Eye surgery: focusing on the risks
21 Feb 2003
Laser surgery is sold as a modern, simple cure for sight problems. But Health Which? recently warned that some providers of the service are being less than honest about the procedure’s risks. What’s the story?
The magazine’s two most disturbing conclusions were that patients are often misled about the risks of the procedure, and that under-qualified surgeons carry out the operation.
But how risky is laser eye surgery, and how successful is it? Are surgeons offering this costly operation – prices range from £750 to £2,000 per eye – really misleading patients? And if so, what is being done about it?
To understand the risks, it’s first necessary to understand the procedure. The type of operation that is heavily advertised, and which an estimated 100,000 people in the UK have done each year, is called LASIK, standing for Laser-Assisted In-Situ Keratomileusis.
In LASIK, a laser is used to reshape the cornea – the clear covering on the front of the eye. A flap is cut in the cornea using a special machine and the surgeon folds the flap back. A laser reshapes the tissue behind it by burning off parts, much like creating a sculpture by chipping away at the stone. This new shape should bend the light so images are sharper on the back of the eye, improving the person’s vision.
Once this is done, the cornea flap is put down, the patient is given a short rest and the operation is complete. The whole thing takes 20 minutes and the effects are usually immediate. The great advantage of LASIK over other types of eye surgery, say practitioners, is that it is relatively pain-free, giving it mass appeal and pushing a tricky procedure on an extremely sensitive part of the body into the realms of cosmetic surgery.
What’s the problem?
The problem is that while LASIK – particularly in the hands of a highly experienced eye surgeon – is extremely safe, it remains a surgical operation and so there is always the risk of complications.
Reported problems have included seeing halos on objects, haziness, glare, poor night vision and double vision.
But Dr Gerald Panting, the communications and policy director for the Medical Protection Society (MPS), says part of the trouble with laser surgery is inflated expectations, poor-quality information and misleading advertising.
As the insurance provider for doctors, the MPS is dismayed at the number of claims being brought and won against ophthalmologists carrying out LASIK. In response, it has raised the premium for these doctors and drawn up a list of guidelines that will be released in about a month, which it expects surgeons to sign up to and follow.
“This is an area of practice in which there is a large amount of advertising direct to the public,” says Dr Panting. “And as such, expectation is very high and therefore often not met – it is the same with most forms of cosmetic procedure.”
The MPS guidelines will advise on patient selection, informed consent (giving patients all the relevant information) and follow-up care. “We want to make sure no hopes are unduly raised,” he explains.
Getting a clearer picture
The most essential element for anyone thinking of undergoing LASIK is to choose the best surgeon available and ask all the right questions. Experienced surgeons are significantly better than those new to LASIK.
Two surgeons documented their cases and the first found a complication rate of 4.5 per cent for the first 200 eyes operated on, slumping to 0.87 per cent for the following 4,800 cases. The second recorded a 6 per cent complication rate for the first 100 eyes, 2.3 per cent for the next 600 and just 0.3 per cent for the next 300.
But Health Which? found that some clinics hire people with limited skills and revealed that the Royal College of Ophthalmologists had even heard of keen GPs being allowed to carry out the procedure.
Mr Dan Reinstein, one of the people drawing up the MPS guidelines and also a specialist refractive eye surgeon and medical director of the London Vision Clinic, takes it one step further. He says there is a marked difference between “expert” and “experienced” surgeons.
An expert, he says, is one who has both training and experience. If someone untrained is operating on their 1,000th eye and comes across a problem they haven’t seen before, it is equivalent to someone operating on their first eye. His clinic’s website contains a lengthy guide on what to ask a surgeon. “Any surgeon should be able to answer the questions,” he says.
Mr Reinstein is keen to make people realise that eye surgery is not something to enter into lightly. “We are dealing with one of the five senses and possibly the most critical one,” he says. “But this surgery has been trivialised far too much; it’s been made to look like a lunchtime massage, but it’s not – it’s a medical procedure.”
So what’s the solution?
Put simply, patients should be aware that laser eye surgery is not without risks. It is generally accepted that there is a problem in 1 per cent of operations. The worst of these problems can mean lengthy and dangerous follow-up surgery, and deterioration in sight.
There are “minor” complications in around 5 per cent of cases. This is the risk element you need to consider, and the risk will be different for every individual due to the make-up of their eyes. But many people say laser eye surgery has made a significant difference to them. You may still need glasses later in life as the eye stiffens, but you might not have to wear them for 20 years.
If you’re willing to take this risk (and with new technology, that risk is reducing every year), your best bet is to do the necessary research and visit the best surgeon you can find.
Lasik Eyes (patient-led site)
London Vision Clinic
Medical Protection Society
Royal College of Ophthalmologists