Visionary Role for lasers

If you have long wanted to wake up and see the clock or swim, ski, or scuba dive without reaching for your spectacles, you may be in luck. Laser eye surgery is now available for short-sighted, long-sighted and astigmatic people. 

Improvements in laser technology have made a wider range of patients eligible, and demand for refractive surgery is rising. The number of surgeons trained in the procedures is growing rapidly, and specialist clinics now operate in most big UK and US cities. An estimated 12,000 people a year are having laser eye surgery in the UK, while in the US 900,000 had it done last year, including a number of opthalmologists, says Julian Stevens, consultant opthalmologist at Moorfields Eye Hospital in London. 

While laser surgery does not mean you can throw away your spectacles for ever - some people still need to wear them for reading or driving - it can make a great difference to everyday life. High-profile myopes (people who are short-sighted) including Virgin chief Richard Branson and US actress Courtney Cox are among those reportedly delighted with the results. "Lasik [laser surgery] has already made a huge impact on my life," says Penny Joseph, an administrator in Norwich who had her surgery at an Optimax laser eye clinic. "It is absolute luxury to be able to play face-to-face with my children and not worry. I wish I'd had it done ages ago." 

The two types of refractive surgery available, PRK and Lasik, are performed on out-patients in less than half an hour, using a local anaesthetic. PRK, or photo-refractive keratectomy, has been practised for nine years to correct mild to moderate short sight. PRK gently reshapes the cornea by removing microscopic amounts of tissue from the outer surface with an ultraviolet beam of light. The eyes heal during several months, with some soreness, clouding and possibly other short-term side-effects, so the second eye is usually treated a month or so later. According to the US Food and Drug Administration (FDA), clinical studies show about 5 per cent of patients still need glasses after PRK for distance, and up to 15 per cent need them occasionally for driving or reading. 

Lasik has been offered in the UK for five years, but demand soared in 1997 after technical refinements improved results. The surgeon uses a knife called a microkeratome to cut a flap of corneal tissue, removes the targeted tissue beneath it with a laser and replaces the flap, which heals within hours. Advantages are a pain-free recovery, quick restoration of sight and better results for severe short-sightedness. Because of the fast recovery time, some patients can have their second eye done a day or two after the first, and have good vision within a week. About 20 per cent of patients will need further treatment to achieve a result closer to perfect 20/20 vision. PRK costs start at about £1,000 for both eyes, and Lasik charges at about £1,500. Procedures by consultant surgeons in hospitals are more expensive. But there are risks, and reports of disappointing outcomes are not uncommon. Opthalmic surgeons say results vary depending on each eye; that the smaller the correction, the better the outcome. An estimated 5 per cent of patients suffer post-operative complications. These include infections, over-correction, or regression; and permanent halo effects, worsened night vision, blurring or dry eyes. Most patients sign a consent form accepting that their vision might be worse afterwards. "Complications that reduce the quality of vision are one in 200, in good hands," says Mr Stevens, a Lasik enthusiast who has run laser surgery clinical trials at Moorfields for a decade. "All refractive surgery must be considered to a certain extent unpredictable, and all has some risk." A US group whose members have had post-surgery complications publishes descriptions of their bad experiences on its web site, and is lobbying for surgeons to provide better pre-operative information and aftercare for complications. Mitch Ferro, an internet product manager in Virginia, writes on www.surgicaleyes.org  that he was left with haloes, starbursts, dry eyes, sensitivity to bright light and diminished vision: "I would pay any amount of money to get my pre-surgical corneas back." 

The Home Office last year issued strict guidelines on laser surgery recruits joining the police force, and the fire brigade discourages it. Manek Patel, an opthalmic surgeon for Optimax in London, says that in spite of the scare stories, most people are satisfied with the results: "If it caused permanent damage, we would be told we couldn't do it any more, nor would we want to do it." Optimax operates only on those with healthy eyes who will gain at least a 90 per cent advantage. Mr Patel advises prospective patients to get a reference for a surgeon from someone who is pleased with their operation, to ask lots of questions at the consultation and not to proceed if there are doubts. .

Do Night Lights Lead To Nearsightedness?

Leaving a light on in a sleeping infant's room will not increase the chance of that child becoming nearsighted, according to a new study published in the journal Nature. The study, conducted by researchers at The Ohio State University, The New England College of Optometry The University of Alabama at Birmingham,The University of Houston and The Southern California College of Optometry, contradicts previous research published in the May 1999 issue of Nature that found babies younger than two who slept with a night light were at an increased risk of developing myopia later in life. The more recent study did, however, find a link between nearsighted parents and nearsighted children.

Tinted view

MANY CHILDREN who are struggling to read could be helped by wearing coloured contact lenses. The finding supports a theory linking dyslexia and other reading problems to distorted visual perception.

David Harris, a researcher at the Ultralase Clinic in Chester, was intrigued by patients who told him that tinted lenses prescribed to remedy poor colour vision also helped their reading. So he took 47 children and adults who had been diagnosed as dyslexic, and fitted them with different coloured lenses to find which colour made it easiest for them to read.

All the volunteers were then given reading tests with and without these lenses, and with lightly tinted "placebo" lenses that they were told had been specially designed to help with reading. On average, they read 6 words per minute faster with the placebo lenses and about 12 words per minute faster with the most effective coloured lenses--an improvement of about 15 per cent (Journal of the American Optometric Association, vol 70, p 629).

Harris thinks the treatment could best help those who experience visual distortions of print. "They see words moving, or patterns like snakes or rivers running through the text," he says.

One theory of how the lenses work, championed by John Stein of the University of Oxford, is that dyslexia is caused by defective nerve cells that form a pathway from the retina to the brain's visual cortex (New Scientist, 24 April, p 27). These cells respond most strongly to yellow-orange light, so coloured lenses may help by filtering this light.

The End Of Bifocals?

Does anyone enjoy wearing bifocals? How about the need to carry reading glasses in addition to regular glasses? Have you noticed that older people hold menus at arms length to read?

As the years pass and we reach our 40s we gradually lose our ability to focus on printed material or small objects that are up close. "Reading glasses" eventually become an unwelcome necessity of life.

This eye condition, caused by the effects of time, is known as presbyopia. If you don't yet have presbyopia, eventually you will. We all will.

For once, however, time truly is on our side. Very recently, an American ophthalmologist and physicist, Ronald A. Schachar, developed a procedure that restores the eye's natural ability to focus at close range.

It involves a  surgical technique called Surgical Reversal of Presbyopia (SRP), which uses a patented device explanted on the eye. The device restores the patient's vision to a functional level enjoyed at a much earlier stage of life.

The technique does not yet have FDA approval in the US, but is undergoing trials for approval. Meanwhile it has recieved European Union CE Mark certification and is currently generating revenues in International markets.

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Imagine what it would be like if each time you require a new prescription to correct your vision, new lenses could be inserted surgically in your eyes, eliminating the need for such "old-fashioned" vision correction methods as spectacles or contact lenses. Try to envision the time when advanced medications will prevent or cure eye conditions like cataracts or glaucoma. Ponder the possibility of life-long perfect vision, made possible by genetic engineering

Flights of fancy? Science fiction fantasies? Not necessarily. Not if you listen to the views of some of the world's leading eye care practitioners.

Recently, CIBA Vision conducted interviews with 37 leading eye care experts in nine countries -- Visionaries, the company calls them -- to learn about trends and innovations in vision correction -- and to identify the challenges ahead in meeting the eye care needs of tomorrow.

What's happening now?

Radical innovations such as genetic engineering probably won't appear any time soon. For now, practitioners and patients will continue to rely on eyeglasses, contact lenses and refractive surgery to correct vision. Advancements will depend on a rejuvenation of research -- into everything from the basics of how eye structures work to new materials for contact lenses, the Visionaries said.

Spectacles
Spectacles, now more lightweight and stylish than ever, will continue for the foreseeable future to be the most popular vision correction method. In fact, except for better lenses to address the needs of people who need reading glasses or bifocals, the Visionaries generally believed that glasses may have progressed as far as they can. Only success with genetic engineering to correct vision may unseat spectacles' dominance, the Visionaries predicted. However, radical innovations in contact lenses will go a long way to weaken their dominance of vision correction

Surgery
The newest vision correction option -- refractive surgery -- may sound attractive, but the Visionaries were hesitant to embrace it wholeheartedly, describing it as limited and risky. How so? It is primarily used to correct nearsightedness -- and its value for other eye conditions is not well established. Surgery is considered risky because of unknown long-term consequences and potentially irreversible eye damage if unskilled practitioners perform the procedure.

Among the refractive surgery techniques available today, some are proving more effective than others are. Radial keratotomy (RK) is on its way out, the Visionaries said, while photorefractive keratectomy (PRK) is here to stay in some form. Laser Intrastromal Keratomileusis (LASIK), though superior to PRK, requires the attention of a highly skilled surgeon, then aftercare by a highly skilled eye care practitioner.

Contact Lenses
Contact lenses, popular with adults and teens, could be better, the Visionaries said. They could be made of more comfortable materials -- materials that, at the same time, would better maintain eye health. Contact lenses, especially the kind that wearers dispose of daily, could be made more affordable. In fact, the Visionaries challenged the eye care industry to produce a soft daily disposable lens of consistently high quality, capable of matching the vision correction of rigid gas permeable lenses, and affordable enough that wearers would not be tempted to use them past the recommended period, i.e. a new pair each and every day.

Extended wear lenses -- the kind you can wear continuously for as long as 30 days and nights without jeopardizing eye health -- have long been a dream of eye care practitioners and lens wearers. But the Visionaries said that before the dream can be realized, issues related to safe extended wear must be addressed. Before an extended wear lens will find acceptance, they said, manufacturers will need to develop a lens material that will allow sufficient oxygen to pass through to the cornea -- even during sleep -- to ensure that eyes stay healthy.

Referring to rigid gas permeable lenses, the Visionaries again called for greater comfort. Noting that the population is aging in many countries, the Visionaries also cited the need for improved bifocal contact lenses.

The future: What's in store?

And what did the Visionaries see on the horizon? Consider these possibilities.

Using advanced information technologies, you may soon carry with you a CD-ROM containing your complete eye health records. This electronic medical summary will enable all practitioners, no matter where you go, to better serve you.

You will probably be savvier about taking care of your vision. Through education efforts sponsored by the profession and health care organization, you'll be exposed to the latest thinking on vision correction choices that can prevent or slow the onset of vision conditions.

The role of your eye doctor -- optometrist, ophthalmologist or optician -- is likely to undergo change, especially in markets where the push is to control the costs of eye care. In the future, you may well visit a "shared care" clinic where the expertise of a range of eye care specialties is available. You will be directed to the practitioner whose expertise best suits your vision care needs.