A second look

It began with a dip in a suburban swimming hole on a sweltering summer day.

It ended with a voracious infection, toxic drugs -- and repeated transplant surgeries to save a teenage girl's eye.

All because Jackie Stillmaker, now 18, had plunged into the water wearing contact lenses, which acted like magnets for one-celled creatures lurking in the Chicago-area lake.

"She was in such horrific pain," recalled Jackie's mother, Mary Beth, who now lobbies for better warnings on contacts. "It was like pouring hydrochloric acid in your eye and stabbing it with a knife."

In a society where human fixer-upper projects are all the rage, it has long been assumed that for people like Jackie, who tired of her glasses, contact lenses are safer than letting a surgeon use a laser to reshape the eye.

Now, at medical conferences and in scholarly journals, some specialists are making a heretical suggestion: Maybe getting laser surgery isn't riskier than putting in contact lenses every day for decades.

That argument has staggering implications. It's estimated that 34 million Americans wear contacts and buy all the solutions that go with them. At the same time, at least a million patients this year will reach into their own pockets and pay anywhere from $1,000 to $5,000 to have a surgeon laser away their myopia or farsightedness. So any shift in preference could translate into billions of dollars gained -- or lost.

Dr. William D. Mathers , an ophthalmologist at Oregon Health & Science University , took an especially public stand in last month's Archives of Ophthalmology . Reviewing studies of vision correction, Mathers concluded that the risk of serious complications was low for both contacts and surgery but contacts, used for decades, may be slightly more dangerous. Mathers argues that while long-term contact users suffer vision loss at a rate of one in 2,000, laser patients have serious complications just one time out of 10,000.

But there continues to be a divide on this point between the ophthalmologists, like Mathers, who do surgery, and optometrists, who prescribe contacts.

"I love them both," said Dr. Jack Schaeffer of Birmingham, Ala., a leader of the American Optometric Association , a confederation of eye specialists. "I happen to own a laser center and have a large contact lens practice. But there's no question that contact lenses are safer."

Researchers are trying to resolve the debate by calculating the benefits and risks of contact lenses and laser surgery -- especially the most common form, LASIK, or laser-assisted in situ keratomileusis .

In one study, researchers extensively reviewed medical literature covering a dozen years and found only 103 cases of infection attributable to LASIK. In a landmark report on laser surgery in the US military, the authors reported that when 16,111 soldiers underwent the operation, complications were quite infrequent and the procedure "enhanced the overall readiness" of soldiers.

Patients are drawn to the procedure by the prospect of better vision and fewer hassles. For Gina Matthews, who had worn contacts for two decades, the lenses had become "just intolerable." So last month she went to the Massachusetts Eye and Ear Infirmary for LASIK.

During the procedure, surgeons use either a whirring device that resembles a carpenter's plane or a laser to peel back a hair-thin layer of the cornea, the eye's dome-shaped cover.

Then, a laser is trained on the exposed bed of the cornea for less than a minute, loosing quick bursts of cold ultraviolet rays to obliterate predetermined slivers of tissue and improve the eye's ability to see clearly either close up or far away. When the laser is finished, the surgeon gingerly restores the outer layer of the cornea, and it stays there, needing neither suture nor adhesive.

Nor contacts. "It's very liberating," Matthews said.

When surgeons began performing LASIK in the United States in the 1990s, "the total risk of a problem was much higher" than today, said Dr. Roberto Pineda , director of Mass. Eye's refractive surgery service . There was a drive in the early days to do better. "When someone's coming for an elective procedure, you have to do better than pretty good," he said.

In the past decade, equipment refinements, stronger antibiotics, and more-experienced surgeons have combined to reduce complications, said specialists and officials at the US Food and Drug Administration , which regulates methods for fixing vision.

"They've learned over the last 10 years or so," said Everette Beers , deputy director of the FDA division that oversees ophthalmic devices. "They've learned a lot."

Still, as with any surgical procedure, there's always a risk of infection or the possibility that vision won't meet patients' expectations. And specialists increasingly have recognized that there are certain patients -- those with thin and bulging corneas, for example -- who should not undergo LASIK.

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When problems with laser surgery do arise, they tend to become evident within days or weeks.

"But with a contact lens," said Dr. Dimitri Azar , head of the Illinois Eye and Ear Infirmary , "the longer you wear it, the greater the risk. Every day you put it in, you're increasing the risk."

In part, that's because of human behavior. In part, it's because of the wear and tear the eye can suffer from having a chunk of plastic stuck on top of it.

There are patients who don't follow instructions, such as one Schaeffer treated in Birmingham for a nasty infection last week: She conceded that to save money, she hadn't changed the solution in her contact lens case for two weeks.

When lenses are kept in too long, the eye can't get enough oxygen or lubrication, and microscopic cracks can appear in the cornea, allowing bacteria easier access. A 2005 study of extended-wear contacts found that of 4,999 patients followed during a year, two suffered infections resulting in vision loss and eight others had infections but did not have sight problems.

Other researchers say problems are more evident among users of soft versus hard contact lenses, and extended-wear contacts have been shown to increase the infection risk by at least fivefold.

Specialists said the scientific research so far does not justify telling patients to get laser surgery simply to reduce their chance of infection from contacts.

Or, for that matter, to increase their chance of finding romance.

"What we try to avoid is the unrealistic expectations," said Dr. Peter McDonnell , director of the Wilmer Eye Institute at Johns Hopkins University . "If we hear something like, 'I've never been able to get dates and it must be because of my glasses,' that causes us to hesitate.

"Sometimes you can tell that people have other social issues and that women are not judging them based on their glasses."

And what's so wrong with glasses, anyway? After all, specialists said, they're the safest way to improve vision.