The Truth, The Whole Truth

Laser eye surgery, such as Lenticle Extraction (Small incision Lenticule Extraction), LASIK (Laser-Assisted In Situ Keratomileusis) and PRK (Photo-refractive Keratectomy), has transformed the field of vision correction. It has enabled millions of people to reduce or eliminate their reliance on glasses or contact lenses. An individual’s vision is often better after laser eye surgery than while wearing glasses or contact lenses.

While the safety and effectiveness of these procedures are now extensively documented, it’s essential to understand the risks and associated considerations to ensure you achieve your desired outcome. This article aims to provide an overview of the safety of laser eye surgery, including potential risks, benefits, and factors to consider when deciding if this treatment is right for you. We will also address further considerations, including how to choose your surgeon and review some common concerns.

The Basics of Laser Eye Surgery

Laser eye surgery involves reshaping the cornea, the clear front part of the eye, to correct vision errors such as myopia (shortsight), hyperopia (longsight), and astigmatism. By precisely altering the shape of the cornea, the laser allows light entering the eye to be correctly focused onto the retina, resulting in clearer vision.

Common Types of Laser Eye Surgery

Lenticule Extraction: This is the latest technique with many advantages. A single femtosecond laser very precisely creates air bubbles within the cornea, separating a contact lens-shaped piece of corneal tissue custom-designed to correct vision. The surgeon then removes this tissue through a tiny keyhole opening. This procedure is also known as SMILE, SmartSight and CLEAR.

LASIK: This is the most popular form of laser eye surgery. It involves using a laser and air bubbles to create a thin flap on the front of the cornea.  This is then lifted and a second laser is used to reshape the underlying corneal tissue. The flap is then precisely repositioned and naturally adheres, acting as a natural bandage.

PRK: In PRK, a laser is used directly on the surface of the eye. The outer layer of the cornea (the epithelium) is removed to expose the area to be reshaped by the laser. The epithelium regenerates over the following three days. This is the original method of performing laser eye surgery and is still used today, particularly for patients who are not suitable for other techniques and still offers good longterm results. It has been called many names since the 1980s, which can be confusing. These include ASA (Advanced surface ablation), LASEK and epi-LASIK. ASA uses different branding to describe the same procedure.

In contrast, LASEK and epi-LASIK describe a subtle difference in the procedure. For most patients, PRK is more uncomfortable in the first three days than LASIK or Lenticule extraction. Doctors have endeavoured to reduce post-operative discomfort for LASEK and epi-LASIK patients; however, this is questionable. They both use different methods to replace the epithelium after the procedure. Importantly, this does not affect the outcome or success of the procedure. Post-operative discomfort is very subjective, varying from person to person. Discomfort is managed with the correct post-operative regimen and the understanding that it is very short-lived, with any visual benefit far longer lasting.

Can laser eye surgery be used to treat other eye conditions?

Yes, modern technological advances now mean laser eye surgery can be used to reshape diseased corneas, aiming to restore the quality of vision. Please see https://www.kierendarcy.com/keratoconus and https:/www.visioncareclinic.com/keratoconus

What is the success rate (efficacy) of laser eye surgery?

Laser eye surgeries like Lenticule Extraction, LASIK and PRK have very high success rates. Modern lasers are extremely precise, within fractions of a millimetre of accuracy. According to the American Refractive Surgery Council, over 96% of patients achieve 20/20 vision or better following LASIK surgery. Most patients report significant improvement in their vision and high satisfaction with the results.

What are the long-term outcomes?

Studies have shown that the long-term outcomes of laser eye surgery are invariably favourable. Most patients maintain their improved vision for many years. However, some individuals may experience a gradual regression, particularly if they initially had a high degree of refractive error. Enhancements or repeat procedures can often address this issue.

How safe is laser eye surgery? What are the risks and potential complications?

FDA Approval and UK regulations

The FDA approves laser eye surgery procedures in the US. The FDA is an American regulatory body that is irrelevant to the UK. The Medicines and Healthcare Products Regulatory Agency (MHRA) is the UK equivalent. The availability of laser technology varies across the world. The UK is fortunate to have approved the latest technology and laser platforms, enabling the UK to lead with some laser treatments for conditions such as keratoconus. In the UK, the General Medical Council regulates all UK surgeons. It collaborates with the Royal College of Ophthalmologists to provide regulatory guidance for laser eye surgery surgeons. (https://www.rcophth.ac.uk/resources-listing/professional-standards-for-refractive-surgery). The Royal College sets an entry qualification for all surgeons wishing to perform laser eye surgery CertLRS. After completing this, surgeons should also undertake hands-on specialist fellowship training.

Will I go blind?

This is often the most common fear when considering laser eye surgery. The likelihood of this happening in one eye with laser eye surgery is one in several million. Therefore, the chance of this happening in both eyes is far lower than this. Nearly all issues and the rare complications that could occur are resolvable with the correct care and treatment.

Modern lasers are extremely precise and can be customised to the individual patient’s eye, reducing the risk of complications. Technological advancements have continuously improved their safety and effectiveness. Laser eye surgery was first performed in the 1980s. Modern lasers are unrecognisable from even those of the turn of this century. Original lasers could correct gross spectacle, prescription errors, but modern technology enables highly bespoke customised treatments. While very safe, laser eye surgery carries some risks, similar to any surgical procedure. When deciding whether to have surgery, any potential risks and dangers must be balanced against limitations of not having surgery. Glasses and contact lenses transform sight and, most patients with vision issues, they have been life-enabling for years. However, they can be challenging in certain situations.

An example, is that contact lenses should never be worn in water due to the risk of transmission of water-borne infections to the eyes. This can make simple situations such as swimming and paddling with children challenging or even dangerous. Everybody has their motivators, and it is essential to weigh the pros and cons as an individual.

What are the potential risks?

• Failure to complete the procedure: All three types of laser eye surgery provide the same outcomes. The benefits of LASIK and Lenticular extraction are a faster visual recovery. A femtosecond laser is used for both. Completing this laser procedure may be challenging in a tiny proportion of patients. This laser creates air bubbles in the cornea. If the treatment is abandoned, these bubbles will naturally disappear within hours and not affect your vision but will delay treatment.  However, a PRK surface laser surgery procedure can still be performed, correcting the glasses prescription.
• Dry Eyes: Many patients temporarily experience dryness following surgery, which may cause discomfort and blurred vision. This is usually temporary and managed with artificial tears and other medications.
• Glare, Halos, and Double Vision: Some original treatments in the 1980s, 1990s, and early 2000s caused some patients to see halos around lights or experience glare, particularly at night. While this is still normal in the first few days following treatment while the eyes are healing, it is now very uncommon for these to persist. In addition, technological advancements now mean correcting the effects people experienced following laser eye surgery in those early days is often possible. Booking an assessment in a specialist laser eye surgery centre is advised in that case.
• Under-correction or over-correction: Most patients have their vision corrected after the first procedure. A small percentage may require a minor enhancement to correct any residual prescription. Some may still need or choose to have glasses or contact lenses for certain activities.
• Flap Complications (LASIK-specific): Issues can arise with the corneal flap created during LASIK surgery. LASIK may not be the most appropriate option if, for example, you undertake contact sports. The flap settles over the first few days. During this period, it is important to avoid rubbing your eyes. Lifelong, the flap remains slightly weaker, although typically, the type of injury required to cause disruption or damage is likely to be traumatic to the eye, irrespectively. This is a benefit of lenticule extraction, where there isn’t a flap and only a tiny keyhole.

What are the potential serious complications?

• Infection: Although very rare, infections can occur and may lead to vision loss if not treated promptly.
• Corneal Ectasia: When you have a thorough, comprehensive pre-surgical work-up, where corneal measurements including depth, shape and strength are taken into account, this is very uncommon. Ectasia is when the cornea becomes weakened, progressively thinner and bulges. This can lead to vision impairment and may require further treatment, such as corneal cross-linking or, in severe cases, a corneal transplant. Technological advancements and the addition of collagen- provide methods to help improve the quality of vision in ectasias.
• Vision Loss: As you would image, vision loss is the main fear, which prevents people from having laser eye surgery. This risk of vision loss is rare. A comprehensive pre-operative review and modern technology have made it very rare. Still, any surgical procedure comes with some risk. You must feel comfortable with your surgeon before the procedure and know they will be there afterwards to guide your post-operative care. When considering where to have your surgery, it is imperative to ask these questions. In the worst-case scenario, for any severe complications leading to significant vision loss, a corneal transplant can usually restore vision. A corneal refractive specialist would manage this.

How do I know if I am suitable?

There are certain reasons why you may not be suitable for laser eye surgery. In this instance, there are often other ways to correct your vision, such as implantable contact lenses Implantable Contact Lenses (ICL) – Vision Care Clinic. A thorough pre-operative evaluation and review by an experienced ophthalmologist is crucial. Factors that may affect your suitability include:

• Age: Patients should be at least 18, as the eyes may still change in younger individuals.
• Stable vision: Vision should be stable for at least one year before surgery.
• Corneal Thickness: People with thin corneas may not have enough corneal tissue for the necessary reshaping.
• Keratoconus: traditionally, this was a contraindication for laser eye surgery. Modern advances now mean many people with keratoconus can have their vision improved in a specialist centre.
• High Prescription: Extremely high levels of myopia, hyperopia, or astigmatism may not be correctable with laser surgery.
• Overall Eye Health: Conditions such as severe dry eye, glaucoma, or other significant eye diseases may delay or disqualify a patient. In some, preliminary therapy may be suggested, while for others implantable contact lenses (ICLs) or other refractive procedures may be more suitable.
• Pregnancy and Nursing: Hormonal changes can affect vision stability, so wait until after pregnancy and nursing.

How do I know if my vision is stable?

It is advised to wait at least 12 months for stable vision before undergoing laser eye surgery. Our eyes are living organs and, therefore, continually change throughout our lives. Absolute long-term stability is, thus, not realistic. There are specific periods of life when these changes can be more pronounced. The first is when our eyes are growing during childhood and early adulthood. The second, typically in our 40s, is when the crystalline lens inside our eye starts to lose its ability to help us change focus, something called presbyopia. Presbyopia causes people to need help with reading and seeing close objects. In the third period, usually later in life, the crystalline lens becomes thickened and cloudy, called cataracts. Cataract causes blurring of the vision and typically a shift to short-sightedness.

People describe refractive or vision stability as the glasses prescription not changing by more than 0.5 dioptres in twelve months. This is the first number in the line of three you receive after an eye test, entitled Sphere or SPH. However, it is important to understand that there is some natural variability each time your glasses prescription is measured, complicating this further. This can be more pronounced when different people do the test and if you have a higher prescription. Therefore, having the same person remeasure your prescription can often be helpful. It is often worth contacting us if you are considering laser eye surgery and are wondering if your prescription is stable.

Can you treat presbyopia?

Yes. Although it is currently impossible to reverse the natural ageing changes of the crystalline lens that cause presbyopia, many different treatments are now available.

How to choose your eye surgeon?

Choosing an eye surgeon is a critical decision that can significantly impact your vision and overall eye health. Here are some steps and tips to help you make an informed choice:

Get Referrals

• Ask Your local Optometrist: They can provide recommendations based on their knowledge and network.
• Seek Recommendations from Friends and Family: Personal experiences can give you insights into the surgeon’s skills and bedside manner.
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Research the Surgeon’s Credentials

• Check their qualifications: Ensure the surgeon is on the specialist register for Ophthalmology with the GMC (https://www.gmc-uk.org/registration-and-licensing/the-medical-register) and has passed the Certificate in Laser Refractive Surgery (CertLRS)
• Verify their training and experience: Look for a surgeon with specialised training in Refractive Surgery. Refractive Surgery is not covered in the UK’s standard ophthalmologist training. Doctors should undertake higher specialist fellowship training after completing their standard training. Simply ask your surgeon.
• Check for disciplinary actions: Research if the surgeon has any history of malpractice claims or disciplinary actions.

Consider the surgeon’s experience.

• Number of Procedures Performed: Experience is crucial, especially for specialised surgeries. Ask how many procedures the surgeon has performed. As a guide for laser eye surgery, a surgeon is typically very comfortable after 100 of each procedure type. For lens replacement surgery, this number should be over 1000. It is also essential to ask about outcomes.
• Success Rates: Inquire about the surgeon’s success rates and complication rates.

Evaluate the Hospital or Clinic

• Hospital Quality: The quality of the hospital or clinic where the surgeon operates can affect outcomes. Look for facilities known for high standards and positive patient outcomes. Look for a Care Quality Commission rating of Excellent or Good in England. In Wales, this is HQIP.
• Location: Consider the convenience of the location. Consider how you would be affected if you required more follow-up visits than usual.

Review Patient Feedback

• Read Online Reviews: Websites like TrustPilot, Googland Doctify, can provide insights into other patients’ experiences.
• Patient Satisfaction Surveys: Some surgeons or clinics may provide patient satisfaction scores.

Schedule a Consultation

• Prepare Questions: Bring a list of questions regarding the procedure, risks, recovery, and expected outcomes.
• Evaluate Communication Style: Ensure the surgeon listens to your concerns, answers your questions thoroughly, and makes you feel comfortable.

Consider Technology and Techniques

• Up-to-date Technology: Ensure the surgeon uses the latest technology and techniques, which can lead to better outcomes.
• Special Techniques: Ask if the surgeon uses any special techniques that could benefit your specific condition.

Trust Your Instincts

• Comfort Level: Choose a surgeon with whom you feel comfortable and confident is very important.

Sample Questions to Ask During Consultation

1. Credentials and Experience:
   • What are your qualifications and experience in performing this specific type of eye surgery?
   • How many procedures have you performed, and what is your success rate?
2. Procedure Details:
   • What are the potential risks and complications associated with this surgery in my case?
   • What can I expect during the recovery period?
3. Technology and Techniques:
   • Do you use the latest technology and techniques for this procedure?
   • Is the surgeon involved with the aftercare?

By following these steps and carefully evaluating your options, you can choose an eye surgeon who is highly qualified, experienced, and aligned with your needs and expectations.

Conclusion

Laser eye surgery is a safe and effective option for vision correction. It’s essential to consult with a qualified eye surgeon, and we suggest following the simple steps outlined. Ultimately, you must find a surgeon you trust and can develop a relationship with, who will join you throughout your vision improvement journey. Laser eye surgery has been a life-changing option for millions, providing clearer vision.