The eyes have it
25 years of laser eye surgery, the procedure that revolutionized vision care.
When the first laser eye surgery took place in Canada, many medical experts predicted — correctly — that the procedure would revolutionize vision care.
The scene was Calgary’s Gimbel Eye Centre. News cameras focused on a reclining operating bed; gloved hands worked beside a white, protruding metal box, inches away from a patient’s head encased in a gossamer-like sterile cap; and, a laser red dot appeared on 24-year-old Brent Carreau’s eyelid.
This was no ordinary day in the operating room.
As Dr. John van Westenbrugge began the evening procedure, history was being made and Carreau’s life would change for the better.
“That certainly added a little bit of interest to the situation,” van Westenbrugge said of the June 12, 1990 laser eye surgery that would be the first of its kind in Canada.
“You don’t often have that happen. … You are doing a procedure for the first time (and) you’ve got national news coverage in the room at the same time.”
Despite this being the first time laser eye surgery was performed in Canada, the patient wasn’t worried.
Carreau, as a project co-ordinator at the Gimbel Eye Centre, had the privilege of insider knowledge on the procedure. He had pored over reports from the initial surgeries in Germany and his close association with the doctors — van Westenbrugge and clinic founder and renowned cataract surgeon Howard Gimbel — had given him the confidence to sport the title of No. 1
“I was really excited: the technology just made sense to me,” recalls Carreau, who now lives in Portland, Me.
“The results were really impressive. It wasn’t so much of, ‘Wow, I get the chance to be the first.’ It was more like I knew it was coming and it had all the appeal to me as it would anybody else who wears corrective lenses.”
Carreau, who began wearing glasses for nearsightedness when he was 16, says, “I wasn’t going to miss the opportunity to either reduce or eliminate my dependence on corrective lenses, which thankfully turned out to be the latter.”
Recovery included minimal discomfort, he says — so much so that he doesn’t really remember experiencing any post-operative effects.
When we first started laser eye surgery, we had to rustle up a patient here or there, or maybe a staff member that had it done. Now, when you speak up at a cocktail party and say youare interested in getting laser eye surgery, half a dozen people pipe up and say they had it done.
DR. JOHN VAN WESTENBRUGGE
What he does recall, though, is opening his eyes and being able to focus on something a few inches away — without glasses — for the first time. It was a lifechanging moment that, now, rarely crosses the former Calgarian’s mind.
“It certainly feels natural, at this point, to not be dependent on corrective lenses. And that is probably the highest compliment I can give for having undergone the procedure,” says Carreau, who had a routine eye exam in March and still has 20-20 uncorrected vision, compared with his 20-200 pre-surgery prescription. “You couldn’t ask for a better result.”
For Carreau, having 20-20 vision meant waking up and seeing the numbers on the alarm clock, being able to see underwater when swimming and not having to fiddle with contact lenses when playing sports.
“When laser-eye surgery first came along, people looked at it as if you were doing something (that was) a little bit of the fluff of medicine — it was a cosmetic thing so you didn’t have to look goofy wearing glasses,” van Westenbrugge says. “People who don’t have a high degree of nearsightedness just have no appreciation” of how this surgery can really change a life.
He points to the example of a young mother wanting laser eye surgery, who gave him a whole new perspective on the importance of the procedure.
The woman told van Westenbrugge she had a phobia of being in a hotel room with her children, hearing a fire alarm sound and being unable to find her glasses to see the way to safety.
“That was an education to me, actually, that, no, I am not doing something that is simply cosmetic.”
The Gimbel Eye Centre was part of a small group of approximately 10 centres worldwide that became the second set of centres to perform laser eye surgery. Each of the primary three centres, in New Orleans, Boston and Berlin, had only done a few hundred cases before van Westenbrugge’s operation on Carreau.
By December 1990, 45 refractive laser eye surgeries using the $445,000-excimer laser had been completed at Gimbel.
While 60 such lasers were already in use in 11 countries around the globe, each Gimbel Eye Centre patient was prescreened to ensure the optimal outcome and was given full disclosure on the technology’s pioneering entrance into the Canadian ophthalmology field, Gimbel says.
“Health and Welfare Canada had no specific protocols regarding laser eye surgery because none had been established for Canada,” van Westenbrugge adds. “However, every step and every piece of equipment was cleared through the Health Protection Branch before use and implementation.”
While the initial laser eye surgeries involved the photorefractive keratectomy (PRK) approach, the laser-assisted in situ keratomileusis ( LASIK) technique soon followed, resulting in less patient discomfort and quicker recovery times.
Because LASIK required the cutting of a flap in the cornea, it also led to many post-operative complications — so much so that Gimbel wrote a book called LASIK Complications: Prevention and Management in 1998. Fellow ophthalmologist Dr. Robert Mitchell stopped performing the procedure 10 years ago.
Mitchell, who began performing laser eye surgery in late 1991 after doing some of his early surgeries at the Gimbel Eye Centre, chose instead to use Advanced PRK or Advanced Surface Treatment (AST), a procedure similar to the original PRK with faster healing and less discomfort during recovery, and without having to cut the cornea.
The problem was, LASIK’s quicker recovery made it a very salable procedure, explains van Westenbrugge, which led to an explosion of procedures, especially in the U.S.
“Unfortunately, not a lot of people did their due diligence to ensure they were screening properly,” he says, noting the prerequisite, in some cases, was coughing up $2,000 for each eye, a price tag that fell somewhat in the following years.
Because of this lack of prescreening, many patients were undergoing LASIK after spending 10 to 20 years wearing contacts, which in itself caused the eye to be dry before surgery, van Westenbrugge says.
“So, sometimes, the LASIK would get blamed for eye issues that were largely due, in many cases, to previous contact-lens wear.”
In addition, many feared the laser used in the surgeries could cause cancers, alter DNA or lead to the spread of viruses — all of which proved to be entirely unfounded, van Westenbrugge says.
The problem, however, was that you had to wait 10 or 20 years to make sure these concerns weren’t justified, adds Mitchell, founder of the Mitchell Eye Centre in Calgary.
“These were patients in their 20s and nobody knew for sure what would happen in the long haul,” Mitchell says. “And, fortunately, it turned out there really were no long-term serious consequences and the general public loved it.”
At the time, he says ophthalmologists pioneering laser eye surgery were like explorers.
“It was interesting, dynamic and it was constantly changing.”
Surgeons were routinely attending conferences, brainstorming ideas and retooling procedures for the best outcomes for the patients.
“Gradually, the pace of change slowed down … and the new, radical things became less and less frequent to the point where in the last 10 years, we really haven’t changed a thing.”
While the fundamental components of the lasers haven’t changed, high- tech features have evolved, such as eye-tracking, which adjusts or pauses the laser if the eye moves during the procedure.
The effect of laser eye surgery lasts a lifetime, but just as people may need stronger glasses because their eye is changing — that’s the length of the eye changing, not the cornea—theymay have to come back for more surgery later on because their eye has gotten longer, not because they have lost the effect of what was done.
DR. HOWARD GIMBEL Some people are the early adopters and some people wait and see. At the time we were getting into refractive surgery, and it was exciting, yes, for what we could accomplish, but we didn’t feel alone because we had colleagues all over the world who were doing thesameprocedure.We didn’t take any credit for any development of the procedure; we just felt privileged to be early adopters and we felt good about being able to offer it to our community.
DR. HOWARD GIMBEL