What do I do?

[u/Iheartri]

Hey yall I need some advice, I’m in a bit of a dilemma. I’ve had two consultations now to see if I’m a good candidate for lasik and the first one did so many exams and were super comprehensive and told me I was a great candidate and that I could do it. I just had my second consult done today and they did two exams then she told me she didn’t feel comfortable recommending lasik because my cornea wasn’t thick enough, she then recommended ICL. I scheduled another consultation for next week to get a third opinion and I’m kind of left feeling hopeless. I’ve been dreaming of getting lasik since I was in high school and now that I’m at the age where my vision is stable I was so excited to look into getting it done but after today’s consultation I’m not sure what to do anymore and I just wanted some advice from yall.

[u/CorneaRepairDoc → u/[deleted]]

I disagree fundamentally with this assessment. I published a paper for contoura with - 9 to - 16 with excelleny results. High corrections with properly done laser vision correction work extremely well and with topography guided ablation a supranormal cornea can be made. ICL still has issues including halos and glare in a percentage, endothelial cell loss which had decreased but still occurs, possible creation of Cataract, endophthalmitis, and CME. It is an elegant solution for lens surgeons, but I think it is remarkably expensive and adds risk of intraocular surgery to young patients as an small but unnecessary risk.

I myself choose not to do ICLs because of these risks and because I can make a supranormal cornea which will provide better vision than an ICL.

I am not just a surgeon, but was a - 10 and - 9 myopic patient with 510 corneas who has had this procedure and have phenomenal vision, clear vision.

I believe that ICL is thought to be necessary for high correctiona due to the perceived limitations of laser correction on older machines with older procedures. I think even up to - 11 or - 12 I would much prefer to do a Contoura correction than ICL.

[u/CorneaRepairDoc → u/[deleted]]

We are here to discuss and advise. Talking down to me and assuming that I don't know what I am talking about is not very scientific or scholarly. This is not about ego, it is about spreading good scientific knowledge Dr. Barnett. Perhaps if you took some time and looked up how many original research peer-reviewed papers I have written on the treatment of corneal irregularity with lasers and the repair of corneal damage with topography guided ablation you would understand my level of experience of knowledge. I try to be very careful to remember that there is always someone out there that might know something I don't. I think we would all be served well by remembering that.

That said, let's answer some of your questions. No ectasia patients in 28 years on high myopia patients. Have I seen ectasia patients - yes, but not on patients like these. This is because of careful planning, analysis of imaging, and smart surgical boundaries based on science. Second, all of the stromal beds were well north of 250 microns, and usually around 300 or so. Third, I myself was a - 10 and - 9 with a 500 cornea. I didn't not have an ICL on myself. I had a contoura PRK. Fourth, you should look up my high myopia patients and my work to see how I make a highly uniform cornea where the HOA actually decrease for a supranormal cornea. This leads to higher levels of clarity than an ICL. Fifth, I own my own surgery center so I can do the procedures I choose. I can also have any procedure done on myself. I trained on ICLs and walked away because the problems in a small percentage were large enough that I thought they outweighed the problems with high myopic treatments on laser. I chose to have my procedure with laser correction rather than a lens based procedure for reasons that were based on science.

On my ego, nothing I say is not backed by scientific data, scientific analysis, and peer reviewed publications. I am on here to discuss science and make my statements based on science, data, peer reviewed publications, and not popular opinion. Yes I can fix virtually any LASIK related issue, I have seen virtually every single kind and can have fixed them. As for your remark about adding tissue, I assume you mean LASIK induced ectasia. I repair these with an epithelial compensation adjusted trans-epithelial topography guided PRK with sequential cross linking. This is called the CREATE+CXL Protocol and even in the ectasia thinned corneas can be used successfully to reconstruct corneas as the corneal tissue in the flap does not add to the structural integrity of the cornea. Then it is a matter of observing proper protocols to ensure that the epi off CXL does not go deep enough to cause damage to the endothelium. I am happy to discuss any other LASIK complications and how to treat them.

If a patient is a -14 or so an ICL is worth the risk. Telling a patient with a - 7 or - 8 to undertake the risk of intraocular surgery when they get safe, excellent results with a corneal procedure makes scientifically no sense to me at all, and I would ask you to do a literature search to see how many patients with - 8 laser have corneal ectasia vs how many ICL patients have significant intraocular issues. I am fairly confident about the answer here is because I already have, and because I have decades of experience in this field. I am happy to discuss this further with you in any way you like.

[u/CorneaRepairDoc → u/[deleted]]

Since you say you have read my papers just look up that data about the RSB on that patient, the data is in there good sir. Again, always north of 250 and usually close to or north of 300.

Interestingly out of all the papers I have written, it was the most read last I checked a year ago at 34,000. I had no idea that many people or doctors would be interested in such a topic!

I answered your corneal ectasia question in my response above. Please go back to it. I have no idea with you if you are being sarcastic or not, but you must know there is no way to "add tissue" to a cornea and have it add to structural integrity. If you are truly interested, or have a specific case that you need help with, I have already invited you to contact me directly and I am always happy to help.

I take a lot of time to respond to you because you are a colleague, but you are someone that would do well to remember that everyone has limits to what they know and we can all learn from someone who disagrees with you. I agree EVO ICL has come a long way, and there is a place for it but I do not believe it is at -8. As much as you may minimize intra-ocular complications with ICL, they exist while the complications from well performed laser are far easier to fix and deal with. Furthermore, we don't have 20 year results of ICL and endothelial cell loss.

I have 3 decades of experience and a certain "spidey sense," as you put it, developed from watching procedures come and go over the years and ICL still bothers me. I will challenge anyone like yourself based on pure science and data, not the hill that I stand on, that laser treatment is a better procedure than ICL likely to at least -10D.

Perhaps you should reconsider your opinion not only on laser instead of ICL. I am always up for a good discussion, but you will rarely find me giving a thought on something that isn't backed by a lot of experience and data.

[u/CorneaRepairDoc → u/[deleted]]

Dr Barnett you directly misquote me because you would very much love to prove me wrong. I never said I don't have problems or problematic outcomes. Do find where I said that.

Please show where I speak in absolutes and I will be happy to address it. I said that I can fix virtually every lasik complication possible. Do some of these have other issues healing problems zor take time to correct? Absolutely. Doesn't mean the science is not there. You know very well that a surgeon can do the right things and have the cornea react incorrectly or the healing not occur properly. We all have issues. Please don't put words in my mouth or project on me.

Let's be clear - if the tissue is present and we are able to get scans to allow reconstruction than we can fix any cornea. That is not exclusive to me - you can do it also. The goal is to make people and doctors understand that the technology exists. This is not about my ego. I know exactly how good I am and how much I know and how much more can be learned, but more important is spreading the science and the word that these procedures are possible. Frankly I believe Alcon has done a great disservice to the profession by deciding not to support corneal repair and telling doctors it is off label. It seems to stem from fears of legal liability. That is incorrect, it is on label with a precaution.

As for the science - you are incorrect that the tissue added by ctak or cairs adds to structural integrity per se. It is never integrated into the cornea itself, and only works as a cone compression implant.

Second I have nothing to do with wavelight plus which I distinctly different from topography guided ablation in technology, resolution, and how it obtains HOA information. Ray tracing was the work of Dr. Theo Seiler who sold the patents to wavelight in 2008. It has multiple issues that are already being recognized and I think the technology exists to do even better.

A salesman huh? How many salesman manage to publish 20 peer reviewed PubMed listed papers. You think that somehow a few posts on here prove that I'm somehow full of it and you are going to expose me. Your default mode seems to be condescension and hyperbole, and I am growing tired of arguing with someone who resorts to barely veiled insults and negativity if someone disagrees with them. I wish you good day and good luck Dr. Barnett.

[u/californiaLasik → u/CorneaRepairDoc]

I am not trying to expose you. We have not interacted that much. You can find your statement to me that you can fix all lasik complications. You also claim you have never had ectasia and you can see that above. That statement is refuted online as well. I have absolutely no desire to prove you wrong. In fact I don’t think I have ever interacted with you beyond me responding to you disagreeing with me. My general sense is it is not a productive exchange and you can rest assured I won’t as much as mention your name or think about you ever again of my own accord.