The UPMC Refractive Surgery Center opened in 1995, making it the longest running laser center in the entire Western Pennsylvania area. “We’ve been doing this for a long time,” said Dr. Deepinder Dhaliwal, MD, LAc, Professor of Ophthalmology, Chief of Refractive Surgery, and Director, UPMC Laser Vision Center in the Eye & Ear Foundation’s March 14th webinar, “Personalized Refractive Surgery: LASIK and ICL.” “We’re really passionate about it because we really feel that it can change your life if you’re a good candidate.” Dr. Sabrina Mukhtar, MD, MPH, Assistant Professor, Director of the Dry Eye Center, presented with Dr. Dhaliwal.
Burden of Refractive Error
Refractive error is the inability to see without glasses or contacts. Uncorrected refractive error is one of the leading causes of blindness. In the U.S., 40 million people (nearly 17% of the population) report using contact lenses, with 65% (166.5 million people) wearing prescription glasses. Refractive error is a significant burden to quality of life and over time can become a financial burden as well.
Dr. Dhaliwal pointed out that glasses are very safe, but contacts can be quite problematic if they are not taken care of properly. “We sadly see a fair number of infections from contacts,” she said. “If you’re going to wear them, you must be very careful to never use tap water.”
Who We Are
In addition to Drs. Dhaliwal and Mukhtar, the Refractive Surgery team includes Gaurav Prakash, MD; Alex Mammen, MD; and Vishal Jhanji, MD. They think of themselves as the Avengers because they are passionate about offering these services to patients if they are good candidates. “Refractive surgery can be life changing,” Dr. Dhaliwal said. “We’ve had patients crying after the procedure because all of a sudden, they can see across the room without needing to pick up glasses or put contacts in. They feel like they have their life back. So, we do feel like superheroes sometimes because that’s why we do what we do.”
The team offers a wide range of refractive surgery options for patients aiming to become less dependent on contact lenses and glasses. They focus on improving the quality of life for patients. They are also very conservative by nature. Some people are not good candidates for refractive surgery.
A big philosophy of the center is that there is not one size fits all. The team wants to meet you, assess your eyes, speak with you, and then figure out what the best procedure is to meet your goals. This may mean no procedure at all. They are extremely picky, probably turning away around 40-50% of people who come in because they are not good candidates.
What is Refractive Surgery?
Refractive surgery is a surgical intervention to treat your eyeglass or contact lens prescription. These procedures change the way light focuses in the eye. Lasers can be used to change the shape of the cornea (clear dome that covers the colored part of the eye) or a lens can be implanted inside the eye. There are several types of refractive surgery options. The team reviews your history, obtain diagnostic tests, and performs a thorough eye exam to make a recommendation for each patient’s customized surgery. This includes finding out what your expectations and goals are.
A good refractive surgery candidate has the following criteria:
- Anyone who is interested in being contact lens/glasses free!
- Healthy people with healthy eyes – realistic expectations!
- Age: 21 years and older
- Stable refraction
- Generally good ocular health
When you come to the center, you will fill out a form that provides an overview of who you are: hobbies, medications, allergies, past ocular history, medical history, etc. An important part is writing in your own words your expectations for surgery; this has been invaluable for the surgeons to understand what you are looking for.
They like to tell patients that the best vision you can get in glasses is kind of like the best vision you can expect after some type of refractive surgery. If you cannot see currently with your glasses, then surgery will not help you see better.
Contraindications
- Past medical history
- Autoimmune or inflammatory conditions
- Uncontrolled diabetes
- Issues with wound healing
- Women who are pregnant or nursing
- Severe dry eye, corneal dystrophies, cataract
- History herpes simplex or shingles virus in eye
- Patients with unrealistic expectations
Dr. Mukhtar said that they are very aggressive in treating the ocular surface prior to doing any refractive surgery. There are times they have had patients wait months before being operated on, so being very motivated is a must. “It’s like planting a seed,” she said. “You want to make sure the soil is moist and nourishing so your flower can grow. We’re very conservative and do a very thorough history. If we’re at all concerned, we are more likely to turn you away than say we’ll do the surgery.”
One benefit is you get six surgeons for the price of one, because they all talk to each other. If there are any concerns or questions, they help one another out. They are also all corneal specialists, so if you are not a good candidate because you have severe dry eye, then you will be referred to the dry eye center for treatment. “We can help you wherever you are in your ocular journey based on the findings that we see,” Dr. Dhaliwal said. “Nobody died from not having refractive surgery.”
Another thing they like to say is that happiness after one of these procedures equals the postoperative kind of reality minus the expectations before surgery. This is why they spend a lot of time with expectations. After age 40 or so, everybody needs reading glasses, for example. If you think you will be able to see distance and near out of each eye after surgery at 50, that is kind of impossible as the eye has limits.
Sometimes they talk about your recipe for success. They might look at you and say it’s this procedure plus maybe a pair of night glasses. Using occasional glasses is not a failure of having refractive surgery and is actually expected sometimes. This is discussed ahead of time to make sure you are okay with it.
Laser Assisted In-Situ Keratomileusis (LASIK)
- One of the most common refractive procedures
- A laser makes a thin cap in the cornea which is then gently reflected back
- Then a second laser is used to sculpt the underlying cornea to treat nearsightedness, farsightedness, and astigmatism
- The cap is then returned to original position
- Quick procedure
The measurements are so precise that treatment is customized. The center was part of a FDA studies for a machine called the Eye Design, which takes in your data and measurements of your prescription to the 100th degree. It treats aberration; the way light is bent.
The surgeons are very particular; they never switch to the other eye or close the case until they are happy with how the flap looks right after surgery. At the end, on postop day, you are 95% healed, so patients do very well after. You will be asked to take a nap.
There are pluses and minuses to all procedures and every surgeon has their personal experience and will guide you according to that. “The important thing is that here at the UPMC Vision Institute, we do all custom LASIK,” Dr. Dhaliwal said. They measure the eye, not just for the nearsightedness or whatever condition you are treating, but also aberrations or other reasons why your vision is blurred. This does not happen to everyone, but some people after LASIK feel like they see better than they used to in their glasses. “It’s really amazing because we are correcting more things,” Dr. Dhaliwal said.
Photorefractive Keratectomy (PRK)
- Common refractive procedure
- Good for patients with thin corneas or dry eye
- No flap made
- Laser used to change shape of cornea to treat prescription
This procedure has been around for a long time. It removes the superficial/top layer of the cornea. Like LASIK, it is customized. It involves only one step, but healing takes a little longer. The first couple of days are a little more irritating as the surface of the eye heals, but patients do well and are happy. Vision will be a bit blurry and drops have to be used for a little longer. Sunlight exposure can affect healing.
Implantable Collamer Lens (ICL)
- Offered for nearsightedness correction
- A biocompatible, v thin and flexible lens is inserted behind the iris (colored part of the eye) and natural lens
- Does not alter cornea
- Reversible!
This procedure has changed the game in refractive surgery because it offers something that does not alter the cornea and is completely reversible. The surgeons are very diligent about sizing; they spend a lot of time and run a lot of tests to make sure they pick the right size lens for you. A center port helps fluid move through the eye more naturally and makes sizing more reliable.
“At the UPMC Vision Institute, we’re at the forefront, so we’re always looking at what’s new and what’s best for our patients,” Dr. Mukhtar said. “We are quick adapters to adapt technology that will be better for our patients. Dr. Dhaliwal is working with refractive surgery partners across the country and globe to get insights into what our patients need. She is definitely a champion and the main reason why we have the ICL here at the UPMC Vision Institute.”
Dr. Dhaliwal commented on how remarkable it is to see this lens in the eye after 5-7 years; it just stays there and does not really cause much reaction. Even right after the procedure, there is not a lot of inflammation. It is the only procedure that does not involve taking something away. It is also the one that will create the least dry eye, as both LASIK and PRK can cause a little bit more dry eye. So far, no patients have requested to reverse the procedure.
Free LASIK
The center is conducting a FDA trial called the TENEO Hyperopic LASIK Clinical Trial, which means there is free LASIK at the UPMC Vision Institute for qualified candidates. The criteria are: age 22 or older, with refraction of +1.00 to +4.00 and cylinder up to +2.00.
The TENEO laser is already FDA approved for nearsightedness and stigmatism. This trial is to get it approved for farsightedness. If interested, call 412.642.5241. This is the same number to call if you want to be evaluated for any refractive procedure.