[Note: A condensed version of this article was published in The Outreach Connection, Sept. 23, 1998, page 14.]
No, this was not a new and gruesome high-tech torture. Rather, the laser was being fired at my request, and I had paid $4000 for the privilege.
I was one of over half a million patients worldwide to undergo photorefractive keratectomy (PRK), a relatively new procedure which uses an excimer laser to correct nearsightedness and astigmatism. My goal was a simple one: to achieve 20/20 vision without the need for glasses or contact lenses.
Undergoing PRK was not an easy decision to reach. I had worn glasses for about fifteen years, and had gotten quite used to them. With my glasses, my vision was excellent. But glasses still had their inconveniences: limited peripheral vision, awkward for sports or dancing, unusable when swimming or showering, perhaps nerdy-looking or undesirable when performing in public.
Of course, contact lenses offered a solution to some of these difficulties, but they came with their own drawbacks: discomfort, risk of infection, and the need to return home each evening to clean the lenses. In any case, they offered no relief from the feeling of dependency that comes from being unable to see properly without corrective measures.
Fortunately, Canada (due to fewer regulatory restrictions than in the U.S.) is a world leader in PRK surgery. And one of Canada's best-known PRK surgeons, Dr. Harold A. Stein, works at the Bochner Eye Institute a few blocks from my Toronto home. (Other similar clinics include the Beacon Eye Institute, the Herzig Eye Institute, and the Gimbel Eye Centre.)
After much procrastinating, I went to the Bochner for a free consultation. I was given a few glossy pamphlets, which were essentially over-simplistic advertising brochures (e.g. "For years, you've worn glasses or contact lenses. Ironically, getting rid of them takes only minutes"). The procedure was also described in vague and slightly misleading terms, e.g. constantly describing patients as "no longer requiring glasses" to really mean that their uncorrected vision was at least 20/40, which is good enough to drive but far from perfect -- as if driving was everyone's ultimate goal! (Perhaps slight deception is inevitable when the profit motive is involved?) Disappointed, I asked for more details, and was finally offered a copy of Stein's book, The Excimer: Fundamentals and Clinical Use, 2nd ed. (Thorofare, N.J.: SLACK), which was written for other ophthalmologists and thus provided more substantial information.
After a final weekend of research, during which I read most of Stein's book, several web sites, and a number of independent research articles, I nervously made an appointment for the surgery. My research had suggested that PRK was quite safe and had quite a high success rate (the latest figures were apparently that 98% of eyes achieved at least 20/40 vision, with 92% at 20/20). But I was still very nervous about letting anyone mess with my eyeballs, especially when the profit motive could cause them to oversell the benefits of their work. My confidence did not improve when the Bochner people "forgot" to return a follow-up phone call.
It was thus with a pounding heart that I lay on my back one week later and was positioned under the laser. My eyes had been frozen with special anesthetic eye-drops and were held open by a small metal device, and I was told to stare at the blinking red light just above me. Dr. Stein sat down behind me and began preparing for the surgery.
Suddenly I couldn't see the red light anymore! Dr. Stein had placed an object on my eye without warning. (So much for his words "The surgeon must talk to the patient and explain what is happening during surgery", on p. 44 of his book!) Only later did I learn that this object was a sort of sponge to remove excess moisture. It was soon removed.
Next, Dr. Stein manually removed my eye's epithelium, or thin protective coating of the cornea. He did this by scraping, using what was described as a miniature spatula; rather gruesome-sounding, I would say. Since my eye was frozen, I felt nothing.
Finally, the laser itself was used. I stared at the blinking red light, and heard a "click, click, click" sound as the excimer laser delivered a series of precise pulses which "ablated" (i.e., removed) tiny portions of my eye's cornea, to reshape it so that it would focus light onto my retina without the need for corrective lenses. I was extremely tense, not least because I knew that if I moved my eye or head at all, then the laser might ablate the wrong place.
In just a couple of minutes, the whole thing was done. I had felt nothing, and had been awake and comfortable (if not calm) the entire time. Protective (non-refractive) contact lenses were then inserted into my eyes, to act as bandages for a few days while the eye healed. A photo was taken, and I left the operating room.
I noticed right away that I could see distant objects with greater clarity than before without my glasses. On the other hand, for all objects near and far, there was a strange blurriness rather unlike my previous nearsightedness. Reading -- either a nearby book or a faraway sign -- was extremely difficult. I was prepared for this blurriness, and knew that it was supposed to go away as the eyes healed.
After the surgery, I was given a complicated array of eye-drops (five different kinds in total), plus some pain medication and a pair of oversized sunglasses to protect my eyes while outside. I was charged an extra $30 for this package, which seemed a bit stingy since I had just paid $4000 for the surgery. I was given "discharge instructions" and sent home.
Though I had felt no pain during the surgery, I knew that I might feel pain in the days following. Stein's book had claimed (p. 91) that with modern treatment methods, "90% of the patients have essentially no discomfort following laser surgery. The 10% who do have discomfort have usually minimal discomfort". This was contrary to what I had heard elsewhere, so I was prepared for the worst, and rightfully so as it turned out.
Beginning about twelve hours after surgery, and lasting about thirty-six hours, my eyes began to feel very sore and stinging, somewhat as if sand had just blown into them. The pain was fairly overwhelming, and prevented sleep or relaxation. In response, I took in various combinations the pain medication which had been provided, including Tylenol #3, Valium, and sleeping pills. (Later, comments in the Bochner waiting room and from the staff convinced me that my pain was not unusual.)
Between my pain and the fact that I couldn't read instructions or labels, it was virtually impossible for me to deal with all of the eye drops and pain medication that I needed. Happily, my friend Margaret stayed with me and provided fabulous help in the form of good food, encouraging words, and assistance with the drops and medication. I do not know how I could have gotten through those first two days without her, and I think the Bochner should emphasize the importance of having assistance during the initial healing.
In those initial days my eyes were also very sensitive to light. I spent most of my time indoors, with the lights out. When I did venture outside, I wore the oversized sunglasses on top of my regular sunglasses -- and still found direct sunlight too bright. I briefly reflected on the irony that, after having surgery to eliminated my dependence on corrective eyewear, I was currently wearing two pairs of glasses plus one pair of contact lenses.
I had several return visits at the Bochner during these first days. However, my third day post-operative was a Sunday, and the institute was completely closed. Thus, I had to wait until day four to have the protective contact lenses removed. This was somewhat annoying, since the removal of the protective lenses seemed to signify the end of my "initial healing" phase. Finally, on day four, my eye was examined and found to be healing properly, and the lenses were removed from my eyes.
The first few days following surgery had been painful, but I was fully prepared for this and did not mind too much. However, once the lenses were removed and my initial healing phase was over, I was anxious for my vision to return to normal as quickly as possible.
I knew that final healing of the eye would take months, and that my vision would fluctuate somewhat during this time as my epithelium grew in. (Indeed, the difficulties of epithelial healing are the main motivation for an even newer technique known as laser assisted in situ keratomileusis, or LASIK. With LASIK, a thin flap of cornea is peeled back so that the laser can operate on the interior of the cornea, leaving the epithelium intact. LASIK allows for faster healing, but there is more room for error in replacing the corneal flap. At the Bochner, LASIK is only used on very highly nearsighted patients.)
Despite this, I was optimistic that I would achieve fairly good vision in a short time. Certain anecdotal evidence, plus certain phrases in the Bochner pamphlets (e.g. "Your vision will improve slowly and you may return to your normal activities of daily living after 3-4 days"), had led me to believe that within a week or so, I would more or less be seeing normally, with just an occasional visual fluctuation or anomaly in the months ahead. The pamphlets' mild suggestions of warning, such as "everyone has their own rate of healing -- please be patient", seemed so vague as to be meaningless and easily ignored.
My optimism proved to be unjustified. One week after my surgery, that strange blurriness in my vision was still very much present. It had decreased somewhat, for example I could now read the cash-register numbers and count out my change, but I was still very far from seeing normally. I could not comfortably read or use my computer. I could get around well enough but could not do anything requiring visual concentration. This was taking longer than expected, and wasn't so much fun anymore. I purchased some "talking book" audio cassettes and tried to be a patient patient.
At ten days post-surgery, there was some definite improvement. My vision was still blurry, and I still couldn't read for very long. Furthermore I had noticed the expected -- and hopefully temporary -- "halo" effect when looking at lighted objects in dark conditions. But now, going for a walk in daytime was quite comfortable. Reading for a short time was possible. Using my computer briefly was feasible. I even managed to do a little bit of office work. I was still very concerned about my slowly-recovering vision, but I was hopeful that I would soon be seeing well again.
On my eleventh night after surgery, I awoke at 5:30 am with a searing pain in both eyes. They felt dry and sore, and the discomfort was sharper even than during the initial two days of healing. Opening my eyes was very painful; turning on the light was even worse. What was going on? And why?
I tried to remain calm. I knew that "somewhat dry eyes" was a possible symptom during the healing process, so maybe that was all I was experiencing. But the pain was so sharp that, given my previous concerns about my speed of recovery, I had my first real fears that something had gone horribly wrong.
To deal with my pain, I attempted to take a Tylenol. As I fumbled around with my eyes nearly closed, I cursed the inventor of child-proof bottles. Finally I managed to get back to sleep.
The next morning my eyes felt better, much to my relief. But as I looked around I discovered another disturbing fact: the vision in my right eye had become much more blurry! It felt as if the eye had been "smudged", a bit like when you first wake up or when your eyes are wet in the shower. But no amount of rubbing or moisturizing made any difference to the blurriness.
Around the same time, I made another disturbing discovery, this one regarding eye-drops. Most of the drops I had been given were just for the first few days following surgery, but one of them, called Indocollyre, was to be taken several times a day over a period of five months while the eye healed. I had expected this, having read about corticosteroid drops which are used to modulate the healing of the eye, and are increased or decreased depending on how the eye is healing. But suddenly and accidentally, I discovered that Indocollyre was in fact a non-steroidal anti-inflammatory. That is, this was not a corticosteroid drop at all! Why weren't they following the procedure I had read about?
Further inquiries confirmed my worst fears. The use of Indocollyre was a new "experiment" at the Bochner, used at the urging of the manufacturing drug company in the "hopes" of finding a non-steroidal alternative drop to reduce possible negative side-effects of steroids. As a fellow scientist, I understood the need for experimentation to improve techniques. But did they have to experiment on me? And without my knowledge or consent?
I started to get genuinely worried, and imagined the worst. They were experimenting on me with a new eye drop. It wasn't working so my eyes weren't healing properly. That's why my right eye was so blurry. That's why I had felt such sharp pain. I found myself wondering if I would ever see properly again.
Soon after, I had a follow-up visit at the Bochner. This visit, like most of my follow-up visits, was with a junior ophthalmologist who introduced himself only as Scott. (Apparently Dr. Stein had become too important to waste much time with patients like me, other than for the few minutes of the surgery itself.)
Scott seemed competent and approachable. He examined my eyes and assured me that they were healing well, that my vision was "right where it should be". He further explained to me that the vision can get temporarily worse as the epithelium continues to heal, since the new epithelial layers do not line up quite right at first, but that such effects are temporary. He reminded me that full healing takes from one to six months.
I asked why, if my slow healing rate was the usual, did the pamphlets claim that I could return to normal activities in three or four days? He said that despite my blurriness, I already had what they consider "good" vision, but that the "fine detail" vision required to read comfortably would come later. Apparently reading and using a computer are not considered "normal daily activities" by the Bochner Eye Institute. Scott admitted that, if he were in charge at the Bochner, he would change the pamphlets to say "good vision after one week, fine detail vision later".
In response to my inquiries, Scott admitted that I was one of the first patients at the Bochner to be given Indocollyre instead of a steroidal drop. But he said Indocollyre had already been tried elsewhere, and he assured me that it had the same healing effect as a steroidal drop. He further said that since my eyes were healing well, there was no cause for concern. I was not 100% convinced -- if this new drop was so great then why weren't they using it on all their patients? Furthermore, how can they be so sure it has the correct healing effect if they've never tried it before? Also, Scott had been slightly self-contradictory about the value of the drops, telling me on the one hand that some institutes don't use any drops at all so using a new and different drop isn't so important, but on the other hand that the drops were crucial for the healing process and I should be sure to use them. Still, overall I felt somewhat re-assured by his words.
(Incidentally, Scott also indicated that most patients do not request information as much as I had, which was consistent with the superficiality of the glossy pamphlets. I found this strange: if complete strangers are operating on your eyes, especially with the profit motive present, then wouldn't you want to know details about what they're doing? Perhaps this "not wanting to know" was symbolic of our modern society ...)
Around that time, there were some visual improvements. I had been so concerned about my right eye that I had hardly noticed that my left eye had sharpened up considerably, to the point where it now had essentially normal 20/20 vision. It still didn't feel quite as strong as my old vision, but it was definitely working well, for both near and distant work.
My right eye, which had been so blurry a few days earlier, had also started to improve. It had become at least as good as it had been before my scary night of pain. It was improving daily and threatening to catch up to the left. I was very anxious for this to happen; I didn't want to start relying on one eye much more than the other. With the right eye somewhat blurry, it threw off my entire vision. But I felt that, if my right eye would just become as good as my left, then I would be seeing well and would be happy.
Finally, gradually, the right eye caught up to the left. By day eighteen, both eyes were approximately as good, and both had close to 20/20 vision. However, they both fluctuated somewhat, were a bit blurry in the fine detail, and didn't "feel" quite right. Furthermore I was still a little bit over-sensitive to light, and still saw something of the "halo" effect when viewing bright lights at night. So my vision was now quite functional -- I now really COULD return to my "daily activities" -- but still not as good as it had been with glasses before the operation. And I still could not work or read for very long periods of time.
I was calmer now than I had been earlier, thinking that my vision was now FAIRLY good, and that some visual fluctuations were apparently "normal" as the eyes healed. Still, I found it annoying that I couldn't see perfectly sharply, and I couldn't completely stop worrying that some of these vision difficulties would be permanent. I found myself longing for my very-sharp, pre-operation, bespectacled vision; and I still wasn't entirely convinced that laser-eye surgery had been the right choice.
In the third month, the healing continued, but very slowly. I was now measured at 20/20 in each eye, yet the strange fuzziness (depending on the lighting and colours) did not totally disappear. I was less worried about my eyes now, but still anxious for the final healing to take place.
Towards the end of the third month, my eyes began to feel dryer again. I would sometimes wake up in the middle of the night with slightly stingy eyes. Artificial tears helped somewhat but did not completely alleviate the problem. At least it wasn't nearly as painful as that awful eleventh night had been. And, hopefully, it indicated that the healing process was continuing.
Things continued in much the same fashion during the following months. Overall my vision continued to improve, but the "fuzziness" and halo effect did not completely disappear. My eyes often felt dry, especially in the middle of the night, but generally the associated pain was only mild. At the end of the fifth month, I finished with the Indocollyre (and all other) eye-drops, which was a relief. And my vision was mostly quite good. However, it was still not truly sharp like it had been with glasses before the operation, and this still worried me.
After six months, I had another eye examination at the Bochner, this time with Dr. Stein himself. He indicated satisfaction with my progress. When I asked him about the fuzziness and halo effect, he assured me that they would go away but that "it takes about a year." A year?!? What about their earlier assertion that final healing takes from three to six months?
In the months since then, my vision has sharpened up further. But a year after the surgery, I still experience some minor halo effect, and I am still in a position of waiting to see how my vision will finally turn out.
Undergoing PRK has entailed several days of pain, several weeks of very blurry vision, many months of inconvenience and suboptimal vision, and a cost of more than $4000, all so that I no longer require glasses.
The Bochner staff were competent in their treatment of my eyes. However, their service component was less impressive: unreturned phone calls, lack of detailed information, limited contact with the senior ophthalmologist, and eye-drop experimentation without my consent.
PRK is indeed a miraculous procedure. On the other hand, my recovery was far more difficult and time-consuming than I'd been led to believe. Rather than taking "minutes", it had most definitely taken "months".
Knowing what I know now, am I glad I undertook PRK laser eye surgery? Was it worth all the trouble I went through, just to achieve the convenience of life without corrective lenses? Probably it was, though it's hard to be sure. Sometimes even hindsight isn't 20/20.
Dr. Rosenthal is an Associate Professor in the Department of Statistics at the University of Toronto. To contact him click here.
P.S. To answer two frequently-asked questions: When I had the PRK surgery, I was 29 years old, and my eyeglasses prescription was about -4.0 to -4.5 in each eye, with an astigmatism of about -1 in each eye.
Generally, my eyes are doing well. My vision is usually quite good, almost (but perhaps not quite) as sharp as it used to be with glasses. I do not own or wear glasses at all. I do still sometimes experience a small amount of blurriness (i.e. halo effect) in bad lighting, but it isn't too bad. I still occasionally suffer from "dry eyes", but this is quite rare and never as painful as it used to be. I am still slightly sensitive to bright sunlight, and tend to wear sunglasses in such conditions, but I can get by fine without sunglasses as well.
Overall my eyes are doing well enough that I only rarely remember all that I have gone through. Mostly, I see things fine, without thought and without glasses. I have enjoyed certain advantages from not wearing glasses. For example, in the past month I have played water-volleyball, have played soccer in the rain, have performed music, and have performed in a play, all without glasses and with excellent vision.
A number of people have asked me if I recommend that they get laser eye surgery themselves. I am hesitant to offer an opinion. I personally am now glad that I had the surgery. However, there was some risk involved, in addition to a difficult recovery time and the fact that certain difficulties (halo effect, dry eyes) haven't completely disappeared. Furthermore, it is a truism that while there are certain specific times when it is convenient not to wear glasses, having good eyesight is important for every single waking moment. So, the decision is far from clear-cut.
In the past two years, the LASIK (as opposed to PRK) option has become more popular. While this option includes more risk of human error (during the manual re-attachment of the corneal flap), it also apparently has a much faster recovery rate. For example, one person e-mailed me that he had PRK done on one eye and then LASIK on the other, and reported:
Although the PRK eye is ok, there's a fuzziness that I don't have with the LASIK eye. And, the PRK eye ... took forever to heal properly, and then it slid from 20/20 to 20/80 eight months following the surgery and had to be done again. ... I get the sharp pain in it every few months now at night. On the other hand, the LASIK worked like a dream. Literally took one day to heal before I was seeing really well out of it with no pain, no drops at all, and no healing time, and it never varied from the first day at 20/15. It's awesome.Another wrote:
I also got laser eye surgery (LASIK) and now have 20/20+ vision. The procedure only caused discomfort for about a week, and I had functional vision within 24 hours. My experience was so positive that my brother got the procedure last Monday and my sister-in-law is getting it done in a few weeks.but later followed up with:
My brother's surgery went fine, but my sister-in-law had some kind of "corneal flaking" and had to wear a contact lens bandage for a few weeks. It's over a month after the procedure, and the discomfort is just about gone now. She is about 20/20 in one eye, but worse than 20/40 in the other.I once saw some statistics that indicated a slightly smaller percentage of "successes" (by which they meant uncorrected vision at least 20/40) from LASIK than from PRK. So overall, it is difficult to be certain about LASIK either.
I guess my recommendation, for anyone considering PRK or LASIK, would be to talk to a large number of people who have had the procedure done. Find out what clinic they used, what service they received, and what results they got. Then decide whether the benefits and risks are worth it to you.
-- Jeffrey S. Rosenthal (contact me)
Over the past year, I have had the sense that my eyesight has gotten a bit worse, so that in addition to the "not quite right" post-surgery feeling, I had also re-developed some plain old-fashioned nearsightedness.
So, finally I went to see a non-surgical optometrist (Dr. Jerry Nolfi, a very helpful and talkative person who happily provided lots of useful information). He confirmed that, in addition to the halo effect, my vision had deteriorated to about 20/30 in the right eye, and about 20/50 in the left (though actually I think my vision fluctuates from day to day, plus it was not helped by his using a bright-light projector, so overall I suspect I'm a tad better than that). He prescribed glasses with a prescription of -0.75 (and -0.25 astigmatism) in the right eye, and -1.25 (with no astigmatism) in the left, to be worn only when I feel I need them. (In response to a question, he said that for six years post-PRK, I "wasn't doing badly", i.e. that many PRK patients will re-develop nearsightedness later on.)
I finally got around to ordering the glasses. With them I can again see very well, perhaps as well as I used to with glasses. I do notice a functional difference, e.g. while wearing my new glasses today, I could read the newspaper box headlines as I whiz by on my bicycle. So, in some ways that is a good thing. But obviously, in other ways it is quite a defeat, since the whole point of going through the surgery was to never have to worry about glasses again (or at least not until I reached my mid-forties and needed reading glasses). Still, it is much better (for me) to just need glasses a little bit, than to require them constantly and urgently for all waking activities. Anyway, I guess for now I will usually not wear the glasses, but will keep them handy for such things as attending seminars, watching plays, night driving, etc.
Naturally, a small part of me wonders about the possibility of getting a second surgery (a "touch up", in the laser eye surgery lingo), to possibly regain excellent vision without glasses. The optometrist did offer to refer me to a laser eye clinic that he deals with (or there is always the Bochner again), though he did say my current prescription is "at the minimum" of what they would normally consider correcting with laser eye surgery. (He also claimed an advantage to being slightly nearsighted, namely that I would probably not require reading glasses until around my late-fifties.) On the other hand, he did claim that the laser technology is more sophisticated now than it was in 1997, not to mention that LASIK is now considered significantly better than PRK. So, probably I will schedule a follow-up appointment at some point to consider this ... though probably I will not end up going through with it. (If I do, I'll be sure to let you know!)
-- Jeffrey S. Rosenthal (contact me)
ADDENDUM #3 (July, 2005):
In response to queries, let me add that there have been no real updates since 2003. I now have glasses which I wear for certain activities (driving, play-watching, tennis) but not all the time. So, that is somewhat disappointing, but not the end of the world. I haven't had any follow-up eye operation, nor even another optometrist appointment. I do sometimes consider enquiring about a LASIK operation, at least for one eye (my left), but I have not yet done so. Overall I am still glad I had the surgery, but it has certainly been a far messier experience than I anticipated. (For far worse experiences, click here.)
-- Jeffrey S. Rosenthal (contact me)
ADDENDUM #4 (June, 2013):
I am now 16 years post-surgery. I have had essentially no further major difficulties such as dry eyes or halos. On the other hand, my nearsightedness has gradually worsened in recent years. My latest pescription is -1.5 (plus -0.25 astigmatism) in my right eye, and -2.0 in my left eye. This means that I am now "moderately" nearsighted: I wear glasses (often pescription sunglasses) for driving and biking and perhaps walking outside, and for watching plays and perhaps movies and lectures, but I don't normally wear them when working or socialising indoors. Naturally I am somewhat disappointed that my nearsightedness has "returned" to this extent, but it is definitely still better than before when I was so nearsighted that I couldn't function properly without glasses.
An additional issue is that I am now 45 years old and have reached the point where I would normally start to require reading glasses. Being moderately nearsighted does have the advantage that I can still read and do close work (e.g. computer work) very comfortably without any glasses. (By contrast, it is now somewhat uncomfortable for me to read while wearing my latest pescription glasses, i.e. with my nearsightedness is corrected.) So, that is a silver lining.
My optomitrist told me that he thinks my current nearsightedness is the result not of "regression" from my PRK surgery, but rather simply of increasing nearsightedness (so that without the surgery, my perscription would now be something like - 4.5 - 1.5 = -6.0 or whatever). He said that such increasing nearsightedness even after the age of 29 (when I had the surgery) isn't too common but does occur in about 15% of patients. If so, then I guess I was unlucky in this sense (despite the above silver lining). Still, overall I feel very lucky that I haven't had any worse vision problems, plus I am glad to be only moderately nearsighted (and fine for reading and close work), so overall I can't complain.
-- Jeffrey S. Rosenthal (contact me)