Choosing a Clinic

1) TECHNOLOGY

Many centers position themselves on the basis of technology. This is an important area; however most technology is now converging and using similar methods. There are numerous claims about being the best and latest. All this requires scientific verification and this can be derived from the literature or independent sites such as that of the Food and Drug Administration in the USA. Data from manufacturers are submitted for evaluation by the FDA panel of expert scientists and ophthalmologists and are in the public domain. Information from the medical literature can be obtained through Medline searches. Note that authors of the papers may well have a bias as they will be presenting data from their own technology. There usually is no independent or comparative basis which will be left to you.

2) WAVEFRONT & CUSTOM ABLATIONS

This technology holds great promise, and has been available since late 1999 / early 2000 at Moorfield’s Eye Hospital and at East Grinstead (Centre for Sight). Other commercial centres are acquiring this technology and using this to position themselves ahead of others. While there is some basis for these claims one must bear in mind this, the technology is not suitable for all patients. Wavefront treatments aim to regularize the optical system individually and remove aberrations in the subject with the aim of improving visual quality (elimination of pre-existing glare and halos) and acuity (more lines on the chart). There is much to still understand in the area and many respected surgeons are using this technology judiciously, treating patients who have visually significant aberrations rather than all who walk through the door. The danger is patients may be led to believe they are receiving Wavefront treatments (and paying for it) but in actual fact are not. The best way to know for certain is to ask for a copy of the Wavefront map and the print out from the laser. As a patient you have a right to request this. Most centres are only too happy to provide copies of these multicoloured images to the patient.

3) THE SURGEON

More than technology this is probably the most important factor. Having good technology is all very well; however the person operating must be competent, experienced and well versed with the technology in question. How do you as a consumer know how good your surgeon is in these areas? This is where you the consumer need to do your homework.

Questions to ask:

a) Is the surgeon truly a “Consultant” surgeon?

This is a title used by many doctors, which infers they are the type seen in the NHS. Find out if your surgeon has in the past or currently works in the NHS as a consultant. That is not to say only consultants are good at performing Lasik. There are some consultants who are not well experienced in this area and there are others who are not consultants who are able to do a fine job.

b) Where did they train?

Find out where they obtained their ophthalmic training as well as subspecialty training (see c) below).

c) What experience do they have in the Cornea?

Lasik is after all a procedure involving the cornea. The surgeon needs to understand how the cornea behaves and who better than an individual who has had specialist training in the Cornea and well versed with medical and surgical diseases of the cornea. Some surgeons have had fellowship training, which is where they are immersed in their choice of specialty for a year or more. If something were to go wrong, you would want some reassurance that your surgeon would be able to handle this so that in the long term you would not know the difference.

d) What is their experience in the area of LASIK?

e) Are they academic? Do they perform research? Do they present their data at international meetings?

f) Do they Audit their outcomes?

If so what are their complication rates and what are their outcomes like. This is how you will know what your likely outcome will be.

g) What is their enhancement rate (touch-up) rate?

4) THE EVALUATION PROCESS

Ideally the operating surgeon should be the one to fully evaluate you prior to your operation. They should counsel you, provide you with a consent form that you can take home and read for at least 24 hours before surgery. Practically in many centers the evaluation process is conducted by optometrists or ophthalmologists as part of the team. The process should include the following:

1). Vision Testing

2). Refraction – testing the eyes to know the correction required

3). Corneal Topography – ideally using a 3-D system that evaluates the back surface as well. The only system available that does this presently is the Orbscan (Bausch & Lomb). This is to ensure the condition “posterior keratoconus” does not exist.

4). Pupil size estimation in dim/dark light

5). Corneal thickness evaluation (Pachymetry)

6). Slit Lamp Evaluation

7). Intraocular pressure

8).A dilated fundus examination to evaluate your retinas and optic nerves at the back of your eyes.

You may not see your surgeon until the day of surgery, but make sure that the surgeon plans to examine you before the procedure. There are conditions in the eye that can be picked up by a trained ophthalmologist that may have been missed.

5) SURGERY

The Lasik procedure is a team effort. It is difficult to determine whether good practice is being observed, however there is no harm in asking questions related to health and safety. Although common practice is to use the flap cutting device (Keratome) and a single blade on both eyes, there is a theoretical risk of infection to both eyes. Do not be alarmed, infection is uncommon, however would be devastating if it involved both eyes! Blades do not perform well after initial use and flaps have been reported to be thinner. This raises the risk of flap complications. Epithelial in-growth is also reportedly more common in the second eye. Some centers in the interests of health and safety and advocate treating each eye as a new surgical case using a freshly sterilized Keratome and a new blade per eye.

6) POSTOPERATIVE CARE

You should be seen postoperatively soon after the procedure, certainly within the first few days. Check to ensure there is a 24-hour help available in case of an emergency. Some centers suggest you go to the nearest casualty for care outside hours. This is unacceptable as often casualty officers are very junior staff and have no knowledge of the Lasik procedure and the things that may go wrong. Certainly the 4 operating surgeon / centre should take the responsibility to look after you should this be necessary.

7) RETREATMENTS / ENHANCEMENTS

This is a “touch-up” procedure to correct regression or a less than ideal initial outcome. Ideally these should be performed when refraction is stable. This is best performed at 3 months. The rate of enhancements varies from centre to centre ranging from as low as 2% to 18%. For short-sighted treatments rates up to 7% are common – anything more than this suggests, a problem with preoperative evaluation, technology or surgical technique. Farsighted treatments are less predictable and re-treatment rates can be as high as 18%. Ideally they should be less than 10%. Bear in mind, a re-treatment is another invasive procedure and has its own set of potential complications.

Some centers charge for re-treatments. Determine the re-treatment rate of that centre before embarking on surgery and find out if there is a charge.

10) PRICING

Several posts on this website enquire why there is such a difference between centers. There is clearly a spectrum of care available and generally you “get what you pay for”. Overall good surgeons will command a higher price as will centers that practice beyond accepted standard of care.

a. Consultation

Many centers do not charge for consultation and usually they utilize optometrists to perform the preoperative evaluation. Centers that do charge a consultation fee typically have ophthalmic surgeons, (often the operating surgeon) perform the evaluation. Remember this is a surgical procedure and it is important that one develops a relationship with the doctor. Many patients find out if they are suitable for Lasik at centers where consultations are free. If judged not to be suitable then they may save themselves a consultation fee. Note however the 5 parameters for treatment at many commercial centers are quite narrow (-8.00 to +2.50D), to minimize the risk of problems. This is not a bad approach as the centers are working within their limitations. However the centers in question may well be turning away candidates who could have successful surgery at a centre with a highly knowledgeable and experienced surgeon.

Best advice is to seek the centre and surgeon that suits you best and develop a relationship with them. Going from centre to centre can lead to confusion.

b. Surgery

Beware of attractive introductory prices that draw the punter in e.g. “From £899 per eye” as it is very rare that anyone actually pays this price for surgery. This would be the price for a very low level of correction and for any higher level there would be added fees. You could land up paying even more for surgery than at some of the best centers! Fortunately most centers use one “Global Fee” that covers surgery, no matter what level of refraction is involved as well as re-treatments where needed. Determine what is covered at each centre.

Wavefront evaluations and treatments are longer and more laborious thus more expensive. Again if a centre professes to perform this type of treatment, ask them for a copy of the Wavefront printout. (It would be useful to determine if there was indeed an improvement in the aberrations following surgery!).

It is necessary that you do your homework well and make your choice of centre based on parameters you feel are important and match these to what you can afford.

Remember this is not a reversible procedure and it can be unforgiving!!!

Disclaimer:

THE CONTENT OF THIS DOCUMENT HAS BEEN RESEARCHED BY QUALIFIED EXPERTS FROM WITHIN THE REFRACTIVE EYE FRATERNITY. IT IS REPRODUCED FOR INFORMATION PURPOSES ONLY AND IS IN NO WAY INTENDED TO BE A SUBSTITUTE FOR A CONSULTATION WITH A FULLY QUALIFIED PROFESSIONAL. WE ENCOURAGE VISITORS TO THIS SITE TO BE CAREFUL WHEN USING ANY OF THE INFORMATION CONTAINED HEREIN, AND INDEED INFORMATION ON OTHER RELATED SITES. IF YOU ARE UNSURE ABOUT YOUR SUITABILITY FOR TREATMENT CONSULT A QUALIFIED OPTOMETRIST OR OPHTHALMIC SURGEON. ALTHOUGH WE CAREFULLY REVIEW THE CONTENT OF OUR SITE WE CANNOT GUARANTEE NOR TAKE RESPONSIBILITY FOR THE ADVICE AND ACCURACY OF DOCUMENTS WE PUBLISH, NOR CAN WE ASSUME ANY LIABILITY FOR THE CONTENT OF WEB SITES LINKED TO OUR SITE - ‘ZEUS’

For more information on Laser Eye Surgery in the UK please visit our parent site at http://www.lasik-eyes.co.uk