QUESTION: Tell us, Dr. Ellis, how did you happen to become one of the pioneers in refractive surgery?
ANSWER: It goes back a long ways to my engineering training at UC Berkeley. Back when I was a young engineering student, I realized that there was very little technological input in medicine. In those days we had Sputnik and the space race, but technical knowledge somehow wasn’t getting into medicine.
QUESTION: So it was your goal to help bring technical knowledge into medicine?
ANSWER: Yes, it was always my plan to go through engineering and to continue on into medicine. I’m lucky I completed my engineering and pre-med in four years. Most people took five years to get through engineering, but I knew I had to move quickly because of the training involved.
QUESTION: Where did you go for medical school?
ANSWER: After my initial training I went to the National Heart Institute in Bethesda, Maryland, where I helped to do research on the artificial heart. I became increasingly concerned about problems of vision and blindness and decided to pursue ophthalmology.
QUESTION: Is that how you happened to meet Professor Fyodorov, the world-famous Russian eye surgeon who developed radial keratotomy?
ANSWER: While traveling the globe to meet the greatest surgeons, I learned about a new procedure in Moscow on how to correct nearsightedness called radial keratotomy.
QUESTION: Does that mean that in some instances you don’t strictly use laser?
ANSWER: Yes, that’s right. Laser is the latest development. I compare the laser to the Pentium chip in comparison to RK, which is like the 286. In some instances, incisional keratotomy can be used to enhance and perfect laser surgery to give us a result that we can’t achieve with either procedure alone.
QUESTION: Dr. Ellis, does that mean that laser may not be perfect?
ANSWER: Yes, over the next few months and years you’re going to hear a lot of hype about lasers. The laser companies have expensive machines they’ve sold to ophthalmologists, and ophthalmologists are going to have to do a large number of patients to make it pay. As an engineer who learned about lasers from the ground up, I can say that it’s a wonderful device, but if not used properly there can be problems and complications.
QUESTION: Dr. Ellis, do you mean that Excimer laser treatment may be associated with problems in certain instances?
ANSWER: Yes, it’s not all the pretty picture that the laser manufacturers like to paint. Some doctors without a background in refractive surgery will depend on a cook book “one size fits all” solution. Unfortunately, it isn’t that easy. Surgeons need to think for themselves and computer programs cannot be relied upon 100% of the time to treat patients. We have the greatest computer in the world sitting right in our brain. As a trained refractive surgeon, we have to change and vary our procedures to tailor fit the individual.
QUESTION: Do you mean Dr. Ellis that laser machines as they come off the assembly line now are fixed with one program?
ANSWER: Yes, that’s right. A present laser manufactured by one company requires that all PK surgery be performed at a 6.0 mm. optical zone – that’s the width of the beam and that beam has a fairly high power level of 180 mj/cm2.
QUESTION: Dr. Ellis, that sounds complicated. Would you simplify it for the audience?
ANSWER: What that means is we have to deliver very high amounts of power to the eye, and recent evidence indicates that retinal detachments and other problems can sometimes develop at these high levels of power.
QUESTION: Dr. Ellis, how do you solve that problem?
ANSWER: Well, we can reduce the level of power in the beam, and by doing it a little slower, we can achieve the same result of laser vision correction or, we can reduce the size of the optical zone by performing the surgery under a protective flap, as they do in LASIK.
QUESTION: Dr. Ellis, you’ve talked about the LASIK procedure earlier. Tell us a little bit about it.
ANSWER: I don’t want this to be perceived as an advertisement for LASIK. We’re just talking about it as an alternative. Many surgeons around the world have found that LASIK is superior to surface photoablation.
QUESTION: Dr. Ellis, tell us again what the difference is?
ANSWER: When we perform surface ablation on the cornea, we simply put the patient under the laser, set the computer, aim and fire. It’s just that simple. Some surgeons remove the outer most covering of the cornea called the epithelium, and others ablate right through it. Regardless of the technique, at end of the procedure you have an open wound that requires 6 or 7 days for the epithelium to recover it. That usually means wearing a bandage contact lens and the recovery period, with or without a contact lens, is often very uncomfortable.
QUESTION: How new is the LASIK procedure?
ANSWER: The LASIK procedure evolved from lamellar refractive surgery or ALK. Automated Lamellar Keratoplasty was invented in 1948 by Professor Barraquerer, one of the most famous names in refractive surgery. Both Professor Barraquerer and Professor Fyodorov are recognized as the two founders of refractive surgery. I am proud to have known both Professor Barraquerer and Fyodorov for almost 20 years. In fact, Professor Fyodorov co-authored a refractive surgical textbook with me. Professor Barraquerer quotes my textbook in his surgical textbook.
QUESTION: How was the LASIK procedure evolved?
ANSWER: The LASIK procedure was developed as a refinement of Dr. Barraquerer’s work. He began his procedures almost 50 years ago. That’s a long track record! LASIK represents a combination of procedures. An ALK flap is raised and the cornea is sculpted by the laser underneath this protective flap. When the procedure is done, the flap is simply laid back over the cornea. This helps promote faster healing. A very precise instrument called the microkeratome is used to produce the flap.
QUESTION: Dr. Ellis, what does the microkeratome do?
ANSWER: The microkeratome raises a thin flap of cornea in the LASIK procedure. Therefore, instead of using the laser to remove tissue from the outer surface of the cornea, the laser can sculpt the cornea underneath this protective flap. When the laser PK is finished, the flap is replaced over the ablation site. Healing is usually quicker this way. In contrast to surface ablation, there is no open wound on the surface of the cornea. In surface PK, an open wound is left which must heal. This healing is often slow in contrast to the rapid healing we see with LASIK.
QUESTION: Tell us more about LASIK, Dr. Ellis?
ANSWER: In the LASIK approach, a thin 160 micron corneal flap is raised by the microkeratome. The flap is not taken all the way off the cornea, but remains hinged towards the nose. The laser then precisely removes a small portion of underlying corneal tissue, which is often less than the thickness of a single human hair. The corneal flap is then folded back and re-aligned on the corneal surface, just the way it was before the surgery. This flap often heals quickly and aides in speeding up the entire healing process. Suturing is rarely required. In most instances our patients feel quite comfortable the next day. I’ve been amazed that even when looking at the eye through a microscope, it is sometimes difficult to detect the flap even on the first day following surgery.
QUESTION: Dr. Ellis, how does this compare to surface PK?
ANSWER: In surface PK, the laser ablation creates an open wound on the very front surface of the eye. The epithelial covering of the cornea usually takes about a week to cover the defect. Actual healing often takes much longer. The refraction, or visual correction, can continue changing for many months in surface PK. Corticosteroid drops are used to help control the healing. Sometimes they’re used for up to 6 months. These steroid drops are thought to help reduce haze in order to achieve a better result. However, a significant number of patients can have complications from these drops including glaucoma and cataract in some cases.
QUESTION : Dr. Ellis, do you have to use steroid drops in LASIK?
ANSWER: No, most often steroid drops aren’t used. The healing is quick, and we usually don’t need them. There is much less concern about hazing or scarring with the LASIK procedure.
QUESTION: Can there be complications with the LASIK procedure?
ANSWER: Of course, there can be complications with any procedure. If the surgeon is not experienced with the refractive procedures, the results for that particular surgeon might be better if he used simple surface PK. An experienced surgeon who is comfortable using the microkeratome, LASIK may be the best way to go.
QUESTION: So, Dr. Ellis, what you’re telling us is that there are variations on PK?
ANSWER: Yes, there are variations on PK. In many cases combinations of techniques such as combining PK with ALK can give a better result. As an example, astigmatism correction can be performed under the corneal flap using arcuate incisional keratotomy, or AK for short.
QUESTION: We’ve heard that keratotomy can cause side effects such as night glare and starbursts.
ANSWER: In RK, the incisions come very close to the center of the eye, but in arcuate keratotomy, or AK, the incisions are far away from the center of the pupil and rarely cause this side effect.
QUESTION: Dr. Ellis what you’ve been telling us seems to indicate that experience is very important, and that more than one technique may help to achieve the best result. Combined techniques may include AK or arcuate keratotomy for astigmatism, ALK surgery to create the lamellar flap of LASIK, and the excimer laser itself to correct the myopia present.
ANSWER: Yes, the laser manufacturers would like you to think laser PK is quick and easy; that any surgeon can do it. They try to give the impression that the laser, not the surgeon, does the work. The laser is just part of the story. It’s in the doctor’s power to manipulate the laser and use it to it’s best advantage; to change the software, or even to modify the laser itself, depending upon the patient. These modifications, combined with combinations of procedures in the hands of an experienced laser surgeon, may yield the optimal result in each case. There is no such thing as “one size fits all” surgery. Every individual is different, and the thinking experienced surgeon may vary his approach in order to achieve the best results.
QUESTION: Dr. Ellis, your engineering background is certainly an asset to you.
ANSWER: Yes, it has been an asset and we at the Ellis Eye and Laser Centers plan to continue to perform PK surgery in the very best manner, so that we can achieve the best results possible for our patients.
Thank you, Dr. Ellis
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