Eye Surgery

I've begun researching the possibility of getting laser eye surgery and would like to hear from athletes and active peoples about their experiences both good and bad. Thanks.

I was researching LASIK, but after talking to my brother-in-law I don't think it's for me. He says that he is more aggravated at having to keep up with reading glasses and not being able to see close up than he was with his former lack of distance vision. Add in the fact that my eyes seem to change a little every couple of years and it all adds up to needing glasses again which kind of defeats the purpose of the surgery. He also claims that the majority of people who get LASIK for near-sightedness will need reading glasses at some point.

I had laser eye surgery at TLC in 2000 after wearing glasses for years. Best decision I ever made! Brief recovery. No problems, no regrets! Make sure to get PLENTY OF REFERENCES, and do your research before choosing a laser center to perform the surgery. Most reputable doctors will be happy to provide this information. CHOOSE THE BEST! (Don't scrimp and be a cheapskate here...) After a preliminary exam, the laser center will determine whether you are a good candidate for surgery...based on the specifics of your eyes and prescription needs. Once qualified, the actual surgical procedure itself is quite short...about 5-6 minutes per eye. (...though I wasn't prepared for the slight "burning" odor!!!.....hmm....is that my eye?!?!)

In my case, besides the obvious convenience, the main reason (annoyance) at the time was the fogging-up of my glasses when whitewater kayaking...rolling, splashing...cold water + warm air = fogged-up glasses. Plus, I was tired of paying big $$$ for prescription sunglasses. Now, 6+ years later, vision is still great, no complications, endless benefits for us "outdoor" types, and I buy sunglasses off the rack! (woo hoo!!) I say GO FOR IT!!!
Hope this helps..good luck.

Dave

i got LASIK about two months ago. so far, i couldn't be happier with it. my closeup vision is fine, and my distant vision is now 20/15. i went skiing at alta the day after the surgery.

older people will need reading glasses, but that is in place of needing bifocals or having to take off you glasses to read. pretty small drawback in my book, especially because reading glasses are less of a hassle than buying prescription sunglasses or dealing with ski goggles and glasses.

I got LASIK done about 1.5 years ago. It was the best decision I ever made. I can see 20/10 and its fantastic. One drawback for me is its a little difficult driving at night because of increased halos and my eyes dry out so I just put in some preservative free drops in the morning and at night before I goto bed. I'm good then. I can climb fine, do what I want, but like I said the only draw back for me is a little dryness in the eyes in the morning and at night. Its also brighter outside so I wear sunglasses alot. big deal.

Thanks,
Rhett Burroughs

Thanks for all the responses. I, like a few of ther posters, have reservations about this procedure. Years ago I heard that altitude affects those who've had the procedure, though I'm assuming this problem has been rectified. I have also heard that it is like "pressing the reset button" on your eyes, and that irregardless of what was done, genetics will ultimately win (i.e. you'll need glasses again.). I have had the preliminary tests, so I know I am a candidate, as well.

My other considerations are these: I have been so dependent on glasses/contacts for years now that I think separation anxiety is a real possibilty, but something that will most assuredly pass with time. Being that I am from the Northeast, I have, at my fingertips, some of the world's foremost authorities on this type of surgery just across the Canadian border, so that is a bonus.

Thanks again.

Chris

Rhett, did you have the flap cut with a blade, or the intralase? I had the intralase, and after a month and a half i have no halos and also no eye dryness. It was a bit more expensive to do it that way, but the doctor said it would cut down on those side effects and so far i am really pleased.

The altitude thing was for RFK, not LASIK. LASIK has no such issues.

My wife & I had 'em done probably 8 & 7 yrs ago at TLC. They've been great. Best not to do them for women who are gonna still have kids. Halos calm down over time. Seems best to choose someone with lots of experience. Was told <1% have problems. Biggest issue is risk for flap injury...not high percentage, but if you're unlucky....

I'm a climber; had Lasik 8.75 yrs ago; have been thrilled with the results, and have opinions based on my experience running a laser center for over 11 years. (Disclaimer: I manage Clarity Laser Vision Center [www.claritylasercenter.com] in Denver. I'd agree with the comments that say LASIK can't be compared to old style RK. Most sites that report significant problems with LASIK are dedicated to talking about problems, which are a very low percentage of the cases performed. The problems is that the vast majority of extremely happy patients don't report to a website. The procedures have evolved, generally including a larger and larger percentage of the population who can be included in the treatment parameters. It requires details that I don't have, obviously, but a good independent ophthalmologist who has access to the latest technologies can treat most patients, one way or another. If you think your activity level is somewhat extreme (including blows to the face) I would encourage you to consider PRK, which has an even safer risk profile. Otherwise, most of us can be safely treated with LASIK. Send us an e-mail if you have specific questions, since we pride ourselves on education before surgery.

Hey Chris,

This will be rather long winded -- since it was a detailed response I typed up in response to a hi-altitude mail list question (and don't think it ever was distibuted). Pick and choose what you want, but there is some useful information.

Personally, PRK was the right decision for me and do it again in a heart beat. I still have some dryness issues -- but those existed before hand and were part of the reason for choosing PRK.

And, it was well worth it to me to drive down to Denver from Boulder for the surgery and follow-ups for Dr. Levinson -- the only physician I've met to take so much genunine personal interest in his patients.

Here we go... hope this fits and some people find it useful or time saving. I initially had eye surgery July 2005.

Cheers!
Avery

• ** HI-ALT OWNER: please CC me on this at this e-mail address, so I know it went out (originally sent to another address) ***

LASIK/PRK IN A NUTSHELL

Hi George,

I did some pretty expensive research for the year prior to having PRK last July. I've researched what I deem to be all available peer-reviewed medical journals, internet, spoken with or e-mailed many ophthalmologists in the Denver area, etc.

Here is a very brief (in comparison to the research I did) summary of my findings, which I needed to put together for a friend, anyhow. Verify and validate all I say on your own -- these are just my unprofessional personal notes.

First off, there are at least two procedures you may want to consider as a high altitude climber. These are PRK and LASIK. Note PRK is nothing like RK (slits cut radially in the eye; Beck Weathers), more-so it's the precursor/sister-surgery to LASIK.

PRK is a procedure in which the following steps occur:

1. Alcohol is applied to the eye, and the epithelium (most outer layer) releases and is removed/discarded 2. The outer surface of the cornea is now exposed, and the laser removes material from the surface of the cornea 3. Mytomycin-C topical solution is applied for a handful of seconds with a sponge 4. Temporary clear contacts are put into place for the first few days, until the epithelium crosses-over again 5. Epithelium continues to heal/smooth-out for 6mos-1yr, during which time your vision will reach final-state. No enhancements (if necessary) are typically done before this stage is complete.

LASIK is a procedure in which the following steps occur:
1. Microkeratome is typically used to cut a hinged flap, at some depth in the middle of the cornea (thus the epithelium remains intact) 2. The inner surface of the cornea is now exposed, and the laser removes material from the surface of the cornea 3. Flap is hinged back into place 4. Temporary clear contacts may be used for the first few days (?) 5. You see with 'final' vision, almost immediately

Both use the same laser.

So, what's the difference?

Well, LASIK is the 'sweet and sexy' procedure. 'Flap and Zap', I've also heard it called. Apparently, the Canadians and some of the Europeans think the US a bit crazy for using it as the primary procedure. Why 'sweet and sexy'? The patient sees their near-final vision almost immediately. It's relatively painless, too. You only need a day or two off work, even if you work in front of a computer.

Why are we crazy? The biggest risks around lasik are flap complications and dry eye. In addition, because you're weakening the structure of the cornea by cutting through the center portion of it, a minimal cornea thickness is required.

Flap complications -- there are lots of potential complications here. Most disconcerting to me was the fact that there is the potential that in that in obscure situations the flap can actually be knocked loose or torn YEARS after the procedure. To me this is an indicator that the cornea will never regain its full strength.

Why increased risk of lasting dry eye? There are two nerves on each eye which sense moisture on the surface of the eye. When you cut the eye the physician may use a microkeratome that allows the hinge point to remain either a) at the top of the eye -or- b) at the inside side of the eye. The nerves that sense moisture come in from the left and right sides of the eye.
If you know anything about physiology, you know that in theory nerve cells never regenerate. You have a finite number of nerve cells at birth (like brain cells), and that's what you get; although, more recent studies demonstrate that there is the possibility for some nerve to reconnect. This is a little bit of a gray area, even to ophthalmologists. They used to believe that just the tip of these nerves needed to 'regrow', but then recognized that a typical scenario was more along the lines of 6-12 months before a LASIK patient reached their maximal eye moisture again. They believed that the nerves needed to 'regrow' completely from the spinal cord; however, as mentioned before -- you can see that this conflicts with general physiology knowledge. There are for sure some unknowns. Do know that it is possible (and more likely with LASIK than PRK) to have lasting negative moisture issues - serious or minor. But -- something to consider for those of us living in dry areas, or traveling to areas with cold dry air (i.e.
high altitude).

So, how does PRK compare?

First off, PRK *isn't* 'sweet and sexy'. Why? The first few days are moderately painful. My physician stated it pretty accurately when he said "There are going to be a couple days where you're holding your head in your hands type of pain" I also found that was extremely light sensitive, and my eyes never stopped watering excessively in the first few days. After about day two or three, I could withstand light enough with sunglasses to be able to drive down to my follow-up appointment in Denver. I think at that time, I was seeing 20/40 and 20/50. After about 4 days, I could stand to look at a monitor, and do some work (you will need off at least 3-5 days for this procedure). At about 1 week, my follow-up indicated vision about 20/25 and 20/30. My eyes were relatively back to 'normal', and I even traveled to Atlanta for business.

What other risks does PRK have?

I will just mention the primary risk -- which should be something you consider if you look at this procedure, given the group this e-mail is going out to. It is also the only 'major' risk I'm aware of that PRK has, but LASIK doesn't. Of course, LASIK has a whole list of complications around the flap that PRK has none of. The risk is called 'corneal haze'. It is essentially a coating of haze that covers the cornea. This is associated with the removal and regrowth of the epithelium. The degree of haze can vary from unnoticeable to being like looking through wax paper. That extreme, by the way is HIGHLY uncommon. For the most part, this risk has been dropped into a significantly lower category than originally, as the physician now applies a small dose of topical mitomycin-c after the procedure. The doses have been pushed lower and lower, and occurrence rate of corneal haze has been significantly reduced. In my research, I did not find any medical journals indicating toxicity of the substance. There are some unknowns about it, however -- and its history of usage is relatively recent. Occurrence of corneal haze is typically treatable by steroid drops. Another key finding was that many scientists believe that corneal haze (occurrence rate drops off strongly after the first year) is triggered predominantly by UV!

ALTITUDE - which is better?

Unfortunately, I found no studies that compare PRK against LASIK for altitude issues. In general, it appears that the physicians believe that both of these are very reasonable procedures with small risks for individuals traveling to high-altitude.

There are two LASIK articles in particular that you may want to review. The first is on Everest; the second on Aconcagua:

Dimmig JW, Tabin G.
The ascent of Mount Everest following laser in situ keratomileusis.
J Refract Surg. 2003 Jan-Feb;19(1):48-51.

(^ this is the article someone sent out the eurotimes link for
escrs.org/eurotimes/April20…)

Boes DA, Omura AK, Hennessy MJ.
Effect of high-altitude exposure on myopic laser in situ keratomileusis.
J Cataract Refract Surg. 2001 Dec;27(12):1937-41

I won't send these out to a newsgroup, as they're copyrighted. Contact me (use address below) if you are genuinely interested in the articles -- I do have copies to discuss.

I have spoken with both Dr. Tabin (above article). For those of you who do not know, Dr. Geoff Tabin was the first American to summit the seven summits by Carstenz. He has climbed several 8,000m peaks, and co-founded the Himalayan Cataract Project (www.cureblindness.org) which has cured TENS OF THOUSANDS of cases of blindness!!! What a guy. He co-authored the article listed above, but was not there -- I believe the other doctor was. I was fortunate enough to speak to him on a couple occasions, but only for a brief few minutes. is a very busy guy - teaches ophthalmology at University of Utah (note e-mail from the eurotimes article is old) and helps/travels for the Himalayan Cataract project. I believe his general take was that he believes LASIK is a good and reasonable procedure for HA climbers to consider. "Good" I'd read it as just that. Read the article for some more statistics.

I also spoke with Dr. Boes (Montana), who was a little less open to give opinions over the phone, but I think he considered it a reasonable procedure for HA climbers to consider as well. Again, read the article for some more statistics.

Another very important point to understand is that at certain levels, PRK has been certified by the US military for flight; I believe LASIK is still uncertified. There are some military journal articles as well. If you're a diver (high pressures), you may also want to do some research on that. Once again, PRK is minimally invasive with respect to corneal weakening, in comparison to LASIK.

How did mine turn out?

Reasonably well. Still time to tell, though. I'm 6 months out. I postponed my surgery from earlier in the year until July, as I had a trip up in Alaska to take care of first, and didn't want to risk triggering corneal haze with the Alaskan UV. My vision is better than I had hoped for.
I think 20/15 and 20/25. My previously dry eyes (the biggest driver for me doing PRK over LASIK) are infact dryer. PRK doesn't eliminate dry eye risk, but it is a documented less-occuring and less severe risk than LASIK. Mine will likely improve over time. Haloing/starbursts at night are better than with my contacts; about the same as with glasses (note I did have the 'custom/wavefront' version, which I would highly recommend for this and other reasons - though the use of the newer laser costs more to the physician, which is passed on to you; note generally speaking, physicians use a shared-resource laser-center). The bigger issue I'm facing now is that I have generated some level 1 corneal haze (believe me, I've been protecting against UV ALL the time with sunglasses - even when I go get my mail). My physician believes this could be due to dry-eye, so we've plugged two additional lacirmal ducts (tear drains in your eye) and I am doing some steroid drops. Time to tell. I didn't suspect corneal haze prior to my follow up appointment. For a wearer of glasses and contacts (which I could barely tolerate anymore), it's an amazing experience waking up in-focus and also throwing out all that contact lens stuff once and for all.

Also, I haven't been over 14,255' yet, but they were fine there.

A quick word on dry eyes. If you live in Colorado or another dry state, there is a good chance you have dry eyes. There are tests to establish 'how dry' your eyes actually are. Mine were basically very dry and extremely dry.
Whether or not you laser vision correction, if you have dry eyes -- ask an ophthalmologist about having your tear drainage ducts plugged. This is simply inserting a tiny-tiny plug into the hole in your eyelid (you have 1 upper, 1 lower on the inside of each eye). Alternatively, they can also use a piece of dissolvable plug - very similar to dissolvable sutures. It's not a painful procedure, and is typically covered by medical (not vision) insurance - if you have dry eyes. They get billed a few hundred bucks. It's not painful, and they can be removed in a second by an ophthalmologist, if they happen to rub your eye uncomfortably. With all 4 of mine plugged, I actually get some occasional streaming tears down my nose.

Ophthalmologists (ophthalmologists are full Medical Doctors, b.t.w)

I did a lot of calling and talking to individuals to get recommendations to those 'best in the trade'. I had to recommendations to a particular surgeon in Lakewood, who apparently is very gifted. Upon consultation, I didn't feel that he had a personal interest in me. I'm sure he's an excellent surgeon, though.

I visited Dr. Richard Levinson ( levinsoneyeclinic.com/) in Denver. At first, I questioned him about high-altitude and actually disagreed on some of his points, based on the journal articles that I had read. He offered to review the journal articles, and agreed with me. What I found of Dr.
Levinson is that he is the most caring physician I've ever had. This should speak volumes to anyone local who is interested in having an evaluation for LASIK or PRK. I've never met a physician that was willing to give him his cell phone number, his personal e-mail address, and would return phone calls almost immediately. He had more of an interest in me than any other physician I've had over recent years with multiple nerve and knee surgeries.
I might add, that it appears he has a very busy and successful practice as well. I have no connection or benefit from it, but please tell him I sent you if you decide to visit him. As a side note, 6 months before seeing me, he also did PRK on an individual, who summitted Aconcagua about seven months after his procedure. We traded e-mails, and he has had zero issues.

I recommend you find a physician who
a) is relatively seasoned
b) you feel good about/talking to
c) isn't offering the deal for a $999 special

Other notes:
- The FDA approves given lasers for different ranges of procedures; one manufactures lasers may be certified to -7.0D, while another is only certified for -6.0D. If you are on the border, you frequently won't know until they do a full wavescan if you can use one laser versus another
- The better your natural vision is, the better chance you have all been corrected to perfect
- many patients that are not candidates for LASIK may be candidate for PRK (due to corneal thickness (measured in office visit by touching a probe to the surface of the eye for a second), dry eye, etc)
- Find a physician that really knows what they're doing and actually takes an interest in you as a patient. Expect this to be in the $4000-$4500 range for doing both eyes with wavefront (highly recommended to use this newer
equipment)
- There is at least one alternative procedure that is 'bleeding edge' - I believe called corneal rings. I don't know the details of this, but you may want to investigate. I believe the rings are pressed into place, and no cutting of the eyes necessary. Supposedly, they can be removed as well. I'm not sure if this is yet FDA approved.
- LASEK also exists, kind of like PRK, but they try to put back the epithelium; think this may be loosing momentum -- but have a look
- Those seeking LASIK may consider some debatable topics: top or center hinged flap and benefits/drawbacks; whether or not a new blade will be used for each cut (some theorize that a micro film on the blade from the first eye, could cause an inexact cut on the second eye; I think most physicians do not consider this to be the case)
- Search resources:
www.pubmed.gov (this searches all major peer-reviewed medical journals).
Typically abstracts are available for free. Try your local university's library computer for access to full articles.

If you have questions, please feel free to contact me. Hope you find this helpful.

-Avery

Andrew Gram wrote:The altitude thing was for RFK, not LASIK. LASIK has no such issues .

Not completely true, Andrew. See above and the journal articles for more detail.

Avery did an extremely good job of recapping the general situation. A few updates are worth pointing out. For the last several years we can treat folks with Customvue (wavefront-guided) treatments up to -12 diopters and/or 3.5 diopters of astigmatism and up to +6.0 diopters with the same astigmatic considerations. We can treat higher amounts of astigmatism with "standard" LASIK or PRK. (Wavefront treatments can be either PRK or LASIK.) The military chooses to do PRK mainly for three main reasons: 1) Traditional advantages in Contrast Sensitivity profiles favored PRK over standard LASIK, which is huge to pilots. 2) The more robust nature of not having a flap. (Pilots are exposed to combat, after all.) 3) Quicker return to active duty.
BTW, the military is now studying wavefront LASIK for pilots due to the increased Contrast Sensitivity profiles afforded by wavefront treatments. (They're better than standard treatment, i.e. we can actually improve it). The FAA, which has studied this, has permitted LASIK or PRK for its pilots for many years now. They never allowed pilots to have RK. BTW, the military has done lots of LASIK for non-combatants.
Hope this helps.

Sorry, I think read all of what you posted, but my LASIK corrected eyes may have teared over and I missed something. Where are the issues with LASIK and high altitude? I know about the LASIK and trauma issues, but didn't see anything there about altitude.

BTW, did you ever talk to a doc about the Intralase vs the old way of cutting the flap? Apparently the Intralase makes a much cleaner cut that heals better and more evenly. So far so good with me - no halos or dryness at all. All of my dryness went away after about 4 days, though I still put in drop because my doctor tells me to.

Andrew Gram wrote:Where are the issues with LASIK and high altitude?

Junior -- see the Tabin Everest journal article for details. Some patients were fine, some had some temporarily altered vision. Oh -- and I get your joke, but PRK actually yields less dryness than LASIK.

Rob -- thanks for that info.

Intralase/Intralasik allows us to make more reliably thinner flaps than most doctors would try with mechanical microkeratomes. The advantages with respect to dry-eyes is that we don't cut into the deeper nerves, which decreases the risks of dry-eye. Additionally, smoother surfaces are better optical interfaces, which improves acuity and lowers higher-order aberrations, resulting in better statistical odds of improving vision, rather than potentially increasing HO aberrations which can impact visual outcomes. There are variables that your doctor should identify. It typically costs $350.00 to 500.00 more per eye, depending on doctor. Many doctors aren't trained or don't have access to this technology,

BTW, I suspect that HA climbers are at slightly greater risk for slightly altered vision due to dehydration, rather than atmospheric effects on the eye.

rob bauer wrote:BTW, I suspect that HA climbers are at slightly greater risk for slightly altered vision due to dehydration, rather than atmospheric effects on the eye.

Hmmm...

You're right -- dehydration causes many physiological issues. But... how come dehydration wouldn't affect visual acuity of folks who haven't had any corrective eye surgery? (I don't believe distorted vision is experienced/reported with any regularity at altitude by climbers who do not have corrected vision)

It seems some suspect the corneal-weakening + ocular pressure type thing.

Most folks with "natural" 20/20 vision might not notice if their vision fluctuates down to 20/25 or 20/30, it's plently good for the activity. ( I used to notice one line changes daily before I had surgery, but I was actually checking it everyday on the path to my office, and I was in my 20's.) Another example involves my experience with microscopists who must daily (at minimum) adjust oculars: many of them notice larger changes to their usual adjustments, especially after they skied, ran, biked, etc. and didn't stay "properly hydrated." I think most of us are more critical of our vision after surgery than we were before treatment, always wondering whether it was the surgery, aging, etc. In my opinion, it is a very small price to pay for the overall advantages. I don't want to discount the many physiologic changes that occur at altitiude. I'm not aware of any good studies that address all these complexities, and I'd be delighted to be sent to Everest to be studied. FWIW

All 6 LASIK pts were measured on a chart at 17,600'. Some had post-op UCVA vision, and some had lost one line.

PT 1: no complications until 28500, where 'milkiness' occurred until summit; disappeared at 27,000 on descent.

PT 2: No complications to summit

PT 3: 'Blurred Vision', 'Like looking through waxed paper' at 27,000 - 27,500 (high pt). Vision fully returned 36 hrs later while descending

PT 4: No complications to summit

PT 5: No complications to summit

PT 6: Mild blurring with ascent to 26,400; improved after return to BC. Did not impede climbing.

All eyes did return to pre-climb visual acuity eventually after descending to BC at 17,600.

Yes, it is interesting to see people who had 20/400 vision complain when post-operatively they have 20/30 vision and there are hundreds of thousands of persons who can't afford or don't have available the most basic cataract removal services to cure near-blindness. Very American! Just something to keep in mind...

Thanks Avery and Rob.

Interesting. Does this study report the particulars about the actual cases? (dates, pre-op, surgical, and post-op info) It would be interesting to know since much has been learned over the years to see whether those who reported abnormalities had anything in common.

Also, since you mentioned intrastromal rings; yes, they're FDA approved, but don't do much for most people (and never met the maunfacturers' dreams due to low power range, no astigmatic correction, pt intolerance, etc.) Anyhow, the rings are actually plastic semicircles that are slid into curved channels which we cut relatively deep into the stoma. They probably get used more in keratoconus cases than refractive purposes.