TITLE:  "Keratorefractive Surgery, Success, and the Public Health"

Editorial
Dr. Leo J. Maguire
Mayo Clinic
American Journal of Ophthalmology
Volume 117, Number 3
March, 1994

"We need to think in detail about corneal optics after refractive surgery because the
normal cornea is relatively trouble-free.  The cornea after refractive surgery is not
trouble-free.  It frequently has a more aberrated optical performance than its pre-
operative counterpart.  It is often unstable during diurnal cycles and in time periods
measured in months and years.  Its optical performance can even change
instantaneously with changes in pupil size."

"In 1988 Consumer Reports magazine reviewed the data on radial keratonomy
and advised its readers against the procedure.  They reconfirmed that judgment
in their 1992 health letter."

"When the cornea is irregular over the entrance pupil, the image generated by
the cornea loses contrast and edge definition.  Glare and ghost images can occur
that are particularly disturbing under conditions of low illumination."

"These effects occur in disturbingly hgih numbers of cases.  For example, a
recent topographic study foudn that only 42% of 97 consecutive cases of
excimer laser photorefractive keratectomy for myopia showed a uniform
pattern of refractive power within the ablation zone; 10% had distortion severe
enough to cause spontaneous complaints of aberration in central vision."

"Unfortunately many authorities continue to assume that these procedures are
an unqualified success as long as uncorrected visual acuity is 20/40 or better."

"DIAMETER OF CLEAR OPTICAL ZONE FOR GLARE-FREE DISTANCE
VISION"

<table>
horizontal axis ... pupil size, in mm
vertical axis ... visual field radius, in degrees

"What factors raise concern about visual performance at night ??  First, the
pupil enlarges.  As it does, aberration of central vision increases as more
distorted paracentral cornea falls within the pupillary space."

"Holladay and associates' study found pupil-induced changes in refractive
error in 36% of the Prospective Evaluation of Radial Keratotomy subgroup
he studied compared with 9% of controls."

"People die at night in motor vehicle accidents four times as frequently as
they do during the day and these figures are adjusted for miles driven.
Night driving presents a hazardous visual experience to adults without
aberration.  When we discuss aberration at night we are considering a
possible morbid effect of refractive surgery."

TITLE:  "How to Answer the Irregular Astigmatism Challenge"

September 1994
Review of Ophthalmology

W. Andrew Maxwell, MD, PhD
Fresno, Calif.

"Here's how to diagnose and manage this frustrating refractive complication."

<a little section below the article above>

SUBTITLE:  "What causes Irregular Corneal Astigmatism?"

"Here are etiologies to consider:

*  An irregular corneal surface, due to edema, keratoconjunctivitis sicca or
    subepithelial scarring;
*  Central or paracentral thinning, due to keratoconus or pellucid degeneration;
*  Marginal corneal thinning, due to Terrien's degeneration, rheumatic
    keratopathy or Mooren's ulcer;
*  Trama from lacerations or chemical burns;
*  External pressure from contact lens warpage, an eyelid mass, or eye rubbing; or
*  Surgery, including penetrating keratoplasty, cataract extraction and refractive
    surgery."

"News and Trends"
October 1994
Review of Ophthalmology

TITLE:  " "Exaggerated" RK Advertising Prompts FTC Investigation"

"Are refractive surgeons who advertise claims of "life without lenses" to
prospective patients guilty of false advertising ??  The Federal Trade
Commission has reportedly begun an investigation to determine whether
such claims are misleading in light of several lawsuits filed against surgeons
by dissatisfied patients, sources say."

"I understand that the FTC wants to protect the consumer, but I personally
think we have enough government intervention already," says Florida's Eric
Rothchild, MD.  "Government is involved enough in ophthalmology with
Medicare.  Why get government involved in refractive surgery ??" he says."

January, 1995
Review of Ophthalmology
TITLE:  "Why Spin Doctor PRK"
Stan Herrin, Editor in Chief

"In the early 1980's, a couple of years after radial keratotomy first made its appearance in this country, the media discovered the procedure and hailed it as a "miracle" operation that would allow people to throw away their glasses and contact lenses forever."

"Unlike radial keratotomy,  PRK cannot stand a "starvation period."  There is too much investment involved."

"We can't control the coverage of excimer PRK, but we can do a lot to "spin doctor" it.  Let's not repeat our mistakes of the past."

"Ophthalmologists as well as the excimer laser industry should work hard to make sure excimer PRK does not get oversold."

March 1995

TITLE:  "Understanding Wound Healing after Refractive Surgery"

"Descemet's Membrane and the endothelium.  Because of its low wavelength, excimer laser energy cannot penetrate corneal tissue beyond a few microns.  Direct injury to Descemet's membrane or the endothelium is therefore unlikely.  However, there is a possibility of endothelial damage due to shock waves, fluorescence, secondary irradiation and posterior migration of toxic byproducts."

"Variability in corneal wound healing following refractive surgical procedures may explain the differences in individual refractive correction and visual outcome.  It may be the ultimate determinant of success or failure in patients after refractive surgery."

TITLE:  "Evaluating New Refractive Surgical Procedures:
Free Market Madness Versus Regulatory Rigor Mortis"

George O. Waring III, MD, FACS, FRCOphth

"The urge to use the latest surgical technique is particularly strong in refractive surgery because development is rapid, surgeons want to offer patients the most current advantages, there is a prevalent attitude of hype, competition is intense to gain professional leadership, and the economic stakes are high for both practitioners and industry.  These factors push unproven techniques into clinical use before their advantages and disadvantages are well defined, creating a pattern of free market madness that is unhealthy for refractive surgeons and patients."

SUBTITLE:  "PROBLEMS WITH THE AGGRESSIVE MARKET APPROACH"

"All of the above procedures have increased our knowledge of refractive surgery but I think the clinical morbidity has been too great, as a result of free market madness and its resultant flaws:

1.  The interests of surgeons are put before the interests of patients.
2.  Too many procedures are done on too many patients before the risks and benefits are
 well defined.
3.  The surgeon's true belief that each technique is a real advance reduces his or her ability
 to see and report complications and then to document the reasons that the procedure
 was stopped or changed.
4.  There is inadequate collection and reporting of early clinical data.

<Note:  this article discussed the histories of the following 3 procedures:
 1.  Hexagonal Keratotomy for Hyperopia.
 2.  Myopic Epikeratoplasty.
 3.  ALK, Automated Lamellar Keratoplasty.>

FTC Requests consent to marketing guidelines
November 13th, 1995
Ocular Surgery News Intelligence Report

TITLE:  "FTC requests consent to marketing guidelines"

"Washington, D.C. -- Ophthalmic practices under investigation by the Federal Trade Commission for marketing refractive surgery were sent individual "consent decrees" requesting adherence to a set of advertising guidelines."

"The FTC guidelines as described by the Washington firm of Arent, Fox, Kintner, Plotkin, & Kahn reportedly reflect the FTC's current stance on refractive surgery marketing and the essence of the consent decrees."

"The International Society of Refractive Surgery (ISRS) worries that the FTC's views on marketing refractive surgery will dampen acceptance and development of the procedures.  The FTC appears to believe that 10-year data -- such as provided by the Prospective Evalutaion of Radial Keratotomy study -- are needed to support claims about predictability and stability."

Ocular Surgery News
December 1, 1995
OSN Roundtable
TITLE:  "The future of cornea/external disease"

Michael Vrabec, MD
"I always assume first that patients are spectacle and contact lens intolerant."

Ocular Surgery News
February 15, 1996
TITLE:  "Just how secure is the flap with LASIK?"

"One question that needs to be answered is "just how secure is the flap anyway?"  The beginning of an answer to this question can be found in a most interesting patient one day after a LASIK procedure."

<The article goes on to describe a young man who was struck by a wire across the eye one day post-op.  This resulted in a corneal abrasion and micro-striae in the flap.  The original question was not answered, relative to the majority of LASIK patients.>

Ocular Surgery News
March 15, 1996

TITLE:  "Patient's third enhancement procedure"

by Lisa A. Kearns

"Many optometrists feared refractive surgery would put them out of business.  In my experience, the opposite is true.  Instead of needing new lenses once every couple of years, I now need new ones at least every couple of months."

Ocular Surgery News
June, 1996

TITLE:  "Clear-lens extraction, LASIK successfully treat high myopia, but not without risk.  Both procedures offer predictable results, but both carry threat of serious complications."

by Harvey Black

"Complications exist with LASIK, as well.  Endothelial cell loss, which occurred in one patient, is an example. "In this patient, only 180 micrometers was left after stromal ablation.  You need more than 180 micrometers after stromal ablation to protect the endothelium," he said."

<"He" in this section refers to Joon Y. Kim, MD.>

Ocular Surgery News
October 1, 1996

TITLE:  "Ophthalmologists to FDA:  Get off our backs"
SUBTITLE:  "The Food and Drug Administration invited public comment.  Boy, did they get it."

"Ralph Berkeley, MD, of Houston's Mann Berkeley Eye Center, told the panel he traveled to the nation's capitol because noninterference with a physician's practice of medicine is in patients' best interests."

Ocular Surgery News
October 1, 1996

TITLE:  "FDA should expedite approval of expanded laser uses"

by J. Robert Griffin, MD

"Excimer laser manufacturers in the United States and elsewhere have spent eight years and more than $100 million seeking Food and Drug Adminitration (FDA) approval to use their devices to treat nearsightedness, astigmatism and farsightedness."

"Ophthalmic Mutual Insurance Company, the medical liability carrier that came into being with the help of the American Academy of Ophthalmology, initially approved all off-label uses, except for simultaneous bilateral treatment, believing that such bilateral treatment posed an unacceptably high liability risk."

"Many ophthalmologists regard LASIK as the off-label laser refractive surgical procedure with the greatest potential to cause harm to a patient.  Extended visual disability and profound, permanent impairment of vision have followed globe perforation with the microkeratome.  Other, less serious but more common misadventures with the microkeratome include the various corneal flap problems, which result in extended visual disability and reduced visual function."

Checklist of Information Usually Submitted in an Investigational Device Exemptions (IDE) Application for Refractive Surgery Lasers
October 10, 1996
United States Food and Drug Administration
WWW code 9/42

p. 14

"3.2.6.2 Complications

E.  Foreign Body Sensation at 1 month or later
F.  Pain at one month or later"

"3.3 Risk/Benefit Analysis

The risks of performing (PRK/LASIK) on sighted eyes include improper correction, decrease in best corrected visual acuity, glare, halo, foreign body sensations, corneal scarring, corneal ulceration or perforation, intraocular infection, corneal decompensation,
persistent corneal edema, hyphema, hypopyon, endophthalmitis, microbial keratitis or cataract.  Also the long term risks of the procedure are unknown.  The LASIK procedure has additional risks related to the characteristics of the microkeratome."

WWW code 14/42
United States Food and Drug Administration
TITLE:  "Not a Cure-All:  Eye Surgery Helps Some See Better"
by Marian Segal
December 1996

"The procedures should not be done on patients with connective tissue diseases such as rheumatoid arthritis or lupus erythematosus, or on people with uncontrolled diabetes, autoimmune disease, or some eye diseases such as poorly controlled glaucoma, macular disease, retinal problems, extremely dry eyes, and certain corneal problems."

Ocular Surgery News
January, 1997
TITLE: "LASIK dominates refractive surgery's ongoing evolution"
SUBTITLE:  "While clinical trials continue for all refractive procedures, many companies
consider LASIK to be the brass ring."
January 1, 1997

"The significance of LASIK is much higher than people initially thought," said
Daniel S. Durrie, M.D., Refractive Surgery Section Editor for the Ocular Surgery
News Editorial Board and a surgeon in Kansas City, Mo. "It gives the patients
more of what they want. They want to have a quick visual recovery and no pain."

SUB-TITLE:  "Companies advance trials"

"For your information"
"_____ has a financial interest in products mentioned in this article. He is a paid
consultant for _____."

Ocular Surgery News
February 1997
TITLE:  "Microkeratome may provide smoother surface excisions than others, or
the excimer."
by Bob Kronemyer
SUBTITLE:  "UniversalKeratome "traps" the cornea in a PMMA disk; disk can
be customized to cut any shape."

"Scottsdale, U.S.A. -- A recently introduced microkeratome employs a PMMA
disk that allows surgeons the ability to cut corneal tissue to any shape."

"Our microkeratome differs from all other microkeratomes in that the cornea is
trapped in a PMMA disk, then cut," explained Perry S. Binder, MD, medical
director of the UniversalKeratome's (UK) manufacturer, Phoenix Keratek Inc.,
which is located here.

"Dr. Binder, who owns stock in the company, said, "The first key benefit of
this technique is that you can design the PMMA disk to cut any shape you want."
The UK system permits a surgeon to alter the profile of tissue to be removed,
similar to the way an excimer laser removes tissue. "It is the only microkeratome
that can remove optically shaped pieces of tissue," he said.

"The UK has been on the market for 1 year and retails for about US $50,000."
"Scanning electron microscopy was used to compare the UK to excimer laser
PRK. Dr. Binder said that predicted tissue excision shape, diameter and thickness
were superior with the UK for KMIS. Clinical KMIS cases were undercorrected
using the initial algorithm, whereas the LASIK cases were more predictably
corrected."

"For both sets of experiments, "We've answered the question of smoothness,"
said Dr. Binder. "But what we have to answer now is predictability and wound
healing response. Those are the two remaining issues requiring further study."

< KMIS = keratomileusis in situ >
< PMMA = polymethyl methacrylate ?? >

March 1997
Ocular Surgery News
TITLE:  "Avoiding LASIK complications takes patience"

SUBTITLE:  "The quality of the keratectomy and the thickness of the cap are crucial in avoiding irregular astigmatism, the most common complication."

By Lee T. Nordan, MD

"Three important elements come to mind when discussing LASIK:  the quality of postoperative vision; stability of the visual results; and the safety of the procedure."

SUBTITLE:  "Millimeters Matter"

"The cap must be at least .12 mm thick; remember Bowman's membrane and the epithelium are approximately .08 mm thick.  If the cap is thinner than .12 mm, Bowman's membrane may be entered, thereby causing irregular astigmatism and poor quality of vision.  The minimum thickness the surgeon should attempt to cut is 0.16 mm."

"Too often surgeons know the keratectomy they have created is mediocre at best, but they think the laser will somehow keep irregular astigmatism from developing.  Nothing could be farther from the truth."

Journal of Cataract & Refractive Surgery
April 1997
TITLE:  "Laser in situ Keratomileusis to correct high myopia"

"Current surgical algorithms must be modified to improve predictability in higher corrections.  Longer follow-up is necessary to evaluate long-term evidence of vision-threatening complications."

Cornea
May 1997
TITLE:  "Epithelial growth withing the lamellar interface after laser in situ keratomileusis."

Helena MC, Meisler D, Wilson SE

"Each eye with epithelium within the interface after LASIK developed interface opacities and surface irregularity."

"CONCLUSIONS:  The presence of epithelium within the lamellar interface is a significant complication after LASIK."

Journal of Refractive Surgery
May/June 1997

TITLE:  "Quality of Vision and Freedom from Optical Correction after Refractive Surgery"

George O. Waring III, MD, FACS, FRCOphth

"Unfortunately, published data on how many patients wear spectacles and contact lenses after refractive surgery is almost nonexistent -- a remarkable indictment of clinical repporting from the refractive surgery community, since the most important criterion for success for patients who have refractive surgery is freedom from corrective lenses.

"It is not only the refractive outcome after surgery that determines spectacle wearing status, but also the stability of refraction over time."

PAIN

Journal of Refractive Surgery
August 1997
TITLE:  "LASIK for Myopia of -1 to -3.50 Diopters"
Pirzada & Kalaawry

"Mild discomfort was felt by all patients but the majority reported no perioperative or postoperative pain."

Journal of Refractive Surgery
August 1997

TITLE:  "First Year Experience with Laser in situ Keratomileusis"

John Hill, FRCS, MD

"The induced astigmatism is of concern."

Primary Care Optometry News
"Dry eye may be at the root of your troubled postoperative corneas"
Paul M. Karpecki, OD
November 1997

"The majority of patients who elect to undergo refractive surgery are contact lens intolerant.  Because a primary cause of contact lens intolerance is dry eye, this article will focus on dry eye conditions."

Journal of Refractive Surgery
1997 Nov-Dec
TITLE:  "Treatment of Irregular Astigmatism with a broad beam excimer laser"

Buzard KA, Fundingsland BR

"CONCLUSIONS:  Irregular astigmatism is an important complication of refractive surgery."

Airplane Owners and Pilots Association Magazine
Ingrid E. Zimmer-Galler, MD, is a vitreo-retinal surgeon at the Wilmer Eye Institute of Johns Hopkiins Hospital in Baltimore.
December 1997

TITLE:  "Eyecare Options - Surgery Can Improve Your Vision - But There Are Risks"

"At high altitudes, pesons who have had RK may temporarily become farsighted.  Although this is reversible upon returning to lower altitudes, fluctuations in altitude may lead to fluctuations in vision.  This is obviously a potential problem for pilots.  Thus far, this effect has not been detected in patients after PRK or LASIK procedures.  A small percentage of patients may be more susceptible to glaucoma after the procedure.  Until further research trials are completed, the long term safety and effectiveness of PRK and LASIK are not yet entirely understood."

Ocular Surgery News
TITLE:  "Etiology and Prevention of Microstriations following LASIK"
by F.L. Lavery, FRCS
December 15, 1997

"They can result in irregular astigmatism, causing reduced best corrected visual acuity.  Once present they are, in my view, virtually impossible to eradicate.  They do have a natural tendency to lessen over a long period of time.  More commonly, they are permanent to some degree."

Journal of Refractive Surgery
January/February 1998

TITLE:  "Peripheral Melt of Flap after Laser in situ Keratomileusis"

Alfredo Castillo, MD, PhD, et al

"Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia.  It may have complications related to the flap, such as epithelial ingrowth and stromal melt."

"We report on a patient who developed extensive epithelial ingrowth and partial keratolysis of the flap following LASIK.  This complication was treated by lifting the flap and removing the epithelium from within the interface."

"Progressive kerolysis (stromal melt) can result in irregular astigmatism and loss of vision as well as photophobic and ciliary injection.  The pathogenesis is not completely understood although the epithelial ingrowth in the interface is always present, and epithelial-stromal interaction with production of proteases may be involved."

BLEPHARITIS
DRY EYE SYNDROME

Ophthalmic Devices Advisory Panel
Friday, Feb. 13, 1998
WWW Code 1/42

"Precautions should include:  Severe dry eye syndrome, glaucoma; uveitis; blepharitis; psoriasis; immunosuppression; keratoconus without thinning; pregnancy, and systemic or topical use of steroids."

Dr. Kremer

"We assessed patient symptoms following these procedures, and we have listed here the incidence of settings in which the patients felt that they had these symptoms to a bothersome degree.  That would include bothersome glare, bothersome halos, difficulty with night driving, ghosts or double images, foreign body sensation, anxiety, and pain.  We stratified these symptoms based upon their postoperative refraction and, as you might expect, they tended to be more prevalent in patients who had a larger residual refraction."

Ocular Surgery News
March 15 1998

"One of the most commonly unnoticed or misdiagnosed ocular conditions is keratitis sicca, or dry eye syndrome.  Dry eye patients' complaints range from burning, redness, foreign body sensation and photophobia, to stringy mucus, sandy or gritty sensation and tearing, all of which are characteristics of other ocular diseases and disorders."

"Dry eye is a very common eye problem, especially in women and the elderly.  It is the chief reason for patients' inability to wear contact lenses comfortably."

"There are a number of tests used to determine the severity of dry eye syndrome."

"Other nonsurgical treatments include moisture goggles, ointments and plastic eye shields."

Ocular Surgery News
April, 1998

TITLE:  "CRS-USA data indicate postop LASIK complications most threatening to vision."

SUBTITLE:  "The CRS-USA study expected but did not find that intraoperative problems would cause more losses of one of more lines of acuity."

"Unlike intraoperative complications, postoperative complications did show a slight but statistically significant increase in loss of best lines of BCVA."

"We always thought it would be the other way around," Dr. Casebeer said.  "The intraoperative complications with the keratome can be pretty wild."

"Irregular cuts resulted in damage to the stromal bed in 0.03% of LASIK operations, Dr. Casebeer said, while damage to the epithelium during the course of the keratectomy occurred in 0.47%."

"Post-operatively, the study found an overall complication rate of 5.8%.  Complications included corneal edema (0.6%), corneal scar (0.1%), persistent epithelial defect (0.5%), significant glare (0.2%), persistent discomfort or pain (0.5%), interface debris (3.2%), interface epithelium (0.6%) and cap thinning (0.1%).  Some single cases with complications were reported as two events."

"CRS broke out 754 eyes that were treated for spherical error only, with no treatment for astigmatism.  At 3 months, 106 patients reported one or more lines of vision lost.

In 65% of these cases, surgeons attributed the loss of acuity to laser-induced problems, including decentered ablations or irregular astigmatism.  Only 13% of cases could be attributed to a problem with the keratome, with the remaining 22% categorized as uncertain etiology, Dr. Kezirian said."

Ocular Surgery News
April 1998

"An extremely rare, unexplained and potentially sight-threatening complication associated with laser in situ keratomileusis (LASIK) has been anecdotally reported by several refractive surgeons across the United States following both refractive procedures and enhancements."

"The effect, known as diffuse lamellar keratitis, has been nicknamed "Sands of the Sahara" syndrome by Robert "Bobby" Maddox, MD, because it is characterized by a film that manifests within the chatter ridges left behind by the microkeratome blade, and resembles wind-sifted sand or powder."

Ocular Surgery News
April 15, 1998

TITLE:  "LASIK:  Retreating the back of the flap"

by Michael C. Knorz, MD

"I have been involved with LASIK from the early days.  Back in 1993, we used a flap thickness of 130 micrometers.  Later on, a flap thickness of 160 micrometers became the accepted standard.  A thicker flap is more stable and, therefore, both easier to handle and less likely to wrinkle and cause irregular astigmatism.  A disadvantage of the thicker flap is that it leaves less stroma to be ablated.  The thickness of the stromal bed, however, is the most important factor to prevent progressive corneal ectasia causing significant visual loss."

"I have seen some cases of keratectasia, which usually develop 1 to 2 years after the initial surgery.  It usually presents as a very steep central island, as the cornea is thinnest in the center and, therefore, most likely to become ectatic centrally.  In all cases, the thickness of the stromal bed was less than 200 micrometers, in some cases even less than 150 micrometers.  In order to prevent late keratectasia, we must leave a stromal bed of at least 200 micrometers, probably even 250 micrometers.

Monograph to the June 1, 1998 issue
Ocular Surgery News

TITLE:  "Evolving Trends, Techniques, & Pearls in Cataract and Refractive Surgery"

SUBTITLE:  "Cataract Surgery:  Medical Regimen and Postoperative Outcomes"

Richard L. Lindstrom, MD:  "In particular, we will address the ocular surface with regard to prevention and reduction of toxicity."

"We have been working toward the reduction and prevention of significant inflammation in surgery.  The ocular surface in some older patients with dry eyes and blepharitis is badly damaged during cataract surgery, particularly with topical anesthesia."

SUBTITLE:  "Refractive Surgery"

"Lindstrom:  We have found that a good patient is the contact lens patient."

SUBTITLE:  "LASIK Pearls"

Lindstrom:  "The worst case that I have seen in refractive surgery, in patients that I have done, is a patient who needed a corneal transplant."

SUBTITLE:  "The Process"

"Machat:  Patients always complain that the second eye hurts more than the first eye, which is absolutely true."

Lindstrom:  "Also, they have more epithelial problems with the second eye."

"Kelley:  You will see a host of patients with superficial keratitis one day postop, probably from not blinking."  "I tell these patients that they will need to keep a bottle of drops with them at all times, and to use them often because they have lost their "windshield."  They have spent their entire adult life and most of their childhood with either a contact or a pair of glasses in front of their cornea and now they are going to feel dry for months or more."

Lindstrom:  "Does anybody else have any suggestions for reducing the interface debris ?  How much do you irrigate."

"Machat:  If a patient has a little bit of debris it is not the end of the world.  It mainly effects your referrals, it does not affect their vision."

"OBrien:  This is the point of the operation where everybody has their own unique ritual."

SUBTITLE:  "The Future of LASIK"

Kelley:  "I think like any other operation, if we push its limit we are going to see problems.  If we make corneas too thin, if we make optic zones too small, we are going to have some unhappy patients."

Ocular Surgery News
August 1, 1998

TITLE:  "Which refractive procedure is preferred, LASIK or PRK ?"

SUBTITLE:  " "No-touch" PRK"

Donald G. Johnson, MD, FRCS:  "LASIK cannot and does not compare to the safety of the "no touch" technique."

SUBTITLE:  "Depends on degree of refractive error"

Roberto Zaldivar, MD:  "The real difficulty in LASIK is creating and manipulating the corneal flap."

SUBTITLE:  "LASIK"

Daniel S. Durrie, MD:  "I do convert one out of 400 patients in the operating room to PRK, if I feel that there is inadequate post suction pressure or some other reason that indicates to me that a patient is not a good candidate for LASIK."

"I limit LASIK to patients whose corneas are thick enough to leave at least 200 micrometers of residual cornea and whose pupils are small enough so they will not have significant glare."

SUBTITLE:  "LASIK"

Peter S. Hersh, MD:  "The patient, therefore, can return to his or her normal routine sooner with LASIK.  I do not perform simultaneous bilateral surgery, however.  First, I do feel there are increased risks involved; although severe bilateral complications are rare, we know all too well that not all patients are happy, even with uncomplicated surgery."

Ocular Surgery News
Special Meeting Report
Dec. 15, 1999

TITLE:  "LASIK-dry eye connection gets attention at AAO-PAAO"

"At this year's meeting, there was an emerging recognition of an important complication of laser in situ keratomileusis (LASIK) -- postoperative dry eye.

"During his keynote address in a session on LASIK complications and their management at the Refractive Surgery Subspecialty Day, Richard L. Lindstrom, MD, noted the the overall frequency of complications after LASIK is decreasing.  Severe vision loss after LASIK is now a rare occurrence."

"However, he said, dry eye is being seen with increasing frequency, is making patients very unhappy and must be recognized and treated aggressively.  In his practice in Minneapolis, he said, he often uses punctal occlusion to address patient complaints of dry eye."

Roger Steinert, MD, echoed these remarks in his address later in the same complications session.  He noted that LASIK patients tend to be "self-selected dry eye patients."  That is, many seek LASIK because of contact lens intolerance.  He too noted that silicone punctum plugs are being used frequently in his practice."