What is Wavefront Technology?

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Let’s Begin with a Quick Look at How Laser Vision Correction Works:

It’s helpful to look at common vision problems and the solutions that treat them. When you first realize you have a problem with your vision, you take a trip to the eye doctor and get checked for errors in your refraction. This helps determine how light is focused through your eye.

Errors in refraction or refractive errors, are the main cause of problems with visual acuity.  The most common are called lower-order aberrations. Examples of which are nearsightedness, farsightedness, and astigmatism. They are basically subtle imperfections in the way light passes through from the cornea—through the lens of the eye—to the retina—where the light is focused, which allows the eye to see images properly.
Treating individual refractive errors through glasses, contacts or laser vision correction are all successful ways of delivering clear vision to people. But the reality is each individual’s eyes also have their own, unique irregularities outside of the lower order aberrations. These can include ghost images, decreased contrast sensitivity in low light, glare, after-images, ghosting, and halos. This is where wavefront technology comes in.

What is Wavefront Technology?

The difference between a standard LASIK procedure and one that is wavefront optimized is that the former corrects only what your glasses fix, near- or farsightedness and astigmatism. This is around 90% to 95% of the total refractive error you have and are the lower-order aberrations. Wavefront-guided technology allows us to measure the smaller amount of higher-order aberration that’s left over, using what’s known as a wavefront aberrometer.

This technology measures the higher-order aberrations of the eye—the unique irregularities which affect the finer quality aspects of your vision. It does this by picking multiple spots in the visual pathway and producing a computerized, detailed map showing all the imperfections which exist in the visual system of an individual eye.

This is important point! Different aberrometers have different capabilities. Some are only able to record data from 60 points, whereas others as many as 1500. Think about the detail a watercolour captures compared to the accuracy of a HD camera. At Acuity, our aberrometer is manufactured by the samecompany that makes our laser system, and measures 1500 individuals points in the visual pathway for the most accurate determination of all the eye’s aberrations, both lower and higher order.

Today, advances in laser vision technology allow us to take a more holistic approach to vision correction. Now we can Geometric-Designnot only adjust your eyesight to correct common refractive errors, but according to your unique and individual optical irregularities as well. It’s only natural that such advances in technology should be embraced as the new norm rather than offered as expensive or rare add-ons. So make sure you choose Acuity and Dr. Steven Vale to get the best laser vision correction available anywhere at the most affordable prices!

An Overview and Tips for Your FREE Consultation


At Acuity we offer a free, no obligation LASIK consultation to ALL prospective patients. This is an information session about the procedures we offer, recovery and required appointments. Any questions you may have about the overall experience of laser vision correction will be addressed. During this session, our patient counselor will use an auto-refractor to determine your prescription. Based on this reading, a price for LASIK or PRK surgery will be determined. Your price will be based on your prescription, including any astigmatism. However, you will not definitively know if you are a candidate for laser vision correction until you have a pre-operative exam. You may schedule your pre-operative exam and consultation together if you wish.

Feel free to bring a friend or your spouse to your consultation!

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To schedule your consultation and/ or pre-operative exam call  877-520-EYES (3937)

Contact Lens Wearers: Because laser vision correction involves the reshaping of the cornea, it’s imperative that potential patients refrain from wearing prescribed contact lenses for specific periods prior to surgery, depending on the type of lenses. Contact lenses change the shape of the cornea and your cornea must be in it’s natural shape to make a precise correction possible. The recommended time periods to be out of your contact lenses are listed on the pamphlet below.

TIP: Verify the type of contact lenses you wear with your optometrist or ophthalmologist and plan to stop wearing your contact lenses for the recommended time period before scheduling your pre-operative exam.  

If you are beyond 40 years of age and notice a need for reading glasses:
Please be aware that laser vision correction is a reshaping of the cornea, and does not involve Geometric-Designsurgery inside the eye. The need for reading glasses or bifocals that occurs in most individuals around age 44 is believed to be the result of a weakening of the focusing muscle inside the eye. Laser vision correction can compensate greatly for this weakening but cannot stop the gradual weakening of the muscle.
We recommend Monovision for those who would like to reduce their dependence on reading glasses, in addition to removing astigmatism and/or correcting farsightedness or nearsightedness. Monovision generally involves correcting the dominant eye for distance viewing and the non-dominant eye for close up viewing or reading. A “monovision trial” during your pre-operative exam, using trial lenses, can establish that monovision is right for you. Most people find they are quickly able to adapt to using their non-dominant eye for their close-up viewing/reading. Those with a monovision correction describe the shift between close and distant viewing as similar to the difference between how you see things in the periphery when your eyes are focused on an object or person. The brain selects the view that is desired between close up, mid-range or distant.


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How Custom Laser Vision Correction Uses Wavefront Mapping to Perfect Vision

CUSTOM laser vision correction procedures such as LASIK, PRK, and Epi-LASIK are good choices for most patients.

Custom is a laser vision correction technology that allows Dr. Vale to individualize the correction to your own eyes by eliminating glare, halos, poor contrast and other visual disturbances at the same time the refractive error is corrected. It allows for a more perfect or higher definition visual experience, especially under low light conditions. Custom LASIK may result in your vision becoming clearer and sharper than it ever was before.

How Does Custom Laser Vision Correction Work?

Custom LASIK, PRK and Epi-LASIK use wavefront technology to measure the way individual light waves travel through your eye. This technology performs a detailed analysis of your eye that examines the entire optical system, not just the parts that are operated on during LASIK surgery.

The wavefront analyzer used at Acuity is manufactured by the same company that makes our Excimer vision correction laser.

The wavefront analyzer used at Acuity is manufactured by the same company that makes our Excimer vision correction laser.

The wavefront analyzer provides information about the unique visual characteristics of your eye, allowing for an additional level of data about your vision.  This in turn allows Dr. Vale to further customize your vision correction. The data is used to guide the laser during your Custom laser vision correction procedure for optimal results.

Better Quality Vision

Custom LASIK, PRK or Epi-LASIK may be necessary for patients with bad glare or poor contrast in low light, and may be desirable for many others. Everyone’s eyes are different. A pre-procedure comprehensive eye exam with Dr. Vale will help determine if Custom laser vision correction is right for you based on your particular prescription, healing profile and expectations.

Compared to other forms of laser vision correction, Custom laser vision correction has been shown to provide patients with:

• A greater chance of achieving 20/20 vision

• The potential, in many cases, for vision better than is possible with contacts or glasses

• Much lower incidence of glare, halos and night vision disturbances such as poor contrast

Wavefront Technology

About Visual Aberrations
Two classes of visual imperfections, referred to as lower- and higher-order aberrations, exist within the eye. These imperfections can affect both the sharpness (acuity) and quality of vision.

Lower-order aberrations, which people are familiar with and are commonly measured and treated with standard LASIK, PRK or Epi-LASIK include:
• Myopia
• Hyperopia
• Astigmatism

Higher-order aberrations cannot be corrected with glasses, contact lenses or standard laser vision correction treatments. In fact, some researchers have found that some imperfections may actually be increased by conventional (non-customized) laser eye surgery.

About Wavefront Technology

Wavefront analyzers (also known as aberrometers) measure aberrations in your visual system by send light into the eye and measuring how it is distorted upon exit. When light rays enter the eye and pass through the different structures inside, the wavefront surface changes, taking on a shape unique to that eye. These variations are called wavefront errors.

The wavefront analyzer’s software performs complicated measurements and presents a graphical and numerical representation of how light is aberrated by your eye for the surgeon to evaluate. Data from this process may be transferred to the laser and used by your surgeon to create a treatment plan for your refractive error that includes treatment for both low and higher-order aberrations. Treating a patient with the information taken from the wavefront analyzer can result in greater clarity of vision and fewer complaints of glare or night halos.

How Does the Wavefront Analyzer Work?

Most laser manufacturers provide compatible wavefront analyzers  for their laser systems that are based on Hartmann-Shack aberrometry.  At Acuity, we use a different technology based on a principle known as Dynamic Skiascopy. With Dynamic Skiascopy, A specially designed lenslet array measures the change in the wavefront of light as it passes through your visual system at over 15,000 individual points. The system essentially performs a refraction on each of these individual points, then numerically and graphically represents this information for each eye as a whole to the doctor.

Correcting Aberrations

Zernike Polynomials

The Zernike polynomials represent the optical characteristics of the aberrations within the visual system.

The Zernike polynomials represent the optical characteristics of the aberrations within the visual system.

One way the Wavefront laser eye surgery data is analyzed is by using Zernike polynomials, also called modes. Each mode describes a certain three-dimensional surface and the Zernike polynomials correspond to the ocular aberrations. For instance, second-order Zernike polynomials represent the conventional aberrations such as defocus and astigmatism. Zernike polynomials above the second order represent the higher-order aberrations that cause night glare and halos. Zernike polynomials help to simplify the Wavefront technology used in laser eye surgery by combining all aberrations into one simple map. This is called a Zernike decomposition.

Zernike Polynomials Shapes and Relation to Real Life Vision

Eye surgeons are given information by the aberrometer as a conventional refraction in dioptersGeometric-Design as well as in Zernike form. The data is processed and presented in a fashion similar to a topographical map and can easily be read by Dr. Vale. However, determining what aberrations require treatment is actually somewhat trickier and requires a skilled and experienced eye surgeon, not just one who will rely on the recommendations the aberrometer spits out.

Dr. Vale is one of America’s most experienced laser vision correction specialists, and has performed over 29,500 vision correction procedures since 1994.

This information is then transferred to the laser, enabling the surgeon to address the patient’s unique visual imperfections. Trust the experience of Dr. Vale to make your vision as clear and aberration free as possible through this phenomenal technology!

Laser Eye Surgery Benefits

Laser eye surgery can greatly improve your vision.

There are many laser eye surgery benefits. Using lasers for vision correction has been a huge success in the field of eye surgery and offers the potential to restore the eyesight of millions of people around the world. Although laser eye surgery is a fast and safe way to correct vision, it is always best to have some advance knowledge before you undergo it.

The cornea is the part of your eye that is reshaped during laser eye surgery. The cornea has two parts: the epithelium, which is the clear ‘skin’ located on the surface, and the stroma, a thicker layer that lies beneath.

Having laser eye surgery is one of the most effective ways of correcting or restoring your vision. Other vision correction measures, such as eyeglasses and contact lenses, only temporarily change the way light enters the cornea to correct vision. However, with laser eye surgery, the cornea is reshaped permanently and those treated usually no longer require any sort of appliances such as glasses or contacts to correction vision.

Laser eye surgery is an affordable vision correction method. Interest-free financing, flex spending accounts, health savings accounts as well as savings or major credit cards provide our patients with many different payment options at Acuity.

5 Important Benefits of Laser Eye Treatment

It is important to look at the pros and cons when considering any type of surgery. Laser vision correction is achieved using highly advanced technology that has been available since the 1980’s. There are few, if any, cons or side effects involved. Here are some of the advantages of laser eye surgery!

1. History of Success:
The majority of patients who have undergone laser eye treatment have achieved the level of vision they wanted. This is a major success of laser vision correction compared to other methods of vision correction.

2. Less Pain:
Laser vision correction is less painful than any other type of eye surgery. In fact, there is usually little or no discomfort.

3. Relatively Quick Results:
With LASIK, vision correction usually takes place immediately after the surgery, or within the next 24 to 48 hours. Eyesight is obviously a big part of our lives, hence quick results after laser vision correction are a major advance over prior methods of vision correction involving incisional surgery or other means. 

4. Quick Recovery:
Laser vision correction usually produces quick results, and the recovery time is also fast compared to most other types of surgery. Laser eye surgery also does not require eye patches or stitches.

5. No More Eye Accessories:
The biggest advantage of laser eye treatment is that it corrects vision so well that patients usually no longer require contact lenses or eyeglasses.

Advantages of Laser Eye Surgery

Not everyone has perfect vision. There are many people with some deficiency in their eyesight. In order to correct their vision, many people use eyewear like contact lenses or glasses. Some feel embarrassed and less confident when wearing glasses. Glasses and contact lenses are not always comfortable when carrying out various activities. For example, if you want to swim, you cannot wear glasses or contact lenses directly in the water. In such cases you may require contact lenses along with special swimming goggles. This is not a good option for most people.

In summary, one of the best options to get rid of all these hassles is laser eye surgery. After laser eye surgery the need to wear any lenses is usually eliminated, or at least significantly reduced. Laser vision correction will improve the eyesight of nearly everyone. Laser eye surgery is quick, effective and has a long track record of safety. With laser eye surgery, a laser beam, not a knife, is used to correct vision by changing the shape of the cornea. After laser eye surgery one can often return to work within a couple of days.

Advantages of LASIK Eye Surgery and What To Expect After Surgery

LASIK Eye Surgery:

LASIK, which stands for laser in-situ keratomileusis, is a popular surgery used to correct vision in people who are nearsighted, farsighted, or have astigmatism. There are many advantages to LASIK.
All laser vision correction surgeries work by reshaping the cornea, the clear front part of the eye, so that light traveling through it is properly focused onto the retina located in the back of the eye. LASIK is one of a number of different surgical techniques used to reshape the cornea.

What Are the Advantages of LASIK Eye Surgery?

LASIK has many benefits, including:
• It works! It corrects vision. Around 96% of patients will have their desired vision after LASIK. An enhancement can further increase this number.
• LASIK is associated with very little pain due to the numbing and anti-inflammatory drops that are used.
• Vision is corrected nearly immediately or by the day after LASIK.
• No bandages or stitches are required after LASIK.
• Adjustments can be made years after LASIK to further correct vision if vision changes while you age.

• After having LASIK, most patients have a dramatic reduction in eyeglass or contact lens dependence and many patients no longer need them at all.

What Should I Expect
After LASIK Eye Surgery?

Your eyes will temporarily be dry even though they do not feel that way. Your doctor will give you prescription eye drops to prevent infection and inflammation and eyedrops to keep your eyes moist. These drops may cause a momentary slight burn or blurring of your vision when you use them. Do not use any eye drops not approved by your eye doctor.

Healing after LASIK eye surgery usually occurs very rapidly. Vision may be blurry and hazy for the first day, but most patients notice improved vision within a few days of surgery.

Specific follow-up after the surgery varies from one surgeon to another. You will revisit the doctor for an evaluation 24 to 48 hours after LASIK eye surgery, as well as at regular intervals within the first six months.

Call with any questions or to schedule a FREE 30-minute consultation!

LASIK and Sports, A Great Mix with Caveats….

by Steven Vale, M.D.

One of the more common questions I hear from patients inquiring about LASIK is, “Can I still play sports after my surgery?”

It’s a valid question. I wrote this short article explaining what you can expect when it comes to sports and LASIK surgery.

I wish I had done this years ago…

At Acuity we hear these words very often! Especially from active people and athletes.

Whether you’re involved in competitive athletics at the high school, collegiate or professional level, or maybe just enjoy a game of pickleball with your friends, or hitting the tennis courts on a weekend morning, LASIK may actually enhance your performance by providing freedom from glasses or contact lenses. but caution is also indicated, as it would be with ANY eye surgery.

There are many professional athletes who play football, basketball, soccer, tennis, golf, baseball and those participating in a variety of other sports such as skiing, cycling and mountain biking who have undergone the laser vision correction procedures. Some of them right here in eastern Pennsylvania at Acuity Laser Eye & Vision Center.

What Precautions Do Athletes Need to Take After Having LASIK?

There are certain precautions that all patients need to take immediately following their surgery. For athletes, these are especially important. Here are a few important guidelines to adhere to:

  • Avoid participating in strenuous exercise for at least one week. Your eyes need time to heal.
  • Avoid dusty, dirty environments for at least 3 weeks after surgery.
  • You can bathe or shower the day of your surgery, but avoid lakes and fresh water for 3 weeks , pools, hot tubs, oceans, etc. for at least 10 days.

What About Recovery Time After Surgery?

Tennis woman

Sure you’re anxious to return to the sports you love, but it is important to be very careful in the weeks and months following your surgery. As with an athlete rehabbing an injury, you don’t want to come back too soon and risk complications.

It’s also important to note that while LASIK is a great procedure for the majority of athletes, there are a few sports (such as boxing or mixed martial arts) where another procedure such as PRK or Epi-LASIK may be a better fit as there is no flap in those cases.

At Acuity, our first priority is to ensure patients receive the treatment that is right for them, whether it is LASIK, PRK, or another vision correction procedure. Please feel free to discuss your lifestyle and avocations with our Patient Counselor DURING YOUR FREE, NO OBLIGATION CONSULTATION

What Procedures Should Be Avoided?

If your primary goal is to play sports, especially ones that require good depth perception, like golf or tennis, treating both eyes for good distance vision makes sense. Monovision treatment corrects one eye for far and one for near, and helps patients over 40 avoid reading glasses, but probably won’t help much to keep your eye on the ball.

Epi-LASIK and PRK are the two procedures most commonly recommended for athletes involved in contact and high velocity projectile sports. A consultation with our Patient Counselor will confirm candidacy for the procedure that best meets your needs.

If you’re an athlete interested in LASIK, give us a call! (877) 520-3937

Athletes are generally great candidates for LASIK, but to be sure, we need to see you in person. Give our office a call today or fill out the contact form on this website for a free, no obligation consultation.

Can Laser Vision Correction Help After Cataract Surgery?

by Steven Vale, M.D.

After cataract surgery, some patients still need glasses or contacts. LASIK and PRK are better at touching up residual nearsightedness, farsightedness, and astigmatism than either lens exchange surgery or piggyback intraocular lens implant placement, both of which require entering the eye again, with the inherent risks associated with intra-ocular surgery.

Standard modern day cataract surgery involves taking the cloudy lens out of the eye and replacing it with a synthetic lens implant made of polymethylmethacrylate (what airplane windows are made from), silicone or acrylic. Ideally, a patient’s required prescription power is placed into the implant so that, after cataract surgery, the patient can see well without glasses or contact lenses. In as much as 10% of cases, however, it is not possible to perfectly achieve the ideal result with cataract surgery alone, due to inherent inaccuracies in calculating the power of the implant that is placed in the eye. This is particularly true in eyes that are especially long or short. The vision in many of these eyes can then be fine-tuned after cataract surgery with LASIK or other laser eye surgeries such as PRK, or with further lens-based surgery including exchanging the implant for a new implant with an updated prescription or simply adding a second implant on top of the first implant, which is called a “piggyback” IOL. Studies show that LASIK is the most accurate way to “touch up” cataract surgery. It’s also the safest.

In one study, 65 eyes of 54 patients were studied who did not achieve adequate correction after cataract surgery and still needed glasses or contacts. 17 of those eyes were treated by an exchange surgery in which the previous lens implant (IOL) was removed and a new intraocular lens was put in its place (“IOL exchange”). 20 eyes had a second implant placed on top of the existing implant (“piggyback IOL”). 28 eyes had LASIK. The results of these three approaches to touching up cataract surgery were compared.

Intraocular lens implants can be placed on top of each other, or ‘piggybacked’, inside the eye.

The two lens-based approaches had similar results. IOL exchange and piggyback IOL surgery produced similar correction of nearsightedness, farsightedness, and astigmatism (“refractive error”). The eyes in which LASIK was used to touch up the cataract surgery result, however, had better overall correction results. In terms of visual outcomes, 62.5% of eyes in the IOL lens implant exchange group were within 1 diopter of the intended result, compared to 82% in the piggyback IOL group and an impressive 100% in the LASIK group.

A lens implant made of acrylic material is very small, but can focus light just as well as the natural lens you were born with.

The results of this rather tiny study confirm my own experience. Not only is LASIK or PRK more accurate than either intraocular lens exchange or piggyback techniques, but it is inherently safer as well as LASIK or PRK procedures do not physically enter inside the eye, while both of the lens-based techniques do. Keeping surgery limited to the cornea means LASIK or PRK have better safety profiles. The exception, both in this study, and in our experience at Acuity, is in patient’s where there are very large degrees of refractive error. For these rare patients, a lens based technique will sometimes be necessary, since the amount of correction can be outside the effective range of LASIK or PRK.

For most patients after cataract surgery, Dr. Vale considers PRK to be a better option to fine-tune vision after cataract surgery, as there is no risk of re-opening the cataract surgery incision as there would be with LASIK.

If you’ve had cataract surgery and suspect you need a fine-tuning with laser vision correction, call Acuity Laser Eye and Vision Center today for a free, no obligation consultation!

What To Expect After Laser Vision Correction Surgery

The recovery times and aspects of laser eye surgery recovery differ depending on the procedure you have.

Generally, LASIK requires a 2-3 day recovery period before returning to your normal routine. PRK and Epi-LASIK will require 4-7 days before returning to driving and many normal daily tasks.

There are many questions people have about the recovery after laser vision correction:

Will my eyes hurt after my eye surgery? Can I wear makeup the next day? When can I work out or play sports? These are some of the more frequent questions patients ask as they prepare for vision correction surgery.

When you have LASIK surgery, you are very focused on one thing: seeing better. The good news is that happens almost immediately for the vast majority of LASIK patients. They sit up from having the procedure seeing the world in a whole new way and it is very exciting. However, it’s important for LASIK patients to understand that, as with any surgery, there will be a recovery phase and healing period after you have your procedure. For most people, LASIK recovery is very fast and patients resume most normal activities within a day or two. The healing period takes a little while longer, typically lasting 3-6 months during which time you should expect your vision to improve. Knowing what to expect after your procedure can be helpful, so here are a few guidelines about what you might experience expect in the days, weeks and months after your surgery – and what you can do to help take care of your eyes as they heal:

The First 24 Hours

• After the topical anesthesia wears off, you will likely have some discomfort after surgery. Some discomfort is normal and your doctor will have given you instructions about how to relieve the discomfort.

• When you get home, rest your eyes for 2-4 hours and avoid any strenuous activity. You can return to your normal routine the next day. Protect your eyes by wearing sunglasses if you’re outside during the day and eye shields in bed at night.

• Right after the procedure your vision will be foggy as if you opened your eyes underwater. You should be able to see much better within hours of the procedure but you may have some temporary side effects as you go through the healing process. The most common is dryness, and your doctor will likely have provided you with lubricating eye drops. Make sure to use them as instructed to keep your eyes moist.

• Other potential symptoms you may experience after surgery include halos around your eyes at night, tearing eyes, puffy eyelids and sensitivity to light. These should all diminish within a week.

The First Month

• Your doctor will want to see you the day after your surgery, one week after, and to remove protective lenses 5 days after surgery, if you have had PRK or Epi-LASIK. During these visits, the doctor and medical technicians will test your vision and examine your eyes to make sure your recovery is going well.

• It’s very important that you do not rub or touch your eyes. Your eyes will be sensitive and you don’t want to disturb the healing.

• You should be able to shower the day after your surgery, just be sure to keep soap and any chemicals out of your eyes.

• Avoid any water that could be contaminated. This includes hot tubs, swimming pools lakes, rivers and the ocean for 3 weeks.

• You can start exercising after the first week.

• Stay away from contact sports, such as football for a week and wear sports goggles after that for a month – you don’t want to risk getting poked in the eye.

The First Three To Six Months

• If you have severe myopia (nearsightedness), your eyes may take longer to heal. Your doctor should have provided you with your recovery plan, which may include wearing glasses for a short period of time as your eyes heal.

• Your eyes will still be healing during this time. Attend all your follow-up visits with your eye doctor so she can continue to monitor your vision and eye health.

Working with your laser vision correction surgeon throughout the recovery and healing process is essential to an overall good outcome, so keep him updated on how you are doing and ask any questions you may have about your vision. Most patients have a short recovery time after laser vision correction and are very happy with the results.

Having a laser vision correction procedure doesn’t end your relationship with your eye doctor; you will still need to have regular eye exams. Laser vision correction doesn’t prevent your eyes from changing as you age, so staying on top of your eye health is important.

Call 877-520-3937 with any questions or to schedule a free consultation. 

Punctal Occlusion After Laser Vision Correction Surgery, Does it Help?

Why Dry Eye Occurs After LASIK…
by Steven Vale, M.D.

A dissolvable collagen plug can be placed in either the inferior or superior lacrimal punctum to decrease the rate of drainage of tears from the eye.

Dry eye is a common problem after laser vision correction, particularly following LASIK. With LASIK, the cutting of the flap results in approximately 85% of the corneal nerves, which sense dryness, being severed. These nerves are the primary motivators in the production of tears through a reflex arc that tells the Lacrimal Center in the brain that the eyes are dry and tears need to be produced. Once severed, these corneal nerves need to grow back in order for the normal sensation of dryness to return. This generally takes anywhere from 3 to 6 months, with the latter being more common. PRK and Ep-LASIK are characterized by much less dryness than LASIK, as no flap cutting is performed. Hence, the majority of the corneal nerves are preserved during laser vision correction, although a few nerve endings may be ablated during the excimer laser portion of these procedures. Generally, individuals with pre-exisitng severe dry eye should refrain from having LASIK and have only advanced surface ablation procedures such as PRK and Epi-LASIK, so that their dry eye is not made worse by laser vision correction surgery.

Resulting dryness after LASIK can be a problem, particularly in those accustomed to working in dry environments, those non-compliant with artificial tear use after surgery, those who take medications such as diuretics and anti-histamines that have the side effect of decreasing tear production and those who have inflammatory eyelid conditions such as Blepharitis and Meibomianitis, that have not been resolved prior to eye surgery. In many cases, temporary or permanent occlusion of the lacrimal drainage system can aid in resolving dry eye issues after LASIK, and even in PRK and Epi-LASIK.

Options for Punctal Occlusion

A variety of plugs to facilitate this occlusion have been developed over the years. These plugs fall into 3 general categories, Collagen or other biodegradable plugs, silicone punctal plugs, and intra-canalicular plugs made from hydrogel, the same material that contact lenses are produced from. It’s also possible to permanently occlude the tear ducts with thermal cautery in rare cases where the dry eye is so severe that it can not be managed sufficiently with less aggressive methods.

Punctal Plugs

Punctal plugs, or lacrimal plugs, are tiny biocompatible devices placed in the tear ducts (punctum) to block drainage during a procedure called punctal occlusion. This blockage helps keep the eyes moist by retaining more of the tears or any artificial tears that the dry eye patient may be using. These plugs are removable when your condition improves. The biodegradable ones dissolved over a period of 45 to 60 days

I sometimes first attempt a punctal occlusion with collagen or extended biodegradable material as a solution that has the least permanence first, to see if it benefits the patient. If it does, a more permanent version may be selected later if needed. Sometimes, the dryness after laser vision correction is self-limited enough that biodegradable plugs are all that is needed.

We also have the option of using five different types of semi-permanent punctual plugs:

  1. Umbrella or Mushroom cap: These plugs are visible in the tear duct

    Hydrogel punctal plugs like the one seen on the tip of this insertion device offer a permanent solution for dry eye and are very comfortable as well.

    and easy to remove.

  2. Hollow: This shape helps the plugs stay in place, conforming to the shape of your tear duct.
  3. Tapered: This shape keeps the plug in place by exerting pressure horizontally.
  4. Slanted or low profile cap: These plugs provide extra stability and comfort.
  5. Intracanalicular: These plugs swell once placed into the tear ducts. They are essentially permanent but can be removed if needed by irrigating the lacrimal system with a pressurized cannula.

Thermal Cautery

I can also offer a more permanent solution called thermal cautery. This procedure uses heat to permanently block the opening to the tear drainage system, forcing the tears you produce naturally and artificial tears to stay in your eye.

None of these solutions provide total relief from the regimen of artificial tears, however. Patients still need to use artificial tears to varying degrees to supplement their own tear production. These procedures assist in keeping the eyes sufficiently moist for comfort, good vision and prevention of infection.

Plug Installation

Prior to the procedure, we measure the size and shape of your tear ducts using a special instrument. This helps determine which type to use, and where to place them for maximum benefit. Before the procedure, I instill a local, topical anesthetic for greater comfort. The procedure, done in the office or in the laser suite after the laser vision correction procedure, takes only minutes to complete with little to no discomfort.

Each of the eyes has two punctum, one in each eyelid. Plugs can be inserted in one or both. I also sometimes use a special instrument to enlarge the punctum, making insertion easier. Most often, this procedure is quick and painless. After the process, patients can go home to resume normal activities almost immediately.

FAQ: Can I Have LASIK If I Have Astigmatism, How About After Cataract Surgery?


Yes, LASIK can fully and permanently correct astigmatism!

Astigmatism is a very common vision problem. Despite having a somewhat scary-sounding name, astigmatism is not an eye disease — it’s simply a refractive error like nearsightedness and farsightedness — and it can be corrected with eyeglasses, contact lenses and LASIK surgery.

Astigmatism typically is caused by the front surface of the eye (cornea) having an asymmetrical shape.

An analogy that’s often used to describe this is to say the cornea is shaped like a football rather than like a baseball. Another is to say that an eye with astigmatism is shaped like an egg or the back of a spoon, rather than like a ping-pong ball.

The ultra-precise lasers used for LASIK surgery can be programmed to reshape the cornea so the front surface of the eye is more symmetrical, thereby eliminating vision problems caused by astigmatism.

When astigmatism is present, it typically does not exceed 3.0 diopters (D) in magnitude and can be fully corrected with a single LASIK procedure. Even higher amounts of astigmatism can be corrected with LASIK, though this increases the likelihood a follow-up LASIK enhancement may be needed to fine-tune the correction.

If you have high astigmatism, this may affect your LASIK surgery cost, depending on the policies of the LASIK surgeon and/or surgery center you choose. If so, this will be discussed with you during your preoperative exam and consultation.

Yes, LASIK can be performed after cataract surgery! 

Following cataract surgery, a LASIK surgeon can correct your nearsightedness, farsightedness and/or astigmatism and greatly reduce or eliminate your need for eyeglasses after surgery.

LASIK surgery usually takes less than 10 minutes and does not require general anesthesia. The laser that reshapes the cornea typically is on less than one minute per eye.

General anesthesia (being “put asleep”) during any type of surgery has its own risks and would significantly increase the cost of LASIK without adding significant benefits.
If you fear you will be anxious during the procedure, Dr. Vale or his staff will give you a mild sedative or other medication prior to surgery to help you relax.

Most patients are surprised by how quickly their LASIK procedure goes and feel afterward it was much easier and less stressful than they expected it would be.

Epi-LASIK: The Perfect Procedure


As patient discomfort is minimized and recovery time shrinks, more surgeons are trying it—and many prefer it to LASIK.

As a patient-pleasing refractive procedure, LASIK has been hard to beat. Some other ablative procedures have offered equally good visual results, but most have had comparative drawbacks such as greater patient pain or longer healing times.

Now, advanced versions of epi-LASIK (in which an epithelial flap is mechanically pushed back using a blunt, plastic oscillating plate, followed by laser ablation at the surface) are eliminating many of these drawbacks. These improvements have made believers out of many surgeons andGeometric-Design their patients. If their enthusiasm is any indication, this could signal the beginning of a major shift in the marketplace.

To find out more about the latest iterations of epi-LASIK, we asked five experienced surgeons to share their experience and insights in response to four questions: Why did they decide to shift away from LASIK toward epi-LASIK? How do they minimize patient pain and prevent haze? Should the epithelial flap made during epi-LASIK be replaced on the eye or removed? And what pearls could they offer to help make epi-LASIK more efficient and successful?

The Move to Epi-LASIK

Most of the surgeons we spoke to began using epi-LASIK because some patients were poor candidates for LASIK; eventually, they ended up favoring it. Rick Milne, MD, who is in private practice at the Eye Center in Columbia, S.C., is a case in point. Dr. Milne has now performed close to 1,000 epi-LASIK procedures; his practice was one of the 10 international investigational sites for the prerelease of Moria’s epi-K system.

The epithelial sheet made during epi-LASIK avoids a host of potential flap complications associated with LASIK, and many surgeons now believe removing it speeds healing.
Barrie D. Soloway, MD, FACS
“Ninety-nine percent of the laser vision correction I do today is epi-LASIK—specifically, a version that most people are calling ‘advanced surface treatment,’ or AST, in which you completely remove the epithelium,” he says. “Initially, I reserved epi-LASIK for patients who weren’t good LASIK candidates, but they did so well that I kept finding more and more excuses to ablate the surface instead of performing LASIK. Eventually I asked, why am I still doing LASIK at all?”
Dr. Milne and others we interviewed mentioned a number of specific reasons they’ve come to favor epi-LASIK:

• It eliminates potential flap complications seen with LASIK

Richard Rashid, MD, associate clinical professor of ophthalmology at the West Virginia School of Medicine in Charleston, estimates that he’s performed more than 500 epi-LASIK procedures, and says that in the past year he’s done about 75 percent epi-LASIK (with flap removal). “LASIK has a very low rate of complications,” he notes, “but 90 percent of the complications that do occur are associated with making the flap, postop slipping of the flap or epithelial ingrowth. Epi-LASIK avoids all of that. And it’s a safer eye in case of trauma in the future.”

• More patients can be treated

Epi-LASIK can be used to treat many patients with thin corneas who would have to be excluded from LASIK treatment.

• Epi-LASIK doesn’t weaken the cornea

Mark A. Swanson, MD, director of the Swann Institute in Sonora, Mexico and Douglas, Ariz., says his group has performed more than 800 epi-LASIK surgeries to date. “In my practice more than 40 percent of our procedures are epi-LASIK, and the number is growing,” he notes.

One of the reasons he lists for this shift is that making a LASIK flap can, in rare cases, compromise the biomechanical strength of the cornea, whereas epi-LASIK does not. “I’ve checked that with many instruments, including Reichert’s Ocular Response Analyzer,” he says. “This can be especially important when the patient has glaucoma. Epi-LASIK avoids weakening or thinning the cornea further, so we can continue to accurately monitor IOP.”

• Healing is better and faster than with PRK and LASEK

Dr. Swanson notes that some surgeons wonder why purchasing an epikeratome is necessary. “We compared a normal PRK to epi-LASIK done with a keratome,” he says. “We found that it’s better to take the epithelium off with the tool rather than the solution used in PRK. The reason is that the healing is a lot faster and discomfort is almost nonexistent, especially with the medications we use.”


Gasp! What You Know About LASIK and Astigmatism Might Be Wrong!


The good news is…LASIK can fix astigmatism!

Astigmatism is an extremely well-known, yet poorly understood phenomenon. It’s like the gluten intolerance of vision, except in this case pretty much everyone has it. People are told at some point by someone wearing a white coat—either in a clinic or on a book cover—they’ve got this diagnosis and then, well, that’s that. You can’t do anything about it, except for explain your condition to strangers if the opportunity arises. In the case of gluten sensitivity, as far as I understand it, the only solution is to stay away from pasta and bread. That makes me sad. My hope is that many people have been given a wrong diagnosis, and they can one day enjoy Olive Garden’s never-ending breadsticks again. With astigmatism, however, there’s much more to say.

If you’ve been diagnosed with astigmatism, it’s positively certain you have it. Nearly everyone has some level of astigmatism. This includes most people who don’t need to wear glasses because they’ve always had good vision. But the second point about it has a much more impactful upshot: the people who’ve been told their astigmatism means they have to stay away from LASIK have nearly all been relying on information that’s no longer relevant. Today, I’d like to clarify as best I can what astigmatism actually is, and why LASIK is not only possible, but ideal for treating it.

I too had the diagnosis of astigmatism from a young age. And I too was told it meant my eye was shaped like a football. I’d like to think the optometrist who told me this did a poor job of explaining it rather than admit I was such a nerd I didn’t know what a football was. The football analogy didn’t help me at all. I thought it did at the time, until I understood what astigmatism was. Only then was I able to work backward toward why eye doctors say, “Your eye is shaped like a football.” It turns out they mean the curved part in the middle, not the pointy ends. So to get away from football, with all of its incomprehensible rules and ball shapes, let me explain astigmatism in a way that would have been easier for my young, un-athletic mind to understand.

Astigmatism = Distortion + Blur

You know how a contact lens is shaped like a dome? It’s shaped that way because it has to match the shape of the cornea, which is the dome-like window on the front of your eye. The cornea is where astigmatism occurs, but to understand what that means, it’s easier to forget that it’s a dome for a moment. Picture this instead: you’re holding a big square piece of flexible plexiglass with one hand on each side. When you’re holding it without applying any tension, that piece of plexiglass is flat: it has no astigmatism. But if you squeeze your hands towards each other and flex that plexiglass, it isn’t flat anymore. It’s got a curve along the axis where you’re putting pressure. The shape of it looks more like the curve of a cylinder now. You’ve given it astigmatism.

This situation is exactly what’s going on with the dome of your cornea when you’ve got astigmatism. Instead of a flat piece of plexiglass, it’s a small round dome, but the dynamics are the same. If you imagine a tiny pair of hands applying some pressure to opposite sides of that dome, you’ve created astigmatism. This is the kind astigmatism we’re talking about here. The reason it’s so common is because it’s incredibly rare to find perfectly round, symmetrical corneas without even the slightest trace of squeeze in some direction. Those people who have astigmatism, but aren’t aware of it (and there are many), just don’t have enough distortion/squeeze to cause noticeable vision loss.

When astigmatism does cause a decrease in the quality of vision, it does so by distorting the image being focused through the corneal window. If you imagine looking at someone through your piece of plexiglass, then squeezing the top and bottom of it, you’d see that they got shorter and wider as you squeeze. The same thing happens on the cornea, except that since the cornea is such a powerful lens, the blur from the distortion outweighs the funhouse mirror effect. So how do we fix the vision for people who have enough astigmatism for it to cause noticeable blur? With glasses, the goal is to neutralize the distortion of the image. If you’ve got a cornea with top-to-bottom squeeze (making everybody the slightest bit shorter and wider, but mostly just blurrier), your glasses prescription will have lenses that squeeze in from the right and left side an equal amount (making everybody the slightest bit taller and skinnier, but mostly just clearer).

Here’s why people think LASIK and astigmatism don’t mix.

When LASIK first became popular, it became really popular really fast. In the late 90s and early 2000s, around a million LASIK procedures were happening a year in the U.S. But when laser vision correction first got FDA approval, it wasn’t approved for astigmatism correction (which was wise because it couldn’t correct astigmatism at the time). Over that first decade, the ability of LASIK to treat astigmatism evolved from “unable to fix astigmatism” all the way to “sometimes it can fix simple astigmatism.” So when people heard, “you shouldn’t get LASIK because you’ve got astigmatism,” most of the time, they were getting good information.

Although it seems off topic to point this out, in the early 2000s it still sounded improbable that digital music would really take off or that any smartphone would ever dethrone the Blackberry. Technology improves rapidly, and it’s easiest to recognize in those areas where we would have reason to stay updated. In the case of LASIK, when patients and optometrists checked it out during its early, popular heyday, they found out it didn’t correct astigmatism. That fact was the authoritative information they absorbed. Somehow, a decade and a half later, that same information still abounds despite the fact that LASIK started to get really good at fixing astigmatism around the same time the original iPhone first debuted.
As the computers that control the laser responsible for LASIK became faster and more technologically advanced, the ability to correct astigmatism changed from “it’s possible” to “LASIK can fix astigmatism better than glasses or contacts ever could.” And the reason for this has to do the knee-deep astigmatism explanation we waded through a few paragraphs ago. Instead of just looking through a lens with an equal and opposite astigmatism to that of your cornea (which is what glasses and contacts do), imagine you had the ability to get rid of the distortion altogether.

LASIK and astigmatism: BFFs. For real.

What if your eyes had wonderful, clear optics because they were distortion-free—without any need for correction? That’s what LASIK can now do for the overwhelming majority of people with astigmatism. This fact has been true for years, but has remained oddly undiscovered by the majority of people who might benefit from it. I’m not a conspiracy theorist shouting, “Big Glasses is perpetuating a myth to keep you buying glasses!” But I do believe that when patients (and many optometrists) heard LASIK couldn’t fix astigmatism (which was around the same time that AOL was synonymous with email), they never had a good reason to circle back and stay updated as the technology evolved.

So yes, LASIK can fix astigmatism, and it can do it with incredible accuracy and ease. And while I hope this information is helpful to you, the genuine goal of this article is to dispel the pesky myth that LASIK can’t fix astigmatism. I imagine if I worked at Apple and often heard people say, “My doctor says Apple doesn’t make mobile phones,” I would’ve written about how the iPhone exists. I don’t think I’d try to convince you to get an iPhone, I’d just want you to know the truth—especially if it might have an impact on your quality of life. I’m not saying you have to fix your astigmatism with LASIK. I just want you to know it can, because it’s something I care about, and I thought you might care about it too.

By Joel Hunter, MD

Acuity’s 3 Steps to Surgery


Consultation: Aproximately 30 minutes images

  • You will be quoted a price for surgery based on your prescription following a brief exam on an auto refractor. We will also discuss the procedures we offer, recovery periods and recovery details, preparation for surgery and financing options in that meeting, then address any questions you may have.
  • Your quoted price for surgery will include all follow-up exams for the first three months and your pre-operative exam.
  • We will not determine whether you are a candidate for LASIK (2-3 day recovery) or PRK (5-7 day recovery) in the consultation. This determination will occur in your pre-operative exam. You may schedule your pre-operative exam (2 hours) to follow your consultation.
  • Acuity offers 24 months interest free financing through Wells Fargo Health Care Advantage or Care Credit. Apply at wellsfargo.com/cardholders or CareCredit.com .
  • You may want to call to apply to Wells fargo Health Care Advantage at 1-800-459-8451 or CareCredit at  800-365-8295 .

Your free, no obligation consultation will be an information session about the procedures offered at Acuity, including recovery times for each procedure offered. Call 877-520-3937 to schedule your free consultation.


Dr. Vale of Acuity performing a pre-operative exam.

Pre-operative Exam: 90-120 minutes

  •  You will be asked to pay an exam fee the day of your pre-operative exam, but that fee will be deducted from the price quoted for your surgery in your consultation. The balance will be due the day of surgery.
  • Your pre-operative exam should be scheduled a minimum of one week before surgery or a maximum of two months before you intend to have surgery.
  • You may call Acuity for the scheduled surgery dates available, or ask for dates during your consultation, in order to plan for your surgery and recovery.
  • View this graphic for useful information. Be sure to verify the type of contact lenses you wear with your optometrist, to determine the number of days or weeks that you must refrain from wearing them to be prepared for your pre-operative exam and surgery.Color-Brochure-for-Lasik-outsideColor-Brochure-for-Lasik-inside

Surgery: approx. 10 minutes 

You will need someone to drive you home after surgery and during your immediate recovery period.


Is Custom Treatment A Better Quality Vision Correction?


All human eyes suffer from optical aberrations or distortions. Most people have mainly lower-order aberrations; myopia or near-sightedness, hyperopia or far-sightedness, and astigmatism. These are easily corrected by glasses, contact lenses, or standard laser vision correction procedures such as LASIK, PRK or Epi-LASIK.

Before the laser vision correction procedure the information about the anatomy of each eye derived from the wavefront map is transferred and loaded into the excimer laser. The laser ablation pattern used to reshape the cornea then includes both the refraction used for standard laser vision correction, and for the higher order aberrations identified on the map.

Specifically, higher order aberrations are often described as the inability to see well in low or dim light, ” This is referred to as poor contrast sensitivity,” said the late Roger Steinert, MD, who at the time of his death was the vice chair of clinical ophthalmology and professor at University of California Irvine. Bright lights can also be a problem with higher order aberrations, particularly when the pupils are more dilated at night. This often manifests as glare, halos, spoking or starbursts around lights.

“Prior to the advent of wavefront measurements, there wasn’t anything we could do to measure or treat higher-order aberrations,” Steinert said. “With this technology breakthrough, we can now measure these disorders, show the patient what’s going on in their eye, link that information to the laser, and actually correct higher-order aberrations that diminish contrast sensitivity. Wavefront technology enables the surgeon to improve overall vision quality better than in the past.”

While visual outcomes as noted on familiar eye charts can be similar for wavefront-guided and conventional LASIK, research has linked wavefront-guided procedures to better results in areas such as improved contrast sensitivity.

A study reported in June 2009* found that 84 percent of 324 eyes that underwent wavefront-guided LASIK procedures for myopia with or without astigmatism achieved 20/20 uncorrected vision or better. In specific tests measuring contrast sensitivity and night vision, significant improvement was noted. Custom LASIK was found to induce certain types of aberrations, which did not appear to affect good visual outcomes.

In August 2004, the U.S. Navy announced that patients at its refractive surgery center were achieving better distance vision and night vision after custom LASIK than after traditional LASIK.

In a small study, 88 percent of contrast sensitivity measurements improved after wavefront-guided LASIK, while only 40 percent improved after regular LASIK. This was one month after surgery. Uncorrected visual acuity of 20/20 or better was achieved by similar numbers, however: 72 percent of the wavefront group and 70 percent of the regular LASIK group. The study was published in the March 2004 issue of Ophthalmology, the clinical journal of the American Academy of Ophthalmology. Many people, however, have higher-order aberrations which cannot be measured with a standard refraction or treated with glasses or contacts. They are measured by scanning the eye with a computerized instrument called an aberrometer, which measures the total amount of aberrations in the eye, including the familiar refraction, and transforms this data into a wavefront map.In most cases, improved visual outcomes with regard to night vision with use of wavefront-guided LASIK appear to surpass results that can be achieved with conventional LASIK.


Over 40? No More Readers or Cheaters! Get Monovision Instead!!!


Another surgery for presbyopia that can reduce the need for reading glasses is monovision LASIK. In this technique, the LASIK surgeon fully corrects the distance vision of one eye (usually
the dominant eye), and intentionally makes the non-dominant eye mildly nearsighted.

Monovision LASIK is effective in lessening near vision problems caused by presbyopia because a mildly nearsighted eye sees near objects clearly without glasses. So, after monovision LASIK, the dominant eye takes the lead to provide clear distance vision and the non-dominant eye is responsible for sharpening near vision.

Though the two eyes continue to work together as a team, distance vision typically is not as crystal-clear after monovision as it would be if the non-dominant eye wasn’t nearsighted.

Still, most people who undergo monovision LASIK feel the convenience of being able to see acceptably well at all distances without glasses is worth the tradeoff of accepting the minor loss
of clarity in distance vision that monovision entails.
Also, if additional distance vision clarity is desired for specific activities (such as driving at night) after monovision LASIK, special-purpose eyeglasses or contact lenses can be prescribed that correct the nearsightedness in the non-dominant eye and optimize distance vision.


Prep for the Pre-Operative Exam; Lid Scrubs, Warm Compress Therapy


WITH ANY QUESTIONS! 877-520-3937



1. Soft Daily Wear = 7 days
2. If you sleep in soft daily wear lenses = 21 days
3. Toric Lenses or Lenses Treating Astigmatism = 21 days
4. Hard/ Gas Permeable Lenses = 30 days per every 10 years of wear.

Please Do not wear your contact lenses again after your pre-operative exam.


Please do not wear eye make-up for 5 days prior to your pre-operative exam and 5 days before surgery.

This is especially important if you wear waterproof eyeliner or mascara. Be sure to remove all liner and mascara and use a eye makeup remover if necessary.


These should be done twice a day for at least one week before your pre-operative exam and again twice a day for at least a week before your surgery day. This will clear the oil producing glands in your eyelids of any debris blocking the expression of oil into the eye’s tear film. This oil is important to your comfort and healing process following surgery.

This should be done twice a day for the week before your pre-operative exam and again twice aimages day, the week before your laser vision correction surgery.

  1. Place a wash cloth under the tap and rinse it thoroughly with hot water.
  2. pumpApply Ocusoft® or Sterilid® (one pump) to the wash cloth creating a lather.
  3. Gently close your eyes and apply the face towel to your eyelids. With a gentle side to side motion, scrub your eyelids and the margins of your eyelashes on both your upper and lower eyelids, thoroughly cleaning at the base of your eyelashes.
  4. Cleanse the upper and lower lid margins separately to ensure they are thoroughly clean.

Perform the scrubs 2-3 minutes, two times daily for each eye.

Warm Compress Therapy:

This will open the oil producing pores in your eyes and allow the oil they produce to be expressed into the eye.

  1. Place a wet wash cloth in a microwave for 10-30 seconds or use tap water as hot as possible but do not burn yourself! The washcloth should be warm but not hot or scalding when applied to the face.
  2. Lightly wring out the wash cloth so it is warm and moist then place it gently over closed eyes making sure the cloth is in contact with the base of your eyelashes or the lid margins.
  3. When the wash cloth is no longer warm, reheat and wring out the cloth and reapply immediately.
  4. Perform this therapy for 5-10 minutes, making sure to reheat the wash cloth 2-3 Blepharitis2times.

Lid Margin Compressions:

This assists the expression of oil produced in the eyes to be expressed into the eyes.

  1. Apply gentle pressure to lid margins, up and in for lower lids and down and in for the upper lids by placing your finger tips on the base of your lashes. Compress either the upper or lower lid completely before moving to the other eyelid. You will feel a mild tenderness as you compress, if done correctly.
  2. Look in the mirror while compressing. Use the white of your eye as a counter-force to apply pressure against.
    Press with fingers from one edge of the eyelid to the other, overlapping the areas where pressure is applied.

Repeat procedure on upper and lower lid margins for 2 minutes.


  Epi-LASIK: Procedure of Choice

CALL 877-520-3937



This article by doctor Richard Lindstom discusses the benefits of Epi-LASIK using the Epithelial Separator: The Moria Epi-K. This is the same instrument used by Dr. Vale at Acuity to perform all Epi-LASIK procedures.

by Richard L. Lindstrom, M.D.

There have always been good arguments for surface ablation, but in most cases I have personally preferred LASIK. Yet every year I find myself performing more and more surface ablation cases—and I am not alone in this.

The question of which surface technique offers the best comfort, safety, and visual recovery has been highly debated. My procedure of choice is now Epi-LASIK with the Epi-K by Moria because of the speed of visual recovery compared to other alternatives. I was, frankly, surprised by these results. Earlier on, I tried another epikeratome and was not impressed, so when I agreed to evaluate the Moria Epi-K, my expectations were fairly low. I did not expect it to be an improvement over PRK, but it is.


The number one reason I recommend Epi-LASIK is to treat patients with thin corneas, but increasingly I also recommend it for patients with some inferior steepening or other unusual topographies, dry eye, or lifestyles that carry an increased risk of flap dislodgment.  However, Epi-LASIK is not appropriate for anyone with a history of previous refractive surgery, or a corneal scar. Furthermore, there will always be a segment of the population that doesn’t want a flap, doesn’t want anything to cut their eye, or wants the “safest” procedure. Despite the excellent safety profile of LASIK, when a patient requests the safest procedure, I choose surface ablation.


Speed of visual recovery: Epi-LASIK has replaced PRK in my practice primarily because it speeds visual recovery and epithelial healing. We analyzed results in 74 eyes of 38 patients who had bilateral Epi-LASIK with epithelial flap removal. They were followed for three months and compared retrospectively with published PRK results. More than half our Epi-LASIK patients were already 20/40 the day after surgery. At one week, 91% were seeing 20/40, compared to published rates of 40% to 58% following PRK. By one month, visual acuity results with Epi-LASIK and PRK are about the same, but the significant difference in the early post-operative period is important for patient satisfaction. Most of our patients are able to drive and return to work within three to four days, and many can do so after only one to two days. Vision recovers faster with Epi-LASIK because the epithelium heals more rapidly. This may also improve the safety of the procedure by limiting the risk of infection and haze to a shorter period of re-epithelialization. High myopes (>6 D) may take longer to fully heal, up to one to two weeks.

Epi-LASIK may allow surgeons to reduce the number of topical and/or oral medications, as some of my colleagues have done, without increasing discomfort. The safety of Epi-LASIK, as with PRK, is very high. There are almost no meaningful complications.

Obtaining Optimal results with Epi-LASIK

I still perform LASIK for the majority of my laser refractive surgery patients, but we are increasingly turning to surface ablation for cases in which it may be safer or more desirable for the patient. When I do choose surface ablation, my clear preference is for Epi-LASIK using the Moria Epi-K.

Dr. Lindstrom is adjunct professor emeritus at the University of Minnesota and in private practice at Minnesota Eye Consultants. He does not have any financial interests with Moria. Contact him at (612) 813-3633 or rllindstrom@mneye.com.


Learn More About Astigmatism And How LASIK Can Help



About one in three people suffers from astigmatism, yet many would be surprised to know so many others also suffer from this condition. While common, astigmatism is often misunderstood, and many don’t know that LASIK surgery can treat it.

What is Astigmatism?
A normal cornea’s shape should mimic that of a baseball. A person with astigmatism has a cornea that is shaped more like a football. Because the cornea is oddly shaped, light bends unequally as it enters the eye, causing vision distortion or blurriness.
Some people with astigmatism might frequently squint in an effort to see clearly because astigmatism can make it hard to focus on fine details or objects. Squinting too much can cause headaches from the strain of trying to focus.

Regular vs. Irregular Astigmatism
Regular astigmatism, the most common type of this condition, is found in almost half of the adult population. Irregular astigmatism is less common and can be caused by eye disease, surgery or injury. The most common cause of irregular astigmatism is a disease called keratoconus, which gradually thins the cornea, typically in the second decade of life. Irregular astigmatism can be difficult to treat with eye glasses. Custom contacts may be useful depending on the severity of irregular astigmatism.

Can Laser Eye Surgery Treat Astigmatism?
Depending on the type and severity of astigmatism, the condition can often be treated with laser eye surgery. Laser-assisted in situ keratomileusis (LASIK) is a type of laser eye surgery that reshapes the inner layer of the cornea to correct astigmatism. It is important to determine which type of astigmatism you have in order to determine which eye treatment option is best for you.
LASIK eye surgery has proven an effective treatment for people with mild or moderate astigmatism. LASIK is also a convenient option for physically active people who find eye glasses or contacts a nuisance, even if they don’t have astigmatism.
Outdoorsman Angus Chan suffered from astigmatism and wore prescription lenses for 24 years before he opted for LASIK eye surgery.
Chan had worse than 20/500 vision, which means what a normal person could see from 500 feet away, Chan could not see from 20 feet away.
“Prior to LASIK, my world was really just a big blur unless something was about a foot in front of my nose,” Chan said. His eye doctor suggested LASIK five years ago, but Chan didn’t think he’d need it. He changed his mind later, as he became a father of kids who liked to snatch his eye glasses from his face, and as he was a swimmer and snowboarder. Eye glasses tended to get in the way, and contact lenses dried his eyes.
I’ve been giving my daughter swimming lessons,” Chan said. “Being able to demonstrate how to do front floats and glides without worrying about my glasses falling to the bottom of the pool is a joy.”
It’s been three months since LASIK eye surgery corrected Chan’s astigmatism. He noticed significantly improved vision immediately after LASIK, and his eyesight continued to improve over the following days.
“After experiencing the results, I regret not taking advantage of the procedure when I first could have,” Chan said. “Not having to worry about glasses or contact lenses provides much more freedom than I realized.”


What Is Astigmatism?



Astigmatism Defined

What is astigmatism?
Astigmatism is a common type of refractive error. It is a condition in which the eye does not focus light evenly onto the retina, the light-sensitive tissue at the back of the eye.

What is refraction?
Refraction is the bending of light as it passes through one object to another. Vision occurs when light rays are bent (refracted) as they pass through the cornea and the lens. The light is then focused on the retina. The retina converts the light-rays into messages that are sent through the optic nerve to the brain. The brain interprets these messages into the images we see.

Causes and Risk Factors
How does astigmatism occur?
Astigmatism occurs when light is bent differently depending on where it strikes the cornea and passes through the eyeball. The cornea of a normal eye is curved like a basketball, with the same degree of roundness in all areas. An eye with astigmatism has a cornea that is curved more like a football, with some areas that are steeper or more rounded than others. This can cause images to appear blurry and stretched out.

Who is at risk for astigmatism?
Astigmatism can affect both children and adults. Some patients with slight astigmatism will not notice much change in their vision. It is important to have eye examinations at regular intervals in order to detect any astigmatism early on for children.

What are the signs and symptoms of astigmatism?
Signs and symptoms include:
• Headaches

• Eyestrain
• Squinting
• Distorted or blurred vision at all distances
• Difficulty driving at night

If you experience any of these symptoms, visit your eye care professional. If you wear glasses or contact lenses and still have these issues, a new prescription might be needed.

How is astigmatism diagnosed?
Astigmatism is usually found during a comprehensive dilated eye exam. Being aware of any changes in your vision is important. It can help in detecting any common vision problems. If you notice any changes in your vision, visit your eye care professional for a comprehensive dilated eye examination.

Can you have astigmatism and not know it?
It is possible to have mild astigmatism and not know about it. This is especially true for children, who are not aware of their vision being other than normal. Some adults may also have mild astigmatism without any symptoms. It’s important to have comprehensive dilated eye exams to make sure you are seeing your best.

How is astigmatism corrected?
Astigmatism can be corrected with eyeglasses, contact lenses, or surgery. Individual lifestyles affect the way astigmatism is treated.

Eyeglasses are the simplest and safest way to correct astigmatism. Your eye care professional will prescribe appropriate lenses to help you see as clearly as possible.

Contact Lenses work by becoming the first refractive surface for light rays entering the eye, causing a more precise refraction or focus. In many cases, contact lenses provide clearer vision, a wider field of vision, and greater comfort. They are a safe and effective option if fitted and used properly. However, contact lenses are not right for everyone. Discuss this with your eye care professional.

Refractive Surgery aims to change the shape of the cornea permanently. This change in eye shape restores the focusing power of the eye by allowing the light rays to focus precisely on the retina for improved vision. There are many types of refractive surgeries. Your eye care professional can help you decide if surgery is an option for you.

The National Eye Institute (NEI) is part of the National Institutes of Health (NIH) and is the Federal government’s lead agency for vision research that leads to sight-saving treatments and plays a key role in reducing visual impairment and blindness.

This information was developed by the National Eye Institute to help patients and their families search for general information about astigmatism. An eye care professional who has examined the patient’s eyes and is familiar with his or her medical history is the best person to answer specific questions.


Additional Information: What Is Corneal Astigmatism

The cornea is a transparent layer of tissue that covers the front of the eye. It transmits and focuses light into the back of the eye while protecting the eye from infection and damage. A perfectly curved cornea can bend, or refract, light properly as it enters the eye.

If the cornea does not curve perfectly, the light that hits it will not correctly refract, and the retina at the back of the eye will receive an imperfect image.
The person will have blurred vision in that eye.
In a person with astigmatism, the cornea is often oval- shaped rather than perfectly round. If the curve is like an oblong, the light rays will focus on two points in the retina instead of one.

Exactly why some people are born with a cornea that does not curve properly is unclear, but there may be a genetic component. A higher percentage of infants who are born preterm have astigmatism, compared with those born closer to their due date. Certain types of surgery or eye injuries that cause scarring of the cornea may cause astigmatism.

Keratoconus is a degenerative disorder of the eye where the cornea gradually thins and changes to a more conical shape. This can cause a condition known as irregular astigmatism.

LASIK Surgery: Is It Right For You?


If you’re tired of wearing eyeglasses or contact lenses, you may wonder whether LASIK surgery is right for you. LASIK is a type of refractive eye surgery. In general, most people who have laser-assisted in-situ keratomileusis (LASIK) eye surgery achieve 20/25 vision or better, which works well for most activities. But most people still eventually need glasses for reading as they get older.

LASIK surgery has a good track record, most people are satisfied with the results. Certain side effects, particularly dry eyes and temporary visual disturbances, are fairly common. But these usually clear up after a few weeks or months, and very few people consider them to be a long-term problem.

Your results depend on your refractive error and other factors. People with mild nearsightedness tend to have the most success with refractive surgery. There are several variations of laser refractive surgery. LASIK is the best known and most commonly performed. Many articles, including this one, will use the term “LASIK” to refer to all types of laser eye surgery.

Normally, images are focused on the retina in the back of your eye. With nearsightedness (myopia), farsightedness (hyperopia) or astigmatism, they end up being focused elsewhere, resulting in blurred vision.

Nearsightedness (myopia) is a condition in which you see nearby objects clearly, but distant objects are blurry. When your eyeball is slightly longer than normal or when the cornea curves too sharply, light rays focus in front of the retina and blur distant vision. You can see objects that are close more clearly, but not those that are far away.

Farsightedness (hyperopia) is a condition in which you can see far objects clearly, but nearby objects are blurry. When you have a shorter than average eyeball or a cornea that is too flat, light focuses behind the retina instead of on it. This blurs near vision and sometimes distant vision.

Astigmatism causes overall blurry vision. When the cornea curves or flattens unevenly, the result is astigmatism, which disrupts focus of near and distant vision.

Traditionally, blurry vision is corrected by bending (refracting) light rays with glasses or contact lenses. But reshaping the cornea (the dome-shaped transparent tissue at the front of your eye) itself will also provide the necessary refraction and vision correction.

Before a LASIK procedure your eye surgeon will assess detailed measurements of your eye. Then he or she will use a special type of cutting laser to precisely alter the curvature of your cornea. With each pulse of the laser beam, a tiny amount of corneal tissue is removed, allowing your eye surgeon to flatten the curve of your cornea or make it steeper.

Most commonly, the surgeon creates a flap in the cornea and then raises it up before reshaping the cornea. There are also variations in which a very thin flap is raised or no flap is used at all or no flap at all, is raised. Each technique has advantages and disadvantages.

Individual eye surgeons may specialize in specific types of laser eye procedures. The differences among them are generally minor and none are clearly better than any others. Depending on your individual circumstances and preferences you may consider:

• Photorefractive keratectomy (PRK). With PRK, rather than forming a flap, the top surface (epithelium) is scraped away. This corneal abrasion takes three or four days to heal, resulting in moderate pain and blurred vision in the short term. It was thought that these drawbacks were outweighed by the theoretical advantage that PRK was safer for people who are more likely to be struck in the eye — for example, those involved in contact sports, law enforcement or the military. But even with standard LASIK, the risk of eyeball rupture is still very low, so there is probably no significant advantage with PRK. LASIK is also a better option than PRK for correcting more severe nearsightedness (myopia).

• Laser-assisted subepithelial keratectomy (LASEK). LASEK is similar to LASIK surgery, but the flap is created by using a special cutting device (microkeratome) and exposing the cornea to ethanol. The procedure allows the surgeon to remove less of the cornea, making it a good option for people who have thin corneas. For people at greater risk of eye injuries, LASEK does not have any significant advantages over LASIK.

• Epithelial laser-assisted in-situ keratomileusis (epi-LASIK). In an epi-LASIK procedure, your surgeon separates the epithelium from the cornea using a an epikeratome and reshapes the cornea with a laser. This procedure is similar to LASEK.

• Implantable lenses. Corrective lenses can be surgically inserted in the eye to improve vision. This is routinely done as part of cataract surgery (in which the old, cloudy natural lens is removed). It may also be an alternative to LASIK for older adults who may need cataract surgery in the future.
Younger people with high degrees of nearsightedness that cannot be satisfactorily treated with corrective lenses may also be offered implantable lenses. But this is not a routine option for most people.

• Bioptics. Bioptics combines one or more techniques, such as implantable lenses and LASIK, to treat nearsightedness or farsightedness. Again, this is not an option for most people seeking refractive eye surgery.

Are your eyes healthy?

In general, laser eye surgery is most appropriate for people who have a moderate degree of refractive error and no unusual vision problems. Your eye surgeon will ask detailed questions about your eye health and evaluate your eyes to make sure you don’t have any conditions that might result in complications or poor outcomes of surgery. These include:

• An eye disease that results in a progressive deterioration of your vision and thinning of your cornea (keratoconus). In fact, if keratoconus runs in your family, even if you don’t have it, be very cautious about elective eye surgery.

• Keratitis, uveitis, herpes simplex affecting the eye area, and other eye infections.

• Eye injuries or lid disorders.

• Dry eyes. If you have dry eyes, LASIK surgery may make the condition worse.

• Large pupils. If your pupils are large, especially in dim light, LASIK may not be appropriate. Surgery may result in debilitating symptoms such as glare, halos, star bursts and ghost images.

• Glaucoma. The surgical procedure can raise your eye pressure, which can make glaucoma worse.

• Cataracts.

You might also rethink having LASIK surgery if:

• You have severe nearsightedness or have been diagnosed with a high refractive error. The possible benefits of LASIK surgery may not justify the risks.

• You have fairly good (overall) vision. If you see well enough to need contacts or glasses only part of the time, improvement from the surgery may not be worth the risks.

• You have age-related eye changes that cause you to have less clear vision (presbyopia).

• You actively participate in contact sports. If you regularly receive blows to the face and eyes, such as during martial arts or boxing, LASIK surgery may not be a good choice for you.

Are you healthy?

Your eye surgeon will also ask detailed questions about your general health. Certain medical conditions, unrelated to your eyes, can increase the risks associated with LASIK surgery or make the outcome less predictable. These include:

• Any disease or condition that affects your immune system and impairs your ability to heal or makes you more prone to infections, such as rheumatoid arthritis, lupus, HIV and other autoimmune disorders.

• Taking an immunosuppressive medication for any reason.

• Diabetes.

• Depression or certain chronic pain conditions, such as migraine, irritable bowel syndrome and fibromyalgia. If you have one or more of these conditions, you may have more problems with dry eyes and postoperative pain than other people. The reasons for this are not entirely clear but may be related to how you perceive pain.

Is your vision stable?

If you have myopia, your vision may continue to change throughout your teenage years, or even longer, requiring periodic changes in the prescription of your glasses or contact lenses. Therefore, people must be over age 18, and preferably older, before considering LASIK eye surgery.

Certain conditions and medications — pregnancy, breast-feeding, steroid drugs — may cause temporary fluctuations in your vision. Wait until your vision has stabilized before considering LASIK eye surgery.

Can you afford it?

Most insurance plans consider laser eye surgery to be an elective procedure and don’t cover the cost. Know what the surgery will cost you.

Do you understand possible side effects and complications?

While complications that result in a loss of vision are rare, certain side effects, particularly dry eyes and temporary visual disturbances are fairly common. But these usually resolve after a few weeks or months, and very few people consider them to be a long-term problem.

• Dry eyes. LASIK surgery causes a temporary decrease in tear production. For the first six months or so after your surgery, your eyes may feel unusually dry as they heal. Even after healing, you may experience an increase in dry eye.
Your eye doctor might recommend that you use eyedrops during this time. If you experience severe dry eyes, you could opt for another procedure to get special plugs put in your tear ducts to prevent your tears from draining away from the surface of your eyes.

• Glare, halos and double vision. After surgery you may have difficulty seeing at night. You might notice glare, halos around bright lights or double vision. This generally lasts a few days to a few weeks.

LASIK versus reading glasses

By their early to mid-40s, all adults lose some ability to focus on nearby objects (presbyopia), which results in difficulty reading small print or doing close-up tasks.
One possible benefit of having been nearsighted most of your life is that this condition actually compensates for the presbyopia that inevitability develops as you get older. A nearsighted eye will focus near objects by itself without reading glasses. LASIK surgery removes this near focus because the nearsightedness has been corrected. This means that as you get older you will need to use reading glasses. Many people are happy to trade clear distance vision when they are younger for having to wear “cheaters” for reading when they are older.

If you are an older adult considering LASIK, you might choose to have your vision corrected for monovision, to maintain your ability to see objects close up. With monovision, one eye is corrected for distant vision, and the other eye is corrected for near vision. Not everyone is able to adjust to or tolerate monovision. It’s best to do a trial with contact lenses before having a permanent surgical procedure.

Can you go without your contact lenses for several weeks before surgery?

This is usually not an issue, but know that you’ll have to completely stop wearing your contact lenses and switch to glasses for at least a few weeks before your surgery. Contact lenses distort the natural shape of your cornea, which can lead to inaccurate measurements and a less than optimal surgical outcome. Your doctor will provide specific guidelines depending on your situation and how long you’ve been a contact lens wearer.

What are your expectations for LASIK?

Most people who undergo LASIK surgery will have good to excellent vision in most situations, for many years or decades. You’ll be able to play sports and swim, or even just see the clock first thing in the morning, without having to worry about your glasses or contact lenses. But as you get older or in low-light conditions, you may still need to wear glasses.

Most people report high satisfaction after LASIK surgery. But long-term results often aren’t available or haven’t been well-studied. Part of the reason for this is that people are overall satisfied after surgery, so they don’t feel a need for repeat examinations and follow-up data is not collected. Also, the LASIK procedure has been refined over time — the techniques and technology is continually changing. This makes it difficult to draw conclusions from the data that is reported.
Keep in mind that even when postoperative follow-up is done and reported, vision is measured under optimal testing conditions. Your vision in dim light (such as at dusk or in fog) may not be as good as published reports suggest it will be.
Over time your refraction may slowly worsen with age and your vision may not be quite as good as it was immediately after surgery. This does not seem to be a large problem, but the exact degree of change to be expected is sometimes unpredictable.

How do you choose an eye surgeon?

Most people don’t have firsthand knowledge about LASIK or an eye surgeon. A good starting point when choosing an eye surgeon is to talk with the eye professional you know and trust. Or ask friends or family members who have had successful LASIK.
Your eye surgeon will probably work with a team, who may help with your initial evaluation and measurements. But it is your surgeon who takes the ultimate responsibility for determining whether LASIK is an appropriate choice for you, who confirms the measurements to guide the procedure, who performs the procedure, and who provides postoperative care.

Talk with your eye surgeon about your questions and concerns and how LASIK will benefit you. He or she can help you understand the benefits and limitations of surgery.

The final decision

When it comes to LASIK eye surgery, there are no right answers. Carefully consider the factors outlined here, weigh your preferences and risk tolerance, and make sure you have realistic expectations. Talk to an eye surgeon in whom you feel confident and get your questions answered. In the end, if it feels right, then proceed, but if it doesn’t, don’t rush into anything.

This article is an edited version of a report that was written by the Mayo Clinic Staff


The FIVE Best Reasons to Have Laser Vision Correction!

LASIK surgery offers a wealth of benefits for the average eyeglasses wearer. If you’ve been wearing eyeglasses for a long time, consider the benefits of LASIK.

1. Improved vision. Studies have shown that about 95% of patients who receive LASIK surgery achieve uncorrected visual acuity (UCVA) of at least 20/40 and 85% achieve 20/20 vision or better. Patients can enjoy greatly enhanced vision following one outpatient procedure.

2. Long-lasting results. Following a stabilization period of about 3 months for the eye to adjust, LASIK results are expected to be permanent. There is no need for follow-up procedures, unless the surgery over or under-corrected to repair a vision, and the patients improved eyesight will last barring any normal loss due to aging or illness.

3. Quick results and quick recovery. You won’t be able to drive immediately after a LASIK surgery but most ophthalmologists estimate that patients can return to their normal schedule as soon as the day after surgery, unless you have an especially dirty or dusty workplace. Imagine having near perfect vision within a day!

4. No more contacts. It’s estimated that the annual cost of contact lenses is 375 to 450 dollars per year. Granted, LASIK surgery costs several times that amount but you only have to pay for it once- after several years LASIK surgery will pay for itself by eliminating the need for contacts and even begin to save you money. Not to mention that you won’t have to bother with solutions, sticking your finger in your eye, or crawling around on the floor looking for a lost contact.

5. No more glasses. It’s safe to say that we’re past the days of being called “four-eyes” when pro athletes wear glasses without lenses in them but isn’t it nice to have the option of not wearing glasses? Your look can radically change as simply as taking off your glasses. Plus you can wear all the styles of shades you please, without shopping for special lenses for your eyeglasses or purchasing expensive prescription sunglasses.


A History of Wavefront Mapping and Custom


Clinical Study Results
Some of the early trial results, such as the 2003 VISX multi-center clinical study, that led to FDA approval for wavefront-guided laser vision correction showed the following:


• At one year after the Custom procedure:

• 100% of the clinical study participants could pass a driving test without glasses or contacts
• 98% of the clinical study participants could see 20/20 or better without glasses or contacts
• 70% of the clinical study participants could see 20/16 or better without glasses or contacts
• Four times as many clinical study participants were very satisfied with their night vision after the VISX CustomVue procedure compared to their night vision before with glasses or contacts.

What Is Wave Front Mapping?
Wavefront mapping is the technology that makes custom laser eye surgery possible by precisely measuring and diagraming the imperfections of an optical system, such as the eye. These imperfections are divided into lower-order aberrations, such as myopia, hyperopia, and astigmatism, and higher-order aberrations that affect night vision. Wavefront-guided technology is used in CustomVue laser eye surgery to correct refractive error and to improve night vision.
Wavefront Analysis and Mapping:

Wavefront analyzers are used to map aberrations in the eye. Several types of visual imperfections, referred to as lower and higher-order aberrations, exist within the eye and can affect both visual acuity and the quality of vision. Prior to wavefront technology, only lower-order aberrations such as myopia, hyperopia, and astigmatism could be measured and treated. However, these do not account for all potential vision imperfections. Higher-order aberrations can also have a significant impact on quality of vision and are often linked to glare and halos that may cause night vision problems.

Wavefront analyzers use a Hartmann-Shack sensor, which maps both lower and higher-order aberrations by projecting waves of light into a patient’s eye and mapping the waves that bounce back through the pupil. A perfect wavefront would be completely flat. When light rays enter the eye and traverse the different refractive indices, the wavefront surface changes, taking on a shape unique to that eye. These variations are called wavefront aberrations. The aberration data is collected and then converted into a treatment formula by using Zernike polynomials, which are also called modes. Each mode describes a certain three-dimensional surface and the Zernike polynomials correspond with ocular aberrations. For instance, second-order Zernike polynomials represent the conventional aberrations such as defocus and astigmatism. Zernike polynomials above the second order represent the higher-order aberrations that are suspected of causing night glare and halos. Zernike polynomials help to simplify the wavefront technology by combining all aberrations into one simple map. This is called Zernike decomposition.

History of Wavefront Technology:
Wavefront technology was originally developed for use in astronomy. In the 1900s, an astrophysicist named Johannes Hartmann devised a method of measuring the ray aberrations of mirrors and lenses. The Hartmann test used a metal disk in which regularly spaced holes had been drilled. The disk or screen was then placed over the mirror that was to be tested and a photographic plate was placed near the focus of the mirror. When exposed to light, a perfect mirror will produce an image of regularly spaced dots. If the mirror does not produce regularly spaced dots, the irregularities, or aberrations, of the mirror can be determined.

In the 1970s, Dr. Roland Shack and Dr. Ben Platt advanced the concept by replacing the screen with a sensor based on an array of tiny lenslets, thus creating the Hartmann-Shack sensor. In 1978, Dr. Josef Bille of Germany was the first person to use the Hartmann-Shack sensor in ophthalmology. Other wavefront pioneers include Dr. Junzhong Liang and Dr. David Williams who developed a wavefront device that could be used in a clinical setting.

In 1997, Drs. Liang and Williams presented a paper at the Association for Research in Vision and Ophthalmology that discussed the early clinical results attained with the wavefront device. At this time, ophthalmologists and major laser manufacturers, such as VISX, Bausch & Lomb, and Alcon, began to look at the possibilities of wavefront technology for correcting refractive error and to develop their own wavefront analyzers. In 2002, the FDA approved the first wavefront-guided custom LASIK application. Today, there are many integrated wavefront-guided LASIK systems that first generate a wavefront map of a patient’s unique optical imperfections, then send this information to an excimer laser that performs the custom LASIK procedure.

Zernike Polynomials Shapes

The wavefront analyzer software condenses the wavefront information into a conventional refraction in diopters as well as in Zernike form. This map is then transferred to the laser, enabling treatment of the patient’s lower and higher order aberrations.


Over 40? Monovision. It Might Fit Your Life Best!

Ultimately, deciding between a Full Distance correction and a Monovision correction after laser vision correction is an individualized choice that is based on multiple factors. There is not one ‘right’ answer or ‘one size fits all’ solution. After getting to know your goals and lifestyle, Dr. Vale can help guide you to the most appropriate procedure for your specific needs.

The customary goal of laser vision correction is usually stated as, “to reduce or eliminate the need for glasses and contacts”. If you are over 40, you may wonder, “What about reading glasses and near vision problems that occur with age?” For patients over age 40, Monovision
may be a great choice. It can help the majority of patients achieve good distance and near vision without glasses. Keep reading if you are trying to figure out if Monovision may be right for you.

First, a brief tutorial may be helpful. Presbyopia is the normal age related change in vision in which the natural lens of the eye loses the ability to “accommodate ” or focus at near. Presbyopia causes a gradual worsening of near vision in most individuals in their forties. Whether or not you have laser vision correction, you can expect to eventually become “presbyopic” during those years. That is why people begin wearing bifocals, reading glasses, or taking off their distance glasses (if they are nearsighted) to read small print. Yes, even after laser vision correction, if you are corrected for perfect distance vision (“Full Distance”) in both eyes, you will eventually need reading glasses for near work. Many patients are not opposed to using over-the-counter reading glasses for near work after surgery. Other patients truly want to be “glasses-free”, and the mere thought of needing reading glasses would defeat the point of having laser vision correction in the first place.

With Monovision, one eye is “set” for distance focus, and the other eye is set for better near focus. Having mild nearsightedness in one eye can help negate the effects of presbyopia and both restore and preserve near reading ability. Monovision allows a patient to see both distance and near images without glasses by having blended visual focal points. The goal of Monovision is to be independent of glasses for most day-to-day activities. After Monovision it is realistic to be able to read a menu, do computer work, watch TV, and still drive a car legally without glasses.

While Monovision is not a “perfect” solution to presbyopia, for carefully selected patients, it is well tolerated and very satisfactory over 85% of the time. Most patients who choose Monovision are satisfied with both near and far vision without glasses. Alternatively, about 15% of Monovision patients notice certain tradeoffs, including difficulty with high performance sports or night driving, or with intricate close work. Monovision may be appropriate for a 50 year-old accountant, but not appropriate for a 50 year-old motorcycle police officer. Our goal at Acuity is to help our patients be satisfied with their vision, for their specific lifestyle and activities, regardless of their age. Ultimately, deciding between a Full Distance correction and a Monovision correction is an individualized choice that is based on many factors. Accordingly, there is not one “right” answer. After getting to know your goals and lifestyle, Dr. Vale and his staff can help guide you to the most appropriate procedure for your specific needs.


Reasons for considering Monovision Laser Vision Correction:

  •  Age 40 or older seeking the convenience of “glasses-free” lifestyle.
  • Opposed to needing reading glasses for near work.
  •  Not active in high performance sports (i.e. tennis, motorcycle riding.)
  •  Tried Monovision with contact lenses and liked it.
  • Being ‘okay’ at the possibility of using distance glasses to fine-tune distance vision for sports or night driving (so both eyes see 20/20).
  • Understanding that LASIK re-treatment can “un-do” Monovision at a later date, if desired.

Reasons for considering Full Distance/not Monovision:

  •  Age 40 or younger (eventually will use readers in mid-forties.)
  •  Over age 40, but seeking the most “perfect” distance vision possible for sports or night driving
  • Being “okay” with needing over-the-counter reading glasses for close work (usually after age 43)
  •  Tried Monovision with contact lens trial, but did not like it
  • Difficulty adapting to changes to vision (new bifocals, new glasses prescription) or just “feeling” that Monovision will not work for you
  •  Having a very large amount of Farsightedness
  •  Having a weak/lazy eye (amblyopia)

Real Case Scenarios and Teaching Points:

To help you decide if Monovision may be right for you, read these real patient situations to help clarify certain issues that may still be confusing. See if you identify with any of these situations listed below:
Case 1: Should a 30 year-old computer programmer consider Monovision?
Case 2: Can Monovision be fine-tuned, if distance vision is not good enough?
Case 3: “Doc, just make me 20/20, I can deal with readers”
Case 4: “I want better distance vision, but don’t want to lose my near vision”
Case 5: “I want better near vision, but don’t want to ruin my distance vision”
Case 6: A change of heart!
Case 7: Some expectations just can’t be realistically fulfilled.
Case 8: Still on the fence? What is Mini-Monovision?

Case #1:
Mary S. is a 30 yr old woman with mild nearsightedness, who works for a high-tech company as a software programmer.
• Goal: She does not want to need any glasses after LASIK.
• Recommendation: Full distance correction. Because of her young age, she should have no problem with her near vision after LASIK. I explained to her about the eventual age related presbyopic changes that will be expected about age 43. She will eventually need reading glasses, or I could do a LASIK enhancement to adjust for Monovision at that time, if she desires.
• Take home point: Age is THE key factor. Until the early 40’s, near vision should be very good after laser vision correction.

Case #2:
Jose H. is a 56 year-old attorney with moderate nearsightedness and mild astigmatism. He currently uses progressive bifocals. He spends most of his workday on a computer or doing deskwork. He does drive at night a few times a week, if he works late. He also plays recreational tennis during the day about twice per month and skis a few times per year.
• Goal: He wants to be glasses free, as much as possible.
• Recommendation: Monovision. After trying a simulation of Monovision with trial lenses, he was pleasantly surprised with the clarity of his distance and near vision and elected to have Monovision LASIK. Since Jose spends a large percentage of his time doing near work, and a small percentage doing distance tasks, Monovision seemed appropriate. We told Jose that there is a possibility that he may want to wear glasses (glove compartment glasses) to fine-tune distance vision at night, which he rarely does. Also, since he usually wears sunglasses when he skis and plays tennis, he could opt for a pair of prescription sunglasses (with the distance prescription placed in the near eye and no correction in the distance eye) for optimal distance vision during sports.
• Take home point: With Monovision, distance vision can be fine-tuned with glasses, if desired, for optimal distance vision. Whether or not you choose Monovision, you WILL be able to feel safe driving after LASIK. Likewise, if distance with Monovision is not quite to your satisfaction, you could elect to have a LASIK retreatment to “un-do” Monovision, and then use reading glasses.

Case #3:
Seymour R. is a 44 year-old contractor with farsightedness and astigmatism. He only rarely does any deskwork, but he wants to be able to comfortably see his dashboard instruments and GPS navigation system in his car.
• Goal: To have great distance vision and be able to read his dashboard and GPS navigation without glasses.
• Recommendation: Full distance correction. Seymour initially told me that he wanted to be “glasses-free”. Since his job requires him to do a lot of driving, we explained the potential problems with Monovision. After learning about Monovision, he thought that “it sounded weird” and that he didn’t think that he would get used to it. Because Seymour is only 44 years old (barely presbyopic), we explained that he should still have fairly good near vision with a full distance correction, but would eventually need readers for near work. After demonstrating Monovision and Full distance options with a loose lens trial simulation in our office, he was most satisfied with a full distance correction, and able to read his dashboard gauges.

• Take home point: During the early stages of presbyopia, near vision may still be adequate for many near tasks. A full distance LASIK correction will improve distance vision, and a patient will gradually notice a need for reading glasses with age. For patients over 40 who are not opposed to reading glasses, a full distance correction is tough to beat.

Case 4:
Sandy K. is a 53-year-old nurse with mild nearsightedness. She only occasionally wears her distance glasses for driving at night and watching movies. She has excellent near vision without glasses. She normally does not even wear glasses when she is at work or home.
• Goal: She wants to improve her distance vision for driving, but she does not want to “lose” her near vision.
• Recommendation: Monovision (LASIK in just one eye). We recommended that Sandy do LASIK in only her dominant right eye. This will improve her uncorrected distance vision for driving, and will preserve her near vision that is important for her job. Though Sandy has never had any difficulty with near work, it was important to inform her that if she did LASIK in both eyes for distance, her near vision would not be as good after surgery.
• Take home point: For a patient with mild nearsightedness, We may suggest doing LASIK in only one eye. LASIK could be performed on the other eye in the future, if desired. After assessing the patient’s lifestyle and goals, it is best to do the least “amount” of surgery to fix the problem.

Case #5:
Lyndall S. is a 46 year-old women who always had great distance vision without glasses, but now requires reading glasses for close vision. She is tired of having to put glasses on & off throughout the day. She wants to be able to see her cell phone, price tags in a store, a menu, and putting on makeup. She also wants to be able to watch TV and feel safe driving. After a contact lens trial in her non-dominant left eye, Lyndall was reassured that her distance vision would still be good enough after having Monovision LASIK to improve near vision.
• Goal: Ease and convenience of being independent of reading glasses. 
Recommendation: Monovision (LASIK in her non-dominant eye)
• Take home point: For people with naturally good distance vision, Monovision LASIK can improve near vision. Often only one eye needs to be treated.

Case #6:
Nancy S. is a 55 year-old paralegal with moderate nearsightedness and mild astigmatism. She doesn’t play sports but she does a fair amount of driving at night. As a paralegal, most of her job entails near/computer work. She was primarily interested in good near vision, but was slightly skeptical if she would tolerate Monovision. Because she was “on the fence”, We suggested a Monovision trial with contact lenses. With the Monovision contact lenses, she said that her near vision was good, but distance was still a little blurry with night driving. Weighing all the pros and cons, Nancy felt comfortable with the tradeoffs and benefits of Monovision.
• Goal: Good distance and near vision, preferably without glasses.
• Recommendation: Monovision LASIK. Since Nancy liked her Monovision trial, she elected to have Monovision with LASIK.
• Update: Nancy initially liked Monovision with contact lenses and with LASIK, but 4 years later, she decided she would prefer full distance instead because she was working less often. She requested an enhancement in her near eye (to be set for distance). She decided that she would be happier with optimal distance vision, and wouldn’t mind needing readers. When Nancy’s needs changed, our recommendations change.
• Take home point: Our goal is to help our patients be satisfied with their vision, for their specific lifestyle and activities, regardless of their age (even as time passes). A retreatment can be performed to adjust vision, if necessary to accomplish a patient’s goal.

Case #7:
Will M. is a 72 year-old retired banker. He has mild farsightedness and advanced presbyopia. He has moderate signs of cataract formation.
• Goal: Glasses free, if possible.
• Recommendation: Refractive Lens Exchange (RLE) Due to Will’s age and cataracts, the RLE option can treat the cataract and the farsightedness at the same time. Currently, Multifocal and accommodative lens implant technology can also improve near vision.
• Take home point: Laser Vision Correction is not the best choice for everybody.

Case #8:
Cliff is a 47 year-old business owner who is very active in sports and fitness. He would like to have “some” near vision, but is worried about the potential tradeoffs of Monovision. He is not completely opposed to reading glasses, but it would be nice to be able to check emails on his blackberry without glasses.
• Goal: Cliff’s primary goal is to have good distance vision for sports. His secondary goal is to have decent near vision.
• Recommendation: “Mini” Monovision.
• Take home point: Mini-Monovision is a hybrid between full distance and Typical Monovision. For some patients, we may leave one eye very slightly nearsighted (i.e. -0.75 D) to get some of the benefits from Monovision, but with less of the possible tradeoffs. Laser Vision Correction is not “one size fits all.”

Are You Wondering, “Should I get LASIK?”


Should I get LASIK? If you struggle with glasses or contact lenses in order to see well, you may be asking yourself this very question.  Asking questions – a lot of questions –  is the best way to determine if it’s right for you.

Because, frankly, if you are considering a vision correction procedure – or surgery of any kind – being an informed patient is the most important first step. And becoming an informed patient means spending the time to research and consider. LASIK is an elective procedure, which means the choice to have it is yours. Determining whether it will fit your lifestyle and personality, understanding both the risks and benefits and working with a trusted surgeon, should all be part of your research.

If you’re considering LASIK, this will help you on your journey – from identifying your personal goals to writing down questions.

Goals: It’s important to understand what you want out of a vision correction – is it a lifestyle choice? A career need? Or simply the desire to rid yourself of glasses or contact lenses. Writing 2-3 sentences about what you want out of LASIK will help you have a better conversation with your surgeon.

Friends and Family: Talk with your friends and family who have had LASIK and learn as much as you can about what their experience was like. Ask about everything from the first consultation to recovery.

LASIK Surgeons In My Area: As part of your conversations with friends and families, note their surgeons. Referrals from friends and family are a good first start to finding a surgeon who will be right for you.

Questions: What do you want to know about LASIK? What are your questions? Should I get LASIK? Am I a good candidate? What are the risks? What can I expect post-LASIK and throughout recovery?


Custom LASIK, The Latest in Laser Eye Surgery

Custom LASIK is the most advanced laser technology available. Custom LASIK laser treatments are based upon the unique visual characteristics of your eye. Up until now, with glasses, contacts and conventional LASIK surgery, corrections were quite similar for each type of prescription. Custom LASIK involves measuring the eye from front to back with a special laser, using what’s called “wavefront” technology, to create a three-dimensional (3-D) image of the eye. The information contained in the wavefront-map guides the laser in customizing the treatment to your individual visual system.

Possible Benefits of Custom LASIK

Custom LASIK wavefront technology is revolutionary because it has the potential to improve not only the quantity of your vision (i.e. the visual acuity measured by the standard 20/20 Snellen eye chart), but also the quality of how well you can see (i.e. visual acuity measured in terms of contrast sensitivity and fine vision). This may translate into a reduced risk of post-LASIK untoward side-effects, such as difficulty with night vision.

How much you see depends on what lower-order and higher-order aberrations you have; lower-order aberrations are also called refractive errors (i.e nearsightedness, farsightedness and astigmatism). Conventional LASIK treats these lower-order aberrations. How well you see can also depends on what higher-order aberrations you have; higher-order aberrations are irregularities other than refractive errors, and can cause such problems as decreased contrast sensitivity or night vision, glare, shadows and halos. Higher-order aberrations do not always affect vision. Custom LASIK has the potential to treat both lower- and higher-order aberrations. Some of the potential advantages of wavefront LASIK are:

· Potentially a greater chance of achieving 20/20 vision without glasses
· Potentially a greater chance of achieving better than 20/20 vision
· A potential reduction in the chance of losing best-spectacle corrected vision
· A potential reduction in the chance of losing visual quality or contrast sensitivity
· A potential reduction in the chance of night-vision disturbances
· The potential to use wavefront-LASIK to treat eyes that have previously had laser surgery and suffer from untoward side-effects (Off-label use of technology)

Wavefront-guided excimer laser technology

The Visx Wavescan system was the first laser to be approved by the U.S FDA for the treatment of nearsightedness and astigmatism. The VISX WaveScan system is made up of the Star S4 laser and the WaveScan wavefront device. The company calls its custom LASIK procedure “CustomVue.” The FDA approval is for eyes with up to -11 diopters of myopia, with or without up to -3 diopters of astigmatism. Surgeons can, for the first time, measure and treat visual disorders that previously could not be detected.

In the U.S. FDA clinical trials, 94% of patients who had the Visx CustomVue procedure achieved 20/20 or better vision. The trial participants were four times more likely to say they were “very satisfied” with their night vision following CustomVue than they were with their night vision with their glasses or contacts.

How Custom LASIK Works

The ophthalmic technician  will begin by using the wavefront device to transmit a safe ray of light into your eye. The light is then reflected back off the posterior portion of the eye, out through the pupil, and into the aberrometry device. The reflected wave of light is received and arranged into a unique pattern that measures both lower- and higher-order aberrations.

All of these visual measurements are then displayed as a 3-D map, referred to as a wavefront map. This information is then electronically transferred to the laser, and computer-matched to the eye’s position, enabling the surgeon to customize the LASIK procedure to your unique visual requirements.

Getting Custom LASIK

Like conventional LASIK, custom LASIK is a surgical procedure and has risks associated with it. It’s important you discuss its applications and potential complications with Dr. Vale to determine if you are a good candidate for this procedure.