Seth A. Biser, M.D., P.C.

LASIK 102: Advanced Questions and Answers

Seth A. Biser, M.D.

Note: the following guide is based on my own experience of treating thousands of laser vision patients. Other surgeons are likely to have different opinions regarding specific issues.

Should I have LASIK, IntraLASIK, or PRK?

Good question!  First, let’s run through the basics. These terms refer to the way the cornea is surgically prepared before it is treated with the vision-correcting (excimer) laser.  LASIK and IntraLASIK involve creating a flap in the cornea, whereas PRK does not. In LASIK, this flap is created with a blade; in IntraLASIK, the flap is created with a special laser (femtosecond laser).  While several individual studies have suggested benefits of one method over another, the entire spectrum of studies seems to indicate that all 3 methods result in equivalent visual outcomes, following a healing period.

Note that the actual vision-correcting portion of the laser treatment is always performed with the excimer laser. This is exactly the same whether you are having LASIK, IntraLASIK, or PRK, and it is why the visual outcomes are nearly the same after all 3 methods of surgery. Only IntraLASIK patients are treated with two lasers: one to create the corneal flap, and the other to change the shape of the cornea.

LASIK.  LASIK is the most popular method of vision correction. It allows very rapid healing, with most patients seeing 20/20 to 20/30 the morning after their procedure. Patients need to take eye drops for only one week following surgery. LASIK involves creating a flap in the cornea using a small mechanical device called a microkeratome, which employs a fine metal disposable blade. There is some uncomfortable pressure right at the start of each LASIK procedure, but this typically lasts for only 20 seconds. (Some patients say they don’t remember the pressure at all, and others say it is intense.) The entire LASIK procedure typically lasts less than 5 minutes per eye. LASIK has been practiced since the 1990s and is an extremely safe and reliable procedure. LASIK costs less than IntraLASIK, and achieves much more rapid healing and less overall discomfort than PRK. However, some patients may not be good candidates for LASIK, and may have to be switched to IntraLASIK or PRK.

IntraLASIK, or “all-laser LASIK.”  IntraLASIK uses the Intralase device, which is an extraordinarily accurate and reliable laser-powered tool that has been available since the early 2000’s. The Intralase creates a corneal flap using computer-guided femtosecond laser energy. During the creation of the Intralase flap, there is some pressure placed on the eye, which is occasionally uncomfortable. This lasts for less than 45 seconds, and the laser creation of the flap only takes 15 seconds. The visual recovery is the same as with LASIK. As a result of the computer-guided technology, the architecture of the Intralase-created flaps is highly predictable. If it is within your budget, I strongly recommend IntraLASIK because of the much greater degree of accuracy and safety involved with the creation of an Intralase flap. Many patients whose corneas are too thin or whose prescriptions are too high for LASIK can safely undergo IntraLASIK. IntraLASIK is, however, more expensive than LASIK.

Flap Complications. You should know that there are a number of rare but potential “flap complications” with LASIK and IntraLASIK, and these need to be carefully guarded against before, during, and after the procedure. While IntraLASIK is safer than LASIK for these procedures, in some cases the risks are too great to have any corneal flap, and patients may only have PRK.

PRK.  If you are not a candidate for either LASIK or IntraLASIK, you may still be a good candidate for PRK.  In PRK, there are no risks of flap complications. PRK involves brushing the surface of the cornea for around 30 seconds, which patients feel as a vibration. This removes the epithelium, an ultra-thin layer which is 7 cell layers thick and which grows back in 3-5 days after removal. Healing from PRK can be uncomfortable during the first 3-5 days, including a 1-2 day period when the vision is very blurry. However, the discomfort is variable, and I have even treated some patients with very high prescriptions who report no discomfort whatsoever. Patients who are careful in avoiding smoke and adhering to the postop directions tend to do better. Stable functional vision usually takes one week to achieve after PRK, and the fine-tuned vision typically takes longer.

Should I have CustomVue?

CustomVue refers to a computer-enhanced method of applying laser vision correction to the cornea. Whereas LASIK, IntraLASIK, and PRK refer to the surgical method of preparing the eye for laser vision correction, CustomVue refers to the calculations involved in treating your nearsightedness, farsightedness, and/or astigmatism.  

Yes, I recommend CustomVue to most patients. CustomVue, which is a wavefront-guided treatment, allows your laser treatment to be customized to the "fingerprint" of your own individual optical system. As such, CustomVue goes beyond our usual measures of nearsightedness, farsightedness, and astigmatism to give you a more advanced form of vision improvement than can be achieved with standard glasses and contact lenses. CustomVue can also improve the accuracy and reliability of your treatment, and can reduce the risk of postoperative glare. This is especially true in patients with large pupils and higher amounts of astigmatism.

Final candidacy for CustomVue can sometimes only be determined on the day of surgery, however. If a patient is not a good candidate for CustomVue, then a standard laser formula is used. Still, even patients who prove not to be good candidates for CustomVue respond excellently to standard laser treatments, and many of my standard laser patients see 20/15 postoperatively.

What will happen to my vision after age 39? Will I need “Monovision”?

All patients over 39 face increasing challenges of seeing up close. The vast majority of people over 40 either need reading glasses, or need to take off their glasses in order to read. This issue must be address when patients who want Laser Vision Correction are approaching, or past, 40 years old.

The majority of patients undergoing Laser Vision Correction choose to be corrected for clear distance vision with both eyes. This means, of course, that they will need reading glasses at some point after the operation. Some patients, however, can reduce their dependence on reading glasses through Monovision, or "blended vision," in which one eye is focused primarily for distance, and the other eye primarily for near vision. Monovision is an entirely individual issue, and is best addressed during careful preoperative testing. I always insist on a “test drive” of blended vision prior to surgery, so that both I and the patient can see whether this is the right approach.

Will I feel the laser?

Not at all. While you may feel pressure or vibration while your cornea is being prepared for surgery, the actual laser application is completely painless whether you have LASIK, IntraLASIK, or PRK.

How will I keep my eye open during surgery?

Don’t worry! A small device called an eyelid speculum keeps your eye comfortably open. Even if you blink your other eye, the eye having surgery will not close. Moreover, a "pupil tracker" tracks every movement of your eye, adjusting within hundredths of a second if you move your eye during surgery. This assures that your treatment is always centered where it is needed.

What about LASEK and Epi-LASIK?

These refer to PRK-type procedures in which the epithelium (the thin skin on the surface of the cornea) is removed with means other than a gentle brush (LASEK uses alcohol and Epi-LASIK uses a special mechanical blade). My understanding of the literature, supported in part by my previous surgical experience with these techniques, is that PRK offers outcomes and recovery that are absolutely equivalent to these procedures, but with less discomfort and less risk. Therefore, when a flap procedure must be avoided, I offer PRK rather than LASEK or Epi-LASIK.

What are the restrictions during the recovery period?

IntraLASIK and LASIK patients can return to work the next day as long as they are not exposed to dusty or dirty environments (in which case one week is desirable, or less if eye shields are worn at all times). Absolutely no eye rubbing is allowed for 3 weeks after these flap-based procedures. PRK patients may return to work the day after surgery as well, but patients usually experience blurred vision during days 3-4, and time off from work is strongly recommended. Showering is allowed with all procedures the day after surgery as long as absolutely no water gets in the eye. Light aerobics may begin 4-5 days after surgery, and heavy workouts 2 weeks afterward. Underwater swimming may begin 3 weeks after surgery. You can get on an airplane 3 days after surgery but should not plan any long-term air travel until around 2 weeks after your scheduled surgery, so that you can be seen promptly should any issues or emergencies arise during your initial healing period.

What will happen to my vision in the years following my treatment?

I always consider the long-term effects when measuring and preparing patients for surgery, and I aim to build in some longer-term protection against “regression”—that is, any loss of crisp vision over time. If your prescription is stable prior to surgery, and there is no need for touch-ups within the first year after your vision correction (these touch-ups are covered at no charge), then typically the vision will stay clear and sharp for many years to come. If the vision does decline over time, it is typically in very small amounts that can be easily corrected at a fraction of the original cost of surgery. However, your vision will never “regress” to anything like your original prescription, and you will continue to benefit from your laser vision correction for decades after your procedure.

What if I have more questions?

 Contact us!  Feel free to call us at 914-664-2300 and ask to speak to one of our technicians about Laser Vision Correction. If there are questions the technician cannot answer, you will be referred to Dr. Biser.