Alternatives to LASIK : options for laser eye surgery

When people come to me and say they want LASIK, I think what they are saying is that they want to live their lives free of the burden of contact lenses and glasses. There are many alternatives to LASIK eye surgery, and while LASIK is still the best procedure for the majority of people, there are an increasing number of superb procedures that constitute a LASIK eye surgery alternative. Even within LASIK, there are differences that your surgeon can tailor to what best fits your needs.

One of my duties as your eye surgeon is to make sure you are fully informed about the alternatives to LASIK. There are several LASIK alternatives. Our goal at SharpeVision is to make sure that as many people as possible can live their lives without the burden of glasses or contact lenses. The options can include PRK, LASIK, ICL (Implantable Contact Lens), SMILE (SMall Incision Lenticular Extraction), RLE (Refractive Lens Exchange), or cataract surgery.

In this blog, I’ll discuss LASIK and each alternative to LASIK, including:

• PRK
• ICL
• SMILE
• RLE
• Cataract surgery

Each are alternatives to laser eye surgery that can allow you to see clearly without contacts or glasses. With each LASIK alternative, I’ll discuss the pros, cons, and to whom it is generally most suited.

LASIK

The first “laser eye surgery alternative”

We can’t have a discussion on LASIK alternatives to vision correction without addressing the most common vision correction choice. There’s a reason LASIK has remained the most popular choice for vision correction for over 25 years. It is quick (my patients allow me to complete bilateral LASIK in 6-7 minutes), painless (most people feel only a pressure on their eyes for 20 seconds while the first laser creates the flap), achieves superb results (my patients achieve 20/20 or better vision 99% of the time in young patients with low to moderate nearsightedness, and 96% of the time if we include high degrees of nearsightedness and older patients). Recovery from LASIK is quick, with most patients experiencing about 4 hours of burning, watery eyes, and over 80% have 20/20 or better vision within 24 hours (although it continues to get clearer and less foggy for days to weeks). It’s an amazing value, and pays dividends not only in lifestyle but in dollars not spent on contacts, glasses, solution for decades in the future.

LASIK Pros:

• Quick
• Painless
• Rapid recovery
• Accurate
• Lifestyle
• Lifetime savings

LASIK Cons:

• Can’t fix aging of the eye: cataract and presbyopia will still happen
• Not suitable for everyone
• Almost all will have temporary dry eyes
• Most, but not all branches of military allow it

LASIK is most suitable for:

• 18-50+ year-olds
• Low to moderate and even high degrees of nearsightedness and astigmatism
• Busy active people who desire the minimum down time
• Anyone who is tired of being tethered to glasses and contacts every waking moment!

Alternatives to LASIK : PRK

PRK (PhotoRefractive Keratectomy) is not a new LASIK alternative. On the contrary, it’s a little older than LASIK and was approved in the US in 1995. It shares a lot of the pros and cons of LASIK, in that it’s the same laser, the same results, and yet the laser is applied to the surface of the eye, rather than under the LASIK flap. We recommend PRK over LASIK for patients with thinner corneas and/or higher prescriptions to allow adequate residual corneal thickness. A few branches of the military allow PRK but not LASIK. For our military patients, I recommend consulting your recruiter or commanding officer and get permission in writing. Sometimes a patient simply requests PRK over LASIK. We can always perform PRK on someone who is a LASIK candidate but can’t always perform LASIK on a PRK candidate. Sometimes the anatomy of your cornea, eye socket (the bones around your eyes) or certain corneal disorders will result in the recommendation of PRK. People who have had previous LASIK and need a touch up years later will require PRK. Recovery of vision takes longer because the surface skin layer has to grow back over the surface of the eye. This usually takes 3-5 days, and vision continues to improve for weeks to months. There is also more discomfort after the procedure as compared to LASIK. Whereas LASIK patients experience burning and irritation for 4-5 hours, PRK patients experience burning and irritation for 2-3 days.

I believe that LASIK is very safe, but PRK is always a tiny bit safer because there is no flap. I’ll happily discuss what I’ve seen with the LASIK flap over my 20+ years performing LASIK on over 70,000 eyes. I have full confidence in LASIK, as I had LASIK on my own -8.00 (highly nearsighted) eyes in 1998, and I am thankful for this gift every day.

PRK Pros:

• Excellent results that are the same statistically to LASIK
• Perhaps the safest of all vision correction procedures
• Quick: 6-7 minutes total for both eyes
• Painless during procedure
• Best choice for highly anxious patients
• Accurate
• Lifetime savings on vision “crutches” (i.e., glasses and contacts)
• Lifestyle: camping, snowboarding without worry!
• Allowed by all military
• The lowest risk of all procedures in my opinion

PRK cons:

• More discomfort than LASIK in the first two days
• More blur than LASIK in the first week: more down time (3-5 days typically)
• Can’t fix aging of the eye of cataract and presbyopia
• Not suitable for everyone (about 90% of people with glasses are candidates for either LASIK or PRK)

PRK is most suitable for:

• Low to moderate and even highly nearsighted people with or without astigmatism
• Active lifestyle: we recommend for MMA fighters, Navy Seal types, boxers
• Age 18-50+
• Anyone wanting the safest, most effective vision correction procedure in the world

Alternatives to LASIK : ICL

The ICL (Implantable Contact Lens) procedure is one that I love for people who had often previously been told that they were not LASIK candidates. They are often resigned to not only wearing glasses or contacts but to wearing extraordinarily thick glasses due to their extreme nearsightedness. There’s nothing that makes me happier than helping someone who wears -14 glasses. We can safely and effectively rid them of their glasses with the ICL procedure. There is overlap between LASIK and PRK candidates and ICL candidates. Sometimes the anatomy of their eyes dictates the procedure recommendation. If some has corneal thickness that will allow laser vision correction but not enough space in their eye to allow an ICL, we recommend LASIK or PRK. Sometimes the reverse is true, where they have plenty of room to implant the ICL, but not enough corneal tissue to allow laser vision correction. ICL has been performed in over a million eyes worldwide to date since 2005, and is an excellent choice for moderate to extreme nearsightedness as long as the appropriate criteria are met. This can only be determined with a complete eye exam at a vision correction practice such as SharpeVision (where the exam is free)

ICL Pros:

• Accurate in highly nearsighted patients
• Time-tested
• No dryness
• Removable (although we’d only do that in the case of the lens being too big/small or cataract development)
• Painless implant in about 8-9 minutes per eye
• Doesn’t remove any corneal tissue
• Lifestyle perhaps even more positively impacted due to extreme nearsightedness
• Cost savings even greater due to the higher cost of highly nearsighted contacts and glasses: LensCrafters will rake you over the coals if you need strong glasses or contacts as you probably know!
• Exciting to know you’re a great candidate when you may have thought there was nothing that could be done

ICL Cons:

• More invasive in that it’s put inside your eye, although this risk is extremely low
• Costs more, but at SVML we are extremely competitive at $3500/eye total
• Currently requires a laser iridotomy but will hopefully be eliminated by the end of 2021 due to an FDA expected approved design change that has been available in the rest of the world since 2013
• Lens sizing can be an issue in about 1-2% (in my hands) where the lens is too small/big and needs to be exchanged
• Cataract risk: about 1% develop cataract after 7 years, according to a recent military study. This is consistent with what I’ve seen in our practice, where we’ve had two patients develop cataract in 366 eyes treated with ICL over 6 years. Keep in mind that highly nearsighted people are more likely to develop a premature cataract anyway. One of the two patients was over 50 when the cataract developed. Successful cataract surgery was performed with an excellent result

ICL is most suitable for:

• Highly nearsighted people (approved for-3 to -15 with or without significant astigmatism)
• Active young people wanting freedom from glasses and who have perhaps been deemed non-candidates in the past
• Age 18-50 (approved for 21-45, but can be performed outside this range as long as the patient is fully informed)
• Corneal anatomy doesn’t allow laser vision correction
• Those who simply prefer it
• Where the patient is worried about dryness. I don’t believe laser vision correction causes permanently worse dryness, but definitely temporary dryness in most people.

Alternatives to LASIK : SMILE

The SMILE (Small Incision Lenticule Extraction) procedure is an amazingly elegant and relatively new procedure. It uses the time tested femtosecond laser to create a posterior cut parallel to and just in front of the back surface of the cornea. This is immediately followed by a cut inside the front surface of the cornea that is joined at the periphery. The final portion of the treatment is a small incision at the edge of the two internal faces of the lenticule. The thickness of the “lenticule” increases as the amount of nearsightedness increases. This “lenticule” is then removed through a “SMall Incision” at the edge of the cornea. (See figure 1 above) It’s really quite elegant.  It’s currently approved in the US for nearsightedness from -1 to -10 with up to -3 diopters of astigmatism. The results still lag slightly behind LASIK, but it’s an important option for the treatment of nearsightedness without creating a flap.

SMILE Pros:

• Large range of nearsightedness and astigmatism is treatable
• No worries about a LASIK flap
• Less dryness in the first 6 months
• Rapid visual recovery similar to LASIK, and ICL, but quicker than PRK
• Excellent results with about nearly the same percentage of 20/20 vision as LASIK/PRK
• Even less immediate postoperative discomfort than LASIK because the incision is so small

SMILE Cons:

• More expensive on average (about $2500-$3000/eye on average)
• Results close but not quite as good as LASIK in most reported studies
• No easy way to do enhancements, but can be adjusted if necessary with PRK

SMILE is most suitable for:

• Age 18-50 with moderate to high amounts of nearsightedness and/or astigmatism
• Those seeking a painless, quick, and accurate vision correction procedure that has a very small risk of complications
• Any active lifestyle, even martial artist, boxer military personnel with higher than average risk for ocular trauma

Alternatives to LASIK : RLE

I love RLE (Refractive Lens Exchange) also. It’s a wonderful and definitive procedure for the right patient. In a nutshell, it is cataract surgery that takes place before insurance will approve payment for it. In our mid-40s, the lens of our eye starts to become dysfunctional. The lens becomes less flexible, which creates the need for either bifocals, reading glasses, multifocal contacts, or monovision contacts. We can’t see both distant objects and near objects without glasses for one or the other. Then typically in our mid-60s and older, that same lens becomes less clear, which creates glare and haloes that negatively impact our night vision, driving vision, and even reading vision. At some point along this spectrum, insurance will cover a portion of the cost. RLE is simply bypassing the insurance process and allows you to eliminate glasses and contacts earlier, and allows something none of the others do: it’s a one-time procedure that eliminates the need for glasses for distant and near objects and obviates the need for later cataract surgery! I think it’s great for someone who is starting to see the effects of lens dysfunction, and who has farsightedness, extreme nearsightedness, or who is not a good candidate for laser vision correction, ICL, or SMILE for any other reason. I think of it whenever I have a patient in their mid 50s or older. If in my exam I see the start of cataracts but know that it may be years or decades before the insurance company will pay (and they’re paying a smaller and smaller portion of the cost anyway) then I may recommend RLE. This is especially true of anyone who is farsighted, because LASIK/PRK is not as accurate for farsightedness, often has regression, and will require future cataract surgery anyway.

RLE Pros:

• Definitive: that is, it’s a one-time procedure that solves the problem of presbyopia, eliminates future cataract surgery
• It’s painless and quick (usually 10-12 minutes in experienced hands)
• Quick recovery: most patients see 20/20 the next day, although the vision will improve for days to weeks
• Multifocal lenses allow good distance and near vision without glasses!
• Low risk, high reward

RLE Cons:

• Risk is low but higher than LASIK due to it being an intraocular procedure
• Expensive: may be $12-15,000 total for both eyes
• Could require a laser touch up, but so can all the others
• Lots of drops required for the first week postop

CATARACT SURGERY

Cataract surgery is the most common procedure in the US today, and has been for many years. The reason is that everyone (if you live long enough) will get them at some point. Cataract surgery is the same as RLE but is defined by the lens being clouded enough to affect your vision to the point where insurance will approve it. All the above information for RLE applies to cataract surgery also.

As you can see, there are many superb choices for LASIK alternatives to vision correction, and sometimes more than one, for you to consider that will help you achieve excellent clear uncorrected vision. It’s our job at SharpeVision to carefully listen to you, to examine you, to analyze the data, and to make our recommendation. I spend a lot of time discussing the options with people and often perform a procedure based on patient preferences, as long as I also strongly believe it’s going to be safe, and highly likely to get perfect results. I love having all the options available so that we only do what’s best, rather than what we have available. So what are you waiting for? Schedule your free comprehensive exam today and take the first step toward living your best life with clear uncorrected vision!

-Dr. Matthew Sharpe