Reply-To: Jjsalzeye@aol.com
Date: Tue, 19 Mar 2002 00:59:47 EST
To: omar_eye@yahoo.com
Cc: kera-net@ucdavis.edu, isrsnet@sand.lyris.net, refractive@lists.ascrs.org, SCSchallhorn@nmcsd.med.navy.mil
Subject: Re: Plaintiff's med expert: pupil size less important
In a message dated 3/16/2002 8:19:41 AM Pacific Standard Time, omar_eye@yahoo.com writes:

Plaintiff's medical experts are placing an unecessary
negative outlook on the LASIK procedure because the
issue is far more complex than simply pupil size. The
plaintiff's medical expert has also set a dangerous
precedent to allow ANY issue regarding pupil size as
an excuse to sue.
NOW your comment regarding the wavefronts will be
adapted by attorneys and YOURSELF a plaintiff's
medical expert that sits on the board of OMIC (which
is supposed to look out for the best interests of
ophthalmologists) only to support your view that the
pupil size issue is important.

Sam Omar
Dear Sam, do you really think it is only my view that pupils size is important? I recall that one of your earlier e-mails stated that because of our modern lasers pupil size in no longer important. Also for your information, I have given depositions for 2 LA surgeons who were being sued because of pupil issues that resulted in the cases being dropped. I also helped a patient who had 8 mm pupils and tremendous night time symptoms obtain a settlement because her pupils were not measured at all (in the year 2000) and she was not tol d that she was "potentially at an increased risk of glare". I am also tired off debating with you about this as I am quite confident that the majority of LASIK surgeons would agree that at the present time pupil measurements are an important part of the pre op workup and and large pupils, even with large ablations may be associated with increased night glare and halos.
James J. Salz, M. D.
444 South San Vicente, Suite 704
Mark Goodson Building, Cedars-Sinai Medical Center
Los Angeles, CA 90048
Phone 323 653-3800 Fax 323 653-3898
e-mail jjsalzeye@aol.com Web Page www.drsalz.com

------ Forwarded Message
From: Jjsalzeye@aol.com

Re: Pupil Size
I am with Dr. Schallhorn this weekend and heard him report his study on 100 patients. I have asked him to clarify his thoughts on this forum. It would be a mistake to conclude th at his study, the study by Manche mean that pupil size is not a potentially important factor in night time symptoms of glare and halos. The responsible refractive surgeon will point out to patients with large pupils that they are possibly at increased risk of glare should they proceeed with surgery, even with the larger treatment zones and smoother ablations now possible. We alll have patients with large pupils and smaller ablations who happily are asymptomatic just as we have patients with larger ablations then their pupils size who are miserable. Many of these patients have increased spherical aberrations which can be documented with wave front testing which shows the aberration is present when the pupils is large and reduced when the pupil! s is reduced. To imply that measuring the pupils and counseling the patients accordingly pre operatively is no longer important is unwise.
James J. Salz, M. D.
Laser Vision Medical Associates, Inc.
444 S. San Vicente B lvd. Suite 703
Cedars Sinai Medial Center
Los Angeles, CA 90048
Phone 323 653-3800 Fax 323 653-3898
www.drsalz.com e-mail jjsalzeye@aol.com
From: "Trattler" <jtrat@bellsouth.net>
To: <omar_eye@yahoo.com>; <refractive@lists.ascrs.org>;
<kera-net@ucdavis.edu>
Sent: Friday, March 01, 2002 11:03 PM
Subject: Re: PUPIL SIZE

> Sam,
> I hate to say this - but your comment is completely untrue. You
> may find that some patients with large pupils do not develop severe
> aberrations at night, but the risk of night time problems is related both
> to the optical zone and pupil size (pupil size is not the only factor, but
> it is an import ant factor).
> First - if all you need is a 6.0mm optical zone - why would the
> Autonomous allow one to treat out to an 8.0mm optical zone? And why would
> the VISX need to develop the expanded optical zone (to 6.5mm) and the
> transition zone (out to 8.2 mm). Are you saying that using wider optical
> zones is a waste of cornea?
> As well - modern lasers (VISX) still treats with an ellipitical
> ablation zone for astigmatism (6.5 X 5.0) - so there can be a potentially
> huge mismatch for a patient with an 8.0mm pupil size who requires
> significant astigmatic correction with the VISX laser. I wonder if your
> comments on "modern lasers with optical zones of 6.0mm includes the VISX
> laser for these 6.5 X 5.0 (or with the 6.0mm zone setting - 6.0mm X 4.5mm)
> The VISX laser also shrinks down the optical zone when treating
> higher degrees of myopia. I do not know the a lgorithm exactly, but part of
> the treatment for a patient with a high degree of myopia will be smaller
> than the selected optical zone (Again this is with the VISX laser system).
>
> I would agree that large pupils are only a risk factor for severe
> night time problems. There are other potential causes of severe night
time
> visual problems besides pupil size issues - but it is important to explain
> to patients with large pupils that they are at higher risk of night time
> vision problems compared to a similar patient with smaller pupils and the
> same degree of myopia and/or astigmatism. As well, it is possible to
> reduce the risk of night time visual problems by providing wider
ablations.
>
> Barrie Soloway, MD provided an example of how taking pupil size
> into account preoperatively was shown to reduce the risk of night time
> vision problems. Dr. Soloway presented a paper at the ISRS in Miami in
> Summer 2000 on the reduction of patient complaints of night time vision
> problems by using the Autonomous laser and matching the optical zone to
the
> pupil size (this paper was also discussed in Ocular Surgery News)
>
> Another prominent researcher in the importance of pupil size is
> Keith Thompson, MD at Emory University. He is using "Interwave", which is
> a patient-interactive method for mapping visual abberations, and then
links
> the Interwave results to excimer treatments. He has reported success in
> helping patients with large pupils and severe night time problems by
> expanding the optical zones with this type of treatment.
>
> Finally - I recommend that you read the paper by Dr. Brian Boxer-Wachler,
> which provides a good overview on the literature of the role of pupil size
> in refractive surgery.
> http://www.refractivesource.com/doctors/clinical_pearls/role_pupil.htm
> He cites 4 articles that demonstrated that Night vision
> disturbances are more frequent with smaller ablation diameter (11,12)
> larger pupil diameter (11,12,13) and greater attempted correction (14).
>
> (11) Anschutz T. Pupil size, ablation diameter, and halo incidence after
> photorefractive keratectomy. In: Best Papers of Sessions: Symposium on
> Cataract, IOL and Refractive Surgery, April 1-5, 1995 San Diego, CA.
> Fairfax, VA: American Society of Cataract and Refractive Surgery; 1995.
> (12) Roberts CW, Koester CJ. Optical zone diameters for photorefractive
> corneal surgery. Invest Ophthalmol Vis Sci. 1993;34:2275-2281.
> (13) Martinez CE, Applegate RA, Klyce SD, et al. Effects of pupillary
> dilation on corneal optical aberrations after ph otorefractive keratectomy.
> Arch Ophthalmol. 1998;116:1053-1062.
> (14) Halliday B. Refractive and visual results and patient satisfaction
> after excimer laser photorefractive keratectomy for myopia. Br J
> Ophthalmol. 1995;79:881-887.
>
>
>
> I am happy to continue the discussion.
>
> Best regards
>
> Bill Trattler, MD
> Miami, FL
>
>
>
>
>
> >"With modern lasers with optical zones of 6mm or
> >greater, pupil size is a relatively unimportant factor
> >in performing lasik or prk."
> >
> >Sam Omar MD
> >--- jorge cazal <jaocazal@yahoo.com> wrote:
> > >
> > >
> > > Dear Kerafriend:
> > >
> > > Your concern it is well understod, Pupil is a
> > > dynamic organ, its size,like many biological
> > ; > measurements, varies all the time.Studies have shown
> > > that in normals, pupillary Hippus can exist
> > > typically at levels between 0.3 mm to 1.5 mm. If a
> > > ruler is used, it will have its own intrinsic
> > > measurement error. We are also looking with
> > > interest for a different device what can afford for
> > > infrared binocular measurement, associated with a
> > > kind of statistical analysis of the several
> > > measures. We had have the oportunity to see the
> > > Procyon P2000SA working and we found it a charm.
> > > Emmanuel Rosen,M.D. (U.K.) have some paper
> > > presented last ESCRS Winter Meeting.
> > >
> > > Theoretically your case would induce some degree of
> > > espherical aberration .
> > >
> > > Kindest Regards
> > >
> > > ; Jorge Cazal,M.D.; Cornea & Refractive Surgery . Rio
> > > De Janeiro
> > >
> > > reiferman@cs.com wrote: Kera-pals:
> > >
> > > If we measure pupil size with a Colvard, doesn't it
> > > read the size of the "apparent" pupil? For example,
> > > would a pupil measurement of 6.5 cause a problem
> > > with a 6.0mm ablation zone?
> > >
> > > Thanks
> > >
> > > Rich Eiferman
> > > Louisville, KY
> > >
> > >
> >
From: Trattler
To: refractive@lists.ascrs.org ; kera-net@ucdavis.edu
Sent: Friday, March 01, 2002 10:02 PM
Subject: PUPIL SIZE - Articles and Discussions on the importance of pupil size

Dear Nancy & Sam,
It looks like I have missed a good part of this discussion. I would have to disagree with both of your comments - in that pupil size and ablation diameter are critical factors - and there have been publications on this topic for over a decade (since the days of RK) discussing the importance of pupil size (it is even in your VISX training manual). Here is a list of just some of the many articles and book excerpts on this topic:

Till Anschutz, M.D., Pupil Size, Ablation Diameter, and Halo Incidence After PRK, Symp on Cataract, IOL, & Refract Surg, 1995.
""This study found a direct correlation between pupil size and ablation diameter. On average, small ablation diameters caused more halo effects....Ablation diameter should correspond to pupil size. A 7.0 mm ablation zone is recommended for patients 20 to 30 years old, and an enlarged 8.0 mm ablation zone could help diminish halo effects in eyes with larger pupils. Preoperative pupil measurement and selection of a cor responding ablation diameter could help increase visual performance and reduce halo effects."

Charles J. Casebeer et. al., Lamellar Refractive Surgery, SLACK Inc., 1996
"Poor night vision and other problems were found to be associated with small optical zones. At night, a patient's pupils are dilated beyond the zone of correction, so that the edges of the ablation are uncovered. Light coming into the eye is refracted from these edges, and halos are created around point sources of light, such as lamps."
Physician's Training Manual, Visx Star S2 Excimer Laser, 1996, P/N 0030-1724, Rev. A, PRK for Nearsightedness with Astigmatism, p.14.
"Please remember that it is important to check pupil diameter in light and dim conditions. Under certain circumstances, the minor axis of the elliptical ablation that is created to correct the astigmatism can be 4.5 mm. If a patient has large pupils in dim lighting conditions there is the potential for difficulty with vision in poor light conditions following PRKa."
Physician's Training Manual, Visx Star S2 Excimer Laser, 1996, P/N 0030-1724, Rev. A, PRK Complications and Management, p. 11.
"Night Glare, Haloes, and Image Ghosting...Can be seen in young patients with large diameter pupils in dim illumination (some patients can have 9 mm dim illumination pupil). Always check pupil prior to ablation and warn patient of this possibility."
Leon Strauss & Dimitri T. Azar, Optics Rediscovered for the Keratorefractive Surgeon, in Dimitri Azar, ed., Refractive Surgery, 1997, ch. 8, pp.113-24.
"Size of the entrance pupil (the image transmitted through the cornea) should be estimated in brightly and dimly lit conditions. If the entrance pupil is larger than the optical zone in dim but photopic conditions, then an annulus of cornea surrounding the optical zone will transmit rays to the fovea."
Jonathan Carr & Peter Hersh, Patient Evaluation for Refractive Surgery, in Dimitri Azar, ed., Refractive Surgery, 1997, ch. 7, pp.101-8.
Measurement of the diameter of the entrance pupil in both light and dark conditions may identify patients who have very large pupils, which may exacerbate edge effects of the optical zone following refractive procedures (for example, glare, halo, and the starburst phenomenon)."
Howard V. Gimbel et. al., Lasik Complications: Prevention and Management, SLACK Inc., 1999
Ch. 2 - Patient Selection and Preoperative Workup, Table 2-1
"Patients with large pupils need to be forewarned of the possibility of night vision difficulties. Especially important in high corrections. Corneal surgery may not be advisable."
Ch. 2 - Patient Selection and Preoperative Workup, p.17
"Pupil measurements may indicate that a patient will have night vision disturbances if the pupils are widely dilated in dim light, and those patients should be warned that they are at higher than average r isk for this side effect of LASIK or PRK."

Harold Stein, Albert Cheskes, & Raymond Stein, The Excimer - Fundamentals and Clinical Use, 2d ed., 1997, SLACK Inc.
p.34 "One should refrain from operating on individuals with very large pupils (>6 mm) without at least forewarning them about the possible effects on night driving and glare."
pp. 82-3 "The problem with small optical zones is that if the pupil dilates, especially at night, halos can be produced as a result of refraction of light at the edge of the ablation."
p. 143 "Halo Effect...Symptoms are more apt to occur at night when dilation of the pupil allows light transmission at the edge of the ablation zone. Persistent halos rarely occur and are usually related to large pupils or a decentered ablation."

Lasik: Principles and Techniques, Lucio Buratto, Stephen F. Brint, 1998
Preparation for Surgery - Contrast Sensitivity and LASIK, p.41
?Recent studies demonstrate that as the pupil increases in size with increasing darkness, there is a corresponding decrease in the contrast sensitivity, particularly at the lower contrast.?
Preoperative Pupillometry in LASIK, p. 41
?In order to provide a good refractive and visual outcome under all light intensities, it is necessary to perform an ablation with an optic zone proportional to the pupil diameter. As a result, the preoperative measurement of the pupil diameter under scotopic light is very important. Pupil diameter can be measured by a number of methods?In 10% of our patients, the scotopic pupillometry was greater than or equal to 7.0 mm; ?blindly? performing an operation on these patients may therefore be disadvantageous for both the patient and the surgeon.?
Optical Zone, Pupil Diameter, and Requested Correction, p.92
?It is commonly known that the occurrence of halos and night glare can arise from the optical properties governed by the size of the treatment zone and the pupil diameter in dim light conditions, presumably because the scotopic pupil dilates beyond the diameter of the optical surgical zone.?
Ablation Zone, Pupil Diameter, and Requested Correction, p. 92
?The issue of ablation zone diameter (sometimes improperly called ?optic zone?) is certainly crucial in planning LASIK treatment. The appropriate ablation diameter has to be decided, taking into account different parameters such as attempted dioptric correction, residual corneal thickness, and pupil diameter?Pupil diameter can easily be measured using infrared pupillometers?They provide pupil diameter measurements under scotopic conditions, which is the way pupillary diameter has to be measured, because of complaints by patients regarding night vision when the pupil dilates. As a general rule, pupils measuring 6.0 mm in diameter are very unlikely to have visual disturbances at night, at least for low to medium myopic corrections. Larger pupils require larger a blation diameters to avoid visual disturbances, and higher attempted corrections require the same because of the greater light scattering that occurs at the ablation edge.?
p. 226
?Glare, especially at night, is one of the greatest problems, seen more frequently in patients with large pupils and high corrections. The abrupt edge slope created in high corrections defracts light, thus inducing halos?This complication is more important in those patients with unusually large resting pupil diameters. The scotopic pupil diameter should be measured preoperatively and the patient counseled based on this and the amount of planned correction. This complication is due to an accentuated form of spherical aberration, with the diameter of the pupil under low luminance exceeding the effective optical zone created?Patients with a disproportionately large pupil compared to the optic zone should be avoided.?
p.244 - Night Glare and Halos
?Night vision disturbances should be considered a very important side effect of laser surgery. The risk of this complication must be screened pre-operatively through the measurement of pupil diameter, and adequate ablation strategies must be applied to minimize this side effect which, once occurred, is very difficult to deal with?I personally have some patients who had to change their profession because they were unable to drive at night after surgery?Once induced, these disturbances are very difficult to solve?Before surgery, the preoperative visit should include pupil measurements under different light conditions?I personally use the following guidelines: Once a patient is found to have very large pupils in dim illumination (>7.0 mm), I discourage him or her from undergoing laser refractive surgery, or at least I inform him or her of the great risk of night vision problems, regardless of the correction.?

Olivia N. Serdarevic, Refractive Surgery: Current Techniques and Management, Igaku-Sh oin Medical Publishers, 1997
"Patients with smaller optical zones may often complain of visual aberrations at night, but not usually during the day. Aberrations are described as starbursts, halos, and/or blur. It is not uncommon for some patients to experience the full range of these effects. These night vision phenomena increase in incidence with any treatment zone decentration."
Ch. 7, Prevention and Management of Complications of Photorefractive Keratectomy, David S. Gartry, Ronald Stasiuk, & David Robinson, p.87.
"Aberration effects are possible as a result of the demarcation between the central ablation zone and the untreated cornea. Early studies documented these effects. It was found that when the surgery is particularly effective, a halo around lights at night may be noted, especially by patients with large pupils?those patients with a large change in refractive status experienced the greatest halo effect?a high correlation between pupil size and halo effect?patients with larger pupils were much more likely to complain of halo.

Brian Chou, O.D., and Brian S. Boxer-Wachler, M.D., The Role of Pupil Size in Refractive Surgery, February, 2001.
"Night vision disturbances have been reported in over 25% to 35% of patients after PRK and Lasik using a 6.0 mm ablation zone. These disturbances are more frequent with smaller ablation diameter, larger pupil diameter, and greater attempted correction."

Howard V. Gimbel et. al., Lasik Complications: Prevention and Management, SLACK Inc., 2001
Ch. 2 - Patient Selection and Preoperative Assessment, Figure 2-2 (page 13)
Dr. Gimbel descibes a patient with -7.25 diopters of myopia and 8.0mm pupils in dim light who after being counseled that "he would be more likely to experience night vision difficulty and may find this disabling. After this discussion, he elected to cancel surgery."
Section II
Patient Example 24 (page 222):
Night Vision Disturbance Postoperatively"
"This patient had PRK elsewhere for a preoperative refractive error of -11.25-0.75 X 3 OS. An optical zone of 6mm with a transition zone of 7.0mm was used. In spite of preoperative pupil measurements of only 4mm in bright light and 6mm in dim light, the patient experienced significant vision difficulties with marked glare and halos.
Two years later, he was seen for a preoperative assessment for LASIK OD.......In spite of a UCVA of 20/15 -1 OS, the patient elected to cancel surgery OD after the risks of night vision difficulties that might follow LASIK OD were discussed.....this patient felt handicapped by the night vision disturbances that had occurred following PRK.


I hope these excerpts are of interest
Best regards
Bill Trattler, MD


At 06:00 PM 3/1/02 -0500, you wrote:
Dear Nils,
I am not saying that on e should not use the multizone treatment; I would
like to see a study which compares the effect of multizone treatment on
glare and haloes, (as well as perhaps contrast sensitivity), as compared to
single zone treatment with large transition zones. I don't know if any of
the laser companies have this data. The VISX laser automatically switches
to multizone treatment when the treatment is above 6D. I think that we need
to know more about the effects of multi-zone treatment and perhaps VISX
users need to have a choice whether multi-zone is right for their particular
patient. However, the point that I was trying to make in my post, was that
pupil size is probably not the cause of complaints of glare and haloes,
based upon data that has been examined. I do not know whether multizone
treatment is a contributing factor, but if someone on this forum has
reliable information regarding the effects of multi-zone treatment on glare,
haloes, e tc., I think we could all benefit from the facts. I believe that
large transition zones, probably based upon the amount of myopic treatment
are the answer to the difficulties with glare and haloes. Wave-front
analysis, and an analysis of higher order aberrations, will likely provide
many more answers to the causes and best solutions for these problems.
Regards,
Nancy
> ----- Original Message -----
> From: "molander nils" <molandern@yahoo.se>
> To: <vze26hch@verizon.net>
> Sent: Friday, March 01, 2002 2:55 AM
> Subject: Re: PUPIL SIZE
>
>
> > Dear Nancy
> >
> > Do you mean that one should not use multizone
> > treatment with for example the VisX, just the ordinary
> > 6 mm single Zone?
> >
> > Regards,
> >
> > Nils Molander
> > Cornea l Specialist
> > Malmö
> > Sweden
> > --- "Nancy A. Tanchel, MD" <vze26hch@verizon.net>
> > skrev: > Jim,
> > > Sam's point is very well taken. Your statement: "I
> > > doubt that the patients with 8 mm pupils, moderate
> > > to high corrections, who had ablations of 6 to 6.5mm
> > > would agree that their pupil size in unimportant.
> > > The fact that the obtain considerable relief from
> > > Alphagan indicates that at least for some of them,
> > > pupil size can be very important." - is a report of
> > > anecdotal findings - not a scientifically sound
> > > statement based on the study of data.
> > >
> > > Have you determined whether the patients that you
> > > refer to had multizone or single zone treatments?
> > > Perhaps the mult izone treatments to which the VISX
> > > defaults above 6D causes more glare and haloes; it
> > > may induce more higher order aberrations. The only
> > > reported studies that I am aware of that have
> > > assessed the importance of pupil size, optical zone
> > > size, transition zone size, amount of treatment, as
> > > well as some other factors, were performed by Jim
> > > Schumer and Mihai Pop; each of them reported large
> > > series results using the Nidek laser. Separately,
> > > each came to the conclusion that the pupil size and
> > > optical zone size do not correlate with the symptoms
> > > of glare and haloes. The transition zone size and
> > > total amount of myopic treatment were the only
> > > parameters associated with glare and haloes. These
> > > are very difficult studies to perform, and we should
> > > all be grateful to both Dr. Schumer and Dr. Pop for
> > > providing us with this useful data. We don't have
> > > this information available to us for other lasers,
> > > but I believe that Technolas studies resulted in the
> > > same findings, and this is the basis for the large
> > > transition zone sizes that eat up alot of stromal
> > > tissue when performing higher treatments with their
> > > laser. Furthermore, Jack Holladay's mathematical
> > > assessment of the Stiles-Crawford effect also
> > > corroborates these studies.
> > >
> > > So, to get up in court and state that pupil size is
> > > an important risk for glare and haloes, may not be a
> > > declaration of fact, merely opinion based on
> > > possible erroneous conclusions derived from
> > > anecdotal fi ndings.
> > >
> > > Nancy
> > > Nancy A. Tanchel, M.D.
> > > 703-848-1618
> > > 208-279-3669 fax
> > > ----- Original Message -----
> > > From: Jjsalzeye@aol.com
> > > To: omar_eye@YAHOO.COM
> > > Cc: kera-net@ucdavis.edu
> > > Sent: Thursday, February 28, 2002 4:48 PM
> > > Subject: Re: PUPIL SIZE
> > >
> > >
> > > In a message dated 2/28/2002 5:38:08 AM Pacific
> > > Standard Time, omar_eye@yahoo.com writes:
> > >
> > >
> > >
> > > Jim, the other day I performed LASIK on one of
> > > the
> > > dental hygienists that worked next door. I did
&g t; > > the
> > > usual counseling preop on halo and glare. This
> > > lady
> > > came to see me 1.5 years ago and I had noted a
> > > preop
> > > pupil of 7.5 and 7.0 mm. She was -7.25 and
> > > -7.75
> > > sphere and initially i put her off based on her
> > > pupil
> > > size. I thought long and hard about doing her
> > > with
> > > increased optical zone but my experience with
> > > larger
> > > optical zones based on tissue removal and
> > > nomogram
> > > adjustments did not seem to be an optimal
> > > solution for
> > > her. Her pach was 510 OU.
> > >
> > > 2 weeks ago i did her single zone 6.0 with the
> > > Apex
> > > and at her 1 week visit she describes drving
&g t; > > home in
> > > the dark over 300 miles with no problems and
> > > vision
> > > very similar to that provided to her by
> > > contacts.
> > >
> > > I based my treatment decision for her on
> > > thousands of
> > > myopes between -4 and -10 who had pupils between
> > > 6 and
> > > 8 mm.
> > >
> > > For some patients pupil size may be a factor but
> > > it is
> > > much less important than you might think.
> > > Centration
> > > on the mesopic pupil, single zone versus
> > > multizone,
> > > and elimination of the ammetropia are far more
> > > important factors.
> > >
> > > I believe you work sometimes as a expert medical
> > >
> > > witness (plain tiff side??). If i can get you and
> > > other
> > > doctors to understand that the science and
> > > personal
> > > experience of many good doctors doesnt support
> > > pupil
> > > size dogma we may save lots of doctors
> > > unecessary
> > > clinical headaches and litigation.
> > >
> > > Sam Omar MD
> > >
> > >
> > > --- Jjsalzeye@aol.com wrote:
> > > > In a message dated 2/27/2002 2:34:50 PM
> > > Pacific
> > > > Standard Time,
> > > > omar_eye@yahoo.com writes:
> > > >
> > > >
> > > > > With modern lasers with optical zones of 6mm
> > > or
> > > > > greater , pupil size is a relatively
> > > unimportant
> > > > factor
> > > > > in performing lasik or prk.
> > > > >
> > > > > Sam Omar MD
> > > > >
> > >
> > >
> > >
> > > We all have patients like that who do well despite
> > > the large pupils but I see many who are bitter
> > > because it was not even mentioned as a possible risk
> > > factor. Not even mentioning that they are
> > > potentially at incrreased risk I feel is a deviation
> > > from the standard of care and I will say so in
> > > court.
> > > James J. Salz, M. D.
> > > Laser Vision Medical Associates, Inc.
> > > Cedars-Sinai Medical Center, Mark Goodson Building
> > >
> > > 444 South San Vicente, Suite 704
& gt; > > Los Angeles, CA 90048 Phone 323 653-3800 Fax
> > > 323 653-3898
> > > Web site www.drsalz.com e-mail jjsalzeye@aol.com
> > >
> >
> > _____________________________________________________