INTRODUCTIONA full third of the population needs glasses and contact lenses in order to see things in focus. This is caused by
common conditions called myopia, hyperopia and astigmatism. The 20th century was the century of many
inventions in medicine – this includes the invention of laser refractive surgery, which allowed millions of individuals
to get rid of visual aids or at least decrease their use greatly.
Since 2001, the ophthalmologists of Sjonlag Eye Center have been performing laser refractive surgery in Iceland.
Information contained in this booklet describes the preoperative examination needed in order to establish whether
an individual is a candidate for laser refractive surgery. It also describes the operation itself, the possible
complications and what can be expected following the procedure.
Johannes Kari Kristinsson
Ólafur Már Björnsson
Maria Aldis Kristinsdóttir
Maria Boel Gylfadottir
Corneal diseases and laser
Medical retina and laser
THIS BOOKLET ALONE DOES NOT
REPLACE A VISIT WITH OUR DOCTORS.
Our aim is that this booklet in addition to meeting our
ophthalmologists gives you a foundation for making a well-
informed decision on whether this operation is the right choice
four you. We encourage you to ask all the questions you may
have before the operation by asking the ophthalmologist or
MYOPIA, HYPEROPIA AND ASTIGMATISM – WHAT DO ES IT MEAN?The cornea is a transparent dome in front of the eye and creates a part of the front "wall" of the eye. One of
the it's roles is to help focus the light on the retina in the back of the eye. We want the things we see to be in
sharp focus. In myopia (nearsightedness), hyperopia (farsightedness) and astigmatism the world appears out of
focus. The aim of laser refractive surgery is to reshape the cornea with laser so that the picture becomes perfectly
A NORMAL EYEHere we see a normal eye, a ray of light falls on the eye and the focal point falls
exactly on the retina at the back of the eye. The picture will be in focus.
MYOPIAThe myopic eye is shaped like an egg instead of a table tennis ball, and because
of this the focal point ends in front of the retina. The eye is simply too long.
The picture will be out of focus. Nearsighted people can only see things that are
very close too them.
HYPEROPIA In contrast, the hyperopic eye is way too short and the focal point ends
(hypothetically) behind the eye. As a result, the picture will be out of focus, both
at far and even more so at near.
ASTIGMATISMIn astigmatism, the cornea becomes skewed, looking like an american football
instead of a european one. A ray of light falls unevenly on the retina (different
focal points) and the picture is out of focus.
TREATMENT FOR REFRACTIVE DISORDERS, MYOPIA, HYPEROPIA
AND ASTIGMATISMGlasses are the most common device used to treat refractive disorders. A so-called concave lenses are used to
treat myopia. The power of these lenses is measured in diopters, in this case with a minus in front of the
number(for example, -4.0 diopters, or D). The higher the number is, the farther back the focal point ends in the
long eyes of myopic patients. In case of hyperopia, a so-called convex lens is used to bring the focal point up
front in order for it to land on the retina in the short eyes of hyperopic patients. Astigmatic lenses correct
astigmatism, however, it is often difficult to treat high astigmatism with glasses, as the
lenses need to be quite complex in shape in order to bring the object into clear focus
– regardless of where the person is looking.
way of correcting refractive disorders. Many people feel that glasses are a nuisance
and difficult in certain circumstances and activities. Of course, glasses are nothing
but visual crutches and do not bring cure to those with refractive disorders.
Contact lenses treat myopia, hyperopia and some types of astigmatism. They
are placed on the cornea in front of the eye and are seperated from it only
by a thin layer of tear fluid. If they are used in the right manner, they can
be a good alternative for treating refractive errors. Certain problems can occur
with their use, such as allergic reactions, infections and changes in the shape
of the cornea. Contact lenses have in rare cases been associated with visual
impairment and blindness due to corneal ulcers.
LASER REFRACTIVE SURGERYSeveral types of laser refractive surgery are available today. LASIK (Laser-Assisted in Situ Keratomilieusis) is by
far the most common one. In several cases we use different types of treatment, such as PRK, PTK and LASEK.
Usually we treat patients with a "simple" LASIK treatment, as most corneas have a normal dome shape which
lends itself perfectly to this type of treatment. In several cases, however, we choose to use the recently developed
custom treatment (also called fourth or sixth generation treatment) , which is especially developed to treat irregular
corneas, especially so-called irregular astigmatism. We only use the latest technology, including scanning laser
technology, tracking system using the iris as a landmark, rotational tracking system as well as the custom laser
treatment working with the latest NAVEX technology, now both for myopia and since December 2008, hyperopia.
EYE EXAMINATION BEFORE LASER REFRACTIVE SURGERY
Medical history assessed with a detailed history of health and use of prescription medications.
Refraction needs to have been stable for 1-2 years. Also, each patient is asked about eye infections and previous eye trauma.
Visual acuity is measured thoroughly several times, both with glasses as well as best corrective lenses.
Intraocular pressure, pupil size, and corneal thickness are measured
The surface of the cornea is mapped in detail using a special device – this is called corneal topography.
The eyes are examined in great detail with a slit lamp.
Retina and optic nerve including the retinal periphery are examined thoroughly after dilating the pupils with dilating drops.
THINGS TO REMEMBERFollowing the eye examination it is difficult to read for 2-3 hours. Most people can drive home following the
examination, however, it is possible that your vision will not allow driving. After the thorough eye examination,
you will find out whether you are a possible candidate for laser refractive surgery. We emphasize that you
understand completely that the operation is strictly for individuals who want to be less dependent upon glasses
and contact lenses. Although most patients do not have to use glasses for far vision after surgery, the possibility
still exists. We also emphasize that you only undergo surgery if you are fully aware of the risks involved. The
lower age limit of the surgery is eighteen years. A full stability of refraction needs to have been achieved for 1-
For patients living out of the country, trip expenses for additional treatments, if needed, are not included in the
price of the operation. However, the reoperation itself is free of charge. Also, examinations in other countries,
will have to be covered by the patient himself, as well as making sure to get adequate follow-up at 2 weeks, 3
months and 6 months following surgery. The patient would, of course, be welcome to have the postoperative
examinations performed at our eye center free of charge.
1. LASIK is not intended for those who have severe ocular
2. Pregnant women should not undergo
inflammation, infections, severely dry eyes, corneal scarring,
surgery until after childbirth and
corneal dystrophies, autoimmune diseases, certain types of
breastfeeding mothers should wait until
arthritis and severe diabetes. In addition, individuals using
6 months of breastfeeding.
Roaccutane and Cordarone should not undergo laser
The LASIK procedureRefractive procedures such as LASIK are aimed at changing the curvature or shape of the cornea.
This is a description of a typical LASIK procedure:
Make sure that … :
You don't wear soft contact lenses for at least 1 week before surgeryYou don't wear hard contact lenses for at least 2 weeks before surgeryYou wear warm cloting, as the temperature in the OR is not very highYou don't wear eye make-up, perfume or after shave the morning of operationYou tell us what your preference is regarding taking Valium (diazepam) before surgery. You don't have to
take the medication and you can also requestion additional medication if needed.
You don't drive until the doctor has allowed it (usually the day after surgery)
Anesthetic (numbing) drops are given at the beginning of the procedure. You should feel very little or no pain
during the operation. Only one eye is treated at one time. We place a speculum to keep the eye open during the
operation. You will be asked to look at a small red guiding light to keep your eye steadier. The head of the
treatment laser will follow your eye with great precision so you don't need to worry about the laser going anywhere
else than it's supposed to go. First, a so-called microkeratome is used to make an extremely thin flap (0.12 mm)
on your eye. We then perform the laser treatment on the bed underneath the flap and then place the flap back
in it's place. This is usually over and done with within a minute. During the laser treatment, you will smell a slight
burning smell, which is normal. We then wait for the flap to become adherent to the underlying surface, which
will only take 1-2 minutes, then remove the speculum – the operation is over!
What can you expect after the
operation?Your vision is expected to improve greatly after the
operation without the help of glasses and contact lenses.
In a few cases (usually less than 2%), people need
glasses after surgery to be able to see at great distances,
usually however, the glasses are much weaker than the
glasses used before. However, if you are more than 45
years of age, you should expect having to use reading
glasses just like your peers – even though you were
treated with partial monovision abilities. Most people
find it more valuable to be free from glasses during
sports and outside activities. This of course is different
between individuals. Each and everyone must decide
whether the operation is likely to bring you whatever
you want from laser refractive surgery.
Your expectations are a vital part of the preoperative
exam - don't hesitate to ask all questions necessary for
you to make the decision.
This is your decision and yours alone.
FOLLOWING THE OPERATIONLittle or no discomfort is expected after LASIK surgery. A little itching and burning is allowed as well as a small
degree of foreign body sensation, not unlike wearing old contact lenses. If the degree of discomfort is higher,
you need to call our emergency number. Anti-inflammatory and antibiotic medications are used following the
procedure, as described in a separate booklet following the operation. Certain types of activity are not allowed
following the procedure and you have to sleep with a certain kind of goggles provided by us for four nights
afterwards. The eye examinations after the surgery take place the day after surgery, two weeks, three months
and six months later. These are very important and should be performed whether you are here in Iceland or
elsewhere. Let us know immediately if anything comes up, either by calling our emergency number or by sending
an e-mail. We like to emphasize that although most people show extremely fast recovery following the operation and can
read the text on TV that night, for some people it may take longer to experience final results. Hyperopic patients take usually longer to recover than myopic patients and sometimes experience more pronounced
visual fluctuations (vaseline vision) than myopic patients.
PRESBYOPIAIn our forties the presbyopia sets in – nobody is immune to it! Presbyopia is age-related because the lens inside
the eye gets harder with age and the autofocusing ability of the eye consequently decreases. This leads to the
need for reading glasses (readers) when focusing at near. Laser refractive surgery does not treat or prevent
presbyopia. People will still need reading glasses following surgery. To decrease the need for reading glasses,
we sometimes make the non-dominant eye (the eye you use less, for example the eye you close when you squint
in bright sunlight) a little nearsighted. This is called monovision, which involves using the dominant eye at far,
but preferring the non-dominant eye for reading or work up-close. This is a compromise, but, again, not a cure
for presbyopia. Although most people will be able to use the non-dominant eye for reading larger letters, such
as menus and letters on grocery products, everyone will sooner or later need to use reading glasses for fine print.
POSSIBLE COMPLICATIONSNo operation is without risks. This is similar to climbing a mountain. Your reward is to get to the top of the
mountain, however, there are certain risks involved in getting to the top. The risk is very small, however, it is
there and it cannot be predicted which individual will have which complications. None-the-less, the procedure
is one of the safest eye operations known. Each individual must evaluate for him- or herself the pros and cons
of laser refractive surgery and compare them to the pros and cons of the other alternatives for people with
refractive errors, glasses and contact lenses. These latter alternatives are not risk-free, such as vision-threatening
infections caused by contact lenses and ocular lacerations caused by broken glasses. No alternative is completely
DRY EYESAll eyes become dry following laser refractive surgery. You need to use artificial tears for at least four weeks
following the procedure and often longer. After six months, the tear production of the eye has usually reached
its preoperative stage.
INFLAMMATIONInflammatory reactions are normal after all surgical procedures. In some cases (1-5%) the inflammation needs
to be treated with additional anti-inflammatory eye drops. This could affect visual acuity and in very rare cases
the flap needs to be lifted and treated with anti-inflammatory eye drops. Almost all cases of inflammation are
seen on the first day after surgery.
EPITHELIAL INGROWTHFollowing LASIK the flap adheres to the underlying surface without the need of suturing. In a matter of few
hours, the epithelium (outermost layer of the cornea) grows over the edges and closes the surgical wound. In
rare cases (1-2%) the epithelial cells can grow under the flap and in very rarely continue to grow if measures
are not taken. Very rarely, the flap needs to be lifted and the epithelial cells removed. This is usually very effective
and the flap adheres very well to it's underlying surface without any further ingrowth.
INFECTIONThis is exceedingly rare, with a rate of 1/5 000 surgeries. This has not been described in this country as far as
we know. In case of an infection, it can be treated with antibiotic drops.
REMAINING REFRACTIVE ERRORIn most cases the patient becomes less dependent upon glasses and contact lenses following the procedure.
However, in some cases, a certain degree of hyperopia, myopia and astigmatism will remain. In approximately
5% of cases, the procedure requires a second step in order to fine-tune the result. Further treatments may be
needed, although this is very rare. As with many of the complications, this is more common in individuals with
a high degree of refractive error.
IRREGULAR CORNEAL/SURGICAL BED SURFACEIn almost all cases following the procedure, the surgical bed underneath the flap and the corneal surface are very
even and regular. In very rare cases, irregularities of these surfaces may occur for reasons known (among those
sudden movements during the procedure, epithelial sloughing, hidden corneal scars or foreign bodies) or unknown.
These irregularities can cause decrease in visual acuity of 1-2 lines and occasionally double vision as well as haloes
around lights and light streaks from light sources. The incidence of these complications has decreased very much
in the last few years with increased technology. Irregular astigmatism can usually be treated effectively with
custom laser treatment using fourth generation laser technology. This increases greatly the safety level for our
patients, but fortunately it rarely needs to be used.
LIGHT SENSITIVY AND GLARESlight glare following laser refractive surgery is common and should be expected in the first weeks. This has been
called "vaseline vision". This is usually caused by slight edema (fluid collection) and fluid imbalances in the flap,
which almost always decreases and disappears. In rare cases, these symptoms can last for few months following
HALOESSimilarly, haloes can be noted around light sources, especially after dark. This is more noticeable when the pupil
size increases and can occur if the treatment area is smaller than the area treated on the cornea. In most cases,
however, this is due to slight edema in the flap, which usually disappears with time. It's very uncommon for these
symptoms to interfere with daily life. If they appear and persist, it is more common in those with large pupils
and/or a large amount of preoperative refractive error.
DECENTRATION OF TREATMENT AREAIn rare cases, the treatment area may be slightly displaced from the corneal center or, more accurately, the visual
axis of the cornea. This is rarely due to eye movements of the patient, as our laser has very accurate tracking
device following the eye movements (200Hz). However, in extremely rare cases, the treatment area may be
decentrated, resulting in symptoms such as haloes, double vision and experiencing streaks eminating from light
sources. In most cases, custom laser treatment can be used to treat the area.
OTHER COMPLICATIONSAs with all surgical procedures, there may be other complications following this surgery than those who are
already mentioned, causing various symptoms not mentioned here. The most serious visual complication following
an eye operation is blindness and the loss of an eye. Over 20 million laser refractive procedures have now been
performed in the world. Blindness and loss of an eye have not been reported. In contrast, many reports of
blindness and loss of an eye due to the use of contact lenses and glasses have been described. It would be
interesting to learn the answer to the question: "How many people have died due to foggy glasses?"
Emergency numbers (GSM): 898 3288 (Dr. Kristinsson) 895 4441 (Dr. Bjornsson)
If these phone numbers cannot be reached, the hotline for the Eye Department at the University Hospital (Landspitali) is: 543 1000
S J Ó N L A GSjonlag Eye Center is a leading refractive surgery center in Iceland. Established in
2001, thousands of procedures have been successfully performed by skilled surgeons
educated at the finest ophthalmology institutions in the US, Norway and Sweden.
Our primary values include caring for our patient, quality of our education, service
and competence, showing empathy and respect for every individual and to aim
towards technical excellence in our work.
Sjonlag Eye Center offers you
the opportunity to safely
become less dependent on
5. floor104 Reykjavik
the visual aids of glasses and
IcelandTel. +354 577 1001
Fax + 354 577 [email protected]
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