KKCheong's Blog: June 2009

Not sure if this info is correct or not. Read at your own discretion. But I'm glad I did LASEK instead of LASIK.

http://www.parkavenuelaser.com/about-lasek-surgery.php

About LASEK (Bladeless Surgery)
LASEK (Laser-Assisted Subepithelial Keratectomy) is the most recent procedure to come out, and combines the best characteristics of LASIK (rapid recovery, no pain) and PRK (no cutting, no flap, improved safety).

Dr. Chynn was one of the 1st refractive surgeons in NYC to perform LASEK, as well as one of the first in the New York-TriState area to combine LASEK with CustomVue, for "SuperVision." Here's how LASEK works:

A flap of epithelial tissue is created with a special solution by Dr. Chynn, who then gently moves it out of the central optical zone with a sterile Weck-Cell cellulose sponge. This allows the central cornea to be reshaped with the VISX excimer laser (www.VISX.com).

The epithelial tissue is then replaced and a special Bandage Contact Lens (BCL) with no power is worn to protect the delicate replaced epithelial tissue until recovery is complete. After a few days, the BCL is removed by Dr. Chynn, and the antibiotic drops are discontinued, because by then your epithelium is fully healed and you are seeing great!

There are many reasons why almost 90% of Dr. Chynn's patients, starting in 2005, have chosen the newer Bladeless, All-Laser, No-Cut, No-Flap LASEK over traditional LASIK:

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1. THIN CORNEAS--LASEK can safely treat patients with thin corneas, because no flap is made at all, leaving much more tissue available to treat with the laser, and preserving more corneal tissue untouched for greater structural strength after the procedure.

"Studies have been performed, where human eyebank eyes have been treated with either LASIK or LASEK, then cannulated with needle on an air tube, and then pumped up with an specially-designed, extremely accurate air pump until the eye explodes. LASIK eyes exploded at a significantly lower pressure than normal, untreated eyes, which indicates that, even years afterwards, if you get punched in the eye after LASIK, there is a higher chance of a ruptured globe--not good! (Even though I, myself, had LASIK in 1999 up at Harvard.)

"In contrast, post-LASEK eyes withstood the same amount of pressure as the untreated, control eyes, indicating that, for the most part, LASEK eyes are structurally much more sound than LASIK eyes, and statistically as strong as eyes that were never lasered at all!"

--Emil William Chynn, MD, in an interview for CBS News TV, broadcast Nov. 23, 2004.
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2. HIGHER LEVELS OF PRESCRIPTION--for the same reasons as above--because it preserves much more corneal tissue--LASEK can be safely performed on patients with higher levels of prescription than LASIK.

"Let's say you have a high Rx, similar to my Rx before my own LASIK (-7.50 -1.50 x 180, with a spherical equivalent in contacts of -8.25). Let's say that your preoperative corneal pachymetry (measured on each and every patient before surgery at parkavenuelaser.com) was normal, but on the thin side--say 500 microns, or micrometers.

"A LASIK flap, even the thinnest flap you can reliably treat with IntraLase, is 100 microns. Treating myopic astigmatism removes about 12 microns per diopter of treatment, or 8.25 x 12 = 99 microns--let's call it 100 microns for simplicity.

"Starting from 500 microns, you would subtract 100 microns for the flap, and another 100 microns for the laser ablation--leaving you with only 300 microns of untouched corneal tissue, or only 50 microns (one twentieth of a millimeter) above the safe lower limit of 250 microns to prevent corneal ectasia, or iatrogenic keratoconus (KC).

"In contrast, for a LASEK, you would again start with a corneal thickness of 500, but only subtract 100 microns for the ablation, BECAUSE THERE IS NO FLAP. This would leave fully 400 microns of untouched corneal tissue after a LASEK for the same prescription--or 150 microns above the 250 safe limit--or THREE TIMES the amount of extra tissue preserved in LASIK (which was 50 microns in the above example.

"Simply put, LASEK is almost always safer than LASIK, because you are preserving much more corneal tissue in a LASEK compared to a LASIK by definition."

--Emil William Chynn, MD, FACS, MBA

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3. LESS DRY EYES--Most patients experience TEMPORARY Dry Eye Syndrome (DES) after any refractive procedure, whether LASIK, LASEK, or PRK. In the majority of cases, these patients actually had some DES symptoms BEFORE their procedure, like dry and uncomfortable contacts, which lead them to having the procedure performed in the first place!

Many studies, including several published in Ophthalmology, the #1 eye journal in the world (Dr. Chynn is on the Peer Review Board of Ophthalmology, to help decide which articles make it to print), have shown less DES after LASEK compared to LASIK, because no flap is made, so less corneal nerves are cut and need to regrow after the procedure to restart the normal blink reflex.

Dr. Chynn is one of the most experienced surgeons in NYC in treating and preventing these DES symptoms in his LASIK and LASEK patients--probably because he was the 1st LASIK surgeon in NYC to have LASIK himself, so understood personally what dry eyes feel like!

"I test all my patients for DES before their surgery. If I note significant preoperative superficial punctate keratopathy (SPK), I'll perform a painless Schirmer Type II tear test to document and quantify the amount of tear film deficiency.

"100% of my patients are told to begin PRESERVATIVE FREE artificial tears a MINIMUM of 4x/day before even their Free Consultation with me, and then to continue this regime until and well past their surgery to prevent, minimize, or eliminate DES symptoms.

"They are also told to perform Lid Hygiene with commercially available Lid Scrubs, which are available Over The Counter (OTC) at any pharmacy, twice a day. This improved meibomian gland function and secretions, to add the necessary layer of oil that is normally present in tear film to help prevent excess evaporation and to smooth out the surface.

"Patients are also told to increase their water consumption, and to decrease their intake of all substances that dehydrate, such as caffeine, alcohol, and antihistamines prior to their surgery and into their immediate postop. period, to promote better wound healing.

"In severe cases of meibomitis, or meibomian gland dysfunction (MGD), doxycycline, a very mild antibiotic, is prescribed orally. This is not used for its antibiotic properties, but to improve the quality of the meibomian secretions, making them thinner and more like liquid, so they are secreted more normally, rather than being the consistency of a wax and clogging up the meibomian gland pores. Fish liver oil, or TheraTears nutritional caplets, are also prescribed in these cases, for the same reason.

"Patients with DES either before or after surgery are usually treated with dissolvable collagen punctal plugs, which I insert at the Slit Lamp in the exam room, in a totally painless procedure that takes 10 seconds. These go in the tiny hole in the corner of your eyelid near your nose, to partially block the OUTFLOW of your tears from your eye, like plugging up a sink with a stopper, to keep the tears in your eyes longer for reduced DES symptoms.

"In a minority of cases, for people with severe preop. or postop. DES, I will then insert semi-permanent silicone punctal plugs, and keep them in for months until symptoms go away.

"All honest refractive surgeons will admit to their patients that they will be dry for a few weeks after LASEK or a few months after LASIK--I was myself. The important thing is to know how to diagnose and treat this condition appropriately so it doesn't prevent them from enjoying their new vision and new eyes after their procedure."

--Emil W. Chynn, MD, Fellowship Trained in Cornea, External Disease, and Refractive Surgery

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4. NO CHANCE OF AN INTRAOPERATIVE FLAP COMPLICATION--The most common serious complication in LASIK is an intraoperative flap complication, which occurs in about 1 in 1000 cases, no matter what type of keratome is used, whether bladed (e.g., Bausch & Lomb's Hansatome, the #1 keratome in the world in terms of # of eyes performed on it) or laser (i.e., IntraLase). Common flap complications in the OR include partial flaps, irregular flaps, "button-hole" flaps, and total (amputated) flaps--all of which can cause PERMANENT visual problems.

In contrast, with LASEK, there is NO FLAP AT ALL BEING MADE, so there can be NO FLAP COMPLICATIONS. Even IntraLase has been reported in dozens of published articles to have flap complications, because IT IS IMPOSSIBLE TO ELIMINATE FLAP COMPLICATIONS UNLESS YOU ELIMINATE THE FLAP ITSELF. In fact, it is a "dirty little secret" of IntraLase marketing (they are listed on the NASDQ stock exchange and went IPO in 2004) that the flaps are being cut with IntraLase--many patients getting IntraLase have either been told incorrectly, or left to incorrectly assume that there is no cutting and no flap in an IntraLase LASIK.

"I think it is highly unethical that many surgeons and IntraLase representatives are hiding from the public that the "all laser" IntraLase LASIK procedure is still a cutting procedure, with a flap, and all potential flap complications as a normal mechanical microkeratome LASIK. Indeed, not once on the IntraLase website is this clearly stated to the consumer--and for good reason

"I would have no problem with the people using and selling IntraLase if they told potential patients that they were still having their eyes cut, only with a laser instead of a blade, so they could still have intraoperative and postoperative flap complications.

"In fact, there is a peculiar (bad) clinical syndrome UNIQUE to IntraLase LASIK procedures that never has been reported to occur with a standard microkeratome, involving persistent, severe photophobia (light sensitivity) that can last weeks to MONTHS. IntraLase was forced to report this to FDA, and it has been published in many medical journals. However, the only thing the IntraLase people will ever discuss are its advantages over standard LASIK--leaving out its unique DISADVANTAGES.

"I was featured on CBS News TV in NYC as having the most ethical LASIK center in NYC, because others were caught on 'hidden camera' saying things to customers that were not true.

"I may be blunt, I could maybe be more tactful at times, but nobody has ever accused me of being less than straightforward with my patients--which is maybe why I have never been sued!"

--Emil W. Chynn, MD FACS
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5. NO CHANCE OF A PATIENT-INDUCED FLAP COMPLICATION--Patients who are nervous, "blinkers," "squeezers," those who have never worn contacts before so are not used to things near or in their eyes, those who are afraid of "getting cut" in the OR, those with a strong blink reflex, and those with deep set eyes or small palpebral fissures (like some Asian patients) are not good candidates for LASIK, as they can squeeze during the cutting portion of the procedure and cause an intraoperative flap complication (like those listed above in #4).

"I had an attempted LASIK by Dr. Chynn in 2002, and squeezed my eye right as the keratome pass was made. I am a big guy, over 200 lbs., so this squeezing prevented the keratome from making a full pass, despite the speculum that was placed in my eye, so I wound up with an incomplete flap.

"Dr. Chynn immediately recognized this complication, and aborted the laser portion of the procedure, and replaced my incomplete flap perfectly in the right position, then let it heal with a bandage contact lens for a week, and fully for several months. He never panicked, and reassured me that, because of his Corneal Fellowship, he could handle this complication fine.

"After the incomplete flap was fully healed, he performed another LASIK on my same eye, using a different microkeratome to produce a thicker flap, so the flap edge would be in a different plane than the other incomplete flap. This was successful, and the laser portion of the procedure was performed, using CustomVue WaveFront to compensate for the irregularities induced by my first, incomplete flap.

"Using this advanced technique, Dr. Chynn was able to restore my vision, which now, years afterwards is BETTER than 20/20 in that eye--really, a remarkable "save" by him!

"Of course, for the other eye, we both decided on LASEK, and it went totally smoothly, and my final result in that eye is also 20/15--but without all the drama of the LASIK eye!"

--Pedro Bonilla, Certified Ophthalmic Medical Technician (COMT)

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6. NO CHANCE OF FLAP WRINKLES, STRIAE, DEBRIS, or EPITHELIAL INGROWTH--After LASIK, another 1 in 1000 patients has significant problems associated with their flap. Flap wrinkles or striae occur in nearly 1 in 100 patients, but are usually clinically insignificant. However, when they are significant, they can cause visual distortion or double vision. Debris under the flap is also usually insignificant, but rarely is either so big or does not resorb so the flap needs to be re-lifted in the OR and the debris surgically removed. Epithelial in growth can also be a significant problem, sometimes requiring re operation to prevent flap melts.

All of these problems are ELIMINATED with LASEK, because THERE IS NO FLAP!

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7. IMPROVED NIGHT VISION--More of the cornea is exposed for treatment than with LASIK, because there is no flap edge, which makes LASEK a better choice for patients who require a larger treatment diameter because of large pupils or higher degrees of correction. Not having to worry about a flap edge is also advantageous in CustomVue WaveFront, as otherwise some of the custom ablation actually goes over the flap bed, and is wasted on the unexposed cornea. This also contributes to better night vision after LASEK compared to LASIK.

"I had a LASEK procedure by Dr. Chynn in 2003, and before was not legal to drive a car, although I often did this without glasses or contacts. After my LASEK, even without CustomVue, I never had any night vision problems--no glare, no 'halos,' nothing at all! I am so glad that I chose LASEK, and recommend this to all of our patients--more than 50% of whom are now seeing better than 20/20 after their LASEK--just like me!"

--Mizraim "Missy" Reyes, Front Office Manager, parkavenuelaser.com

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8. Advantage over LASIK in CustomVue WaveFront procedures--CustomVue WaveFront involves measuring a patient's eye over literally hundreds of points, and determining exactly what prescription is needed at each individual point--rather than averaging one prescription for the entire eyeball at every point, which is what is done with glasses or contacts.

CustomVue WaveFront also corrects "higher order aberrations" that are not measured or treated in glasses or contacts (see www.VISX.com). This is why, after CustomVue WaveFront corrections, many patients see even better afterwards than they did with glasses or contacts!

However, it is important to know that the WaveFront measurement is made BEFORE surgery, during the consultation, while creating a flap by any means, whether IntraLase or with an automated microkeratome, lifting it up, and replacing it afterwards has been PROVEN in HUNDREDS of studies to induce new "higher order aberrations" that CANNOT be treated, because the measurement is performed BEFORE the flap is made, lifted, or put back!

This means that you can NEVER correct all "higher order aberrations" in a LASIK, because you are producing errors from the surgery itself that are never even measured!

In LASEK, by comparison, NO FLAP IS CREATED, so NO HIGHER ORDER ABBERATIONS ARE INDUCED by making, lifting, or replacing the flap. This is probably why many early studies have shown a trend towards better visual acuities and less higher order aberrations following LASEK as opposed to LASIK.

"I had LASEK in both eyes, and CustomVue in my right (dominant) eye by Dr. Chynn in 2004. I am 20/15 in each eye, and with both eyes open, see 20/10, or twice as well as 20/20 on a good day, and 20/13, or still much better than 20/20 on a 'bad' day!

"After assisting Dr. Chynn close to 1000 procedures, I decided on LASEK instead of LASIK, because I was willing to put up with 2 or 3 days more of discomfort, for better safety and vision in the long run. I am really glad I made this decision, and recommend it to everyone--including 2 of my sisters, both of whom have had LASEK by Dr. Chynn, and both are seeing than 20/20 also afterwards!

"By the way, I also strongly recommend CustomVue over regular ablation, because I see like 'HDTV' in my CustomVue eye! We purposely don't charge much more for CustomVue than regular, unlike the other LASIK centers in NYC, so everyone can afford it--you can even finance the few hundred dollars difference if you want, so there is no reason not to go for it!"

--Nhu "Amber" Ly, Senior Laser Technician, parkavenuelaser.com

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9. Improved Safety After the Procedure--Even years after LASIK, the corneal flap never fully heals, and can be raised by Dr. Chynn with a surgical instrument, or with other objects--as the following testimonial will demonstrate. Therefore, it is always safer to perform LASEK, rather than LASIK in patients with "high risk" or active lifestyles.

This is why Dr. Chynn chose LASEK over LASIK in the following patients of his:

--A professional stunt woman (a former model and the contractually-designated stunt double for Nicole Kidman, because she is thin and apparently Nicole wants an ex-model as a double!)

--A former professional tennis player and member of the Davis Cup team

--A professional kick boxer and another professional boxer, as well as many bouncers

--Many military personnel, including members of the Air Force including pilots, Army including snipers, Navy, Marines, and Homeland Security

--Law enforcement personnel, including members of many police departments including NYPD (there is a NYPD discount at parkavenuelaser.com), FBI, CIA, BATF, and other agencies

(Note that because of HIPAA Federal Regulations regarding Patient Confidentiality, no full patient names can be used in this section, unless they are Staff Members of parkavenuelaser.com. "Celebrity endorsements" by famous athletes for LASIK centers are ALWAYS PAID (and parkavenuelaser.com refuses to pay for these), including endorsements you may see on NYC Subway ads by the following athletes, for the reported following amounts:

Tiki Barber, running back for the NY Giants -- $30,000 (all figures are only approximate)

Bernie Williams, center fielder for the NY Yankees -- $50,000

Wayne Chrebet, wide receiver for the NY Jets -- $25,000

Tiger Woods, professional golfer -- $1,000,000 (This may be why his surgery was performed by TLC, the publicly-traded laser chain (TLCV--NASDQ) where Dr. Chynn used to work, because they were the only center that could afford to pony up the fee that his agent asked for!)

"I had a LASIK in both eyes by Dr. Chynn in 2003. I got to 20/15 in both eyes, and was very happy. A little less than 1 month after my LASIK, I was at a sports bar in the Village. I was not wearing any shades, as Dr. Chynn told me to do whoever in a dangerous environment for a few months after LASIK surgery.

It was the playoffs, and somebody must have made a great play, as a big cheer went up from the crowd. I turned to look at the TV to see what was happening, at the same exact time another patron was pointing at the screen. Guess what--his fingernail caught me exactly in my eye at the flap edge, and the flap came up!

"I was in some pain, and my vision got blurry. Worse than that was the psychological distress that I was in, as I thought I really messed something up and was going to go blind.

"I saw Dr. Chynn the next day, and he calmly replaced my flap, decided not to suture the flap down to prevent causing astigmatism, and placed a bandage lens and shield over my eye for a few days.

"With his care and expertise, Dr. Chynn was able to restore my vision to 20/20 in that eye--perfect, but not the 20/15 I had in both eyes before my flap came up.

"I am so happy I chose Dr. Chynn to perform my LASIK, because he had the Corneal Transplantation Fellowship to fix the serious 'late postop.' complication I had. But if I had to do it all over again, I would probably chose LASEK today, because this problem would have been prevented, because I would not have a flap to come up from some guy poking me in the eye."

--Robert P, Investment Banker, Manhattan

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10. Ease of Enhancements--Approximately 3% of patients at parkavenuelaser.com need enhancement surgery, or a "touch-up" procedure after their LASIK or LASIK. Your actual chance of needing an enhancement is approximately the same as your prescription in diopters, so if you are a -4.00, you have a 4% chance of needing and enhancement, but if you are only a -2.00, your enhancement chance is only 2%. Dr. Chynn's enhancement rate is probably below the national average, because he intentionally over-corrects young myopes (nearsighted patients) to allow for some myopic progression during their 20s.

"Like most surgeons, I prefer enhancing a LASEK over a LASIK, because with a LASEK, you don't have to relift the flap, which is not always easy or even possible, or laser the flap, which can sometimes result in scarring.

"Enhancing a LASEK is very simple, does not induce any astigmatism or striae or wrinkles as can happen in LASIK enhancement, and does not normally result in scarring, if Mitomycin-C is used intraoperatively, branded PredForte and a Medrol DosePak is used postoperatively, and the patient keeps his or her eyes closed and uses tears until they are fully healed and seeing well, as well as using sunglasses for UV protection at all times."

--Emil Chynn, MD, FACS, MBA

For the 10 reasons listed above, LASEK is preferred over LASIK by nearly 90% of all patients at parkavenuelaser.com. If you want greater safety, and potentially a bit better vision, and a higher chance of better than 20/20, and to avoid all the potential complications associated with a flap, and are willing to tolerate a few additional days of discomfort and less-than-perfect vision, you should consider having the newer LASEK procedure.

Read more about LASEK in Bladeless "all-laser" LASEK technique by Dr. Chynn offers maximum safety and vision! by Dr. Chynn.

The LASEK technique requires greater PATIENT COMPLIANCE than LASIK, as you will have to take steroid drops for months after LASEK (rather than weeks after LASIK) to prevent scarring. Patients who are non-compliant should chose LASIK over LASEK for this reason.

To maximize the chance of a good outcome after LASEK, parkavenuelaser.com has uniquely decided, among all LASIK/LASEK centers in NYC, to put their preop. and postop. instructions on their website, for patients to download, read carefully, and put up somewhere prominently at home and also at their workplace, so they can follow everything to do great after their surgery!

Please click on the following links to better prepare yourself for your LASIK/LASEK surgery:

Pre and postoperative instructions

LASEK and epi-LASIK are Safer Than Contacts!
Dr. Chynn has performed an analysis that shows the risk of losing vision is actually less with the newer, safer, non-cutting, all-laser, no-flap procedures LASEK and epi-LASIK, than wearing contact lenses for 20 years!

"If you take the small, but non-zero risk of contact lens wear, like losing vision from an infection from overnight wear, improper cleaning, or improper storage, and multiply it by 20 (the number of years people typically wear contacts)," says Dr. Chynn, that risk is actually HIGHER than the risk of the newest forms of Laser Vision Correction, LASEK and epi-LASIK.

"So, although you take the risk all at once with Laser Vision Correction (LVC), you are then actually reducing your overall risk of losing vision, compared to if you had just continued to wear contacts the rest of your life!

"It's analogous to the financial savings involved with LVC--although you pay for it all at once, you start to save money after 5-7 years compared to continuing to pay for contacts, solutions, and glasses--after which point you actually begin to save money!"

For an article about the possible blinding complications of contact lens use and not cleaning your lenses properly, see:

From Asia to America, How Bausch's Crisis Grew from the New York Times.