Friday, December 30, 2011

Dr. Hyver

We finally went to our consultation with Dr. Hyver. The first thing we noticed immediately was that Dr. Hyver's office was a busy place. He has three offices which he bounces around. This tells me that his volume is high. There was already three individuals waiting there when we arrived. Based on that evidence, he is clearly more busy than the other two doctors we went to.

On the walls were 49ers posters, namely Patrick Willis and Joe Staley. As a 49ers fan, this has a weird comforting draw to it. If P52 and Joe Staley got LASIK with Dr. Hyver, then he must be good! Isn't marketing amazing?

After a good wait, we were finally on our way for the measurements on my wife's eyes. The first technician was dull, didn't say hi to me nor offered me a chair. She was very robotic and mechanical, "do this," "move here," "blink." Then boom, we were moved to another room where an optometrist further measured my wife's eyes. This guy was more lively and I can see that he enjoyed his job more. Finally, we were given a page to read about preparation for LASIK. Once we were done reading, we were lead to the doctor who probably buys more KNBR time than anyone else: Dr. Hyver.

My impression of him was that he has a cool calm demeanor, easy to speak to, and not cold as some Yelp reviews may indicate. He did not rush his answers but instead spoke slowly and calmly, unlike the other doctors who spoke like they had a flight to catch. It's a surprise that he is the easiest of the three doctors we've seen to speak with. It's only when we started asking questions that the highs turned low.

Question 1: On your website, it mentioned that you will perform tests to determine if wavefront-optimized or wavefront-guided procedures would be appropriate? His answer? "Well, our website is a little old and we haven't updated that yet. We have found that optimized work very well for the majority of our patients." In other words, he doesn't test for it and he doesn't provide "custom" or wavefront-guided procedures.

This is from his website word for word: In addition to Wavefront-Optimized LASIK, Dr. Hyver also offers Wavefront-Guided LASIK on the WAVE® Eye-Q laser. In cases where the patient has an unusual higher-order aberration map, Dr. Hyver may recommend Wavefront-Guided rather than Wavefront-Optimized LASIK. However, the vision results of these two technologies are essentially the same, with the Wavefront-Optimized solution producing a slightly higher rate of patients seeing 20/16 (i.e., better than 20/20).


Wavefront guided procedure requires an extra Allegro Analyzer which costs more money, 3 more of these for each of his offices, and the extra consultation required to to analyze your wavefront and set it. That cost time and money.

Question 2: How many years have you had your current laser and how many operations have you performed on it? He had to think for a bit on this which is good because I don't think he has a prepared answer. "I have had this machine for three years and...*pause*... I've performed about 9000 operations on it." Whoa! That is...alot of operations. The man is good and efficient. 3000 operations per year averages to 57 or so patients a week. Conveyor belt much? He's a very nice doctor, but there's no way he can provide personal service to his patients if he lasers 57 eyes a week.

We then asked him about PRK (he recommends LASIK), and pupil size (my wife's pupil is on the bigger size but nothing to be concerned of). Eventually, we finished and he lead us to the case consultant or whatever her title is. Interestingly enough, they do offer a lifetime guarantee of some sort. The only thing is that it's only if your  vision changes beyond -1D, 20/40 and precludes presbyobia. Hmmm...

Dr. Hyver seems like he's a very nice person. However, if we were to compare strictly technology, his technology is similar to Dr. Bindi's. However, his Ziemer femtosecond laser in my opinion is inferior to the iFS 150. His lifetime guarantee is nowhere as good as Bindi's. He does not provide a complete wavefront "custom" analysis or offer this custom procedure like Dr. Furlong's. The Allegretto is the laser of choice for the mass production of eyes. If you have low myopia then the Allegretto laser is not a bad choice. However, between Dr. Bindi and Dr. Hyver, the former appears to offer the better technology and better lifetime guarantee.

Thursday, December 29, 2011

Microkeretome or IntraLase?

Should you choose the Microkeretome or all laser? As with the femtosecond laser, there are arguments between surgeons on whether modern microkeretome blades or intralase is better. Historically, most LASIK problems were related to (a) blade and flap complications, (b) older technologies, and (c) inexperienced surgeons and procedures for unqualified patients.

Nowadays, there are still surgeons who prefer the microkeretome blade over intralase. Studies have shown that laser helps healing faster than some microkeretome, but there are conflicting findings. One thing that is not debatable is that intralase does help improve the flap adhesion better. The inverted bevel of the iFS intralase laser is superior. It's up to you if the quicker healing and stronger strength flap is worth the extra cost for intralase. Only Dr. Bindi and Dr. Manche has the iFS laser as of this writing. Dr. Furlong still uses the FS intralase. Dr. Hyver uses the Ziemer femtosecond laser.

This is a study of the 4th gen FS vs the Ziemer LDV. Another one.

Things to consider is that NASA and the US military only approves intralase and not a microkeretome blade so if you want the military and NASA’s approved method: it’s wavefront-guided LASIK with bladeless flap femtosecond laser.

 References:
http://www.escrs.org/Publications/Eurotimes/08Feb/NASAapprovesalllaser.pdf
http://www.allaboutvision.com/visionsurgery/blade-vs-bladeless.htm
http://www.escrs.org/Publications/Eurotimes/06March/Pdf/Studiesexplorepros.pdf
http://www.crstoday.com/PDF%20Articles/0906/CRST0906_PR.pdf
http://www.ncbi.nlm.nih.gov/pubmed/19044226
http://freevis-lasik-zentren.org/knorz/Knorz_FlapAdhesion_JRS_2008.pdf
http://www.ziemergroup.com/fileadmin/media/media_events/ASCRS_2010_Boston/10_FemtoLDV_Z-LASIK_Durrie_ASCRS10.pdf
http://cxlcongress.com/presentations/Waring_IntralaservsZiemer.pdf

Wavefront-Optimized versus Wavefront-Guided

All surgeons tout some form of wavefront LASIK. However, not all are custom LASIK. All doctors have a preference for one laser over another. Since they are human, bias are built into their thinking. All of the modern lasers have a per click charge for each use. For example, the Allegretto laser charges about $250 per eye. Additionally, the cost of the system cost about $300k to purchase. Add in maintenance fees of $25-$50k a year, and you can see why LASIK with modern technology cost so much. For all laser LASIK, the cost is even higher because femtosecond lasers also adds in a per click cost per eye. In general, the wavefront-guided solution cost on average of $250-$500 per eye more. (Update 1/4/12: I cannot find corroborating evidence of this.) (Update 1/9/12: I knew I didn't just pull the numbers out of my nether region; I have found references on wavefront-guided as being more expensive:
Cost. Custom wavefront treatments add significantly to the costs of performing LASIK. These increased costs lead patients to expect more from their treatments, and we know that unmet expectations are a significant factor in litigation. The higher costs of custom treatments is not justifiable if the aberrometers are simply acting as autorefractors, or if improvements can be traced to better lasers and better nomograms
the VISX laser is, objectively:the most expensive to buythe most expensive to operate/usehas the greatest market share by far (more than all other brands combined in the USA
There is no getting around the fact that wavefront-guided LASIK uses much higher technology and is more expensive. It would be the same as saying that a computer is higher technology and more expensive than an abacus or slide rule. We would all agree that a computer is well worth the extra expense.

Therefore, don't compare optimized with guided and pick the cheaper one as if they are all equal. Wavefront-guided tend to cost $500 to $1000 more than optimized for both eyes! (Ditto)

Most studies indicate that for low myopia, wavefront-optimized and wavefront-guided differences are statistically insignificant. Both lasers provide equally excellent results.  However, wavefront-guided is slightly better to correct higher order aberrations. Guided also has a higher percentage of 20/16 vision.
 The percentages of eyes that achieved 20/16 or better vision in the groups that underwent wavefront-guided and wavefront-optimized LASIK, respectively, at 3 months was 40.2% and 20% for –0.75 to –2 D; 35% and 17.4% for –2.01 to –4 D; 28% and 15.7% for –4.01 to –6 D; 22.5% and 17.6% for –6.01 to –8 D; and 16.3% and 19% for greater than –8 D.
The higher your prescription, the lower the chance of achieving 20/16 vision. However, the chances of achieving it using wavefront-guided is almost 100% higher for myopia between between -75 to -6 than optimized! That is statisticaly significant!

If your wavefront report shows an RMS error of .3 or higher for HOA, the wavefront-guided method is supposedly superior based on various clinical studies. So make sure you ask for the wavefront report from your consultation before you make a decision! Studies after studies have shown that wavefront-guided is superior for eyes with RMS error of HOA of .3 microns or higher. Additionally, for myopia between -2 and -4, optimized and guided provide statistically insignificant differences in the results. However, higher than -4 and the guided technique proves superior.

Update (12/29/11): Dr. Bindi Emailed me this study by Dr. Kezirian which compares very favorably for the wavelight. It is dated 2004 and many studies have been done since. Keep in mind that Dr. Kezirian is paid a consultant for Alcon which is the parrent company of the the wavelight. All FDA studies performed by the manufacturer are biased to the manufacturer. Studies by Dr. Manche is more current and his facility owns both the Wavelight and the VISX S4. Dr Manche prefers the guided solution for eyes with higher HOA and myopia.

The FDA does not currently approve any laser for correcting HOA even though clinical studies have shown that wavefront-guided does just that. Furthermore, all eyes have some form of HOA and certain HOA actually improves the vision due to the particular of those eyes. The studies have shown that wavefront-optimized and guided limits creation of HOA. Guided wavefront actually attempts to correct HOA. This is the reason why the recommendation is to use guided if you already have high existing HOA. Furthermore, All LASIK procedures have a tendency create HOA as a result of the surgery. Standard LASIK creates far more HOA than newer wavefront-optimized, while wavefront-guided does an even better job than wavefront-optimized in limiting the HOA.

So if you ask the doctor what is the best solution and he answers wavefront-guided, don't immediately think he wants to rip you off. It is not because it cost the most, but it is because studies have proven that it is the best solution money can buy. It is up to you if the differences in a few percentage points is worth the additional cost.

Finally, the thing to remember is that LASIK is not forever. Even people with normal eyesight, their eyes will eventually get worse as they reach age 40 and higher. However, for my wife whose eyes are in the 5.25 range, a regression of -.5 to -1 after ten years is still far better than her current practical blindness right now.

References:
http://www.ncbi.nlm.nih.gov/pubmed/21946784.
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/LASIK-outcomes-compared/ArticleStandard/Article/detail/698223
http://www.la-sight.com/los-angeles-lasik-prk-eye-surgery/allegretto-technology/wavefront-lasers-compared.aspx (updated 12/29/11)
(Updated 1/9/12)
http://www.lasiksurgerynews.com/news/what-is-lasik-surgery.shtml
http://www.realself.com/question/allegretto-wave-compare-laser-eye-options-in-terms-effectiveness-source-answers
http://www.allaboutvision.com/askdoc/custom-lasik.htm

Dr. Bindi & Dr. Furlong


My wife went to Dr. Bindi four years ago for a LASIK consultation. At that time, her eyes were still changing so she was declined as a potential LASIK candidate. She went back to see him last week for another consultation. This time, she was declared a candidate. They also had a $1000 off promotion. 

We also went to see Dr. Furlong at the recommendation of my wife's optometrist. Dr. Furlong was also the surgeon who did my cousin's eyes a while back. They offer VSP discount, however his price with discount is still $700 more than Dr. Bindi's. Bear in mind that we opted for the all-laser procedure.
 
After LASIK, we do not want to return to have an annual eye check. With TLC and Dr.Furlong, if you miss an eye appointment with one of their affiliated eye doctors, you may lose the lifetime guarantee! This TLC guarantee is rather weak if you analyze it. Dr. Bindi's lifetime guarantee is much better. He doesn't require an annual eye check at all.

Lifetime guarantees:  It’s better to have it than not. However, remember that only the physician can OK your enhancement request. Also, lifetime is for the lifetime of their business, which is true, but also for the viability of your cornea tissue. If you have thin corneas, chances are you may not be able to get too many enhancements even if you wanted to. Generally, after LASIK, if your cornea below the flap is around 300 microns, you are no longer a candidate for additional LASIK enhancements!

Update 12/30/11: Dr. Hyver also has a lifetime guarantee. The exception is that your sight must degrade by more than -1D and above 20/40. Also it precludes presbyopia. The presbyopia is a given since LASIK cannot fix presbyopia. However, most people would not have their vision degrade beyond -1D. This may be similar to the TLC guarantee.

Make sure you ask them to calculate how much left over of your cornea thickness after surgery. Most problems with ectasia had been due to thin cornea. My wife has an average 530 micron thickness, which is if you subtract 110 for the flap and 80 or so micron for the correction itself, she should have about 340 left which means about 40 micron is left for later correction. This is the reason I recommended that she choose PRK over LASIK. However, the longer recovery time plus the discomfort was too much for her. She chose LASIK instead. This is by far the most popular choice right now.

We initially leaned toward Dr. Bindi. He was initially extremely helpful in answering our questions via Emails. My wife prefers his lifetime guarantee better as well as only one consultation is required before the actual surgery. She doesn't like the exams. Superficially, this sounded better. However, if you dig down further, you will find that this is actually not optimal. I will detail the reason in a later post.

Dr. Bindi felt confident in his technology and based on the Yelp reviews, I assume there have not been any bad problems arising from his procedures. We believe the technologies are comparable for certain prescriptions. The more experienced surgeon should get better results with the technology he is more comfortable with. He also has the best intralase laser the iFS 150 which we liked. 

During our initial consultation, we asked him what's the difference between wavefront and custom LASIK. He said they are the same. Based on my research, this claim is strenuous at best. Wavefront-optimized is still based on your prescription, just like standard LASIK. However, it uses wavefront profiles to improve results. Custom LASIK actually uses customized measurements from  your eyes for the procedure. Strike one.

I continued to dig deeper and realized that there are subtle differences with the technologies. Before Christmas, we asked him a couple more difficult questions.
 A couple more questions. Can you tell me the size of my pupil and the thickness of my cornea? I read that wavefront-guided helps fix higher order aberrations. Do you use the allegro analyzer to determine if I have existing HOA that may require wavefront-guided. Do you offer that option if I require it?
He stopped replying to us after this question.  That’s too bad. Strike two.

The Laser Eye center website touts wavefront as the superior technology and links to studies of wavefront. If you read carefully at the studies, they are mostly for wavefront-guided studies. The 98% success rate in those studies is for the wavefront-guided VISX S4 and not the wavefront-optimized Allegretto Wave. Dr. Bindi does not offer wavefront-guided LASIK with the Allegretto or the VISX S4. It’s interesting that he would tout technology that he doesn’t even offer. Strike two and half?

Dr. Furlong stresses that he has better technology which was what prompted me to do further research. Had we not gone for a second opinion, we would have selected Dr. Bindi. Remember, every doctor will say his technology is better. It's up to you to sift through the information or misinformation.

During our second consultation with Dr. Furlong, my wife had a wavefront analysis done to her eyes. We asked for her report and it showed that her eyes had an HOA RMS error of .39 and .59. This means she has elevated higher order aberrations. Dr. Bindi's consultation does not test for this! Strike three.

We liked Dr. Bindi. Unfortunately, we will have to cross him off our list.

Wednesday, December 28, 2011

Three refractive surgeons


Refractive Surgeons

Doctors: There are three prominent LASIK doctors in the San Jose area: Dr. Bindi, Dr. Hyver, and Dr. Furlong. They do not all use the same technology. For all laser LASIK, there are two lasers that make up the procedure. One is the femtosecond laser which creates the flap and the second is the excimer laser that corrects the problem (myopia, hyperopia, or astigmatism). These are called lower ordered aberrations.

Both Dr. Bindi and Dr. Hyvrer prefers the Alcon Allegretto Wave Eye-Q 400hz laser. This laser is a wavefront-optimized laser, which uses wavefront-data to correct refractive errors. This type of system attempts to limit higher aberration errors. However, it does not attempt to correct the errors. This laser is overtaking the Nidek laser as the second most popular laser in the US. Dr. Bindi uses the most advanced intralase laser on the market, the iFS 150. Dr. Hyver uses the Ziemer LDV femtosecond laser.

The most popular laser system in the US is the Abbot Medical Supply (AMO) Visx S4 which currently controls 52% of the market share. This is also the laser of choice from Dr. Furlong. Dr. Manche of the Stanford Vision Center also prefers the Visx S4. The latest upgrade of the Visx S4 has the IR moniker. All Visx S4 has the capability of upgrading with IR. Visx S4 IR, and the WaveScan wavefront system when combined makes up the CustomVue. This is basically the trade name for the wavefront-guided LASIK system that AMO uses. CustomVue along with intralase FS or IFS femtosecond laser system is called  iLASIK.

We made appointment to see all three local doctors. We did not go see Dr. Manche. Dr. Manche is the opthamalogy professor at Stanford University. I would have preferred to see Dr. Manche as well. Unfortunately, he is the farthest away from us. His price is the highest and he also charges a $130 fee for the full wavescan pre-op appointment which could be rolled into the procedure if elected. He is one of, if not the top surgeon in the Bay Area and he charges accordingly.


Welcome!


This is a blog about my research into LASIK for my wife. Before we make any decision as important as elective surgery, we must understand at least as much as we possibly can. Our priority is always the best possible doctor and the technology that they use first and foremost, the secondary priority is the cost. The most money isn't always the best, but the cheapest should be avoided unless all things are equal.

I am not a doctor nor am I an expert in refractive surgery. The information in here are all gathered from the Internet sources (websites and studies) and interpreted based on my limited understanding of it. You should make the decision based on the doctor you feel comfortable with and then the technology that fits you. It’s your eyes, and generally speaking, LASIK is a one time deal--that is to say that you cannot change your mind after it's been done. You cannot return your surgery like a regular purchase. Do not make a decision based on cost alone. Research, research, research! Before you make a decision that changes your life forever, you should absolutely make sure you know the differences between the competing technologies! Make the best decision for your particular eyes and refractive error(s).