Trying to decide between 2 LASIK doctors (Laser versus Blade?)

Both are highly skilled surgeons in San Francisco (and quite expensive
I might add, but I'm willing to pay for the skill). One is my
opthamalogist who I've been seeing for a few years. Great reputation
in general, very good LASIK guy.

#2 I went to just for a second opinion, but now I'm kind of sold on
her I think. Outstanding medical credentials, and her practice is 90%
focused solely on refractive surgery and cornea surgery. Here's the
thing. #2 uses the new IntraLase, which is a laser to cut the flap.
She is the only doc in San Francisco who has the equipment and
knowledge to use IntraLase as it is so new. She's only been using the
IntraLase instead of the blade for 3-4 months (LASIK and other
procedures for years). When she started using the Intralase, she only
used it on about a third of her patients. Now she uses it on almost
all of her patients because she feels it offers much more precision
and good results over blade.

Whats the general consensus out there about IntraLase laser versus
blade for the initial flap step of LASIK?

(p.s. I'm only interested in knowledgeable opinions from folks who
aren't of the "lasik is evil" stripe. I won't even read those kinds of
posts, and I've been lurking long enough to get a sense of who posts
like that and I ingore those posters.)

Thank you!!!!

Art

 

On paper, the intralase sounds wonderful. It's debatable if it is
more of a marketing tool than a better device.
If a surgeon has an intralase laser, they might as well use it. That
saves them $50/blade for the microkeratome.

 

Art,
I think it's too soon to tell which way is better. Intralase lasik is
a relatively new technique. I think which ever flap you choose,
surgeon skill is of profound importance.


SErebel

 

Thanks Ragnar. Interestingly I found this posting of yours which makes
me a little nervous. My doc who is the first and only to use INtralase
in San Francisco (also she has a great rep and corneal
issues/refractive surgery is her entire practice) says that she finds
the benefits of IntraLase to be better than the blade (better, more
comfortable, quicker healing, less complications).

Whats a guy to do?

From: Ragnar Suomi ()
Subject: Intralase
View: Complete Thread (2 articles)
Original Format
Newsgroups: alt.lasik-eyes
Date: 2003-05-26 10:48:06 PST


This is slightly off topic, but the intralase method takes much longer
to do, is more irritating to the eyes, takes longer to heal, results
in some haze, and costs more than using a microkeratome.

Someone needs to tell me what the benefit of an intralase flap is.

 

Get more advice from a more reliable source.
Ask to speak to some of your doc's patients who've had intralase.
Get a second opinion from another lasik surgeon.

I wouldn't base a decision on advice from Ragnar. His "lasik book" (ie.
what he knows about lasik) was written before intralase was invented.
He has no medical or experiential credentials to give anyone advice on
intralase.

Good luck. Let us know what you decide.

 

I posted that about a year ago, when Intralase was brand new. At the
time, it was completely valid. Although it's a good idea to take
advantage of improved technology, I wouldn't dare be the guinea pig
that tried out a NEW technology like Intralase until it's efficacy was
well established.

 

Well, mercy. I must say that I find myself in the Ragnar camp on this one.
One very prominent surgeon around here referred to Intralase flaps as
Velcro flaps, which speaks - I think - to the sometimes inconsistent
interface created by the femtosecond laser and the minute craters it
causes. The cleavage plane is undoubtedly very precisely and repeatably
located in three dimensional space, and this creates some definite
advantages. I have heard that it can take longer for visual recovery with
this technique, possibly as a result of the stromal absorption of gaseous
products. There's just not enough published yet in the literature.

DrG

 

Hello Art. I hope I can be of assistance.

Like nearly all new technology, there are advantages and
disadvantages. What one must do is determine if the advantages
outweigh the disadvantages. It is my opinion that the advantages of
the Intralase femtosecond laser for creation of the LASIK flap
(IntraLASIK) outweigh the disadvantages, but you must come to your own
conclusion.

The primary advantage of IntraLASIK is accuracy of flap depth and
safety. The primary disadvantage of IntraLASIK is short-term swelling
and a higher probability of a longer healing time before good visual
acuity (weeks instead of days). IntraLASIK is also usually more
expensive.

IntraLASIK is accurate within about 10 microns. A mechanical
microkeratome is usually accurate within 30-50 microns, but there are
case studies of mechanical microkeratomes being off by 150 microns and
more. This is important because at least 250 microns of cornea must
remain untouched to provide stability after surgery, and the average
cornea is around 500 microns thick. Unless you have 150 microns to
spare, there is a slightly higher element of risk with a mechanical
microkeratome. I want to be quick to add that these large variables
are very, very rare, but do occur.

It is virtually impossible to create a buttonhole flap with
IntraLASIK. That is when the microkeratome pass is too shallow and
the blade breaks through the surface in the middle of the flap.
Buttonhole flaps are normally not very problematic. The doctor
repositions the flap, waits about three months, then does the
procedure again. Of course, nobody wants a buttonhole flap, no matter
how well they heal.

If for any reason the IntraLASIK flap is aborted during the process,
such as suction loss, it can be continued later at exactly the same
depth without causing vision problems. If a mechanical microkeratome
aborts during flap creation, there is a risk of ridge formation and a
second flap would need to be created at a different depth. It is
nearly impossible to complete later an aborted LASIK flap made with a
mechanical microkeratome.

The IntraLASIK flap is an even thickness throughout. Think of it like
a man-hole cover with edges that go straight up. A flap created with
a mechanical microkeratome is meniscus shaped with thin edges, thick
mid-periphery, and a slightly thinner center. It is believed, but not
really proven, that the uniform flap provides uniform internal
stresses and therefor is less likely to create the tiny crinkles in
the flap called micro-striaie. With all microkeratomes, micro-striae
is quite rare, but can occur and is difficult to resolve through means
other than healing.

Intralase causes a series of "explosions" along a predetermined plane
within the cornea. These explosions create tiny pockets of gas. With
enough explosions close enough together, a flap is created. Because
the flap is created by a series of bubbles, the IntraLASIK flap is not
quite as smooth as a flap made with a mechanical blade. A smoother
flap is a better flap.

It is surmised that these explosions cause slight swelling that takes
several days to a few weeks to settle down. During this time, the
patient will have less than clear vision. Also, it is surmised that
the relative roughness of the IntraLASIK flap provides less clear
vision during the healing time. What I have seen is that after the
normal healing process this problem resolves completely in virtually
all patients.

Practical experience is important for any doctor who implements a new
technology. Some technologies and techniques require much more
surgical skill than others. Some have a faster learning curve than
others. In our 50 Tough Questions For Your Doctor, we recommend that
a doctor have performed at least 100 of the procedures proposed for
you. That may be a bit restrictive for IntraLASIK, but in a few
months, 100 is probably easily accomplished by a higher volume
surgeon.

So to summarize, IntraLASIK seems to be more accurate and somewhat
safer long-term, but you will put up with less than optimum vision
quality for a few weeks to a few months while the cornea heals.

And your wallet will be a bit lighter with IntraLASIK.

Best of luck with your decision.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAeyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

 

Art,

Excellent post SErebel.

The flap is not really the issue I would be concentrating on. I would
be looking at the experience, results of other patients and
pretesting. Are they both corneal specialists, or general
ophthalmologists that do RS?

One question you may want to ask: What can you do if it goes wrong? Go
through Glenn's 50 tough questions (maybe not all, but select some
good ones).

Do you choose a GP because he has a shiny hew digital stethoscope, or
because he cares for your wellbeing. In the end, you should be going
for the one you feel is going to do the best job.

grant