A Patient s Guide to Understanding Your Life. In Focus.

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1 LASIK A Patient s Guide to Understanding Your Life. In Focus. KEC Quality Assurance Continuous quality assurance and improvement is a way of life at KEC. Our high-level safety standards have been developed for all aspects of care and service. Dr. Herz is affiliated with TLC Laser Vision Centers, whose doctors are part of a team of nationally and internationally recognized leaders in the development of refractive surgery. NATASHA HERZ, MD Take Control of Your Lifestyle Before having LASIK, most of our patients could not imagine waking up in the morning and seeing the alarm clock without glasses. They never dreamed they would be able to drive a car, watch a movie or enjoy sports such as swimming and skiing without contact lenses. The dependence on glasses and contacts has shaped their lives, memories and the way they feel about themselves. Now, these same patients are pursuing life with new confidence, enthusiasm and ease thanks to improved eyesight through LASIK. This remarkable procedure takes only a few minutes to perform, but can have a tremendous impact for the rest of your life. Are You a Candidate? In most cases, LASIK can treat the most severe degrees of nearsightedness, farsightedness and astigmatism. However, candidates must have realistic expectations about their results because LASIK is not right for everyone. That s why Dr. Herz is very careful when determining if you are a candidate. To be a potential candidate for LASIK you must be at least 18 years old, in good general health, and have no eye diseases such as cataracts or glaucoma. Only an in-depth examination of your eyes, your individual case, your expectations and your lifestyle by an experienced, board certified ophthalmologist can determine if you are a candidate. All TLC affiliates meet rigorous guidelines, participate in continuing education and complete required certification and training. TLC equipment, facilities and surgery suites are continuously monitored and maintained for optimum patient safety. With our high safety standards, detailed data tracking and accomplished clinical teams, Dr. Herz is able to provide patients a high quality experience with the best possible surgical outcomes. (See for her biography.) When It Comes to LASIK, Not Just Any Doctor Will Do All three phases of your laser vision correction process are incredibly important to ensuring your desired out come, and Dr. Herz is involved at every step including: 1. Pre-procedure consultation 2. The laser procedure 3. Post-procedure care Throughout these stages, Dr. Herz will be the only physician to take care of you. Not only does she perform your surgery, but Dr. Herz will also provide your pre- and post-operative care. Thus as your surgeon and cornea specialist, she can expertly monitor your healing process every step of the way.

2 Your TLC Affiliated Surgeon - Natasha L. Herz, MD There is much to consider when trusting your eyes to a surgeon. Some laser vision correction providers may try several approaches to attract your business. Be wary of steep discounts on LASIK or surgeons who merely tout their total number of procedures performed. Often times these providers do not offer the latest technology such as Custom and Bladeless LASIK that are critical to ensuring you receive the very best surgical outcome. The skill of TLC s affiliated surgeons and expert support team give you a critical advantage in achieving the best outcome. All doctors affiliated with TLC have been educated in all aspects of laser vision correction. TLC affiliated surgeons must pass the governmentmandated course for each particular laser they use. TLC offers affiliated doctors quarterly training programs on the latest advancements in treatment and technology to better ensure the best outcome for all our patients. The Latest Technology Dr. Herz operates at TLC Laser Eye centers because she believes in offering only the very best in surgical safety and technology. At TLC, she has access to the latest laser technologies including eye trackers and scanning lasers. All TLC Laser Eye Centers in the United States and Canada use only FDA or government approved lasers. The best technology for you is determined during the personal consultation and is dependent on things such as prescription, thickness of your cornea and pupil size. Common Vision Problems Certain vision problems, such as nearsightedness, farsightedness, astigmatism and presbyopia are considered refractive because they relate to your eye s ability to properly bend, or refract, light rays entering the eye. The proper refraction of light onto the retina creates normal eyesight. Refractive visual problems are measured in units called diopters - they represent the level of correction needed in lenses to normalize vision. The more nearsighted or farsighted you are, the higher your prescription in diopters. Myopia More than 70 million people in North America (about one in four) are nearsighted. Myopia is the medical term for nearsightedness. It occurs when your eye is too long in relation to the curvature of your cornea. Myopia causes light rays entering the eye to focus in front of the retina, producing a blurred image. The term nearsighted means that you can see objects that are near to you more clearly than distant objects. The more myopic you are, the more blurred distant objects appear, the higher your prescription in diopters and the thicker your glasses. Hyperopia Hyperopia is the medical term for farsightedness. Hyperopia occurs when your eye is too short in relation to the curvature of your cornea. Light rays entering your eye focus behind the retina, producing a blurred image. Some farsighted people can use their focusing muscles to pull the image forward onto the retina, allowing them to see clearly. But others, who cannot overcome the effects of severe hyperopia, need glasses for distance vision as well as reading glasses or bifocals. Astigmatism Many patients with myopia and hyperopia have some degrees of astigmatism, or an oval shape, to their cornea. It occurs when your cornea is shaped more like a football than a baseball. As a result, you experience distortion or smearing of images due to the unequal bending of light rays entering your eyes. People with high degrees of astigmatism have blurred vision for both near and distant objects. Presbyopia Presbyopia is part of the normal process of aging. It develops as the lens of the eye loses some of the flexibility that characterizes a younger eye. Everyone experiences the effects of presbyopia, typically between the ages of 40 and 50. Nearsighted people who become presbyopic may require bifocals in their forties, and those who never needed glasses before may require reading glasses. Mild myopia counteracts presbyopia. That is why if you re slightly myopic with presbyopia, when you remove your glasses you may still be able to read. Laser vision correction may treat your myopia, but you may need reading glasses for fine print to correct your presbyopia. Some presbyopia patients opt for monovision. The Near and Far of Monovision The need for reading glasses as you get older is called presbyopia. When you have LASIK, you and your doctor may decide to leave one eye slightly nearsighted. This is called monovision, and may allow you to maintain your ability to read after presbyopia begins. Your other eye will be fully treated for distance vision. Gaining this near vision means giving up some distance sharpness. (Many people have already elected monovision correction with their contacts or glasses.) Monovision is helpful for near tasks such as scanning a menu or article, but not for reading fine print or reading for a prolonged time. For active individuals, such as those who play golf or tennis, or who drive a great deal at night, monovision may not be suitable. During your consultation, you and Dr. Herz will decide which choice is best for you.

3 The LASIK Consultation Our complimentary LASIK Consultation is one of the most comprehensive in the industry. At the consultation, Dr. Herz will confirm whether you are a candidate by performing several tests in our office as well as at the TLC center. They will explain the procedure and answer all of your questions to enable you to make an informed decision if LASIK is right for you. Even if you re not a candidate now, you may become one in the future as new technology emerges. What s included in your consultation: Lensometry: The measurement of your glasses to determine the current prescription reading. Manifest Refraction: Your doctor determines your most accurate baseline prescription. *Topography: This test measures the surface of your cornea, including your corneal curvature, steepness, flatness and if you have any astigmatism. *Wavefront: The wavefront maps how light passes in and out of your eye, giving your doctor a better understanding of any imperfections, deep inside your eye. Visual Acuity Testing: These tests measure the eye s ability to see details at near and far distances. The tests usually involve reading letters or looking at symbols of different sizes on any eye chart. An UCVA or Un-Corrected Visual Acuity test will be performed to test your vision without contacts or glasses. A BCVA or Best Corrected Visual Acuity test will be performed to see how you see with your most accurate baseline prescription. Pachymetry: A pachymeter test utilizes an ultrasound device to determine the thickness of the cornea in any given location. The thickness of your cornea is very important when determining whether you are a LASIK candidate. Tonometry: This is an eye test used to help diagnose glaucoma by measuring the pressure in your eyes. Slit-lamp Exam: This test uses a microscope and a small beam of light to closely examine your corneas as well as the iris and lens. *Pupillometry: This test takes a measurement of the size of your pupils in the dark, using infrared technology. Eye Dominance: This test measures which of your eyes is the dominant, or stronger, eye. Retinal Exam: During this eye test, the eye doctor places special drops in the eye that cause the pupil to dilate, or expand. By dilating the pupils, your doctor can examine your retina for certain signs of disease. *These tests will be performed at the Rockville TLC center and are not a substitute for your regular eye exam, which should be performed annually. Understanding the Technology What is Bladeless LASIK? In the first step of the LASIK procedure, a flap of corneal tissue is created and then gently folded back. By creating a flap, the surgeon is able to perform the laser vision correction treatment on the inner layer of the cornea, allowing for rapid visual recovery. This flap can be created using a microkeratome, a mechanical device that utilizes a blade. In Bladeless LASIK, the surgeon uses a computer-controlled laser (the Intralase) to create the corneal flap. Bladeless LASIK offers advantages over a microkeratome becase it: enables customization of the flap so that it will fit more securely after the procedure accounts for the natural curvature of the cornea, creating a flap of uniform thickness allows patients with thin corneas to become LASIK candidates. The Intralase FS Laser uses an infrared beam of light to create the flap below the surface of the cornea using an inside-out process, virtually eliminating severe sight-threatening, blade-related complications as a result. The beam of light is focused to a precise point within the stroma (central layer of the cornea), where a string of microscopic bubbles is formed. Thousands of these tiny bubbles are precisely positioned to define the flap s dimensions and distinct beveled edge, as well as location of the hinge. Bubbles are then stacked along the edge of the flap up to the corneal surface to complete the flap. The Latest in Vision Correction: CustomLASIK While conventional LASIK was a complete revolution in vision correction, Dr. Herz now offers the latest in laser vision correction technology: CustomLASIK. CustomLASIK is a procedure that enables your surgeon to further customize the conventional LASIK procedure to your individual eyes. This customized procedure may result in patients seeing clearer and sharper than ever before and has greatly reduced halos and night vision aberrations. FDA studies show that CustomLASIK may produce better vision than is possible with contact lenses or glasses.

4 In clinical studies, CustomLASIK has been able to provide patients with: o o o A greater chance of having 20/20 vision The potential for better vision than is possible with contacts or glasses Less incidence of glare and halos Once you are prepared for your procedure, you will be escorted to the laser suite for treatment. You will enter the laser suite and lie on your back in a reclining chair. The laser is a large machine with a microscope and a computer screen attached to it. Your surgeon uses information from your extensive testing to set a surgical plan that is then programmed into the laser. The computer calculates the required corneal treatment and directs the laser. Dr. Herz programs and operates the laser during your procedure. The success of your laser procedure depends on several factors including the expertise of your doctor and staff and the sophistication of the equipment. At Kensington Eye Center, our primary objective is to provide you with the best results, the greatest degree of safety and the most advanced technology. The LASIK Procedure Several types of visual imperfections, referred to as lower- and higher-order aberrations, exist within the eye and may affect your vision (the amount of these aberrations vary from person to person). Previously, only lower-order aberrations (such as nearsightedness, farsightedness and astigmatism) could be measured and treated. Higher-order aberrations can have a significant impact on vision and have been linked to glare and halos. Now CustomLASIK may help to further customize your treatment of these higher-order aberrations that, in the past, could not be adequately treated with glasses, contacts or conventional LASIK treatments. Dr. Herz will recommend the best procedure for you based on your personal aberrations. Wavefront Technology CustomLASIK uses a wavefront analyzer to measure the way light travels through your eye. The wavefront analyzer creates a customized 3-D map of your eye that looks at your entire optical system. This map provides information about the unique visual characteristics of your eye which adds an additional level of data about your vision, enabling Dr. Herz to further customize your vision correction. 1. Anesthetic drops are applied to the eye, and a lid speculum is used to hold your eyelids open. 2. A protective flap is created and gently lifted by the surgeon, revealing the inner corneal tissue. Because the corneal flap preserves the surface layer (epithelium) of the cornea, discomfort following LASIK procedures is minimized. 3. Computer-controlled pulses of cool laser light are applied to the inner layers of your cornea. As the laser pulses, it makes a ticking sound. The inner corneal layer is reshaped with the laser to mimic your contact lenses or glasses prescription. 4. The surgeon gently replaces the flap and aligns it to its original position. 5. The flap heals naturally and securely. Watch an actual LASIK procedure on-line at After Your Surgery The Procedure Made Simple LASIK is an outpatient refractive procedure that usually takes about 10 minutes per eye to perform. Immediately prior to your procedure, your eyelids and lashes will be cleaned, and antibiotic, anti-inflammatory and anesthetic drops will be placed in your eyes. A mild sedative may be given. Expectations There are two phases to your procedure: the surgical and the healing phase. Both are equally important to your outcome. The speed of visual recovery, the quality and sharpness of your vision and your final outcome will be determined by many variables, including your healing pattern, pre-operative prescription, ocular findings and corneal shape.

5 While only a very small number of patients experience a complication, all patients have certain expectations. Before proceeding with LASIK, it is important that your expectations are realistic. The most common expectation is to become completely free of glasses and contact lenses. Most patients who undergo laser vision correction significantly reduce their dependence on glasses and contacts. However, as we age, most patients will eventually require reading glasses and some may even require a thin pair of glasses for critical distance activities such as night driving. It is best for you to think of laser vision correction as a procedure that reduces your dependence on glasses or contacts. Risks and Potential Complications LASIK is a surgical procedure, and like all surgeries, there is a potential for risks and complications. In our experience and in recent published studies, most patients achieve excellent results without complications. Also, a recent study suggests that LASIK may be safer than contact lens wear (Archives of Ophthalmology, Oct 2006). The risk of serious complications such as infection and permanent scarring with loss of vision are much higher over 30 years of continued contact lens wear than they are with laser vision correction. Those that would be at risk for continued thinning and bulging forward of the cornea ( ectasia ) after the surgery are carefully identified and removed from potential candidates during the screening process. Most patients want to know the most likely problems that may occur. The first two visits following your surgery are key in identifying and successfully treating potential problems. These include a non-infectious immune response, called DLK or diffuse lamellar keratitis, that usually is treated with steroid drops or pills and rarely requires irrigating under the flap. Trauma causing displacement of the flap in the form of wrinkles or complete dislocation is also a concern and would involve lifting the flap and repositioning it. These issues would be identified and treated during the first 2 visits. The most common potential problem is halos for the first 4-6 weeks after surgery due to swelling and healing of the flap. It is most noticeable at night, but improves with time until the flap is healed. The second most common issue is dryness. Because the corneal nerves are cut during the procedure, the feedback mechanism for keeping the cornea moist takes about 3 months to return to normal. The ten percent of patients that notice this dryness are usually treated with moisturizing drops during this time. Less common problems include epithelial (skin-like) cells on the surface of the eye that can grow underneath the flap and cause distortions. If these distortions are significant enough, the problem is resolved by lifting the flap, brushing away the cells, and replacing the flap. At Kensington Eye Center, risks of the surgery are discussed with the patient prior to the procedure. Proper pre-operative screening and testing ensures that you are considered a candidate only when it is medically advisable. Diligent post-operative care also helps to identify and address potential healing complications. Your LASIK Results While laser vision correction is overwhelmingly successful in reducing dependence on glasses and contact lenses, the degree of improvement may vary from individual to individual. How well and how quickly your vision improves depends on how well you heal and the severity of your prescription. Although no one can promise patients perfect or 20/20 vision, most laser patients with mild to moderate prescriptions do achieve 20/20 vision or are within 1 to 2 lines of 20/20 vision on an eye chart. This means they no longer need glasses or contacts to drive, play sports, watch movies and TV or participate in certain careers requiring excellent vision, such as jobs with police or fire departments. During your pre-procedure consultation, Dr. Herz will help determine the range of your probable outcome based on your particular prescription, healing profile and expectations. Enhancements The more severe your initial prescription, the more correction you will need, the more healing you will require and the greater the chance you will not be fully corrected in just one procedure. Some patients experience an over- or under-response, leaving them with a residual refractive error. Enhancement procedures are performed once the patient s vision has stabilized, which usually takes at least 3 months for LASIK and longer for PRK. The importance of Follow-up Follow-up care and eye medications are just as important to your results as your actual procedure. Periodic examinations are required to ensure that your eye is healing as expected, to verify that there is no evidence of infection, and to measure your visual progress. Each appointment takes between 5 to 15 minutes. Patients must also use prescribed antibiotic and antiinflammatory eye drops during recovery. LASIK patients use eye drops for four to seven days. Annual eye exams are important and we strongly recommend that everyone, not just laser vision correction patients, have a dilated eye exam performed by their eye doctor every year. This is a proactive way to ensure that your eye is healthy and functioning properly. Follow-up Appointment Schedules After LASIK 1 day 1 week 1 month 3 months 6 months 1 year Long-Term Success People often ask how long the benefits of their procedure will last. Laser vision correction has been performed since the late 1980 s. The first nearsighted patient ever treated in the United

6 States with laser vision correction underwent a PRK procedure. That patient achieved 20/20 vision following treatment and was still 20/20 more than 15 years later. In a recent long-term survey of people who had LASIK surgery ninety-five percent reported satisfaction or high satisfaction with the results of their LASIK surgery. Ninety-one percent of patients said the procedure greatly improved or improved their quality of life and would recommend the procedure to others. The patients who responded to the survey were part of the first physiciansponsored FDA clinical trial of the procedure, held in Atlanta, beginning in Today, most experts are confident that they will discover no longterm problems with laser vision correction. Making LASIK Affordable The cost of your LASIK surgery includes a complimentary screening, a pre-operative dilated exam, the surgery, all the postoperative exams through 1 year, and an enhancement if it is needed within 1 year. This fee will be determined by TLC Laser Vision Center at the time of your screening. They will collect one fee to be paid the day of your surgery which will cover all the expenses listed above, including those for the laser surgery center and your doctor. TLC Laser Eye Centers strives to make LASIK affordable for every patient. With a variety of ways to pay, there should be nothing standing between you and improved quality of life through LASIK. Insurance Financing TLC Laser Eye Centers offer several payment plans to help make laser vision correction affordable for almost everyone. Credit lines with flexible terms may be available to cover the cost of the procedure. This easy finance plan allows you to customize your loan by selecting the amount you need and your repayment terms. When you apply for financing, you usually have a decision in a matter of minutes. Credit Cards Many patients opt to pay for their procedure using a personal credit card. This may be a good option, especially if you have a card that carries a low interest rate, offers points or other rewards. For questions on cost and specific financing options, please contact the Rockville TLC at For other questions or concerns, please contact Kensington Eye Center at or visit our website at Vision benefits vary from one health insurance plan to the next. Some plans may have an arrangement with TLC Laser Eye Centers that could substantially reduce your cost for laser vision correction. A TLC representative will be happy to work with you personally to determine how your plan may help you save. You will get this discount regardless of whether or not Dr. Herz is on your vision plan or health care plan as this is a discount from the TLC Laser Eye Center. Pre-Tax Dollars Many employers or insurance providers offer Flexible Spending Accounts, Health Spending Accounts, or Health Reimbursement Arrangements to help offset medical expenses. The accounts may allow you to set aside pre-tax dollars for procedures like LASIK. Ask your employer or insurance provider about deducting pre-tax dollars from your paycheck for potential savings on your laser vision correction procedure. Tax Benefits While LASIK can be deemed an elective surgical procedure and not covered under some plans, it may nevertheless be tax deductible depending on your filing status. Please consult your accountant. Many patients choose to use their tax refund to pay for LASIK, an investment that can last a lifetime. Kensington Eye Center Randolph Medical Center 4701 Randolph Road, Ste G-2 Rockville, MD

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