LASIK surgery: Is it right for you?

If you're tired of wearing eyeglasses or contact lenses, you may wonder whether LASIK surgery is right for you. LASIK is short for laser-assisted in situ keratomileusis. It is a surgery to correct blurry vision.

The result of LASIK surgery for more than 99% of people is 20/40 vision or better. This allows people to do most activities without wearing glasses or contact lenses. Some people may need glasses for driving at night. And people will likely need reading glasses as they grow older.

LASIK surgery has a good track record. Serious complications are rare, and most people are pleased with the results. The most common side effect is dry eyes, which can last weeks to months.

LASIK does not correct more-serious blurry vision, and it is not a good option for all people. Being a good candidate for LASIK surgery requires having healthy eyes, stable vision, reasonable expectations, and a good understanding of the benefits and risks of the procedure.

What is the goal of LASIK surgery

LASIK is the most commonly performed refractive laser surgery. In refractive laser surgeries, lasers change the shape of the clear outer layer of the eye, called the cornea.

Conditions called refractive errors affect how light passes through the cornea and lens. If an eye has no refractive errors, the cornea and lens bend light rays to meet at a single point on the back of the eye. This area, called the retina, translates the light into signals to the brain that allow a person to see a clear image.

A refractive error happens when the light bends in such a way that it doesn't meet on the retina. This can happen because of:

• The condition of the cornea.
• The condition or placement of the lens.
• The size or shape of the eye.

When light doesn't come to a single point on the retina, an object is not in focus and it appears blurry. Refractive errors can cause different types of blurry vision:

• Nearsightedness, called myopia, happens when an image is focused in front of the retina. Near objects are clear, but distant objects are blurry.
• Farsightedness, called hyperopia, happens when light reaches the retina before it meets at a single point. The point at which light rays would meet is behind the retina. Distant objects are clear, but near objects are blurry.
• Astigmatism happens when the shape of the cornea or lens is uneven. Light cannot be bent to meet at a single point. Vision is blurry at all distances.

When a person wears glasses or contacts, the artificial lens bends the light so that it meets at a single point on the retina. The principle with LASIK and other refractive laser surgeries is similar. By changing the shape of the cornea, the surgeon is able to change how light is focused.

What are the types of refractive laser surgery?

While LASIK is the most common surgery for refractive errors, there are other procedures that have similar procedures or goals. Refractive laser surgery options include:

• LASIK. The surgeon uses a laser or blade to create a flap in the outer layers of the cornea. A laser is then used to reshape the part of the cornea that is exposed. The flap is then closed. Discomfort after surgery is minimal, and vision recovery usually takes place in 1 to 2 days.
• Photorefractive keratectomy, also called PRK. With PRK, the very thin top layer of the cornea is removed. Then the cornea is reshaped with a laser. A contact lens is used to protect the eye while it's healing. Pain usually lasts 2 to 3 days. Vision recovery can take several days and vision gradually improves.
• Small-incision lenticule extraction, also called SMILE. With SMILE, the surgeon uses a laser to create a thin disc, called a lenticule, in the cornea below the surface of the eye. Then the surgeon removes the lenticule through a small incision. With the lenticule removed, the shape of the remaining cornea corrects the refractive error. Healing time is similar to that of LASIK, but vision recovery is a bit longer. SMILE is used to correct only nearsightedness and astigmatism.

If you play contact sports or work in a job that has a risk of trauma to the eyes or face, LASIK surgery may not be a good choice for you. These jobs may include police officer, firefighter and positions in the military. PRK and SMILE may be better options.

Intraocular lenses

A less common alternative to refractive laser surgery is the use of artificial lenses placed inside the eyes. These are called intraocular lenses.

Intraocular lenses can treat different types of refractive errors depending on the specific procedure and lens used. They may correct more-severe refractive errors than laser surgeries of the cornea can correct. The recovery of vision after intraocular lens placement is generally shorter than with laser surgeries.

There are three general methods:

• The artificial lens is placed in front of the iris to correct the refractive error.
• The lens is placed behind the iris. This type of lens, called an implantable collamer lens, is a combination of plastic and biological material that allows it to work more like a natural lens.
• An artificial lens also may be used to replace the natural lens. This is called a refractive lens exchange or clear lens extraction. This is essentially the same procedure as that used to treat a cloudy lens, a condition called a cataract.

Is my vision treatable and stable?

Each procedure is approved to treat certain degrees of vision correction. Extreme nearsightedness, farsightedness and astigmatism are generally not treatable with refractive laser surgery. The risk of surgery may not be worth the possible benefit. Talk with your eye specialist about whether one of the laser procedures might work with your vision.

Also, your vision needs to be stable with only minor changes for at least a year. In particular, people who are nearsighted often have vision changes through their teenage years and into their early twenties.

Certain conditions and medicines — pregnancy, breastfeeding, steroid medicines — may cause temporary changes in your vision. Wait until your vision has stabilized before considering LASIK eye surgery.

Are my eyes healthy?

The outcome of surgery depends in part on the condition of the cornea and overall health of your eyes. For example, the cornea itself needs to be a certain thickness and in good condition. Healthy eyes are more likely to heal well and have good treatment outcomes.

Your eye surgeon asks detailed questions about your eyes. The surgeon tests for any conditions that might result in complications or poor outcomes. These include:

• Thinning or damage to the cornea or a family history of diseases of the cornea.
• History of viral infections, disease or injury of the eyes.
• Dry eyes, which can worsen with surgery.
• Large pupils or small corneas, both of which can lead to vision complications.
• Disease of the optic nerve called glaucoma.
• Cloudy lenses called cataracts.

Am I healthy?

Your eye surgeon also asks detailed questions about your general health. Certain medical conditions or the treatments for them can cause poor healing and outcomes. These include:

• Immune system conditions — such as rheumatoid arthritis, lupus, HIV and autoimmune diseases — that affect your ability to heal or make you more prone to infections.
• Medicines that suppress the immune system.
• Diabetes that's not well managed.
• Certain heart conditions or medicines to treat heart conditions.

Can I afford it?

Most insurance plans consider laser eye surgery to be an elective procedure and don't cover the cost. See if your vision care plan has any coverage. Know in detail what the surgery will cost you.

Do I understand possible side effects and complications?

Certain side effects, including dry eyes and temporary vision changes, are fairly common. But these usually resolve after a few weeks or months. In some cases, complications are long-term and cause trouble with vision. Some long-term complications are treated by wearing glasses or contacts. Vision loss is rare.

Complications include:

• Dry eyes. Dry eyes are common for the first six months or so after your surgery. Your healthcare professional may prescribe natural tears or prescription eye drops.
• Vision problems. Trouble with vision may last from a few days to weeks, but there may be long-term complications. Vision problems may include:
  • Cloudy vision.
  • Halos or starbursts around lights, particularly at night.
  • Double vision.
  • Trouble seeing in low light.
  • Sensitivity to light.
• Undercorrections. If the laser removes too little tissue from your eye, your vision may not be as clear as expected. These undercorrections are more common for people who are nearsighted. You may need another refractive laser surgery within a year to remove more tissue.
• Overcorrections. The laser also can remove too much tissue from your eye. Overcorrections may be more difficult to fix than undercorrections. You may need to wear glasses or contact lenses.
• Astigmatism. Astigmatism can be caused by uneven tissue removal. It may require additional surgery, glasses or contact lenses.
• Flap complications. The flap created during LASIK may fold and need to be lifted and replaced. Rarely, a flap may open or become dislodged before it's healed.
• Altered growth of the cornea. The outer layer of the cornea may grow in a way that's not expected under a LASIK flap or in a SMILE incision.
• Infection. In all types of refractive surgery, there is a chance your eye could become infected. This can lead to poor vision outcomes even with treatment.
• Corneal ectasia. Corneal ectasia is rare but it's one of the more serious complications. The cornea is too thin and unstable. It bulges outward, changing the refraction of light and greatly harming vision. Surgery, medicines and contact lenses may improve the outcome.
• Worse vision or loss of vision. Rarely, people have worse vision after surgery even with glasses or contact lenses. Blindness is very rare.

LASIK versus reading glasses

By their early to mid-40s, all adults lose some ability to focus on nearby objects because the lens in the eye becomes less flexible. This condition is called presbyopia. Presbyopia results in difficulty reading small print or doing close-up tasks.

People with low to moderate nearsightedness throughout their lives may find that they can compensate for presbyopia later in life. They may be able to focus for reading or other close vision without reading glasses.

If your nearsightedness is corrected with LASIK or another surgery, you'll likely need reading glasses eventually. But many people are happy to trade clear distance vision when they are younger for having to wear reading glasses when they are older.

One option for older adults with nearsightedness is monovision. With monovision, one eye is corrected for clear distant vision and the other eye is slightly corrected for near vision. Not everyone is able to adjust to or tolerate monovision. Your eye specialist will likely ask you to do a trial with contact lenses before having a permanent surgical procedure.

Can I follow presurgery and postsurgery guidelines?

If you wear contact lenses, you have to completely stop wearing them and switch to glasses for at least a few weeks before your surgery. Contact lenses distort the natural shape of your cornea. This can lead to inaccurate measurements and poor surgical outcomes.

You use eyedrops after surgery to help with healing. If you have PRK surgery, you wear sunglasses outside to prevent scarring. Follow all instructions carefully.

What are my expectations?

Most people who have refractive laser surgery have good to excellent vision for many years. You'll usually be able to play sports and swim — or even just see the clock first thing in the morning — without having to worry about your glasses or contact lenses. But as you get older or in low-light conditions, you may still need to wear glasses.

Most people report high satisfaction after surgery. But long-term results often aren't available. Part of the reason for this is that people are overall satisfied after surgery, so follow-up data is not collected. Also, the techniques have improved, and the guidelines for determining good candidates for the surgery have improved. This makes it difficult to draw conclusions about recent surgeries from the long-term data that is reported.

Keep in mind that even when postoperative follow-up is done and reported, vision is measured under optimal testing conditions. Your vision in dim light — such as at dusk or in fog — may not be as good as published reports suggest it will be.

Over time, your vision may change, and the initial surgery may not correct refractive errors later in life. The exact degree of change is hard to predict.

How do I choose an eye surgeon?

Most people don't have firsthand knowledge about LASIK or eye surgeons. A good starting point when choosing an eye surgeon is to talk with an eye care professional you know and trust. Or ask friends or family members who have had successful LASIK surgery.

Your eye surgeon will probably work with a team that may help with your initial evaluation and measurements. But it is your surgeon who takes the ultimate responsibility for determining whether refractive laser surgery is right for you. The surgeon recommends the best procedure for you, confirms the measurements to guide the procedure, performs the procedure and provides postoperative care.

Questions you can ask include:

• Am I a good candidate for refractive laser surgery?
• Which procedure is best for me?
• What risks do I have?
• Will one procedure have fewer risks for me?
• What are reasonable expectations for outcomes?
• What kind of follow-up care do you provide?
• How often have you done the recommended procedure?

The final decision

When it comes to LASIK eye surgery, there are no right answers. Carefully consider the factors outlined here. Weigh your preferences and risk tolerance, and make sure you have realistic expectations. Work with an eye surgeon who makes you feel confident and can answer your questions. In the end, if it feels right, then proceed. But if it doesn't, don't rush into anything.