research firm in St. Louis. By 2004, the market is expected to peak at $3.8 billion for 3 million procedures.
Last year, the volume of 950,000 domestic Lasik procedures easily surpassed other established elective surgeries such as liposuction (599,000 cases), breast implants (255,000 cases) and face lifts (224,000 cases). Such popularity has drawn the attention of ophthalmologists, optometrists and retail chains who have engaged in an advertising and price war for Lasik customers.
Turn on the radio. Open the newspaper. Look at billboards. In every major city, doctors donning white lab coats are trying to lure customers with ads promising ""perfect'' or ""20/20'' vision and procedures for ""$499 per eye.''
LASIK'S POPULARITY has soared for a symphony of reasons.
For doctors, Lasik gives them the chance to collect from $500 to $2,500 per eye without having to tangle with health insurers bent on lowering costs. As an elective surgery, consumers pay the tab.
For patients, Lasik provides a painless and convenient way to improve sight in 10- to 15-minute sessions. No blood or visible scarring. In some cases, patients can return to work the next day.
The problem is there aren't "enough educational programs to meet demand,'' he said. "That's why the industry is on the verge of more problems.''
To conduct Lasik, the government requires a person to be a medical doctor, though not necessarily an ophthalmologist, an eye specialist. There are no laws prohibiting, say, a gynecologist or pediatrician from performing Lasik.
Still, experts presume all 4,000 doctors performing Lasik in America are ophthalmologists.
In some parts of the country, optometrists are lobbying for the right to perform the surgery. Optometrists are not medical doctors. They specialize in measuring a patient's vision to prescribe corrective lenses, a service common in optical shops selling glasses or contacts.
To perform Lasik surgery, doctors need only attend a weekend course sponsored by laser manufacturers. At these two-day seminars, doctors are shown how to operate the machinery and practice by zapping pig eyeballs.
A doctor cannot be licensed in Lasik because such a standard doesn't exist. It's possible to attend a weekend seminar and perform Lasik on Monday.
Such Minimal standards worry Peter Shriver, an ophthalmologist who runs the Florida Eye Laser Center in Tampa's West Shore area.
"What can you learn practicing on four pig eyes?" he asked. "Not much. We're dealing with people's eyes, not used cars. More training should be required.''
Shriver, like Updegraff, believes doctors should have additional training in refractive surgery before they're allowed to perform Lasik. Refractive training focuses on the cornea.
Independent ophthalmologists have raised an even hotter issue that threatens to split the Lasik industry into two camps.
Many independent ophthalmologists say patients get safer and better treatment from them because low-price centers rely on volume and skimp on service. Retail chains include ICON Laser Eye Centers, Lasik Vision Corp., and TLC Laser Eye Centers.
Independent ophthalmologists say they're deeply involved in patient care from the outset, taking a hands-on approach to preoperative testing and learning about a person's health and lifestyle so treatment is individualized.
Companies offering low prices, they say, let optometrists and other nondoctors conduct crucial eye exams and preoperative care to save money and free center physicians to pump the number of Lasik procedures.
Ophthalmologists argue optometrists don't have the depth of training they have with medical problems or eye surgery, making the odds higher that optometrists will miss factors that could lead to complications.
In addition, because low-price centers focus exclusively on Lasik, ophthalmologists say, staff is less inclined to dissuade borderline candidates from having surgery.
"When staff members are getting bonuses based on the number of people who have Lasik done, everyone is going to talk it up,'' said Ahad Mahootchi, an ophthalmologist at the Florida Eye Center, which has offices in north Tampa and Zephyrhills.
"At our offices, we offer a range of eye services,'' Mahootchi said. ""We don't have to rely only on Lasik.''
David Harmon, president of Market Scope, said there's no statistical evidence to prove independent centers are safer and more effective than big chains.
"It's understandable that little guys are throwing rocks at the big guys,'' he said. "It's a natural reaction. Their claims are good, but there's no study to prove it.''
In 1996 clinical trials, CRS Clinical Research and Statistics in Scottsdale, Ariz., concluded that the quality of outcomes at big centers matched those at smaller ones charging higher prices.
But the study looked only at the results of 35 ophthalmologists who conducted fewer than 3,000 Lasik procedures. In comparison, pharmaceutical companies usually draw conclusions about a drug's safety and efficacy after testing it on tens of thousands of people.
Cristina Cambria, 48, of Clearwater, is a patient who said she had problems after undergoing Lasik at an independent center.
In October 1998, she underwent surgery at a center in West Tampa. She selected the doctor on the recommendation of friends and spent $5,000 to have both eyes corrected.
The surgery was finished in 15 minutes, and Cambria was sent home with drops and thick goggles to protect her eyes.
"Am I going to be able to see?'' she recalled asking before leaving the doctor's office at 9 a.m. She said she was assured everything was OK. A friend drove her home.
That afternoon, Cambria said, she realized her double vision and blurriness remained. By 5 p.m., she was back at the doctor.
"I can't see,'' she recalled telling him. "Nothing's changed.''
She said she was told her vision would improve daily and the results would be most noticeable after three weeks.
Three months passed. Cambria said her sight didn't improve and she couldn't get the doctor to give her another, corrective treatment.
She was left alternating between two pairs of glasses ... one for distance, another for near vision, Cambria said. She has dry eyes that make it impossible to wear contacts, she said.
At work, Cambria, a flight attendant for a major airline, was suspended for two weeks after flipping a safety switch to the wrong position. She blamed her blurry vision. The error sent a 75-person yellow inflatable raft flying onto a runway in Rome.
Now, nearly two years later, Cambria said she still has dry eyes and blurry vision.
"I was stupid,'' she said of her experience. "I didn't do my homework.''
LASIK centers are under enormous economic pressure because of high fixed costs. That means they need a steady flow of patients to ensure profitability, an increasingly difficult task as new entrants crowd the market.
Annual advertising campaigns can surpass $1 million. Lasik machines cost from $200,000 to $500,000 each. Good ophthalmologists can charge a center $2,000 a day for their services. The mix of argon and fluoride gas needed to operate each machine can cost as much as $80,000 annually. Reputable service contracts cost about $55,000 a year per unit. Technicians annually earn from $25,000 to $40,000 or more. Rent adds tens of thousands of dollars in additional expenses per year.
If Lasik centers are saddled with similar operating costs, several questions emerge: How do those charging $500 an eye earn a profit while rivals charge as much as $2,500? If the low-priced centers aren't making money, how do they stay in business?
Many Lasik centers ""are losing money like crazy,'' said Harmon. ""They offer $500-an-eye deals as introductory offers in hopes of saturating a market.
"They're betting they'll make up for initial losses with volume'' and put small players out of business, he said. "Then they'll raise prices.''
Competition has cut prices. In the first quarter of 1999, Lasik centers charged an average of $2,180 per eye, according to Market Scope. By the end of this year, prices are projected to fall to $1,600 per eye.
The Lasik industry doesn't have national standards or a code of ethics to guide patient care. This has led to a lax attitude and patchwork approach to surgery that has opened the industry to errors, according to The Surgical Eyes Foundation, a patient advocacy organization in New York City.
Lasik "outcomes are less predictable because there are no industry standards,'' said executive director Ron Link. "Manufacturers make recommendations not everyone is following.
"How do you know your doctor is following recommendations? How does the government know? With Lasik, anything goes. It's the wild, wild West.''
In May, a San Francisco center notified 2,700 Lasik patients there was a very slight chance they could have been infected with diseases, including hepatitis B and C and the AIDS virus, because of procedural flaws.
For more than two years, LaserVue Eye Center said, its doctors reused disposable microkeratome blades needed to cut flaps in patient's corneas. The blades were cleaned with water solution, but should have been disposed of after each patient. The blades, which cost from $40 to $65 each, were sterilized after every fourth patient, according to a California health department investigation.
In response to what it said are increasing errors, The Surgical Eyes Foundation set up the Web site www.surgicaleyes.com in May 1999 to document complaints. It has logged 4,000 patient complaints from the United States, Canada and England.
The foundation estimates 1 percent to 3 percent of Lasik patients are afflicted with long-term problems such as blurriness and impaired night vision that can prevent some from driving. In rare cases, patients can suffer dry eyes.
Assuming a 1 percent complication rate, the foundation projects 15,000 Americans this year will be afflicted with long-term problems because of Lasik.
"The number of patients with bad outcomes is not acceptable for a procedure that's not medically necessary,'' Link said. "There needs to be better screening of potential patients. Perhaps financial motivation influences some doctors to be less careful.''
Screening is important because even among good candidates for Lasik, there can be different ways to handle the surgery.
A thorough consultation can yield whether a patient prefers to see better up close or at a distance. Especially for those 40 and older, corneas can be ""overcorrected'' or ""undercorrected'' depending on whether they are nearsighted or farsighted.
The tradeoff is that close or distance vision won't be honed to the highest level. For instance, a hairdresser may put a premium on seeing details up close while a police officer might emphasize accurate distance vision.
In another scenario, a doctor could undercorrect one eye, maximizing near vision, and correct the other to full capacity, accentuating distance. The tradeoff is that the patient will lose some depth perception.
People younger than 40 usually retain enough elasticity in the eyes' lenses to see up close naturally. For this group, Lasik focuses almost exclusively on enhancing distance vision.
Linda Roach, a technician who has worked for ophthalmologists more than 25 years, remembers a day last year when she worked with a doctor who seemed ill-prepared.
Roach, who had worked previously with Shriver and now works for him again at the Florida Eye Laser Center, declined to identify the other doctor. He had rented time at a different area Lasik center that provided the equipment and personnel to conduct surgery, she said.
The doctor seemed confused, Roach said. He peppered Roach with questions an experienced doctor wouldn't have asked. He would grab a tool one moment, put it down, grab another, then change it. He didn't know what tool was appropriate for a given moment, she said. His lack of confidence hung heavily in the room.
At one point, the doctor looked at Roach and asked in a soft voice, ""What would Dr. Shriver do now?''
Roach said she put her hand on top of the doctor's and steered it. ""He would do this, take that,'' she advised.
The patient was oblivious to the talk only one foot away because the words were muffled by surgical masks and overpowered by the humming laser.
On a different day, with yet another doctor, Roach threatened to turn off a laser because the doctor wasn't following the rules.
"A lot of Lasik doctors,'' Roach said, "don't know what they're doing.''
Rafael Gerena-Morales covers health care business and can be reached at (813) 259-7624 or firstname.lastname@example.org
Lasik Ad Watch
As competition heats up, doctors are spending more to get you into their offices. The blitz of ads can be confusing for consumers. Some doctors tout ""20-20'' vision, for example, while others highlight their experience and a few play up their ties to professional athletes or celebrities. Here are common claims, what they mean and what really matters.
Claim: "Perfect'' vision.
Reality: No medical technology, including Lasik, yields perfect results. Results vary by person.
Claim: "20-20'' vision.
Reality: While Lasik can give most patients 20-20 vision, a percentage never achieve the result. More important, 20-20 vision is not an accurate measurement of up-close, long-distance or night vision. As a result, 20-20 shouldn't be a goal for everyone.
Claim: "More than a decade of experience in vision correction procedures.''
Reality: While this may be true, it's misleading if it gives the impression the doctor has worked that long with Lasik. Lasik was approved in the United States in 1996. That means no one can have more than four years of experience in this country.
Claim: $499 (or similar cost) per eye.
Reality: Look for the asterisk by the price, which may apply only for certain patients. Whatever price you are quoted, make sure it includes preoperative and follow-up care as well as the surgery. Ask if there are exceptions to the quoted price.