Laser Eye Surgery Options
Last updated in October 2013
While there are several laser-eye-surgery options, LASIK surgery currently is by far the most common and, for most consumers, best option.
All of the surgical methods reshape the cornea, the curved transparent covering at the front of the eyeball (see Figure 1). Along with the lens, the cornea focuses incoming light onto the retina at the back of the eye in much the same way a camera lens focuses light on film. If the cornea is improperly shaped relative to the length and shape of the eyeball, light will not focus properly and you will be nearsighted or farsighted, or have astigmatism.
Although all surgical options alter the shape of the cornea to optimally focus light onto the retina, there are slight differences in the way surgeries are performed.
During LASIK (laser-assisted in-situ keratomileusis) surgery, the patient’s eye is anesthetized with eye drops while the eye not being treated usually is taped shut. After a device is attached to help the patient keep the treated eye open, the patient is told to look at a colored light to help keep his or her gaze forward.
The surgeon begins by holding the eye in place using a suction ring. The surgeon then cuts a thin flap of corneal tissue, which is lifted away from the surface of the cornea while still hinged at one end. After the flap has been created, the suction ring is removed.
The surgeon then uses a laser to remove tiny amounts of corneal tissue, thus reshaping the cornea into the desired contour. The laser is guided by information that has been programmed into its controlling mechanism—information about your unique prescription and other eye specifications.
When the reshaping is complete, the surgeon repositions the flap back over the newly contoured surface. Natural suction in your eye holds the flap in place, so no sutures are needed.
The entire surgical procedure should take less than 30 minutes. Most LASIK patients quickly experience its benefits and within two or three days enjoy normal uncorrected vision.
Bladeless LASIK Option
Eye surgeons disagree as to whether this newer method of using a laser to cut the flap—often advertised as “bladeless” or “all-laser” LASIK—is preferable to the traditional method that uses a special mechanized surgical blade. Those who prefer a blade argue that it shortens the most uncomfortable part of the procedure for the patient: The suction needed to hold the eye still usually lasts only three seconds with a blade but takes 15 to 20 seconds with an all-laser procedure. But surgeons who prefer the all-laser method argue that the flap it creates is more perfectly shaped, with sharper edges and a consistent thickness that heighten chances that the flap will heal quickly and without complications.
Some studies comparing the two methods suggest that all-laser LASIK results in slightly faster average visual recovery times and even slightly better success rates in terms of restoring 20/20 vision without corrective lenswear. But other studies found no significant differences in results. Even the studies that found evidence of improved outcomes with the all-laser method conclude the benefits are quite small.
Many experts—including many surgeons—insist that the main reason some surgical centers favor the all-laser approach is that it is more marketable.
Because surgeons pay a royalty to the cutting device’s manufacturer each time the all-laser procedure is performed, surgical fees for the all-laser approach are usually higher. Our advice is to compare the costs of the two methods and discuss the options with any surgeons you’re considering. Ask them if they have a preference and, if so, to explain why. Keep in mind that surgeons who heavily favor one method over the other perform many more surgeries using their preferred method. Since practice does indeed help make perfect, and since there doesn’t seem to be a significant difference in outcomes, you may want to choose the method your surgeon prefers.
Custom LASIK Option
There are two ways to program the laser device that shapes the corneal material in LASIK surgery—“conventional LASIK” and “custom LASIK.”
With conventional LASIK, the device is programmed according to lower-order aberrations of vision—your eyeglass prescriptions for nearsightedness, farsightedness, and astigmatism. This approach corrects your vision according to how well you can see a standard 20/20 eye chart.
Custom LASIK (also referred to as “wavefront-guided LASIK” or “wavefront-optimized LASIK”) measures and takes into account both lower-order and higher-order aberrations that may cause lack of contrast sensitivity and inability to discern fine detail. Unlike conventional LASIK, which would offer the same treatment to two patients with the same eyeglass prescription, custom LASIK takes into account the steepness and shape of patients’ eyes, often producing better night vision and sharper vision. Custom LASIK aims to reduce the risk of post-LASIK complications like glare, halos, and difficulty with night vision.
Evidence that custom LASIK surgery produces better results than conventional LASIK is very limited. Nonetheless, almost all surgeons who perform it strongly argue that custom LASIK achieves better results. But keep in mind that you can save a considerable amount of money by opting for the conventional LASIK procedure: Among area surgeons who still offer both types of procedures, we found that several charge less for conventional LASIK—sometimes a difference of $2,000 or more.
Choosing a LASIK Option
If you are having trouble deciding between custom LASIK and conventional LASIK, or whether to seek out a surgeon who uses the bladeless-laser method rather than a traditional blade, keep in mind that all these options have very low rates of serious complications. We suggest you focus your decision-making not on method but on finding a surgeon who is experienced, competent, skilled, and careful (see “How Do I Find a Surgeon?” below).
PRK (photorefractive keratectomy), one of the first laser-eye-surgery methods developed for vision correction, has largely been replaced by LASIK. PRK is still used for patients whose corneas are too thin to undergo LASIK or who have jobs or play sports that carry a high risk of eye injury.
Unlike LASIK, PRK involves cutting none of the corneal surface tissue to expose the corneal tissue underneath; instead, the surgeon uses a laser to reshape the surface of the cornea. After surgery, a contact lens is placed on the eye to act as a bandage for three or four days; eventually the raw surface of the cornea heals on its own.
The long-term results from PRK are as good as those of LASIK, and PRK costs about the same. But while PRK requires no cutting, it may take two months or more for the cornea to heal sufficiently to restore normal vision—which explains why PRK is performed only on patients who specifically need it.
LASEK and Epi-LASIK
Like PRK, LASEK (laser epithelial keratomileusis) or Epi-LASIK surgery are options for those who are not good candidates for LASIK surgery because they have thin corneas or have jobs or play sports that carry a high risk of eye injury.
The LASEK and Epi-LASIK procedures are similar to LASIK, except that during LASEK and Epi-LASIK only a very thin layer of corneal tissue is temporarily removed before exposing the cornea to the laser. The surgeon treats the top layer of cells of the cornea with an alcohol solution for about 30 seconds; this treatment loosens the thin layer of cells enough to allow the surgeon to lift it and fold it back. After the laser reshapes the cornea, the surgeon replaces this top corneal layer.
LASEK and Epi-LASIK cost about the same as the standard LASIK procedure.
Like PRK, with LASEK and Epi-LASIK, patients usually have fast initial vision recovery. But about two weeks post-surgery, they experience blurred vision for several weeks as their eyes discard wounded cells and replace them with new ones. Full visual recovery usually takes six to eight weeks.
Many surgeons no longer perform LASEK or Epi-LASIK procedures, but instead rely on PRK for patients who aren’t good candidates for LASIK.
Beginning at age 40 or so, the lenses in one’s eyes begin to lose their flexibility. For most people, this means vision is not equally good at all distances, even while wearing eyeglasses or contacts or after LASIK surgery. Most people between ages 40 and 50 eventually need eyeglasses or other help for close-up vision, a condition called “presbyopia” that can be remedied with multifocal eyeglasses or multifocal contact lenses. It can be dealt with by laser eye surgery if the dominant eye is corrected to see objects far away, and the other eye corrected to see close objects. But some patients who undergo LASIK to treat presbyopia are unable to adjust to these changes—particularly when it comes to depth perception—and must continue to use eyeglasses. The best way to test if monovision LASIK is right for you is to simulate the results of the surgery by wearing contact lenses: If your eyes can adjust to monovision treatment with contacts, they should adjust well to monovision LASIK.
ICL (implantable collamer lens) surgery isn’t laser surgery, but it’s a procedure commonly used for patients who are poor LASIK candidates. During ICL surgery a very small incision is made in the eye and a rolled-up soft flexible lens made of collagen and polymer is inserted underneath the cornea. After insertion, the lens is unrolled and positioned so it reshapes the cornea to its ideal proportions. Because the incisions are so small, no sutures are necessary.
Although implants are primarily used for patients who cannot undergo LASIK, another reason to consider them is that they can be surgically removed if you are unhappy with the results.
Research is ongoing, but it appears that implants are as safe as, if not safer than, LASIK procedures and produce similar results.