VANCOUVER, B.C. - More than 20 times a day, patients walk into Dr. Hugo Sutton's downtown eye-surgery clinic, lie underneath a laser and submit to the "flap and zap."
"There goes the flap," Sutton says from behind a window as he watches a fellow surgeon use a minute slicing device to cut a patient's eye, peeling back a layer of corneal tissue thinner than a human hair. Then comes the zapping: the laser pelts the eye with a flurry of pulses, each flattening the exposed cornea by a tiny fraction of a millimeter.
The vision-correcting procedure - known as LASIK, or laser in-situ keratomileusis - has catapulted in popularity in recent months, fueled by the praise of patients who say it sharpened their vision, sometimes literally overnight.
On the rise in the Seattle area, where the University of Washington recently opened a refractive surgery center, LASIK also is luring scores of Washington residents across the border to Canada, where the expensive procedure often costs thousands less than what U.S. clinics charge.
The 10-minute procedure, nicknamed the "flap and zap," has uncorked a fast-developing, cutthroat industry that is as much marketing as science - and one full of prickly rivalries between U.S. and Canadian clinics. Refractive surgery centers from both countries woo Puget Sound-area patients with seminars and newspaper ads, with one clinic even offering a $100 discount to Americans if they sign up with a friend.
While testimonials from LASIK patients have been overwhelmingly positive, some ophthalmologists are skeptical of the field's breakneck pace. The market is particularly fertile in British Columbia, where up to 25,000 LASIK procedures are expected to be performed this year.
"The concern we have, if we have one, is it is a medical procedure that's promoted and offered as if it's a shoeshine or a haircut," said Dr. Morris Van Andel of the B.C. College of Physicians and Surgeons, which accredits all of the province's private surgical facilities and fields complaints from dissatisfied patients.
More than 1 million Americans are expected to undergo laser eye surgery this year and next. Most patients are nearsighted.
While many will still need reading glasses after the surgery, patients say laser surgery has liberated them from fumbling for their glasses at night, or worrying about their contacts before they jump into a swimming pool.
Refractive surgery uses a laser to alter the cornea, the clear outer layer of the eye, to better focus incoming light. Unlike PRK (photo-refractive keratectomy), in which a small portion of the cornea's surface is scraped away, LASIK consists of cutting a small flap in the cornea, folding it back, reshaping inner layers of tissue with a laser, then reattaching the flap.
Though LASIK has not been specifically approved by the U.S. Food and Drug Administration, the surgery is allowed in the U.S. because it's performed with the same, ultra-precision "excimer" laser used for PRK, which the FDA approved in 1995. In Canada, both procedures have been in practice since the early 1990s.
Most patients choose LASIK, a newer method with a faster and less painful healing period. Complications, such as a corneal infection or a misplaced flap, are rare in LASIK procedures, with estimates ranging between 1 and 5 percent. But they can be severe - some dissatisfied patients have sued their surgeons, claiming their vision was permanently damaged. Others are on waiting lists for cornea transplants because their corneas were marred during the surgery.
And since the procedure is so new, hitting the mainstream population only within the past few years, the long-term effects aren't fully known.
"This is a procedure that's being modified as we speak," Van Andel said.
Still, studies estimate that 98 percent of LASIK patients' vision has improved to at least 20/40, good enough to drive without corrective lenses.
And stories abound of more phenomenal results. Seattle mystery novelist J.A. "Judy" Jance said her vision was diagnosed to be as poor as 20/900 before she underwent LASIK in September. She's now 20/20.
"It's a miracle to wake up in the middle of the night and look at the clock," said Jance, who still uses reading glasses on occasion but has ditched her other pair.
With clinics on both sides of the border jockeying, prospective patients in the Seattle area face a glut of choices.
Canadian clinics offer cheaper prices and a longer track record of laser surgery, but many require a three-day stay in Canada for the surgery, as well as three one-day standard follow-up visits. And there's always the possibility of more visits, should complications arise.
While Seattle-area clinics charge an average of $2,000 per eye, some Canadian outfits charge less than $1,500 for both eyes. LASIK, considered a cosmetic procedure, isn't covered by most insurance plans.
And, though Canadian laser surgeons tout their experience - they logged thousands of procedures before laser surgery was approved in the U.S. - cost is the big factor pulling Americans across the border.
The price difference stems mainly from the head start Canada enjoyed while the FDA mulled over whether to legalize laser surgery in the U.S. Canadian clinics, meanwhile, built patient volume, enabling them to eventually lower prices. And LASIK is growing at a time when the Canadian dollar has been weakening against the U.S. dollar. Though the clinics' prices don't fluctuate daily, exchange rates do play a part in the prices they set for Americans.
In addition, given their high volume, many Canadian clinics are exempt from a $520 royalty fee American clinics still must pay to laser manufacturers for each LASIK patient.
Among the most popular clinics in the Seattle area are the UW's Refractive Surgery Center and TLC Northwest Laser Center, the Lynnwood branch of the Toronto-based TLC chain that operates 47 refractive surgery centers across North America.
Less than a year old, the UW center now performs more than 100 LASIK surgeries each month. Dr. Steven Wilson, center director and one of its surgeons, and chairman of the UW's Department of Ophthalmology, said LASIK "has enjoyed phenomenal growth, to the point that I'm maxed out on the number of procedures I can do a week."
Lasik Vision Canada, which began as one clinic in Vancouver and now has nine clinics across Canada, has seen even more dramatic growth. In the first three months of 1999, Lasik Vision performed 5,092 procedures, an 858 percent increase from 593 during the same period last year. The company plans to expand into the U.S., including the Seattle area, later this year.
At Lasik Vision's Vancouver office, more than 400 patients are undergoing surgery each month. About half of those patients are Americans, the bulk coming from Washington and others filtering in from Oregon, Idaho and Alaska.
In the B.C. market, Lasik Vision's competitors include TLC, Exximer, Gimbel and Lexington LaserVision, a new company now focusing heavily on Puget Sound-area patients.
Lexington, based in Surrey, B.C., has come up with a couple new twists. The company offers a $100 discount if you book with a friend, and patients can arrange for pre- and post-operative visits at Focus Eye Care, a private clinic in Bellevue, rather than travel back to Canada.
The frenetic pace of the Canadian market was evident on a recent afternoon in Vancouver, when - in the course of a 30-minute interview - Lasik Vision CEO Michael Henderson took calls from Britain and Cincinnati, fielded a pitch for a Learjet and even helped move furniture around the office.
"This is why we can keep the prices so low," Henderson said as he and another employee hoisted a couch.
Intense competition has led to a frosty rivalry between U.S. and Canadian laser clinics and optometrists. James Watson, a vice president at Lasik Vision, said one of the clinic's patients was ushered out of a Seattle-area optometrist's office, records in hand, after revealing plans to undergo a LASIK procedure in Canada.
Henderson said U.S. clinics are overcharging for the procedure, "trying to capitalize on the fact that the general public doesn't know the price."
The UW's Wilson disagrees. Noting the university's medical reputation, on top of its proximity to Puget Sound patients, Wilson said, "I think patients, frankly, get what they pay for."
A pair of recent seminars offered at Eastside hotels by Canadian laser clinics drew dozens of curious participants, ranging from a teenager with her father to a retired couple.
Clinic representatives were relatively understated in their pitch, emphasizing the risks and outlining a detailed list of criteria for LASIK candidates. Yet booking hotel conference rooms and running quarter-page newspaper ads is an unmistakably commercial approach.
Laser surgeons, however, bristle at the notion that they're running a revolving-door operation.
"We are very squeamish and protective," said Sutton, who founded Lasik Vision and is now medical director of its Vancouver office.
Sutton noted that all patients sign a voluminous consent form and that about 10 percent of patients who come in for a pre-operative appointment are turned away.
"The punishment for getting one person not right is very severe," Sutton said. "We have to be very realistic."
One of Canada's most prolific refractive surgeons, Sutton has performed more than 6,000 LASIK procedures. Only about a dozen have had complications, he said, translating to a 99.8-percent success rate.
But because LASIK permanently alters your eyes, the consequences can be serious when something does go wrong. Five of Sutton's patients sued him last fall, several claiming that the surgery left them with no useful vision in one eye. Sutton has denied wrongdoing.
Other clinics also face legal tangles. Luke Shanahan, a 27-year-old Everett man, filed suit in King County Superior Court against TLC in April, claiming his vision was damaged when doctors at the Lynnwood clinic switched the LASIK specifications that had been set for each eye. TLC declined comment on the suit.
"People think that because a computer is involved and controls how the excimer laser sculptures your cornea . . . they really gloss over the human error," said Richard Nelson, Shanahan's attorney. "There's an assumption there that shouldn't be made."
As deputy registrar of the B.C. College of Physicians and Surgeons, Van Andel handles complaints levied by patients against laser clinics. He said he's wary of the marketing and hype suddenly surrounding LASIK.
"I have a little concern when a medical practice becomes an `industry,' " he said. "Maybe we're splitting words here, but an industry is something that is profit-motivated."
But Van Andel notes that the satisfaction rate among LASIK patients is high, and says he may simply have more cautious tastes when it comes to medical procedures.
The question potential LASIK patients must ask themselves, Van Andel said, is: "Do you, as a matter of personal choice, want to be part of cutting-edge technology? Or do you sit in the shadows for awhile, and then take your pick?"
Nicole Scadlock of Auburn harbors no regrets about her LASIK procedure. She and a neighbor had the surgery together in April at Lasik Vision in Vancouver - bringing the grand total in her block to four. Two more neighbors are now interested.
Scadlock, a 28-year-old mother of three, had 20/300 vision before LASIK. Now it's 20/15, making those late-night checks of her 1-year-old's crib a lot less cumbersome.
"You can see from the moment you wake up to the moment you go to bed," Scadlock said during a recent one-month checkup in Vancouver.
Jance and her husband, Bill Schilb, preferred the convenience of having the surgery in their own back yard, and enlisted TLC in Lynnwood.
"With my job, eyes are pretty important to me," Jance said. "It is a calculated risk, but any surgery is a calculated risk."
Jance, who began wearing glasses in the second grade, was plagued by the pitfalls of eyewear at an early age. She remembers having her glasses broken during kickball, basketball and volleyball games during recess (each time by the same girl, suspiciously enough).
But today, eight months after LASIK, Jance often leaves her reading glasses in their case while working on novels at her Bellevue home.
"I'm sitting here, I have my computer in my lap with no glasses needed, and I'm looking at Lake Washington on a beautiful, sunny day," Jance said last week. "It's a miracle."
Jake Batsell's phone message number is 206-464-2595. His e-mail address is email@example.com
------------------------------- Compare costs: Canada vs. local -------------------------------
A price comparison of several Canadian and U.S. clinics that perform LASIK laser eye surgery:
Prices are for both eyes. All costs are in U.S. dollars (Canadian clinics quote U.S. rates to American patients).
: : : Pre- and : :
: : : post : Travel :
: : Surgery : appoint- : consid- : Company : Location : cost : ment costs : erations : --------------:------------:---------:------------:----------------. Lasik Vision : Vancouver, : $999 : $499 : Three-day stay : Canada : B.C. : : : for surgery; :
: : : : three follow- :
: : : : up visits (1) : --------------:------------:---------:------------:----------------. Lexington : Surrey, : $1,075/ : included : Overnight stay : LaserVision : B.C. : $975 : : for surgery; :
: : (2) : : pre-and post- :
: : : : surgery visits :
: : : : in Bellevue : --------------:------------:---------:------------:----------------. UW Refractive : Seattle : $4,000 : included : Surgery, pre- : Surgery : : : : and post- : Center : : : : surgery visits : --------------:------------:---------:------------:----------------.
: : : : in Seattle : TLC Northwest : Lynnwood : $4,000 : included : Surgery, pre- : The Laser : : : : and post- : Center : : : : appointment in :
: : : : Lynnwood : --------------:------------:---------:------------:----------------.
(1) Pre- and post-operative appointments also can be arranged with local optometrists, but there may be additional charges.
(2) Lexington LaserVision offers a $100 discount if you sign up with a friend.
----------------------- But what about quality? -----------------------
Price isn't the only factor to consider when evaluating laser eye surgery clinics. These are your eyes we're talking about.
Some questions to ask:
-- How experienced are the clinic's surgeons? How were they trained?
-- How many procedures have been performed by the specific surgeon who will perform your operation?
-- What's the rate of complications? (Not only for the clinic, but also your surgeon.) How many patients have had flap problems, or needed a corneal transplant?
-- Have there been complaints or lawsuits filed by dissatisfied patients against the clinic? To check complaints in Canada, contact the B.C. College of Physicians and Surgeons at 604-733-7758; in Washington, contact the state Medical Quality Assurance Commission at 360-236-4800.
-- What is the clinic's guarantee policy? Does it provide lifetime retreatments at no charge, or are there restrictions? A lifetime guarantee may only be as good as the lifetime of the medical institution.