Laser Vision Correction Eye Surgery Options and Alternatives

Laser eye surgery remains the most appropriate option for most people seeking to improve their vision without glasses or contacts. Phakic IOL surgery, refractive lens exchange, and corneal inlays offer other important alternatives.

I was recently asked to write a column on vision correction surgery options for “Your Health, Your Decision,” an international online health journal based out of Santa Barbara. More in-depth discussion of these topics can be found throughout our website.

(my article from “Your Health, Your Decision”):

Vision correction surgery is eye surgery to help you see without dependency on glasses or contact lenses. There are several options available, which can become quite confusing for the prospective patient.

The vision correction procedure most people have heard of is laser vision correction (LASIK and PRK) and it is still the most widely performed vision correction surgery. Recently, other non-laser surgical options have gained attention as well. These included phakic intraocular lenses (sometimes called “implantable contact lenses”) and refractive lens exchange. In the future, another exciting option will be the use of corneal inlay technology.

Let’s take a look at the pros and cons of each of these options, starting with laser vision correction.

Laser vision correction works by using an extremely precise excimer laser to reshape the cornea, the clear domed cover of the eye, so that it focuses light more precisely. Laser vision correction has proven itself, with nearly twenty years and 17 million cases of clinical experience in the United States. In fact, for most people, laser vision correction remains the most accurate and safest option of vision correction surgery. There are two types of laser vision correction surgery: LASIK and PRK. In fact, these procedures are essentially identical, except that in LASIK a flap is lifted from the corneal surface and the laser is applied to reshape the eye, whereas in PRK, no flap is made. Instead, the laser is applied to the surface of the cornea. LASIK offers much more immediate recovery, but there are many situations in which PRK is the better option. Patients with corneas that are too thin or too weak to withstand a LASIK flap are better treated with PRK. Unlike the situation with LASIK, recovery is not immediate with PRK. Vision after PRK initially typically is good, but not as good as LASIK, for about one month. There are typically about 3 or 4 days or significant irritation after PRK as well. Ultimately, however, most studies confirm that the final results of LASIK and PRK are identical – they differ only in recovery times.

Today, there are two broad categories of lasers used to perform laser vision correction, whether it be LASIK or PRK. The first type is called “conventional laser vision correction.” Conventional surgery is how laser vision correction has traditionally been performed in the United States and internationally. The second format is a newer and more accurate version called “Customized Wavefront laser vision correction” which bases the treatment on a customized “fingerprint” of your vision. While both types have FDA approval, data shows that Customized Wavefront laser vision correction is more accurate, and produces better night vision, than conventional laser vision correction. There are some cases, however, in which conventional surgery is actually to be preferred over Customized Wavefront surgery. In general, laser vision correction benefits from a desirable combination of a high degree of accuracy and a high degree of safety, all confirmed by a track record of millions of cases. Nonetheless, one must always weigh risk versus benefit when considering laser vision correction surgery.

Most patients seeking vision correction surgery fall within the ranges that are optimally treated by laser vision correction. However, some patients are too nearsighted even for laser vision correction. Other patients, as we’ll discuss below, simply are not candidates for laser vision correction. For patients who are not best served by laser vision correction, another option is the phakic intraocular lens. Two examples of phakic intraolucar lenses are the STAAR Visian ICL and the AMO Verisyse lens. Phakic IOL surgery is a non-laser surgery that is sometimes, somewhat inaccurately, referred to as inserting the “implantable contact lens.” With this surgery, an incision is made in the eye and a surgical plastic lens with the patient’s prescription in it is inserted into the eye. This lens can be placed either behind your iris (the colored part of the eye) or in front of your iris, depending on the lens type. In general, because this surgery actually penetrates into the eye in contrast to laser vision correction, it tends to have a higher risk profile than laser vision correction does for most people. However, these are FDA approved surgeries that can offer amazing results for patients who have been told they were not candidates for laser vision correction. With phakic intraocular lens surgery, the patient’s natural lens is not removed – the new lens is simply “added” to the interior of the eye. There is a much longer track record for these lenses in Europe than we have in the United States.

Another option for patients who are not good candidates for laser vision correction is refractive lens exchange. In this surgery, the patient’s natural lens is actually removed from the eye and it is replaced with a new plastic lens with the patient’s prescription in it. In fact, refractive lens exchange is essentially cataract surgery done on an eye that does not yet have significant cataracts. Patients who undergo refractive lens exchange never can develop a cataract in the future because they already will have had their cataract surgery! However, as with phakic intraocular lens surgery, this is a procedure that enters inside the eye and its level of risk must be weighed against its benefits.

Another category of vision correction surgery you’ll be hearing more about in the future is surgery for correcting the need for reading glasses (presbyopia). Currently, the most common method for correcting presbyopia is to use laser vision correction to set one eye for distance and one eye for some degree of near vision, minimizing or eliminating the need for reading glasses (this is called “monovision”). Another laser vision correction option not yet approved by the FDA is “presbyLASIK” in which LASIK is used to treat part of the cornea for near and part of the cornea for far vision. Both phakic intraocular lenses and refractive lens exchange can also be used to produce a monovision result.

Refractive lens exchanged can also be used to correct presbyopia by a different mechanism. There are a new generation of presbyopia correcting lenses that can be put in the eye during the refractive lens exchange process. These lens implants correct both far and near vision. While these do not yield the same vision as a 20 year old with perfect vision, they can be an appealing option for many patients.

Finally, there is an entirely new category of procedures called “corneal inlay” procedures which take a different approach to correcting presbyopia. With these surgeries, a LASIK flap is made and a bio-compatible thin piece of plastic is put under the LASIK flap which heals to hold it in place within the cornea. The inlay is typically put in the non-dominant eye to help it see both near and far. Different companies are using different strategies to achieve this goal and none of them has FDA approval yet. It is also not clear whether these procedures will produce results that are ultimately better than using laser vision correction to produce a degree of monovision.

So, how do you know if you’re a candidate for these procedures? First, as with any of these procedures, you need to know these are elective procedures, so you must always way the risk and the potential benefit to you. Also, it is important to wait until your eyes have stopped growing. This is why we typically don’t do LASIK on a 10 year old. None of these surgeries stop future changes in the eye from happening. It is normal for your prescription to get worse every year in the same way your shoe size gets bigger every year. At some point, these changes should stop. It is important to know we’re talking about distance prescription as it is normal for everyone to develop age related changes in reading, presbyopia, after age 40. Typically most people’s eyes stabilize sometime in their early 20s, but there is variability in this. Once your eyes have stabilized, you can think about vision correction surgery.

Laser vision correction surgery is performed on the cornea, so several of the criteria involve corneal health. First, you should not have a corneal disease called keratoconus and it is not optimal to have a history of herpes infection in your eye. A history of recurrent corneal erosions, in which you wake up in paint most mornings (you’d know it if you had it most likely) makes you a poor candidate for LASIK, but possibly a candidate for PRK. A history of lupus or rheumatoid arthritis is also a contraindication to laser vision correction in most cases. Women who are pregnant, or within 8 weeks of stopping nursing, should not have any form of vision correction surgery. Patients with visually significant cataracts should not have laser vision correction, but should have their cataracts removed to improve their vision – essentially they should have refractive lens exchange. Some people are so farsighted or so nearsighted they cannot have LASIK or PRK, but they may still be excellent candidates for phakic intraocular lens surgery or refractive lens exchange. The good news, however, is that most (but not all!) patients are candidates for some form of vision correction surgery – it’s just a matter of carefully selecting the most appropriate for you one and selecting a surgeon who can do the very best job for you. All of these surgeries involve an element of risk (as does wearing glasses or contact lenses) and it is very important to pick the most qualified surgeon available. Remember, these are all surgeries and your results will depend on your surgeon.

Laser Vision Correction Eye Surgery Options and Alternatives

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