Understanding Your Vision Correction Surgery Options with Dr Ronald Krueger

Podcast Transcript

Nada Youssef:  Hi, thank you for joining us. I'm your host, Nada Youssef. Today we'll be discussing laser vision correction surgery options and how can you find the best option for you? There are many ranges of procedures out there available and today we'll be exploring the options as well as taking your questions live. So if you guys have any questions, put in the comments section below and we'll get to your questions as soon as we can. And today we have with us Cleveland Clinic ophthalmologist Dr. Ronald Krueger. Thank you so much for being here today.

Dr. Krueger: Very welcome.

Nada Youssef:  And I just want to give you a few minutes to introduce yourself as viewers are listening.

Dr. Krueger: Yes, so I'm Ronald Krueger. I am the Medical Director of Refractive Surgery at the Cole Eye Institute of the Cleveland Clinic. I've been here, this is now my 20th year and practicing a little bit before that elsewhere and then when I came here, it was a chance to sort of lead this department of Refractive Surgery, which I've been doing for about 20 years. I've kind of seen the whole generations of different laser vision procedures come and go and been involved in a lot of the development of those things along the way. So I kind of look forward to sharing some of those thoughts with everybody today.

Nada Youssef: Great, can't wait to get started. And before we do get started though, please remember this is for informational purposes only and not intended to replace your own physician's advice. So, I kind of want to start with laser vision correction. What exactly is it fixing? Because it's more than just one thing, right? More than just blurry vision. So let's talk about that.

Dr. Krueger: So most people that are coming in probably fit the category of being near-sighted. And that's the number one thing we correct is myopia or near-sightedness. And that's the primary thing that early laser vision correction did treat. It then expanded to correcting things like a stigmatism, far-sightedness and now we're actually trying to even deal with the reading glasses issues for patients who are over the age of 40, where we can sort of target, sort of a blended compromise that allows them to still see some distance and some near.

And I can go over that in even more details as I go along. But each of those different prescriptions can be treated depending on which technology we use and how we discuss it with the patient in terms of their options.

Nada Youssef: So, near sightedness, far-sightedness, stigmatism, blurry vision.

Dr. Krueger:  And even presbyopia which is the need for both distance and reading glasses.

Nada Youssef:  Okay, okay, all right, excellent. Well, there are so many different procedures out there. I've heard of LASIK, PRK, I believe it's intraocular lens and then there's smile. Can we talk about the differences and which ones to know-

Dr. Krueger:  So going back to 95, 96 when the FDA first approved PRK, that was the first procedure that came along. It was being used around the rest of the world, finally went through the FDA study, but it was the idea of just removing the outer surface layers of the cornea and then letting a laser laze or reshape that cornea into a new curvature that would fit the prescription of the patient's eye.

PRK was popular in the beginning to some extent, but it was more associated with some pain and discomfort and also a little longer recovery to the vision where it needed to be. Just a few years after that, starting around 97, 98, LASIK hit the market and LASIK gave that same outcome but right away, like with one day you can see that well and you really didn't have the pain and discomfort. So that really made it even more popular and most people that hear about laser vision correction, they hear about LASIK, they don't know as much about PRK because was that really popular thing that really grew the market.

 Right now, presently, we do about 70% LASIK and about 20% PRK. So we still do PRK, but not everyone is a good candidate for LASIK. But that's part of what an exam will tell, is what's really the best procedure and sometimes I have to coach patients and say, "You're really a better candidate for PRK," and they say, "Yeah, but that's the one that takes longer to heal." And I'm like, "That's true, but we're talking about long-term success and it would really be in your best interest to do it this way."

Nada Youssef: Sure, so using a visual here for those watching, if we can kind of explain what PRK does versus LASIK and I know even we have more, SMILE, right?

Dr. Krueger: Right, I'm going to talk about SMILE right next. So PRK you can sort of see this blue line, which is the outer diameter area that everything within it is the outer skin layer that's removed. We actually just use a very soft instrument and we kind of soften it a little bit with diluted alcohol and just peel it back.

Nada Youssef:  The surface of the-

Dr. Krueger: Just a real scraping, just kind of peeling back an outer surface layer. And then the laser comes and reshapes the cornea into this new shape that just really fine tunes your prescription.

Nada Youssef:  Right, right.

Dr. Krueger:  That's PRK, which is a surface laser treatment. Then comes LASIK. Now LASIK is a little more invasive in that it goes deeper layers because we use the blue line out here, is actually the edge of where that flap is created. The flap is then opened up and the inside layers are treated with a laser to reshape it to that new curvature. And then the flap comes back because the flap still has that outer surface skin layer on it, it knits together real quick and gives fast return of vision with no real discomfort and pain.

Nada Youssef:  So why is this more invasive? Is this just a bigger dive?

Dr. Krueger:  You could just say because here you got an extra layer. With the other one, you just did everything on the surface. This is a little more invasive in that there's an extra layer there. But that extra layer affords quick return of vision and also less discomfort. And that's what patients really like. So, LASIK is sort of the darling of the procedures because it's just faster. But you have to really qualify to this. You got to make sure that everything about your eye is healthy and normal, that this is the procedure that's recommended. And there might be cases where we say, "No, we're not recommending LASIK, we're recommending PRK."

Nada Youssef: Okay, great.

Dr. Krueger: So there is this third procedure of laser vision correction called SMILE. Now SMILE is sort of, I would almost kind of call it like a laparoscopic LASIK. It's the idea of the tissue needs to be removed, but it's doing it with a very precise laser that creates a layer of tissue that can then be removed. So here you can see there's a tiny incision, small incision, but inside it's corrected and shape the front and back surface of a layer and that layer can just be pulled out. And then that ultimately corrects your vision.

So the nice thing about SMILE is it doesn't have this large incision of a flap, it's just a smaller incision and then that same correction can be removed. So it's nice, the surface, it's outer surface skin is still present. So there's quicker return of vision than the PRK, but it takes maybe a few extra days of real recovery for it to be as sharp as LASIK. We find that LASIK probably gives us the sharpest vision early on. SMILE is really close to that within the first day to week, it really sharpens it and PRK is the one that takes a little longer.

And when I think of all three of them, this procedure has even more benefits to patients with dry eyes. It's cutting less nerves on the outer surface. It doesn't have a full flap. LASIK maybe has a little quicker return of vision and some level for customization. And the PRK is probably better in those cases where you've got a really high correction and your corneas are sort of thin or the shape makes this a little more suspect, and then we want to be a little more conservative, and that's where we recommend PRK. So, it's all about finding out what kind of candidate you are and you need a very thorough eye exam to determine that.

Nada Youssef: Okay, so how do I know which one is best for me, based on everything you just said?

Dr. Krueger: That's the exam. You have to come in. You have to have a trusted specialist give you their professional opinion and they may give you options. They may say, "You could be a candidate for either of these two procedures," and then it's a matter of talking through all the small nuances about what might be better for them as an individual.

Nada Youssef: Sure. Now I see LASIK a lot in malls, in places you don't think of in a hospital setting. Are those okay? I mean, is that something where you can go? Is that reputable? How do we know where to go for LASIK?

Dr. Krueger: I mean, part of that comes into this question about price too. Because some people would say, "Well, I see some of these advertisements that say it's like $500," and then the typical price that we're sort of saying, it's about $5000 for both eyes as opposed to 500 per eye. What's this big differential that people are experiencing? And the bottom line is the cost in providing it does require us paying royalties and the servicing of the laser and there's the expertise of the doctor. So the pricing is going to be costly like that.

But some places really want your business, so they're going to drive the price down. You got to be careful they're not cutting corners in the process. So one of the comments that I always make is that no one ever really goes shopping around for a discount brain surgery. So why would you go looking for discount eye surgery-

Nada Youssef: That's a very good point.

Dr. Krueger:  It's kind of a one and done. You want to do this and this is going to be your eyes for the rest of your life. You really want to get the best quality you can. So, you might find some places that are less expensive, that are really reputable and good quality. I mean, not everybody in the mall is horrible. But you also don't want to get stuck with somebody who may not really have your best interest in mind. And then something as permanent as maybe doing eye surgery, you really want to make careful choices.

Nada Youssef:  Do your research. Now why would some candidates get turned down for this procedure? I mean, is there a good majority of that get turned down or do most people kind of-

Dr. Krueger: So most people have normal enough eyes that they are candidates. So if you think, "Gee, my glasses are just so thick and it's so blurry without glasses, I don't think I'd ever qualify." You'd be surprised. You may qualify very well. But there are some conditions and disorders of the eye that we have to screen out that make you not a good candidate. And those are the ones you really want to know about ahead of time. So patients that have severe dry eyes that could be even related to some kind of an autoimmune condition or something that might lead to that, may not really be the best candidate for certain procedures. And certain other ones might actually still be okay.

 Patients that have keratoconus or maybe the earliest signs of keratoconus that may have not even be diagnosed yet. That's one of the things we really carefully screen out for because we're removing layers of your cornea. We don't want to add to whatever condition and make it worse. And that's part of that screening process. Patients that are using Accutane, sometimes that can be a little bit of a contraindication because it can lead to some excessive dry eyes and things afterwards. And so those are just subtle things you just want to know ahead of time.

Nada Youssef: Okay, great. You covered my next question, so I'm going to go to my third. But if I wasn't a candidate in the past for dry eyes or anything like that, so it was years ago and it sounds like the technology is just booming in this field, can I be a candidate now? If they told me I had dry eyes maybe like five years ago, should I go back? Because you just showed me SMILE could work with dry eyes, it's something to re-evaluate.

Dr. Krueger: So I had one of my early patients who actually had dry eyes and had a little bit of a rheumatologic condition that maybe predisposed her that way and she heard about SMILE and she came and had SMILE procedure and that really was the best procedure for her, because it ultimately gave her the vision correction, while at the same time respecting the fact that there are other factors that we want to really make work for her.

Nada Youssef: Yeah, and there's another one too, right? Intraocular, is that-

Dr. Krueger: Intraocular lens, so in patients who have very high levels of near-sightedness so that it goes outside the range of what we can do with a laser, we can actually put a lens implant in the eye and correct their near-sightedness like that. And that really works well. So what are our ranges? Pretty much around up to a minus 10, we can treat pretty effectively with a PRK, or the LASIK or even the SMILE. The minute we start getting above minus 10 or even maybe up to minus 12 with LASIK in some cases, we're kind of going too high. And so if somebody comes in and says, "But I'm minus 15. Is there anything for me?" The intraocular lens would actually work pretty well that way.

Nada Youssef: Okay, perfect. Thank you. Well, I kind of want to start talking about what happens during the procedures. I know there's a lot of questions. Well, is there any risks to know about with these procedures? Are they pretty safe?

Dr. Krueger: So they are-

Nada Youssef: ... with these procedures, are they pretty safe?

Dr. Krueger: They are pretty safe. LASIK happens to be the most frequently performed elective procedure in all of medicine.

Nada Youssef:  Wow. In all of medicine?

Dr. Krueger:  In all of medicine. So of all the other elective procedures out there LASIK is done the most.

Nada Youssef:  Yeah.

Dr. Krueger:  And so, that really gives it a level of credibility that it’s been out there and it's very popular, and the masses are doing it.

Nada Youssef:  Okay.

Dr. Krueger:  And yet there still is always, there are more patients that could be done than are currently being done. And there's still always this underlying fear that patients have. They say, "Well, it's eye surgery." They're sort of scared of that, but if they happen to have a friend or family member that had it done and had a great result they're like, "Wow, they had it done I think I could do it too."

Nada Youssef:  Yeah.

Dr. Krueger: So that help alleviate the fear a little bit is when it comes home to somebody personally.

Nada Youssef:  Yeah, right.

Dr. Krueger: And that makes it a little bit easier.

Nada Youssef:  So how fast is that procedure, the LASIK procedure?

Dr. Krueger: Typically I would say that a patient can have both eyes done within about 20, 30 minutes.

Nada Youssef:  Wow. Are they awake during the whole thing?

Dr. Krueger:  They're awake during the procedure. We usually give some Valium.

Nada Youssef:  Okay.

Dr. Krueger:  Because we want them to be a little bit relaxed. We don't want them to be tense or fidgety during the procedure because they're your eyes, it's not like going to the dentist where they might be drilling away at your teeth. Here we're doing something and people are just a little more sensitive because it's their eyes.

Nada Youssef:  Yeah.

Dr. Krueger:  So we want them to be nice and relaxed so that they're comfortable, and that just makes the whole procedure better for everybody.

Nada Youssef:  If there is any movement, does that mess anything up 'cause I always think about someone just sitting there, you have to relax, but you get nervous and there's a little movement maybe?

Dr. Krueger: We would much rather have a still patient.

Nada Youssef:  Sure.

Dr. Krueger: Then a patient who’s moving.

Nada Youssef:  Right.

Dr. Krueger: Because then I have to kind of work around that movement, but that's where you want to have a calm surgeon who can talk to their patient, reassure them, give them the comfort they need, a little Valium can help make the difference.

Nada Youssef: Yeah.

Dr. Krueger:  There are steps of the procedure where it's probably even more critical not to move than other steps.

Nada Youssef:  Okay.

Dr. Krueger:   Like when the laser with some suction on the eye is actually treating a layer we don't want you to move so that the suctions lost, that would cause a problem.

Nada Youssef:  Sure.

Dr. Krueger:  Then you'd have to go back and say, well we have to reapply the suction cup.

Nada Youssef:  Okay. And then what's to expect after the procedure?

Dr. Krueger: Usually in the first few hours after say LASIK, which is the one where you have the quickest return of vision and maybe most comfort. The first few hours your eyes are kind of a little light sensitive and stinging. And so, we encourage people to just close their eyes on the way home and take a nap when they get home.

Nada Youssef: Okay.

Dr. Krueger:  Usually they get up from a nap maybe three to four hours later and they will look around the room and they're like, "Wow, I can see already." And their eyes are already feeling more comfortable after that.

Nada Youssef:  Wow, that fast?

Dr. Krueger:  Yeah.

Nada Youssef: That's amazing.

Dr. Krueger:  So just in a few hours they're already pretty functional.

Nada Youssef:  Okay, so you won't drive home but maybe in a few hours after?

Dr. Krueger:  Well someone else is going to drive you home.

Nada Youssef: Yeah.

Dr. Krueger:  But you can certainly talk with the driver, but you close your eyes just kind of rest them, it's a nice environment. You feel like you want to close them.

Nada Youssef: Sure.

Dr. Krueger:  And it's actually good for you to close them.

Nada Youssef: Do you need artificial tears after the procedure?

Dr. Krueger: You do need artificial tears. We give you a topical steroid drop that reduces inflammation.

Nada Youssef:  Okay.

Dr. Krueger: And we also give an antibiotic 'cause we just want to make sure we're preventing any kind of infection that might otherwise happen, and artificial tears.

Nada Youssef: Yeah, artificial tears are just temporary though right? Or is that kind of you continue using it?

Dr. Krueger: We encourage you to use those.

Nada Youssef: Okay.

Dr. Krueger: The steroid and the antibiotic are typically for about a week.

Nada Youssef:  Right.

Dr. Krueger:  But we usually encourage you to keep using the artificial tears even for the first month or so, because there are tendencies were your eyes might be a little bit dry, and just supplementing that with an artificial tear is helpful.

Nada Youssef: Yeah, great. Now I've had siblings that had LASIK and my mother, but they've gone back after a few years, is this always a thing that you need to come back for a touch up?

Dr. Krueger:  Maybe the best way to sort of say it is, your eyes are living tissue. It's not a piece of plastic. If it was a piece of plastic we could reshape it and it would stay the same way and never change, but because it's living tissue it could be subject to just some changes that typically happen with time and age. And you know the same thing, that occasionally you'll get a pair of glasses in a few years your vision may change a little bit and you have to get another pair.

Nada Youssef: Yeah.

Dr. Krueger:  So again, because it's living tissue it can change, but the vast majority of people have this done and maybe 10 years later they have the same good quality vision, but everyone's a little different.

Nada Youssef:  Sure.

Dr. Krueger: So there's still a small percentage that may come back after some years and say, "Hey, I think my eyes have changed."

Nada Youssef:  Right, okay. Well I'm getting a lot of questions, but before I go to live questions I want to read this fun fact I read, and tell me if it's true or not. I've read that custom LASIK is based on the same technology used in the Hubble Space telescope project.

Dr. Krueger: Yes, and that's true.

Nada Youssef:  Yes, okay.

Dr. Krueger: So this is actually going back early 2000's maybe around 2003 or '04 when Wavefront custom LASIK was introduced into the market here in the US, and became a very popular form of customizing. And the idea is that if we can correct small irregularities in addition to your prescription we can get a better quality overall result, and it's all about trying to get the best quality for our patients.

Nada Youssef:  Right.

Dr. Krueger:  Well, that was a number of years ago, like going back maybe 15 years. And in that period of time newer levels of customization have also come along where we've actually compensated for typical small irregularities that the laser wouldn't do, we would start compensating so that wouldn't be the case. And now we're actually treating the front surface irregularities together with a prescription to sort of optimize people where I'd say maybe about 30% of my patients are seeing better than their best pair of glasses.

Nada Youssef:  Wow.

Dr. Krueger: So we're actually trying to really push this into the direction of seeing better than glasses.

Nada Youssef:  Amazing. Yeah, this technology sounds like it's definitely booming. Well, I'm getting a lot of questions so I'm going to start reading those off.

Dr. Krueger:  Okay. Sure.

Nada Youssef:  Let's see, I have Reena. After a cornea ulcer in my left eye I knew I didn't want to go anywhere else. Let me see ... it's cutting off here. Doctor Krueger performed LASIK in my right eye and PRK and a corneal transplant in my left, I highly recommend whole eye. So that's just a nice comment.

Dr. Krueger:  Sure. Thank you so much. And I think I remember that patient too.

Nada Youssef:  You do? And then I have Leslie. Will eye corrective surgery reduce or eliminate floaters?

Dr. Krueger:  Okay, so that's a good question because floaters are fairly common. And what a floater is, is that there's a gel in the back of the eye in front of the retina, and as you age that gel tends to separate from the retina, and when it does it can cast a little shadow that you notice as a floater especially if it's condensed in one place right in the center of your vision.

Nada Youssef:  Yeah.

Dr. Krueger:  Floaters are not something that's easily removed and eliminated, in fact, we have no really great ways of doing it, although there are newer things out there were you could try to use a laser to blast the floater away. Maybe not completely risk free.

Nada Youssef: Yeah.

Dr. Krueger: Some people are beginning to do that, and there's even some surgeons that would say they would remove all the gel of your eye if you had a really bad floater.

Nada Youssef:  Wow.

Dr. Krueger: This is if you have like the worst floater of your life type of thing, where it really blocks what you're seeing. Most of the time it's more of an incidental find. Laser vision corrections not going to take away the floater because it's all about changing the optics to make the sharp focus, there still might be that little condensation area that creates a floater.

Nada Youssef:  Yeah.

Dr. Krueger:  And so, we usually tell people that floaters won't typically go away you might still have them afterwards.

Nada Youssef:  So, you described a floater as dark and like a shadow. I thought or what I see floaters are almost like transparent, they look like worms, is that normal? Does that come and go?

Dr. Krueger:  That's part of what it is, because the gel in the eye in front of the retina is a transparent gel.

Nada Youssef:  Okay.

Dr. Krueger:  But if that gel has a layer and now it's separated right in front of the sharpest part of your retina it could cast a little reflection, it sort of looks translucent a little bit.

Nada Youssef:  Sure.

Dr. Krueger:  Or you might see some small condensation that makes it look like a spot or like a little ring or something along those lines that people sometimes report.

Nada Youssef:  Yeah.

Dr. Krueger:  And they're more of kind of a side annoyance. They don't really take away the crispness of the vision but they just add that extra kind of shadow or translucency.

Nada Youssef:  Extra dimension.

Dr. Krueger:  And for some patients they can be pretty annoying.

Nada Youssef: Of course, of course, thank you. All right, and I have Valerie. Are people over 60 good candidates for the surgery? Can you be too old?

Dr. Krueger:  Well, you won't be too old, but as you age and you start getting into your 60's or 70's we also have to factor in the natural lens in your eye which is getting older and getting closer and closer to becoming a cataract.

Nada Youssef:  Okay.

Dr. Krueger:  So if you are of the age where you don't have a visually significant cataract yet, but you're starting to scatter more of the light and that's degrading and creating halos and distortions a little bit, we can actually do lens replacement surgery even before it's a cataract.

Nada Youssef:  Okay.

Dr. Krueger:  And it's basically the same exact surgery as a cataract surgery but because we can't call it a cataract it becomes more of a self pay item and it's correcting your vision.

Nada Youssef:  Okay.

Dr. Krueger:  And we do a fair number of those as well to get really good sharp clarity without glasses, but at the same time taking care of some of that light scatter of the early not yet visually significant cataract.

Nada Youssef:  Great. And speaking of pay Darlene wants to know how much does it cost. I know you talked earlier maybe $5,000 for both eyes.

Dr. Krueger: Yeah, so typical LASIK if you go to most reputable centers is probably going to be somewhere close to about $5,000 for both eyes.

Nada Youssef:  Okay.

Dr. Krueger:  Sometimes you'll see a little bit less or a little bit more. If you're seeing some places that are really deeply discounting it, I think most people sort of feel like something doesn't seem right.

Nada Youssef: Yeah, absolutely.

Dr. Krueger:  Why is it so low? I'm more scared about that then I am eager to jump and pursue it.

Nada Youssef:  Right.

Dr. Krueger:  And again, it's that idea that it's your eyes. You really don't want to necessarily seek out a discount surgery for your eyes.

Nada Youssef: Right. And then that's the same price for all the different procedures as well?

Dr. Krueger: Yeah, there's small differentials like for instance, SMILE usually could be just a little bit more but our customized LASIK is about the same price as SMILE.

Nada Youssef: Okay.

Dr. Krueger: And PRK is generally a little less because we have less royalties to pay with what we do.

Nada Youssef: Okay, great. And then Sue, can you correct visions issues for both near and far?

Dr. Krueger:  Okay, so that's the Presbyopia question.

Nada Youssef:  Yeah.

Dr. Krueger: We can do that, and for those patients who over the age of 40 they may be saying, "Gee I'd love to have distance in both eyes, but if I can't read I won't like that." And the number one way I deal with that is something called blended vision or mono vision, it's the idea that the strongest eye, the eye that's the dominate one is the one that I fully correct for distance. And then the non dominant opposite eye I correct for some sort of a near mid-range target that allows them to see and read, and then each eye is kind of accentuating that distance a little bit more so they can with both eyes open see both distance and near.

Nada Youssef:  Like a great balance between.

Dr. Krueger:  It's amazing because some people question like, "Well I don't know if I could get used to that." I've done studies of this and I'd say about 93% of my patients over the age of 40 do it this way and like it.

Nada Youssef: Wow.

Dr. Krueger:  So I get more than 9 out of 10 that really accept mono vision make it work. It's my most successful way of dealing with the issue of reading glasses.

Nada Youssef:  Yeah, and that's mono vision?

Dr. Krueger: That's mono vision or blended vision.

Nada Youssef:  That's awesome. Great. And then I have Arlene. Can laser surgery be done if you had cataract operation done before?

Dr. Krueger:  And the answer is yes.

Nada Youssef:  Yes.

Dr. Krueger: So if you've had a cataract surgery and maybe the cataract surgery didn't fully correct your vision you might have some astigmatism left, or it might be a little bit near sighted, you think, "Well can I fix this further?" We do that all the time for subtle cases where maybe they come back and say, "Can I fix that?" We certainly can treat that and get you that extra sharpness.

Nada Youssef: Great. And then Carol Ann. After cataract surgery in both eyes is it true that a person cannot have laser vision corrective surgery, please confirm?

Dr. Krueger: They can definitely have it done.

Nada Youssef:  Okay.

Dr. Krueger:  The real question would be is, what is their best corrected vision? So after cataract surgery if they can be corrected all the way to 20/20 it's just that without glasses they don't see 20/20 then I would say seek out laser vision correction as a way of getting you that full correction.

Nada Youssef:  Great.

Dr. Krueger:  And nowadays whenever people are doing cataract surgery they're sort of expecting that, "I want to see without glasses afterwards." And so when they don't get that they feel like something was sort of deprived, that they sort of missed out on.

Nada Youssef:  Cheated.

Dr. Krueger: Yeah, they're a little cheated, and that they kind of expect that.

Nada Youssef: Yeah.

Dr. Krueger:  We're providing more and more of that expertise of people are coming to expect the things that we can provide.

Nada Youssef:  Sure.

Dr. Krueger:  And so, the answer is that laser vision correction can be very effective to get you that ...

Nada Youssef:  Sure.

Dr. Krueger:  So the answer is that laser vision correction can be very effective to get you that extra where you can fully achieve it.

Nada Youssef: If someone comes back after two or three years for a touch-up, is that full price?

Dr. Krueger: Yeah, so let's say you had LASIK with us, and within a year you're coming back and you say, "I think my vision's a little bit off." We actually guarantee that for the whole first year, that if we did any kind of re-treatments, there's no extra cost for that. That's part of the global period of coverage. Now, as you get into the second year, we say, "Well, we're going to charge you some small amount, because it's been a whole year." Maybe your eyes could be starting to change, and then the third year it may be a little bit more, so by the time you're at about five years out, we feel like okay, we've kind of covered you through the early phases of LASIK, and now if you're coming in for some small change, we're going to be pretty close to the full price.

Nada Youssef:  So it's prorated.

Dr. Krueger: It's prorated, and that's good too, because some people are thinking about their anniversary date and they're like-

Nada Youssef:  Yeah, like I have to do it closer?

Dr. Krueger:   I have to show up and get this checked out, because I don't want to go to full price in one day. We don't want to do that. We want to make it so they can make a conscious, proper decision and not feel rushed about something.

Nada Youssef: Sure, sure. Thank you, it's great to know. Then I have Clara: Is this procedure possible or advised for seniors with cataract issues? I feel like we just talked about this.

Dr. Krueger: Right.

Nada Youssef: Leslie: Can corrective eye surgery be done at the same time as a upper eye lid lift?

Dr. Krueger:  Yeah, so if you have an issue where maybe you need a little bit of a lid lift, best to either have the LASIK done first or the lid lift done first, but maybe wait about up to six months between them.

Nada Youssef: Six months, okay.

Dr. Krueger: You want to do them differently, because you want to let one really fully recover and heal so that you'd be more equipped and ready for the second.

Nada Youssef:  Great. Then Alba: I see like a cloud in one of my eye. Sometimes I have to clear my eye, and it will clear again. Thank you so much.

Dr. Krueger:  Okay, so the cloud could be like a floater, but it also could be some momentary dry eyes, because people sometimes will say, "My vision is occasionally blurry. I blink a few times, it gets a little better." There might be mucus, there might be a little dryness. A lot of people suffer from early dry eyes for a number of different reasons, and if they're coming in for an evaluation, we try to pinpoint that and treat the dry eyes even before we do the surgery.

Nada Youssef:  Okay. Well, isn't macular degeneration, isn't that some kind of cloud in the eye, or is that too ... ?

Dr. Krueger:  That's also a more common cause of vision loss as a person gets older, and that has to do with the retina in the back of the eye, that with age begins to degenerate a little bit, so that you begin to have a little distortion of vision. Because it's common, there are actually some ways to prevent that, using vitamins that supplement things in your diet that might otherwise lead to it. There are certain types of vitamins like zeaxanthin and lutein, which are special vitamins, that might help a person who has early macular degeneration, but that's something you should just go to your doctor and be monitored for.

Nada Youssef:  Talking about diet, I'm going to just bring this up. Do carrots help your eye health? It's always something I've heard.

Dr. Krueger:  Carrots is full of Vitamin A, and Vitamin A is generally good for the retina, although maybe you shouldn't be eating so many carrots or celery that you-

Nada Youssef:  Turn orange.

Dr. Krueger:  Put a toxicity in your own self, you know what I mean?

Nada Youssef:  Yeah.

Dr. Krueger: We've heard of crazy stories like that, where people are so convinced it was so good, that they actually overdosed themselves on it.

Nada Youssef: Oh, my goodness. Wow, overdosing on carrots doesn't sound delicious. I have Leslie: I have lazy eye in the right eye. I wear contacts for both eyes. Would I be a candidate for this?

Dr. Krueger: Okay, so in the case of a lazy eye, we cannot fully correct that vision to make the lazy eye go away.

Nada Youssef:  That's muscles, right?

Dr. Krueger: Well, it's actually ... I mean, usually with children, it could be where their eyes are crossing, but most of the time we define a lazy eye as sort of a layman's term for something called amblyopia, which means that the full correction with the best pair of glasses doesn't get all the way to 20/20, because that eye just didn't develop as well when they were a child, so there's a difference in how sharp it developed, based on the signal or whatever they received as a kid. And because it happened in childhood, that might be as good as that eye can get, so we say yeah, we can still do surgery to correct your prescription, but some of that lazy eye, that limits how sharp it could be, is still going limit.

Nada Youssef: Is still going to be a limitation. Okay, great. Then I have Jane: Can surgery be done if you wear bifocals?

Dr. Krueger: Yes. The issue of wearing of bifocals is presbyopia, which literally means "old vision," so that kind of hits you right at home.

Nada Youssef:  Yeah.

Dr. Krueger:  But the idea is that yeah, if you're losing that up close with your full distance prescription, yes, I could correct both eyes for distance, but then I'm going to leave you wanting to see something up close.

Nada Youssef:  Right.

Dr. Krueger:                     So if I do this slight differential between the eyes, I find that's most effective, and people really like the flexibility they have of seeing distance and near without wearing glasses on and off. And I also tell patients, just because I do this monovision doesn't mean you're never going to wear glasses again. It's just going to mean that you're going to be the most free from glasses in your day to day activities. Glasses could always make something better, like driving at night in the rain, you might say I want both eyes seeing down the road. Or reading small print or working on some small detail, threading needles, you might want to just put something on to make both eyes see up close.

Nada Youssef:  Sure.

Dr. Krueger:  Both those are kind of rarer instances, and you have a whole lot more flexibility, so that you're not on and off with glasses all day long.

Nada Youssef:  Yeah. Yeah, that's good clarification, thank you. Then Wanda: Can you have surgery if you have diabetic damage to your eyes?

Dr. Krueger:  Okay, so diabetes is more common now in the population, and if a diabetic is well controlled and there's no real retinal damage that's coming from the diabetes, then they could be a candidate. But if their diabetes is fairly severe that they're starting to get retinal damage, maybe they should be paying more attention to what the diabetes is doing and maybe worry less about the vision correction aspect of things, just because diabetes could be bad enough that you really lose all your vision.

Nada Youssef:  Right, exactly.

Dr. Krueger:  You really want to take care of that, and that would be a primary focus.

Nada Youssef:  Sure, all right. We do have a lot of questions, but I will give you two before I let you go. I have Paul: I have high astigmatism, negative 10, and have been told LASIK won't work for me. Is this true?

Dr. Krueger:  Okay, so negative 10 sounds like a nearsighted value. Minus 10 would be a high myopia or high nearsightedness. We can treat minus 10 with laser vision correction with a number of the different ones. We can also treat astigmatism up to 6, which is a lot of astigmatism. Most people probably fit somewhere less than 3, but we can even go up to 6, so it gives us a lot of flexibility.

Nada Youssef:  Okay, so make your appointment, right? It could be done.

Dr. Krueger: Have him come in, he can get it checked it out. We can tell him what's possible.

Nada Youssef:  Great, and then last one for you. My son had corrective laser procedure. After one year, he had night vision difficulty. Is this normal?

Dr. Krueger:  Okay, so in the early days of laser vision correction, before some of those customized profiles started happening, patients would come in with 20/20 vision, and they'd say, "I see rings and lights around night," and most of the doctors would say, "Yep, but you see 20/20, so you should be happy." But there were small irregularities that were there, that we didn't even have the technology to really understand fully, until these customized Hubble telescope type things came along, to really describe and characterize those small irregularities, and to then perfect it so we could treat those irregularities right from the get-go.

So right now, we're kind of customizing things to prevent things like halos and glare at night as best as possible. And even some of these newer things that I'm doing with topography-guided correction, the FDA studies have actually shown that there are statistically less halos and glare than pre-op that patients might have had before their surgery, because if you're wearing contacts and stuff, it might be enough that you can get some starbursting or glare at night.

Here, this can sort of blend it out in such a way that you might even see less of that after the laser vision correction as well. So don't necessarily be afraid that that's going to be the thing that's going to make your vision disabling, and for some that maybe have some of those glare and halos from an older procedure, we're even beginning to try to re-treat those patients to try to eliminate some of that.

Nada Youssef: I can only imagine what the next 20 years will look like, let alone 100.

Dr. Krueger: Well, I mean, it's been out there now for 30 years, 25 years, in the US, so there's been a lot of refinement. You know, making this better and better quality, and we're not stopping. We're pushing technology forward to keep making it better and better.

Nada Youssef:  Great. Thank you so much for your time, but before I let you go, is there anything you want to tell our viewers or listeners before we go?

Dr. Krueger: You know, I have some colleagues who would say that this is now getting so good, laser vision correction, that it really should become the primary form of vision correction. So instead of glasses and contacts, everybody should be getting LASIK done. We're not quite there yet. I mean, there's a lot of potential limitations. There's cost, there's just fear in the market. There's questions about where do I go? But as we see this market grow more and more, I think that becomes a more realistic end point. Could we make this so that the next generation looks back and say, "Oh, yeah, that was the generation that really got rid of glasses."?

Nada Youssef:  That paid for glasses, right. Right, exactly.

Dr. Krueger: Yeah, they had all that, and we were able to sort of take this to the level where now everybody can join us.

Nada Youssef:  Yeah, great. Well, thank you so much. To schedule a consultation with our team of experts, you can call us at 216-445-8585 for an appointment. And to stay up to date with Cleveland Clinic health tips and information, make sure to follow us on Twitter, Facebook, Instagram, and Snapchat. Thank you again. We'll see you next time.