Laser Vision Correction
Almost every person who is seriously considering Laser Vision Correction has dozens of questions. This general introduction to Laser Vision Correction will answer the initial questions asked by most patients. Since 2001, I have performed thousands of cases, each with careful attention to individual patient needs. I have found that careful planning and advance preparation, as well as personalized treatment before and after the procedure, is the best guarantee of success.
What is Laser Vision Correction?
It is a precise treatment to correct nearsightedness, farsightedness, and astigmatism in which a “cold” excimer laser gently reshapes the cornea (the clear shield on the front of the eye). The three main subtypes of Laser Vision Correction are LASIK, IntraLASIK, and PRK, although subsets and some newer versions of these procedures (such as SMILE) are also available.
Who can have Laser Vision Correction?
Patients must be at least 18 years old and have good, stable vision in both eyes with glasses or contact lenses. Laser vision is NOT appropriate for people who want to see better than they can with glasses or contact lenses. Because many 18-year-olds still have changing vision, my youngest patients have typically been 20 or over. Patients must also pass a series of preoperative diagnostic tests to make sure that they are good candidates (in other words, that the procedure will be safe for them).
What is the procedure like?
The eye surface is numbed with drops, and an eyelid speculum prevents blinking while the cornea is prepared for the laser. The patient focuses on a small red flashing light as the treatment begins. Sometimes, the patient will actually see the vision improving second by second during the laser application. The entire procedure typically takes 5-7 minutes per eye.
When will I start to see better?
The initial effect is immediate: patients sit up and can read a clock across the room. Although the vision at this early stage is reasonably good, further clearing of vision will come later, and varies by procedure.
What will my vision be, and will it last?
While individual results may vary, nearly all patients achieve 20/20 vision in a single treatment, after the healing process is complete. With higher or more difficult prescriptions, an enhancement, or “touch-up,” may be needed to achieve perfect vision. My enhancement rate is less than 1%, so my first-treatment results tend to be highly accurate. Once the final vision is attained, it tends to stay stable. My aim with all patients is to give them vision that they will remain happy with for many years.
What are LASIK, IntraLASIK, and PRK?
In both LASIK and IntraLASIK, laser is applied under a thin “flap” made in the cornea. In LASIK, this flap is created mechanically. In IntraLASIK, this flap is created with the Intralase machine, using laser energy. IntraLASIK is often known as “all-laser LASIK.” In PRK, no flap is created; the cornea is prepared with a small, rotating brush that prepares the surface of the cornea for the laser.
Is it Safe?
Yes, assuming careful preop preparation and patient selection, laser vision correction is an extremely safe, time-tested, FDA-cleared treatment. Because there are risks with any eye surgery, prevention of problems is the most important step in the process. I start with rigorous preoperative testing to see whether each patient is truly a good candidate. Screening for problems such as dry eye syndrome, blepharitis, subtle corneal dystrophies, presence of early cataracts, and other eye conditions helps to distinguish candidates from non-candidates, and to best prepare patients for the procedure. As a result of these and many other safety measures, I have maintained an excellent record of both safety and accuracy in my postoperative patients.
What model of laser do you use?
I primarily use the VISX Star S4-IR with CustomVue. For IntraLASIK, I use the 60-Hz (FS60) Intralase, which creates ultra-safe flaps in just 15 seconds.
Can I Afford It?
After considering the options, most patients say “yes.” Our rates are very reasonable and very competitive. You can even use your flexible spending account (allowing payment with tax-free dollars) for payment. Most patients decide that having laser vision correction is far less burdensome than repeatedly paying for and dealing with new glasses and contact lenses.
Should I have LASIK, IntraLASIK, or PRK?
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 cutting a flap in the more rigid substance or “stroma” of 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, which is different from the vision-correcting or excimer 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.
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. 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 somewhat 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. PRK is an extremely safe procedure that avoids the risk of flap complications. This is the procedure that I have historically used when treating other physicians (typically because of their own preference for it), and more recently, for other patients as well. 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. Functional vision usually takes one week to achieve after PRK, so most patients go back to work at this point. The fine-tuned vision typically takes much longer to achieve, with minor fluctuations noticeable for up to 3 months after the procedure.
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.
I always obtain a WaveScan (a screening test for CustomVue) on all patients, at no additional cost. If CustomVue seems appropriate, I then recommend it. 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 40 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?
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 exactly on-target, where it is needed.
What about Advanced Surface Ablation and LASEK?
These terms refer to ways that the epithelium, or thin skin on the corneal surface, is removed before surgery. Advanced Surface Ablation is a general term that includes many variations of PRK (including the one I use). LASEK procedures (including a now largely-abandoned variant called Epi-LASIK) involve temporarily removing and then replacing the epithelium at the end of surgery. LASEK procedures typically involve the use of strong alcohol on the ocular surface, a process that can cause difficulties with recovery. I personally used to perform LASEK, and while it worked well, my PRK patients seemed to have better outcomes and less discomfort, so I switched entirely to PRK.
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 travel out of the area 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?
My aim is to plan ahead in order to give all patients many years of great vision after just one procedure. 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 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 and will not regress to anything like the original prescription.
As a result of careful planning, I have had the pleasure of seeing my previous refractive surgery patients show up in the office after up to 10 to 12 years (typically taking a child or parent to see me for an eye care visit), still happy and glasses-free, with excellent vision.