Chat transcript: Franette Armstrong on choosing an eye surgeon

(CNN) -- The following is an edited transcript of a chat with Franette Armstrong, author of "Beyond Glasses." Armstrong joined us on Wednesday August 25, 1999, from California to discuss how to pick eye doctors and procedures.

Chat Host: Welcome to the second of our weeklong series of health chats on eyesight, procedures and the future.

Chat Moderator: Welcome, Franette Armstrong!

Franette Armstrong: Thank you. It's great being here!

Chat Moderator: What should people consider before undergoing eye surgery?

Franette Armstrong: The most important thing is the risk of the procedure for their particular vision problem.

Chat Moderator: What is the best approach for choosing the surgery that is right for each person?

Franette Armstrong: First you have to know what your vision is and what the various procedures are capable of treating. Next, you need to know the risk/reward profile for the procedures. For example, if your nearsightedness is very severe, you won't be able to use the implantable corneal ring (also called Intac), so there's no point in worrying about that one.

Once you know what your options are, the next most important thing is to look at the risks. The categories include whether the procedure involves manual surgical skill, what types of equipment are involved and how likely they are to produce predictable results. Last, what the results are for that procedure for people like you, over the long term?

Chat Moderator: How do you find a doctor? How do you check out the doctor?

Franette Armstrong: That's a great question and not an easy one to answer. The first thing is, don't run to a doctor because he's advertising a special "deal." Money should be your last consideration! Remember, the vision you get will be with you for life (in most cases), so you should save until you can afford the right doctor/procedure, if necessary.

The best doctors to go to are the ones who offer all the procedures you are considering and which are appropriate for your vision problem. If you go to someone who seems to be pushing one procedure over another without being willing to discuss the options, find another doctor.

I also feel strongly that patients should stay away from doctors who aren't willing to meet with them before the day of the procedures (some don't even say 'Hi' until the patient is on the table or in the chair!) You need a doctor who is interested in your results and willing to follow up so that any problems can be nipped before they become serious complications.

Question from Ian: Are consumers frightened by the concept of having a laser in their eyes?

Franette Armstrong: Today I think many people aren't as fearful of the idea of lasers or any vision surgery as they were a few years ago. The bigger worry is what procedure and what doctor.

Question from radfi: How do you find out who is the best doctor?

Franette Armstrong: The best doctor is the one who has enough experience doing the procedure you select and is willing to follow you through the first three months. As for finding this wonderful human being ... that takes research. Don't go to someone just because your friend did, but that can be a place to start. Also, university centers are a resource. And interviewing doctors who are listed in the phone book is a lengthy but productive way if you don't have referrals. I'd start with my own eye doctor, see what she might suggest, and then branch out. There's a chapter in "Beyond Glasses" which lists all the FDA trial doctors by state, which also could help out.

Question from DirkDiggler: Will the procedures eventually come down in price?

Franette Armstrong: I expect they will, as new technologies become approved and as new lasers enter the scene. Right now one of the things holding up the price is the royalties doctors must pay to the laser companies. This is going to change very soon.

Question from brwoody: How can the laser surgery help most people?

Franette Armstrong: If you are within mild to moderate ranges of nearsightedness or farsightedness, or if you have what is known as "regular astigmatism," you can be helped by all the procedures now available. If you have severe farsightedness or nearsightedness or irregular astigmatism, the solutions are more tricky, and you need a very qualified doctor. If you simply have the reading vision problem that comes around age 35 or 40, but no distance vision problems, there is no surgical solution yet available. If you do have reading vision problems AND are nearsighted or farsighted (which is different from reading vision), doctors can compensate for this by giving you something called "monovision." One of the criteria older patients should consider is whether the doctor suggests monovision and is willing to hang in with you while you test it out with contacts before installing it permanently!

Question from Ian: Will insurance companies pay for laser surgery?

Franette Armstrong: A few will. Some of the companies that insure fire and police often offer it to their client corporations. If your job puts you at risk of injury to your eye from glasses or contacts, you also should be able to get this covered. Also, these procedures are deductible from your taxes!

Question from Ian: Are there any viable alternatives to laser surgery? Like medications? (not including corrective lenses)

Franette Armstrong: No, not really. The pinhole glasses you see in infomercials don't do anything but create the same effect you can get from squinting. Eye exercises and other alternative therapies don't really work unless you are extremely committed and are very mildly nearsighted.

Question from MrMagoo: What is the risk 10 years down the road?

Franette Armstrong: We know the risk of PRK -- virtually nil. We do have 12-year results from the earliest patients treated with the earliest lasers. There are no long-term studies on LASIK of this nature that cover a very large patient base. It hasn't been approved for wide use by the FDA. The Intac corneal ring has gone through about five years of clinical trials on hundreds of patients, but we don't have long-term results for that either. One of the issues with LASIK, as opposed to PRK, is that the results are so dependent on the doctor's skill and on his having a good "hand day" (facetious, but even the best doctors have a bad day). With the ring and implantable contacts, the issue long term is what happens to these substances when they are inside the cornea. Will they cause infection or inflammation, or migrate to other parts of the eye? So, the only one that doesn't involve foreign implants or doctor's manual skill to any significant level is PRK, and that's the one we know the most about.

Question from radfi: When doctors talk about a 98 percent success rate, what has happened to the 2 percent of patients who are not success stories?

Franette Armstrong: Good question. And how many patients is he talking about overall? Is he talking about his own success rate, or the composite of many doctors in centers all over the country? There are some serious complications with these procedures, and you need to know the relative risks before you take them.

Question from Candyce: Does the FDA still suggest waiting three months between having both eyes done?

Franette Armstrong: Yes, but most doctors are treating both eyes in the same visit. This is frowned upon by many of the best ophthalmologists in the country.

Question from Doris: My daughter paid $4,000 for her laser surgery. Is that the average cost?

Franette Armstrong: Yes, if you are talking about LASIK. PRK has dropped a bit in price, so you should be able to get both eyes done for $1,500-$1,800 in most places. PRK costs less because less equipment is involved, but it takes more follow-up visits, so the doctor earns less money for time spent per patient.

Question from Candyce: Are we seeing more vision problems, with more and more people sitting in front of computers all day?

Franette Armstrong: I don't know that anyone has discovered permanent vision problems from computers, but we all know about eyestrain, don't we?

Question from allen: Since there is not significant data on long-term effect, why do you think it's proper to promote the procedure?

Franette Armstrong: Depends on the procedure and what we know. How much risk are you willing to accept, and who should be the one to tell you this?

Question from Candyce: As a follow-up to the FDA question: Would you recommend that consumers tell their doctors that they wish to wait the three months, and will doctors be willing to do that?

Franette Armstrong: Yes, consumers can ask the doctor to wait. I think they should offer major discounts if they treat both eyes at once, because it saves the doctor a phenomenal amount of time and cost. A compromise might be having one eye done, waiting a few days, then having the other eye treated. This would likely avoid the possibility of an infection in one eye transferring to the other. Also, if something goes wrong in the first procedure, you will still have an uncorrected eye while complications are being worked out.

Question from Ian: Are there any techniques in the works to integrate laser surgery into correcting blindness?

Franette Armstrong: The causes of blindness are many. If they have to do with the structure of the cornea or the refractive power of the eye, chances are lasers could help right now. If blindness is the result of optical nerve damage, brain damage, or retinal damage (as with macular degeneration, the most common cause of blindness today), treating the surface of the eye won't help. That said, some wonderful new treatments are being developed for these other conditions.

Question from seer: Are there other FDA recommendations that are not being widely followed?

Franette Armstrong: Well, the FDA hasn't approved LASIK on the approved lasers, but it is the most common use of the lasers. And the FDA has made it clear that lasers built by doctors (so-called "black box lasers") are illegal, but many are still in use. Finally, the FDA sets a limit on the degree of vision correction for each laser, but doctors get around that in various ways.

Question from allen: What is the possibility that the HMOs will cover this procedure, and are there any lobbying efforts being made ?

Franette Armstrong: An HMO in California has purchased a bunch of my books and has a laser, but I don't know how they work the finances. It is doubtful that HMOs are going to foot the bill for elective procedures of any kind, and this falls into that category.

Question from Ian: What will replace laser surgery in the future?

Franette Armstrong: Well, we still have RK around, mostly used for treating residual astigmatism after laser surgery. We have the recently approved Intac corneal ring for mild levels of nearsightedness, and we have the holmium LTK procedure that is striving to get through clinical trials but so far hasn't succeeded. On top of those, we have work being done to insert tiny contacts into the cornea or behind the pupil, and to use standard cataract surgery for very farsighted people. One of the interesting prospects farther out is a surgical cure for presbyopia, which is the reading problem that comes with age.

Chat Moderator: What would you caution people before undergoing surgery?

Franette Armstrong: Make sure your expectations are in line with the reality of the procedure -- from a recovery point of view as well as for the long term. Go to the best doctor you can find who has done the most procedures of the one you have selected. Pay attention to what's going on so that there is no possibility of getting the wrong procedure or the right one done on the wrong eye. And take care of yourself afterwards. None of these are casual events, no matter what people will tell you. There is a period of time in which your eye will be at risk of complication and there are things you will need to do to optimize your results. Do them!

Question from SusanS: What are the risks involved with these procedures? Can one's vision be worse after than before?

Franette Armstrong: Let's take the end of that question first: There is "uncorrrected vision" -- and most procedures greatly enhance this. So a patient who is, say, 20/400 without lenses could get to 20/20 or 20/40 and be able to drive without glasses. Or they could get to 20/100 and still feel half blind. There is also "best corrected vision." The vision you have before surgery might be 20/20 with lenses, but after surgery you could end up with 20/40 or worse. Would you be happy? Could the situation be improved? These are questions you need to ask about the risks. Other risks depend on the procedure.

With PRK the risk is primarily of a slight "haze" developing during the recovery period. Less than 1 percent have anything close to a problem that would affect their best corrected vision, and if they do, it usually can be "buffed off" with the laser later. With LASIK, most of the risks involve the flap, although there are risks for highly nearsighted people involved in the suction. Can these be retreated? It depends on the problem. In extreme cases, patients can end up needing a corneal transplant, which is not a risk with PRK.

Most of the time, though, the situation can be helped, and this is why you need an experienced doctor who can anticipate problems both during and after surgery. With the ring, the risks involve infection and the very small risk of the ring migrating into the center of the eye. This happened only once in the clinical trials and was removed before it caused a problem. With the implantable lenses you have the risk of infection mostly, and the possibility that the lens will cause damage or inflammation as it sits near the pupil or natural lens.

Question from jeffp: With five-plus years of trials, what are the long-term prospects of ICR (intracorneal rings) vs. laser procedures?

Franette Armstrong: The results are about the same at the lower levels of nearsightedness. The ring probably produces less undercorrection than LASIK and less overcorrection than PRK, and it can be removed. However, you are talking about someone placing something into your eye. That person had better be good at it!

Question from radfi: Have you or would you have the surgery yourself?

Franette Armstrong: The reason I wrote "Beyond Glasses" is because I went to Canada for PRK a year before it was approved here. My experiences, both positive and negative, made me feel that I needed to understand the whole thing better and help others maximize the opportunity of vision correction.

Chat Moderator: Any final thoughts for us on evaluating your options for eye surgery?

Franette Armstrong: It's worth the pursuit, the trouble and even discomfort to become lens-free. I was in trifocals before I had my procedure five years ago. Now I'm 52, can read the smallest type in good light and have 20/20 20/25 vision the rest of the time. It has given me freedom in more ways than I could have predicted, and I hope all of you will check it out and see it if it's right for you.

Chat Moderator: Thank you, Franette Armstrong, for joining us today to discuss us how to pick eye doctors and procedures.

Franette Armstrong: Thanks, and see well.