Offices in Hayward, Castro Valley, Concord & San Jose
Vision Care Is Our First Priority
Whether your vision needs are just a complete exam, LASIK laser refractive surgery, or anything in between, we promise to provide you with exceptional care as we work to maintain or enhance your vision. Below are just some of the many procedures and services we regularly provide to our patients – with a gentle touch, and stunning results. Your vision is our first priority!
If you have any questions, concerns, or would like to schedule an appointment, please contact us today. We look forward to providing you with the personal care you deserve.
Mark Mandel, MD
Monovision – Presbyopia Treatment
If you have normal distance vision (either with or without lenses, or after refractive surgery), as you reach 42 to 45 years of age, presbyopia develops. There are no exceptions to this rule. Presbyopia is the loss of ability to accommodate. Accommodation is the ability to focus up close. Each year it gets worse. If you are presbyopic, you either need bifocals or a separate pair of reading glasses to see what you normally could see up close when you were younger. By the time you are 60 you will have lost essentially all of your ability to focus closer than 3 feet. So, all close objects will be blurred.
The use of one eye for distance vision and one eye for near vision is referred to as monovision and is one of the options to consider as part of your refractive surgery decision. This is primarily applicable to those 40 years and older. Monovision has been used successfully for many decades with contact lens correction and with various types of refractive and cataract surgery. By correcting one eye to focus in the distance and one eye to focus for near, the vision part of our brain tends to suppress or filter out the image from the eye that is not in clear focus. The patient is not bothered by the eye that is not in focus.
We create monovision using the laser such that the dominant eye focuses at distance and the non-dominant eye at near.
One of the best ways to define monovision in the context of refractive surgery is that you can aim to have each eye corrected to a natural focus at any distance you choose. How well it will see at other distances depends upon how old you are.
For example, if you are 30 and we correct each eye to excellent distance vision, then you will have good vision at almost any distance because, due to your young age, the eye will be able to accommodate (adjust focus) from far to near. If, on the other hand, you are over 40 and we correct each eye to excellent distance vision, you will not see well at a typical reading distance and will need reading or near vision glasses. This change in accommodation (focusing ability) will generally begin to be noticed about age 40 and will usually get worse quite rapidly over the next few years (presbyopia). This loss of ability to change your focusing distance from far to near will occur whether or not you have refractive surgery.
At any age, if you have the vision in one eye corrected to a natural focus for near tasks such as reading, you will not see clearly with it farther away as the ability to change focus only goes from far to near. The brain adjusts to each eye being focused at a different distance within 6 to 8 weeks. You do not need to consciously make any adjustments.
There is no right or wrong answer to the question of whether to have monovision. This information is to help you make this decision.
In our experience, most people over the age of 40 to 45 who try monovision and take a few months to become accustomed to it, like it and find it very useful. Those who have monovision will be able to generally see well enough both at distance and near to do most things at any age without corrective lenses. Depending on the exact result obtained (as is true for everyone having refractive surgery) there might still be some situations when the very best vision or the maximum visual comfort might require wearing glasses (or possibly contacts). Night driving and prolonged reading are two examples that are mentioned frequently, as well as vision at “intermediate” distance (between 3-10 feet). However, glasses may be required for anything for which you feel the need or desire to have the sharpest possible vision.
It is probably helpful to realize that without a specific cure for presbyopia once you are past the 40-year age range, all refractive corrections involve compromise. If you have both eyes corrected for good distance vision, you will need glasses for close vision. If you have both eyes corrected for close vision (not a common choice) you will need glasses to clearly see everything far away. If you choose monovision, although your vision may work well for almost all purposes, you might feel it is less than perfect.
We know of no perfect way to help you make this choice. We would suggest that if significant doubt remains in your mind, that you aim to have your vision corrected for good general distance vision and plan to use reading glasses when necessary.
It is important to note that if you choose monovision and are unable to get used to it, it can be reversed by performing an “enhancement” procedure on the eye left for near. Once the enhancement is performed, the near eye then sees more clearly in the distance and reading glasses are then required for all near tasks.
LASIK for Farsightedness (Hyperopia)
Hyperopia, or farsightedness, is the condition of the eye whereby the corneal curvature is too flat for the length of the eye, or the eye is too short for the corneal curvature. This results in light rays not yet coming to focus by the time they strike the retinal tissue in the back of the eye. A blurred, rather than sharp image of both distance and near objects is produced.
Our VISX S4 and Allegretto Wavefront lasers are FDA approved for the treatment of hyperopia and astigmatism. Both lasers are also approved for hyperopic Wavefront treatment.
From the patient’s perspective, the procedure for the treatment of farsightedness with or without astigmatism is essentially the same as treatment of nearsightedness with or without astigmatism. However, using the excimer laser, rather than flattening the central cornea as is done with the treatment of nearsightedness, the peripheral cornea is flattened allowing the central cornea to become relatively steeper. The relatively steeper central cornea adds refracting power to the surface of the cornea allowing the light rays to focus closer to the central retina. This improves the distance vision of farsighted individuals, and if monovision is performed in one eye, may also help improve the reading vision in the monovision eye.
Because regression back towards hyperopia is slightly more common in the treatment of farsightedness than in nearsightedness, we purposely mildly “overcorrect” patients in the early post-operative period. This means that we actually induce a small amount of myopia (nearsightedness) in both eyes during the early post-operative period. Therefore, the patient will be slightly nearsighted in one or both eyes for a few months after the laser surgery for farsightedness. Glasses for good distance vision may be required in the early post-operative period. Although this induced nearsightedness may be permanent and require surgical correction, in most cases, the early post-operative nearsightedness is temporary.
Because it is impossible to predict exactly who will be nearsighted post-laser and how long the nearsightedness post-laser will last, a farsighted individual undergoing laser refractive surgery must plan to wear glasses for distance (and possibly near) vision for the first few weeks to few months post-operatively.
As you will read in the section on LASIK, whether an individual is farsighted, nearsighted, or has astigmatism, after any form of refractive surgery, it is important to realize that glasses and possibly contacts may be required full-time following the laser procedure. The need for post-operative glasses depends on individual healing factors, as well as the underlying degree of farsightedness, astigmatism, or nearsightedness that exists in your eye prior to the laser procedure.
For individuals with high amounts of farsightedness (above +5.00), we generally recommend clear lens extraction also known as refractive lens exchange rather than the laser to correct the farsightedness. This procedure is the same as cataract surgery in that the lens inside your eye is removed and replaced with a clear plastic intraocular lens. This surgery has the ability to correct large amounts of farsightedness and astigmatism and, if a multifocal implant is used, can improve distance, intermediate and near vision.
Effects of Eye Surgery on Large Pupils
Did you know that your pupil size can impact refractive surgery results? Bay Area LASIK Surgeon Mark Mandel, MD, discusses how large pupils affect LASIK surgery results.
One of the most well-known and publicized risks and disturbing post-operative side effects of refractive surgery is halos, glare, decreased contrast sensitivity, and starbursts seen at night or in a dark environment.
There are a number of complex optical reasons why patients experience post-operative halos, glare, and starbursts, including the induction of higher order aberrations such as spherical aberration, coma, and trefoil, as well as diffraction off the edge of the treatment zone in patients with large pupils, occasionally made worse by high astigmatism or an excessively flat corneal curvature after surgery.
What Pupil Size Is Too Large for LASIK?
In some patients, the pupils can dilate in the dark to as large as 9mm in diameter. Generally, this is not a problem. However, following refractive surgery, the pupil may dilate wider than the zone of treatment, thereby causing reflection and diffraction of incoming light off the edge of the treatment zone. This diffraction can degrade the quality of the image (experienced as decreased contrast sensitivity or a decreased ability to discern subtle shades of gray), or cause halos/starbursts off of point sources of light. This is more common in patients with higher degrees of astigmatism and a “flatter” corneal curvature because of the configuration of the treatment zone.
We have been performing LASIK and advanced surface procedures on patients with pupils up to 9mm using either the Allegretto laser or the VISX Star S4 for 25 years. Both of these wavefront lasers are equipped with large pupil software. Although patients with large pupils still experience glare and halos similar to that with their pre-operative contact lenses or glasses, we have had very few cases of worsening glare or halos in patients with large pupils.
In addition to being able to accommodate patients with very large pupils, the Allegretto and the VISX S4 excimer lasers use an active tracking mechanism whereby the patient’s eye is tracked by the laser, which essentially eliminates problems associated with slight movement of the eye during the surgery.
Large Pupil Eye Surgery Options: LASIK vs PRK
Unfortunately, not all patients with large pupils are good candidates for LASIK using the large pupil laser. This is because as we increase the size of the treatment zone necessary for accommodating patients with large pupils, the laser must remove more corneal tissue. It is wise to leave approximately 250 microns of cornea untreated by the excimer laser. Accordingly, in patients with large pupils who require not only large treatment areas, but also deep treatment, the patient’s cornea must be thick enough to leave approximately 250 microns untouched.
At the pre-operative examination, we measure the patient’s corneal thickness and calculate the treatment depth. In some cases in patients who are highly nearsighted and have large pupils, but do not have enough corneal thickness to leave the approximate 250 microns of untouched cornea, it is not possible to safely perform a LASIK. In these cases, assuming that the cornea is otherwise healthy, a surface PRK or LASEK procedure can be performed. Please consult our web site page on Surface PRK versus LASIK for further details on these procedures.
It is important to emphasize that although LASIK is more convenient for the patient with respect to the fact that the visual recovery time is rapid, PRK has the same visual results, but takes longer to achieve the crispness of vision enjoyed by LASIK patients. On the other hand, one of the main complications of LASIK in the highly nearsighted individual is microfolds in the flap. Because PRK does not use a flap, it is impossible to have the complication of microfolds. We believe that this is a significant advantage. However, the risk of corneal haze and scarring is slightly greater in the high myope with the PRK procedure. Fortunately, with the newer generation lasers such as the Allegretto laser and the VISX S4 Smooth Scan laser, along with the use of Mitomycin-C, the risk of corneal scarring and haze following PRK is minimal. Therefore, in the patient with a large pupil, high myopia, and a thin cornea, we are fortunate that we have the Allegretto large pupil laser, the Visx S4, and PRK at our disposal.
If the patient elects to have PRK, they must decide whether to do one eye at a time or both eyes at the same time. The advantage of doing both eyes at the same time is that the patient does not have to return to the laser center on two occasions. However, it is important to note that, depending on the degree of nearsightedness and astigmatism, it may take up to a month for the vision to become sharp enough to safely drive or function at work. Accordingly, patients who undergo PRK may elect to have one eye done at a time while wearing a contact lens or glasses over the eye that has not been treated. Once the treated eye has achieved functional vision, then the PRK procedure can be performed in the second eye.
Astigmatism is present when the cornea is steeper in one meridian than it is in the opposite 90° meridian, thus being shaped more like a football than a basketball. This usually occurs “naturally,” but may result from prior surgery such as LASIK, EPI-LASEK, PRK, RK or cataract surgery.
The surgical correction of astigmatism can be done with the femtosecond or excimer lasers, or using a precision diamond scalpel. Astigmatism surgery “relaxes” the cornea in the steeper meridian, which results in a decrease in astigmatism. We can perform these incisions in association with cataract surgery or LASIK, or following prior RK, LASIK or cataract surgery in order to “fine-tune” the vision.
Diamond scalpel astigmatic keratotomy (AK) has been performed since the late 1970’s and its effects are well studied. Dr. Mandel has performed thousands of AKs since 1983. The success rate is high and serious complications are rare. Side effects are also low.
Today, most astigmatic surgery is performed with the Excimer laser or the femtosecond laser at the time of LASIK or PRK or during cataract surgery.
The lower the amount of astigmatism, the more accurate the procedure (this is also true of astigmatic correction with the laser). Below 1.50 diopters, the success rate (uncorrected visual acuity 20/40 or better) is more than 95 percent and enhancement procedures are required in less than 10 percent of cases. For over 2.50 diopters, the success rate begins to drop, and is about 50 percent. Accordingly, the need for enhancements increases to about 50 percent.
The procedure takes less than five minutes, is painless (topical anesthetic drops are very effective), and post-operative discomfort is usually minimal. Most patients describe a “foreign body” sensation for one to two days. Very few people experience significant pain. Return of vision occurs within a week, and usually remains quite stable with little or no regression.
Side Effects of Astigmatic Keratotomy (AK)
Side effects are not common and may include mild fluctuation of vision; some glare and light sensitivity, mild haze or “ghost images,” and recurrent erosions (where the cornea develops tiny recurrent surface breakdowns causing discomfort for one to two days at a time).
Using the scalpel (NOT the laser), a microperforation of the cornea into the inside of the eye occurs in about 1 percent of cases and rarely causes any problem. Usually, the only treatment required is antibiotic drops for four to five days and no rubbing of the eye for two weeks. Occasionally, if a perforation occurs, a contact lens or sutures are required to treat the perforation.
Infections, significant overcorrection or under correction, loss of correctable vision, irregular astigmatism, significant corneal scars, and macroperforation of the cornea requiring a suture to close the incision are all quite rare. Exceedingly rare is a perforation that results in the introduction of bacteria into the eye causing a serious, potentially blinding, internal eye infection. Again, this CANNOT occur with the laser.
Dry Eye Treatment
The information below applies to all patients with a dry eye whether you are preparing for LASIK, or whether you simply want educational information and relief from the often-debilitating symptoms of dry eye.
The surface of the eye is covered with a lining of tears called the tear film. The tear film is made up of three layers: a Lipid (oil) layer which lubricates and prevents evaporation of the water layer of tears; an Aqueous (water) layer, which nourishes and protects the eye surface; and a Mucin layer, which allows the water layer to adhere to the eye. Since the tear film is exposed directly to the air, the outer protective lipid layer is essential to maintaining a healthy tear film on the eye.
When the protective lipid layer of the tear film is lacking, the eye surface can become irritated and dry eye symptoms can occur.
Dry Eye Disease Affects More Than 100 Million People Worldwide
Of those, 65 percent suffer from Evaporative Dry Eye as a result of poor quality oil or not enough oil. Common symptoms of dry eye include dryness, grittiness, soreness, irritation, burning, watering, and eye fatigue. These symptoms can hinder people’s daily activities such as reading, using the computer, wearing contact lenses and being outdoors on windy days, or in an air conditioned environment. Many dry eye patients complain that symptoms worsen throughout the day.
Other factors that can contribute to a dry eye are poor blinking and not fully closing the eye at night, or a loose lower eyelid. Some patients do not fully blink. An “incomplete blink” will not allow the tears to lubricate the entire surface of the eye (like a defective windshield wiper), and can contribute significantly to the dry eye. Additionally, some people (especially after upper eyelid lifts/blepharoplasty) do not completely close the eye at night. This can dry out the lower part of the eye and cause considerable symptoms. Redundant conjunctiva (the white lining of the eye) also called conjunctivochalasis can also lead to symptoms of dry eyes. This can be easily repaired by a minor surgical procedure.
Dry Eye After LASIK Surgery
The LASIK procedure itself can either precipitate a dry eye, or exacerbate an underlying dry eye. Accordingly, as not only LASIK specialists but also experts in the cornea and external eye, we strive to ensure that you will have the best possible result from your LASIK procedure. If we diagnose a dry eye prior to your LASIK procedure, we must postpone the surgery until the dry eye is resolved. We realize that this can be extremely disappointing and inconvenient to the patient who has planned for and is excited about their upcoming LASIK. However, your safety is our primary concern and we will do nothing to compromise your care and everything to ensure that you have an outstanding result. To this end, we must vigorously treat your dry eye condition before proceeding with the laser procedure.
Treating the dry eye is a team approach. The patient, my staff, your optometrist, and myself will be intimately involved in your care. Your cooperation and compliance with our recommendations is critical to ensure a salubrious result and will require some sacrifice on your part. This will be a short-term sacrifice for a long-term gain. Specifically, you must stop or decrease your contact lens wear while we are treating the dry eye. We are aware that patients accustomed to contact lens wear will find it extremely annoying and difficult to not wear contact lenses – particularly someone with high degrees of nearsightedness and astigmatism. Some patients may even need to purchase new spectacles. However, the use of the contact lens will exacerbate the dry eye and significantly prolong the treatment. Most importantly, we ask for your patience with the seemingly long time it takes to improve. It is not uncommon for us to treat the dry eye for up to six months before we can proceed with your LASIK.
Your treatment will consist of a number of different steps designed to increase the moisture available to the surface of your eye. It may be necessary to see you 6 to 8 times while treating the dry eye before we are able to proceed with your LASIK procedure.
As mentioned above, a dry eye can develop following the LASIK procedure, especially in women. This can be annoying and will require one or more of the treatment steps delineated below. Fortunately, most cases of post-LASIK dry eye are self-limiting and resolve within 9 to 12 months.
Conventional Dry Eye Treatment Options
Artificial Tears: The mainstay treatment for the dry eye is the frequent application of non-preserved artificial teardrops. We will recommend certain teardrops, but any non-preserved drop in a vial is acceptable. Please do not use a bottled teardrop, even if they claim to be “non-preserved.” We usually start by having you apply one drop every hour.
Omega 3 (dietary supplement): Flax seed oil, or fish/krill oil, which is rich in omega 3 fatty acids, have been shown to be effective in treating the dry eye. This can be taken as 2 gel-caps twice a day with meals. It may take at least 6 to 8 weeks to show positive effects. I recommend Nordic Naturals ProOmega 2000 which is the triglyceride form of fish oil and is best absorbed by the body with no unpleasant side effects. This is available on our website.
Punctal Plugs: The eye is constructed somewhat like a sink. There is a “faucet” located up under your eyebrow which produces tears, a drain in the lower lid by your nose, and a drain in the upper lid by your nose. In order to fill the sink, if your faucet is not working properly, we must close one or both of the drains. This not only preserves the natural tears that your eye makes, but also allows the artificial tear to stay in contact with the ocular surface for a longer period of time. We will start by closing the lower drain (punctum) with a permanent, but removable, silicone plug. Patients can occasionally feel the plug for the first few days after insertion and notice some itching of the lower lid by the nose. If closure of the lower drain is not effective, then after 4 to 6 weeks we may elect to close the upper drain. In some patients both the upper and lower drains are plugged at the same time. Occasionally, closure of the upper drain may result in watering of the eye and the patient may request removal of the upper drain plug due to excessive tearing.
Other Medications: We may add anti-inflammatory drops such as Restasis (cyclosporine), Xiidra or Cequa eye drops. These are non-preserved drops and may be effective in helping resolve the dry eye. However, like all medications, they do not work in every case and may have to be discontinued due to irritation. We may also add doxycycline, minocycline or azithromycin (an antibiotic pill taken orally), which can be an effective adjunctive treatment. Occasionally, we may recommend serum tears. These are special tears compounded by a specialty pharmacy and made out of the components of your own blood, which contains many very powerful healing properties not found in prescription medications.
Cost of Dry Eye Treatment
The cost for plug insertion and the cost of the follow-up visits are not included in the price of your LASIK surgery, but are often covered by insurance. We participate in most, but not all, medical and eye care insurance plans in the Bay Area. If we are a participating provider, then we will assist you in billing your insurance for treatment.
We know that the treatment of the dry eye can be complex, occasionally confusing, and prolonged. Although we share in your frustration, we are committed to providing you with the highest quality care and will not compromise the safety of your eye or the outcome of your procedure by proceeding with laser vision correction prior to the rehabilitation of your dry eye. Fortunately, in decades of practice I have rarely seen a case of dry eye in a young, otherwise healthy patient that did not resolve with treatment.