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Chat transcript: Dr. Roger Steinert on vision surgeries

(CNN) -- The following is an edited transcript of a chat with ophthalmology surgeon Dr. Roger F. Steinert conducted August 27, 1999. provided a typist.

Chat Moderator: Our weeklong health chat series on eyesight, procedures and the future concludes today with ophthalmology surgeon Dr. Roger F. Steinert of the Harvard Medical School. Dr. Roger F. Steinert is joining us today from Boston.

Chat Moderator: Welcome, Dr. Roger Steinert!

Dr. Roger Steinert: It's a pleasure to be here.

Question from: Is: Do you recommend LASIK?

Dr. Roger Steinert: Yes, for the appropriate person. Most optical errors are treatable by LASIK with a high degree of success. The person must have appropriate goals, namely a reduction in dependency on glasses or contacts. They need to realize that they may still need weak or thin glasses for some activities. For example, a middle-aged patient might still need reading glasses. And a patient at any age might still feel glasses are needed for very fine distance details such as reading road signs and driving at night. In addition, it is important, before having LASIK or any other procedure, to have a comprehensive eye examination to determine the exact nature of the optical problems and also to look for other problems that might need to be addressed or that might get in the way of having a successful LASIK procedure.

Question from: Rory: Dr. Steinert, I was told that my eyes weren't bad enough for LASIK procedure. What type of vision must people have before they are considered for LASIK?

Dr. Roger Steinert: In general, there is no absolute lower limit when we would do refractive surgery. Rather, the most important factor is what a patient's functional needs are. At lower levels of correction, the patient needs to consider carefully how much benefit there is because the risk is essentially the same, whether it is a high correction or a low correction. But many of the refractive surgeons who do a high volume of correction have high enough success rates that they will do relatively low amounts of refractive correction if the patients would benefit enough to justify the procedure.

Question from: Vicki: Dr. Steinert, I am having LASIK on Tuesday morning. I'm worried about the experience itself. Will it be worse if I'm nervous?

Dr. Roger Steinert: Almost all patients are nervous the day of the LASIK procedure. There is a mixture of excitement about finally getting rid of the dependency on glasses, with natural concern about whether it will come out as good as you hope that it will. Most laser centers offer a relaxing medication such as Valium to help with the normal nervousness. I have personally never had a patient who was so nervous that he or she could not complete the procedure. The procedure involves only a small amount of brief discomfort. We use numbing drops so you do not feel anything touching the eye, and you do not feel the laser pulses. There is mild pressure on the eyelids by a springlike device that holds the eyelids open. And there is approximately 30 seconds of intense pressure when the LASIK flap is created. But it is not any worse than if you pressed with your thumb on your closed eyelid. Post-op, most patients feel that they have a mild stinging sensation for two to four hours. It is similar to the discomfort after swimming in a chlorinated pool. Using artificial teardrops for lubrication is usually all that is needed to stay reasonably comfortable.

Question from: RKEyes: Dr. Steinert, I had RK four years ago and have irregular astigmatism now. Is there anything in the future that will be able to make vision better for eyes that have been compromised by RK?

Dr. Roger Steinert: Yes, there is good news. One of the areas of intense research right now is to allow the excimer laser beam to follow an irregular pattern and treat irregular astigmatism. This is probably still one or two years away from general availability, but we are optimistic that this will provide the answer for people such as RKEyes.

Question from: RKEyes: Will you do this procedure in Boston?

Dr. Roger Steinert: RKEyes, at some point the answer will be yes. But at the moment we are not able to treat patients such as yourself under the restrictions of the FDA. I'm hopeful that we would have an investigational category for patients such as yourself within a year.

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

Dr. Roger Steinert: The answer depends in part on the procedure and in part on the individual being treated. However, it is always the case that any medical procedure does involve risk. Risk can never be completely eliminated. The results of LASIK, for example, have improved to the point where the risk of a major complication is so low that we routinely treat both eyes at the same setting -- although, clearly, there is a very small chance of having a major complication in both eyes. The risk is lower than the risk of an automobile accident driving to have a second treatment on a second day.

Question from: youknowwho: It seems that the main concern is to fix the cornea. What exactly causes the cornea to turn?

Dr. Roger Steinert: I am not exactly sure what youknowwho is asking, but I think the underlying question is why we treat the cornea. The cornea itself is generally not the reason a person is nearsighted or farsighted. Nearsightedness is usually because the eyeball is too long. Farsightedness is because the eyeball is too short. In the case of astigmatism, however, the cornea usually is the source of the problem because it is shaped more like the side of a football than the side of a basketball. In all cases, however, we treat the cornea because it is the most important optical element in the eye, and because it is on the surface, we can change the shape of the cornea and change the optics of the eye without the danger of doing surgery inside the eye. In a sense, the cornea surgery is changing the shape of the cornea to match the shape of a contact lens. So it is like having a permanent contact lens.

Question from: tn_guy: Are there any new procedures for correcting "lazy eye"? I had one done for cross-eyes when I was 2 or so, and they overcorrected.

Dr. Roger Steinert: There are two parts to the lazy eye problem. What I think you are referring to is muscle surgery to straighten the eye. Muscle surgery is becoming more refined, but eyes that are surgically straightened can still wander in the following years. The second part of "lazy eye," or amblyopia, is that the nervous system that analyzes vision in the brain does not fully develop in the childhood years. Unfortunately, we do not have any currently known technique to stimulate the development later in life.

Question from: Daphne: Will there ever be a procedure that can correct severe farsightedness and astigmatism together?

Dr. Roger Steinert: Yes, right now we are in the final stages of gathering the data so that the FDA will allow approval for using LASIK for moderately high amounts of astigmatism and farsightedness together. However, if the level is high enough, then other treatment will be needed. At the moment we expect that this treatment will be in the form of an implanted lens, either within the cornea or inside the eye itself. Such a treatment will be most likely at least five years away.

Question from: trokhan: How many of these corrective procedures go wrong, where the patient has vision worse than before the surgery?

Dr. Roger Steinert: The accurate answer depends on the precise procedure performed, the amount of correction and the individual results of the surgeon. In general, however, for most patients undergoing LASIK, about 2 to no more than 5 percent of patients will have their best vision reduced by one line on the letter chart. For example, a patient who is 20/20 before LASIK has a 2 to 5 percent chance of being 20/25 after LASIK. The chance of being a lot worse, such as less than 20/40, is generally around 1 in 1,000.

Question from: youknowwho: In astigmatism, you said, the cornea is shaped like a football. How and why does the cornea change shape?

Dr. Roger Steinert: Astigmatism, in some cases, is natural. Most cases of high astigmatism represent a shape that someone is born with. There are several eye conditions where high astigmatism develops later in life. The most common is a disease called keratoconus. Other problems can cause astigmatism, such as direct injury to the eye, or surgery, such as cataract surgery.

Question from: scott: My right eye is -3.00 and my left is -3.75. Am I still a candidate for LASIK with this astigmatism?

Dr. Roger Steinert: Yes.

Question from: Rory: If someone is using progressive bifocals now, will LASIK eliminate the need for bifocals? Would the person just need reading glasses?

Dr. Roger Steinert: For someone who is old enough to be needing bifocals, there are basically two options. The first option is to correct both eyes for distance vision and to wear reading glasses when needed; the second option is a technique called monovision. In monovision, one eye is fully corrected for distance, and one eye is corrected with the goal of having a low amount of remaining nearsightedness. The nearsighted eye can then read things such as a menu or labels at the store or a computer screen without glasses. If a patient can be comfortable with this combination, then monovision has a major advantage of eliminating glasses except for reading extremely fine print. Experience has shown that about three out of four middle-aged patients are pleased with monovision, and one out of four cannot get used to monovision. We try to determine that prior to the laser treatment by simulating monovision with either the glasses prescription or by modifying the contact lens prescription.

Question from: gio: Dr. Steinert, do you think after LASIK you will see in a correct way also in the future?

Dr. Roger Steinert: The laboratory research on laser vision correction dates back to 1983, and human treatments of normal eyes began in 1989. We now have experience for a decade and more than 1 million eyes. Thus far there has been no sign of any long-term changes. There is no reason to anticipate any surprises in the future.

Question from: RICK: Dr. Steinert, you mentioned earlier about some laser that may help RKEYES. I too had RK and left with blurred vision, fluctuation, glare, and some days do not want to continue. You really think there is hope on the horizon?

Dr. Roger Steinert: Yes, but I don't want to raise false hope about a perfect outcome. The patients who have fluctuation in their vision have unstable RK wounds. Even if we have the type of custom treatment in the future that I spoke about, if the cornea is not stable, then it will probably change and deteriorate once again. The treatment of an unstable cornea at the present time is either a full or partial thickness corneal transplant.

Question from: MikeG: Dr. Steinert, I have severe diplopia from strabismus surgery in '97. My eyes are straight, but the double vision is bad. Am I stuck with this for life?

Dr. Roger Steinert: It sounds like you still have a problem with the alignment of the muscles. You should be re-evaluated by a specialist in strabismus.

Question from: gio: Dr. Steinert, which is the age you recommend to do the LASIK?

Dr. Roger Steinert: The most important factor is stability. If the refractive status of the eye is still changing, then the LASIK correction done today won't be the appropriate correction down the road. Most patients with nearsightedness stabilize in the late teens up to the mid-20s. Most patients with farsightedness are stable by the age of 20.

Question from: jake: Do you know anything about the one-day prescription in the future, where you put drops in your eyes and it changes the cornea's shape? If so, when could this be out? And possible problems from it?

Dr. Roger Steinert: There is no known drop that would change the shape in a desirable manner. We have no expectation that any medication could change the shape of the cornea in a controlled fashion.

Question from: gio: Dr. Steinert, do you recommend LASIK?

Dr. Roger Steinert: Yes, I've already answered that. But let me say that I have had laser surgery myself. I have done it on many other doctors, on my wife, and earlier this summer, on my oldest son.

Question from: Candyce: I'd like to ask, does the FDA still recommend waiting three months between eyes? And do you endorse that?

Dr. Roger Steinert: The three-month recommendation was for the original PRK procedure when it was approved in 1995. With LASIK, we have dramatically shortened the recovery time because the laser procedure is performed inside the cornea under a flap instead of on the surface as in PRK. As a result, useful vision is generally returned by the first morning after surgery. Most of my patients go to work after the first morning postoperative checkup. Therefore, the time for most patients is no longer three months; it is closer to three minutes. More than 95 percent of my patients and most experienced LASIK surgeons have both eyes done at the same session.

Chat Moderator: What does the future of eye procedures hold?

Dr. Roger Steinert: In addition to the custom-shaped LASIK that we talked about earlier, there are many investigations on implantable lenses. We also eagerly anticipate the availability of an exciting new laser, perhaps by the end of 1999. This laser uses infrared light to reshape the cornea to correct for low to moderate farsightedness, or to cause monovision for middle-aged patients for reading. This holmium laser treatment takes only seconds and involves no cutting of the surface, so that patient acceptance is high and the speed of recovery is fast.

Chat Moderator: Thank you, Dr. Roger Steinert, for joining us to discuss your LASIK procedure.

Dr. Roger Steinert: It has been a pleasure to participate in this chat room session. Anyone who is interested in more information is invited to visit my Web page at and the Web page of the LASIK Institute at

Chat Moderator: This concludes the weeklong chat series on eyesight, procedures and the future. Thank you all for your questions!

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