ye t · Laser eye surgery and lens replacement address common visual problems that people would...

The UK Guide to Laser Eye Surgery and Lens Replacement

BSc(Hons), MB BS (Hons), MRCP, FRCS, FRCOphth Consultant Ophthalmic Surgeon

Robert Morris

BSc(Hons), MB ChB, FRCS, FRCOphth, MBAConsultant Ophthalmic Surgeon

Paul Rosen

MA (OXON) BM BCH (OXON) FRCS FRCOphth Consultant Ophthalmic Surgeon

A. Keith Bates

Table of contents Introduction 1

The 4 eye problems we can address with laser eye surgery and lens replacement 2

Myopia (short-sightedness) 3

Hyperopia (long-sightedness) 3

Astigmatism 3

Presbyopia 3

Laser eye surgery 5

Laser eye surgery at a glance 5

What is it? 5

What procedures are available? 5

What are conditions that can be treated with laser eye surgery? 6

Is laser eye surgery painful? 6

Why should I consider laser eye surgery? 6

What types of laser eye surgery are available? 7

What is a SMILE procedure? 9

Who is a good candidate, how am I tested to be found suitable for laser eye surgery and are there

any options if I am not? 10

What are the risks of laser eye surgery? 11

Lens replacement 12

Lens replacement at a glance 12

What is it? 12

What lenses are available? 12

What are the conditions treated? 12

Is it painful? 13

What is lens replacement 13

Why should I consider refractive lens exchange? 13

What are the risks of lens replacement? 14

Why should you choose Grange Eye Consultants for laser eye surgery or lens replacement? 16

Expert personalised care 16

Paul Rosen 17

Robert Morris 18

Adrian Keith Bates 19

Introduction Thanks for requesting our Guide to Laser Eye Surgery and Lens Replacement. We wrote this guide to help you navigate your way through the sometimes confusing world of refractive surgery. It's a big subject, with a lot of medical terminology. We're sure you'll have a better understanding of the basics after reading this guide. Laser eye surgery and lens replacement address common visual problems that people would rather live without. Some of us are born with these problems and some problems, like reading vision, begin to deteriorate starting after about the age of forty. We’ll discuss both types of treatments in this guide and answer the most common questions of: Why would you want to have each procedure? What types of surgeons are available? What are the latest procedures? Who makes a good candidate? What are your options if you're not suitable? What are the risks? Most people find that by having these questions answered they are in a much better position to make an informed decision about their treatment.

Finally, we introduce ourselves to you. We'll tell you more about our background, training and experience and of course we'll also tell you why we think we're a good choice to conduct one of these procedures for you. We hope you enjoy learning about this fascinating subject. Most of all we hope that this information is useful to you as you consider your options. This guide is general by design and can't substitute for getting a real medical opinion. Whenever you are ready, we suggest that you seek a consultation with an expert, like ourselves, so that you can receive a custom advice for your unique eyecare needs. Please give us a call and we would welcome the opportunity to serve you in this way.

Best regards,

A Keith Bates, Robert Morris, and Paul Rosen Consultant Ophthalmologists

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The 4 eye problems we can address with laser eye surgery and lens replacement We can address five eye problems (also known as refractive errors) with laser eye surgery and lens replacement. These refractive errors are

1. Shortsightedness (known as myopia) 2. Longsightedness (known as hyperopia) 3. Astigmatism 4. Presbyopia (known as ageing eyes)

A refractive error Is not a disease, it is a problem with how the eye focuses light.

Call us with any questions on: 0800 368 9277 �22

Myopia (short-sightedness) If you have longsightedness, you will have difficulty reading road signs and seeing other distant objects. But, you will be able to see well for close-up tasks such as reading and computer use.

Hyperopia (long-sightedness) People with hyperopia can see distant objects well, but have difficulty focusing on closer objects.

Astigmatism In an eye with astigmatism, light fails to come to a single focus on the retina to produce clear vision. Instead, many focus points occur, either in front of the retina or behind it (or both).

Presbyopia Presbyopia usually occurs beginning at around age 40. People notice it most when reading, sewing or working at the computer.

Presbyopia occurs when you need to have reading glasses. It's one of the inevitabilities of getting older. We can treat your eyes for presbyobia with lens replacement. Lens replacement involves replacing the natural lens in your eye.

This procedure is helpful if you need glasses for distance and near vision because we can combine the treatments for both. We can set your master eye for distance, and set your non-dominant eye for reading. We refer to this as monovision.


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To trial monovision, we will ask you to wear contact lenses for 2 or 3 days to see whether that system will work. Usually, this gives the best quality of vision for surgical outcomes. If you can't tolerate monovision, you can use bifocal or multifocal intraocular lenses. These premium lenses give people good distance vision and near-intermediate vision.

This kind of vision is great if you are looking at your phone, at your computer or if you are cooking or eating. A typical situation involves going out to a restaurant. In this scenario, you don't have to take reading glasses with you. You can just look at the menu and see what you're eating without having to muck about putting glasses on and off.

There are other options for younger people. If you're younger (40s and 50s) and don't have any significant lens opacity or cataract, you can consider laser correction. This technique called laser blended vision. Laser blended

vision will give you a degree of depth of focus and enable you not to be dependent on middle distance or reading glasses. The drawback of laser blended vision is that the results are temporary (5-10 years). The results for lens replacement are permanent, and they save you from ever needing cataract surgery.


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Laser eye surgery

Laser eye surgery at a glance What is it? • Refractive surgery is the term used to describe surgical procedures that

correct common vision problems (shortsightedness, longsightedness, astigmatism and presbyopia) to reduce your dependence on prescription eyeglasses and/or contact lenses.

What procedures are available? • LASIK

• LASEK

• PRK

• SMILE

• FEMTO laser

• Epi LASEK


What are conditions that can be treated with laser eye surgery? • Myopia

• Hyperopia

• Astigmatism

• and sometimes, Presbyopia

Is laser eye surgery painful? • No it is painless

Why should I consider laser eye surgery? There are many reasons why patients may want to consider laser eye surgery.

Younger people tend to have more laser eye surgery than those who are older. Sometimes they're older and it's often a lifestyle choice.

Candidates include those who:

• can't wear contact lenses but needs to wear spectacles

• have an active way of life, be that mountaineering, sport or something similar

• wants to join the forces, are working in the fire brigade or police

Laser eye surgery is an effective and safe treatment for all these groups.

In the United States, surgeons treat most of the military that needs it. If someone in the Army, the Navy and even the Airforce, has a spectacle correction, they will undergo laser eye surgery. Surgeons did a lot of the pioneering work at a San Diego naval base. The fact that American military


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The American military allows their trained, expensive personnel to undergo this procedure. NICE (the National Institute for Health and Care Excellence) in the UK deems the procedure safe and efficacious.

personnel undergo laser eye surgery shows us how safe laser eye surgery is. Over the last 20-25 years, the technologies have advanced. We've seen advancement in how we can measure the eye and do what we call diagnostics. We've also seen lasers increase in their effectiveness. The combination of this

technology and our understanding of laser eye surgery makes it an even safer procedure than it was 20 years ago. The American military allows their trained, expensive personnel to undergo this procedure. NICE (the National Institute for Health and Care Excellence) in the UK deems the procedure safe and efficacious.

If you wear reading glasses, there may be options to treat that. That depends on individual circumstance. If you have excellent distance vision but need reading glasses, then there are fewer options. If besides your reading correction, you also have a distance correction, then there are options where laser eye surgery can address that. With modern lasers, particularly the Zeiss laser which we use in London one can carry out what's called blended vision.

What types of laser eye surgery are available? There are two principle types of laser eye surgery. There are lots of different names for laser eye surgery and that can be confusing. For example, there is "LASIK", "LASEK", "PRK", “Epi-LASEK".

To simplify, you can think about it as there being surface treatments and flap procedures.

A surface treatment involves us lasering the surface of the cornea. The cornea is the clear lens of your eye that is at the front. We call this


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procedure either PRK or LASEK. In a surface procedure, we remove the thin, transparent skin, known as the epithelium, from the cornea. Then we apply the treatment to the surface of the cornea with a laser. Then, depending on the technique we prefer, we replace the skin and the cornea then recovers.

Surface treatments are effective and safe for patients who have may have dry eyes or a thinner cornea. We call these procedures PRK or LASEK. The downside of this procedure is that the recovery is slower than it is with LASIK. For the first two, three, or four days you'll feel the eyes are watery and gritty as if you have your contact lenses in upside down and inside out. You might feel as if you slept in them. It takes 3 or 4 days until

the eyes feel comfortable and then about four weeks for the vision to crisp up. One can be driving after 4 or 5 days. With that said, you should understand that it takes a good month to get that crispness. Still, the outcome with a surface technique is excellent.

The alternative to a surface treatment is what we call LASIK. We use to do LASIK with a surgical blade to create a microscopic layer on the surface of the cornea. We now create this layer with a laser called a femtosecond laser. We place the femtosecond laser on the eye and it creates a layer of microbubbles. It makes these bubbles a hundred microns in the depth of the cornea. So that's just one-tenth of a millimetre - it's a tiny amount. Then, we lift that flap through the layer of bubbles. On the underlying cornea, we apply the treatment with another laser and then replace the flap. Recovery after LASIK that is quick. Most patients can drive the next day.


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We can treat one eye as predominantly the distance eye and the other eye as the reading eye. With an excellent depth of focus, the treatment blends the vision between the distance from the reading. In selected patients the diagnostic laser eye surgery can help you.

You may ask: "Why doesn't everybody have the LASIK procedure if the recovery is quicker than it is with a surface procedure?" The reason is that everybody's eyes are different.

We're careful about patient selection. We make sure we select the right treatment for the right patient. We often can't tell which procedure suits you until we've done all the diagnostics. We then make our calculations on the laser with the computer. Then, we decide which procedure is best for which person.

What is a SMILE procedure? One of the joys of being an eye surgeon is that new technologies are always coming along. Carl Zeiss is a well-known German optical company that produces ophthalmic lasers. They developed a laser that carries out what they call a SMILE procedure.

What the SMILE procedure involves is using a femtosecond laser to create two layers of bubbles in the cornea. Then, we remove a thin disk that's created by the bubbles from the cornea through a small keyhole incision. We then remodel the cornea shape. This approach addresses the short-sightedness or astigmatism and in the future will address long-sightedness.

The SMILE procedure is not for everybody but it can be a helpful procedure for certain groups of people. A great advantage is that instead of having a surface procedure patients can have the SMILE procedure. The SMILE procedure offers a rapid recovery - like a flap procedure - and the comfort for the patient is excellent. It's a more comfortable procedure than a surface procedure. It's also more comfortable than a flap procedure because the only surface incision made in the cornea is in the tiny keyhole incision. This approach makes the procedure more comfortable than a LASIK procedure. With a SMILE procedure, we can maintain the structural integrity of the cornea much better than we can with a flap procedure.


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Who is a good candidate, how am I tested to be found suitable for laser eye surgery and are there any options if I am not?

Knowing if you're a good candidate for laser eye surgery depends on whether you're happy using glasses or contact lenses. If you find that they interfere with what you want to do then you may want to consider it.

If you do a lot of swimming or other activities where glasses are difficult to wear, then you may want to consider some form of a surgical solution. If you don't need glasses for looking in the distance and just use them for reading, then maybe that kind of surgery is not appropriate. But, if you have a problem where you can't see without glasses for the distance before reading, then surgery can be a good option for dealing with that.

It's important the surgeon understands what's motivating you to have surgery. Following that, they will examine you with care. It is important you leave your contact lenses out for the assessment. You need to stop wearing soft contact lenses at least a week before we assess you. You need to stop wearing gas-permeable hard contact lenses at least a month before we see you.

We'll do a thorough eye examination. We'll check to see if you have dry eyes among many other tests. We arrange for you to have tests on a machine that will scan your cornea. The cornea is the


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Patients are often concerned if there is a risk of going blind. In reality, there isn't a danger of going blind with modern laser technology. Years ago, laser eye surgery was in its

bit of the eye you put the contact lens on. We do detailed scanning of both the front surface and the back surface of the cornea. It's that scanning that informs us which procedure might be the best for you. We take those scans and we put them in the laser so that we can individualise each treatment. Our optometrist will assess your spectacle prescription to ensure it isn't changing. The combination of the examination, the diagnostic tests and our optometrist's findings tells us the best way to treat you.

What are the risks of laser eye surgery? Patients are often concerned if there is a risk of going blind. In reality, there isn't a danger of going blind with modern laser technology. Years ago, laser eye surgery was in its infancy and the technology wasn't as good. We didn't perform the same diagnostic tests and we didn't understand it as well as we do now. Since then, surgeons have performed a hundred million or so laser eye surgeries worldwide. We understand what's going on.

There are of course risks because every surgical procedure carries a risk. The most dangerous risk that could happen would be an infection. I've been doing laser eye surgery for 20 years and I've never seen an infection, although they do happen. In contrast, I've seen 100 of contact lens wearers with infections. So the risk of infection at laser eye surgery is much less than the risk of infection if you wear contact lenses.

The reported cases of infection after laser eye surgery has been in people who are healthcare workers exposed to unusual germs. Sometimes they are veterinarians or farm workers exposed to unusual infections. It's important in that group of patients to manage their increased risk and that they are careful, both, before and after the procedure.

Another risk of laser eye surgery that concerned people was what we call ectasia. Ectasia is an eccentricity in the cornea that might develop after laser eye surgery. Since we have better diagnostic tools we can better predict which patients are at risks of that. The incidence vector fell because we are in such a good position to predict that chance. We weren't when we were doing diagnostics twenty years or so ago


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Lens replacement

Lens replacement at a glance What is it? • Lens replacement is also known as refractive lens exchange. In this

procedure, we replace your eye's clear natural lens with an artificial intraocular lens (IOL) to correct your refractive error and achieve sharper focus.

What lenses are available? • multifocal

• bifocal lenses

What are the conditions treated? • Presbyopia

• Can correct astigmatism, myopic and hyperopic


Is it painful? • No it does not hurt.

What is lens replacement Lens replacement may be a better option than laser eye surgery for people with presbyopia. It is also often a better option for patients with high hyperopia (longsightedness).

Lens replacement replaces your eye's clear natural lens with an artificial intraocular lens (IOL). This lens enables you to correct your refractive error and achieve sharper focus. This lens reduces your need for reading glasses or bifocals.

Why should I consider refractive lens exchange? Over the age of 55 (and sometimes earlier), you'll notice that your eye is changing. The lens of the eye of a child or baby is flexible. In infants, it can be as soft as egg white. In a 90-year-old, the lens can be quite hard. It almost has the consistency of a smartie.

Hardening and thickening of the lens throughout life lead to needing reading glasses. Then maybe computer glasses and then glasses in the distance. If you have a significant prescription, then lens replacement may be a better option for you than laser eye surgery. Lens replacement is especially more suitable for those with a long-sighted prescription for distance, intermediate and reading. The reason is that we are dealing with the part of the eye that is causing the problem. We are arresting the progression of that ageing process. In


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Lens replacement may be a better option than laser eye surgery for people with presbyopia. It is also often a better option for patients with high hyperopia (longsightedness).

most patients that have laser eye surgery in the presence of this hardening of the lens, the effect will only be temporary. Lens replacement is better at correcting both distance and reading vision because you can use a varifocal or bifocal lens to adjust both distances. These lenses can do so often much more effectively than laser eye surgery can do. So, laser

eye surgery, to generalise, is an excellent procedure for the younger age group. But over the age of 55, lens replacement becomes more important.

If you have good vision, you will have better contrast sensitivity. You will see colours more brightly and you will have the opportunity to do all the things that you wanted to do without the hindrance of glasses.

What are the risks of lens replacement? The surgery is extremely successful. Lens replacement is the commonest procedure carried out in the UK. In fact, lens replacement is the commonest procedure carried out worldwide.

The principal risk of lens replacement is the risk of infection or haemorrhage. Although infection and haemorrhage is rare, people need to be aware of these as potential complications. The vast majority of patients see well within two or three days. The rest see well within about two or three weeks. It's a successful procedure.

If you suspect that you have an infection you must give us a call straight away. We will see and examine you and instigate the necessary treatment. We need to do this without delay. So, we are available 24 hours a day so if you have any queries you can get in touch with us.


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Lens replacement is an operation and all operations carry risk. There could be technical problems at the time of surgery. A skilled and expert surgeon can address most of those technical issues with ease.

One of the more serious complications which is rare is infection. But we can treat infections provided we see you as soon as symptoms appear.

One of the important things that we do is that we educate you as of what the symptoms of an infection or other complications following surgery might be. We have a 24-hours emergency service. If you have any concerns we can talk to you and if we're concerned we arrange to see you and treat whatever the problem is.


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Why should you choose Grange Eye Consultants for laser eye surgery or lens replacement?

Expert personalised care

Grange Eye Consultants offers eye surgery supported by modern technology in London, Guildford, Southampton, Oxford & Taunton. Read on to learn more about our 3 founding surgeons and how they are sought out for their collaborative working style which allows them to provide the highest level of expert personalised care for patients throughout the South of England.


Paul Rosen In my current role as a consultant in the NHS, I teach the junior surgeons. What I also do is teach nationally and internationally, both within Europe and in the Americas. I teach eye surgery and cataract surgery in particular.

I am the President of the UK and Ireland Society of Cataract and Refractive Surgeons. Then my peers elected me to as the President of the European Society of Cataracts and Refractive Surgeons.

As part of this role I conducted a strategic review and developed society which now has gone to host a meeting of 7,000 or more delegates. As part of that role, I also take part in the teaching programs. I do this both within the meetings, the annual congresses and also at satellite meetings which we call the ESCRS academies.

More recently the National Institute of Health and Care Excellence (NICE) appointed me to their Cataract Guidelines Committee. I am also on the Refractive Surgery Subcommittee of the Royal College of Ophthalmologists.

So throughout my career, I played an active role in teaching and training, both locally, nationally and internationally.


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Robert Morris I think you should choose me as your surgeon because I think I'm a good doctor. I think that part of being a doctor is being able to talk to patients and communicate with patients well.

When you come and see me the most important thing is that I give you time and that I listen to what your problem is. I want to know what's concerning you so that I can understand what we are trying to improve for you. I think first it's about being a good doctor.

Second, I have a wealth of experience. I've been a consultant in the National Health Service for over 25 years. I have excellent training in the Oxford Eye Hospital, Moorfields Eye Hospital, and in America. Throughout my career, I taught junior doctors surgery in a teaching hospital. In the last ten years of my career, I've had a regular operating list teaching other consultants how to refine their surgical techniques. In this way, they can go from being good or average surgeons into excellent surgeons. I believe that excellence in surgery is important. That's what I strive to do. When you teach other people you have to understand what you are doing, because they challenge you and ask you questions. Unless you understand the finer detailed points, you can't teach and bring people forward. Throughout my career, I've done a lot of teaching. I speak at national and international meetings and I've published a lot. I keep up to date with the literature.

I understand what new technologies are coming. That enables me to decide whether a treatment today may be suitable for you today or if you should wait for new technologies to come.

I'm the medical director at Optegra Eye Healthcare. In that role I'm responsible for governance. I'm responsible for maintaining quality and monitoring clinical outcomes. My results are better than the published national cataract dataset - significantly better. So, I know, I'm not guessing, that the quality of my surgery is excellent.


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Adrian Keith Bates Adrian Keith Bates graduated from Oxford University with a Bachelor of Medicine and Surgery. He followed this with a research fellowship in Oxford studying the corneal endothelium, and post-graduate ophthalmic training at the specialist units of University Hospital. He has continued to research and work on the cornea throughout his professional career.

Keith is now a Consultant Ophthalmic Surgeon with the Taunton & Somerset NHS Trust, a

position he has held since 1992. In this position, he performs high volume cataract surgery and corneal transplantation surgery. A regional corneal expert, he treats patients from across the South West at his weekly corneal clinic.

An accomplished cataract and refractive surgeon, he has been performing laser vision correction since its introduction to this country in 1990. He organised the first excimer laser clinical trial at Moorfields Eye Hospital. After further training, he became an accredited VISX laser user in 1993. He has performed surface based treatments, and has been performing LASIK since its start.

As refractive technology continues to develop, so do the requirements for training. In 2002, Keith received VISX accreditation at Moorfields for Wavefront treatments and accreditation for Z-LASIK in 2008. Now with over 15 years experience in laser treatments, he manages a successful independent Laser Eye Surgery practice besides his NHS work.

Keith has been active throughout his career presenting on corneal and refractive surgery at national and international scientific meetings. He has published much of his work in the major peer-reviewed journals, and he is also a reviewer of corneal papers for several leading journals.


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ye t · Laser eye surgery and lens replacement address common visual problems that people would...

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