Lasik: is it worth $6000?


I'm sick and tired of washing my contact lenses everyday, and my dog Malcolm recently broke my glasses with his teeth. That's why I'm thinking about getting Lasik.

Excimer laser technology was first used and developed by IBM to make etchings on computer chips in the 70s. The first excimer eye surgery was conducted in 1988, and the basic underlying technology has remained pretty much the same since then. There are a few things that are new now. The first is how our vision is mapped. The amount of correction needed for Lasik used to be measured the same way one would evaluate for eyeglasses — e.g. by showing the patient Cs facing different directions, giving them different lens options and having them say which eye sees sharper. Around 2002, surgeons started using wavefront-guided corrections, which means the laser relies on multiple detailed topographic maps that show all the quirks in each person's optical system.

The second thing that's different is the way the corneal flap is created. The flap-creating portion of Lasik used to be done using a mechanical keratome, basically a high-speed metal blade that would create a flap while the cornea is under a suction cup. "It's very similar to the guillotine effect you see when you go to a deli and they're slicing meat," says Dr. Manche, a Lasik surgeon at the Stanford Eye Laser Center. Now, most places use a femtosecond laser — a super accurate, super fast flap-making device. In addition to being a lot less invasive, the femtosecond laser creates flaps with a more uniform thickness — the mechanical flap tends to create a thinner center and a thicker peripheral, creating more structural instability in the eye.

Basically, Manche says, when you see tiered pricing at a laser eye surgery center, you should ask yourself these questions: What kind of laser do they use? Are they using wavefront-guided or traditional correction measurements? Is the flap being created by a laser or a blade? Is the surgery being performed by the head surgeon or an apprentice? Depending on these answers, you could end up with prices all along the spectrum, from a couple thousand bucks to $6000 (which is what Manche charges).

"It's lke heart surgery or brain surgery," says Dr. Roy Rubinfeld, a Lasik doctor at Washington Eye Physicians & Surgeons in DC . "Better surgeons will have better equipment, and will understand who is a better candidate and who isn't." Also keep in mind the importance of aftercare, something that many who opt for discount Lasik centers might lose out on.

To date, over 17 million Lasik procedures have been performed worldwide, and according to the FDA, 95-99% of them are complication-free. Of course, this also means that a good number of people who have had Lasik end up seeing halos or having compromised night vision — some have even started their own web sites to share Lasik horror stories and cautionary tales.

As for the next big thing? Some speculate it might be something called instrastromal ablation, which would use femtosecond lasers — the ones that make the flaps in Lasik — to make cuts inside the cornea. Since there's no flap creation process, there would be no possibility of flap complications, and it may be cheaper because it only uses one machine. Instrastromal ablation was used successfully on test subjects with presbyopia in recent tests outside of the US, but it could be years before we see it stateside. "There are three companies pursuing this now, but it's way down the pipeline," says Dr. Marguerite McDonald. She's the president of the International Society of Refractive Surgery, and she's also the person who performed the first excimer laser surgery in 1988. Other things, like eye implants and inlays, have already been done in small numbers and could become more popular in the near future.

McDonald also points out that Lasik is not getting cheaper anytime soon: "It is always going to be expensive because the technology that goes into the surgery is expensive. And there has to be a way to pay for the R&D of each breakthrough."

Armed with all this knowledge, I'm still not sure whether I'm going to get Lasik or not. I would definitely do it if it was a little bit cheaper, but I don't want to go for the discounted surgeon who might skimp on things like cleanliness or attention to detail. (I Googled the place that sent me the $500 off coupon, and found out that the head surgeon there had been sued several years ago for reusing blades.)

And what about just sticking with my Acuvues? "Contacts work briliantly," Manche says. "If you can wear them and they work well, that's a great option." A great option, Rubinfeld points out, that costs more over a decade than single Lasik operation.