Custom Lasik (Wavefront-Optimized, Wavefront-Guided, Topography-Guided)

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What is Custom LASIK?

Custom LASIK is an advanced version of LASIK vision correction surgery. It uses cutting-edge technology to map and evaluate the unique features of your eye.

There are three types of custom LASIK, including:

  • Wavefront-guided LASIK
  • Wavefront-optimized LASIK
  • Topography-guided LASIK

Custom LASIK procedures typically produce better results than standard LASIK. However, due to the advanced technology used, they usually have a higher price tag.

Custom vs Standard LASIK (What's the Difference?)

The main difference between custom and standard LASIK procedures is the technology used. We'll cover the types of technology used in each custom LASIK procedure below.

For now, we'll discuss the two major advantages that custom LASIK procedures provide:

Increased Precision

Diopters are the unit of measurement used to determine your eyeglasses prescription. If you've ever had an eye exam, you're probably familiar with a phoropter, or refractor. This is the machine doctors use to place different lenses in front of your eyes. Each "tick" on the dial represents .25 diopter. This is why prescriptions contain numbers like 1.75 and 2.00, but never 1.8.

Phoropter Refractor

Wavefront LASIK technology has a computer do this measuring. It measures vision correction to the nearest .01 diopter. This makes it 25 times more accurate than standard measurements performed by an optometrist.

Increased Personalization

An eyeglasses prescription measures your eye's ability to focus light as one unit. A custom LASIK measurement creates hundreds of different points to gather data. This creates a unique map or "fingerprint" that details your eye's imperfections.

This fingerprint shows higher-order aberrations, as well as common refractive errors. The excimer laser can then personalize your vision correction based on this data.

What Are Aberrations?

Higher-order aberrations are light-related distortions in your vision. They can occur in your cornea, which is the clear covering in front of your eye.

Higher-order aberration symptoms include:

  • Halos or starbursts around lights
  • Glare
  • Ghosting or shadows in your vision
  • Poor contrast sensitivity
  • Difficulty seeing in low light conditions

In contrast, your refractive error is an example of a lower-order aberration.

Lower-order aberrations include:

  • Myopia (nearsightedness), which is when you are unable to see at a distance.
  • Hyperopia (farsightedness), which is when you have difficulty seeing at near.
  • Astigmatism, which is when you have an irregularly shaped eye. Your eye shape is similar to an egg, versus round like a ball. Astigmatism causes difficulty seeing at distance and near.

Correcting higher-order aberrations can deliver better visual clarity than correcting lower-order aberrations alone. Patients who have a significant amount of higher-order aberrations may be good candidates for a wavefront-guided procedure. 

Lower-order aberrations make up 90 percent of all aberrations in your eye, while higher-order aberrations make up about 10 percent.

Types of Custom LASIK

Wavefront-Guided

Wavefront-guided LASIK is a customized LASIK procedure. When someone says "custom LASIK" they are usually referring to wavefront-guided LASIK.

Conventional LASIK primarily treats your refractive error, which you can think of as the numbers on your eyeglass prescription. Wavefront-guided technology corrects refractive errors along with minor irregularities in your visual system, called higher-order aberrations.

What is a wavefront?

If you imagine multiple rays of light, the wavefront is a surface perpendicular to corresponding points on each of these light rays. 

Wavefront-Guided LASIK Procedure Overview

Before LASIK, your eye surgeon will use an instrument called a wavefront aberrometer to take measurements of your eye. 

First, the wavefront aberrometer sends a beam of light through your eye. The light travels through your cornea and lens. These structures in your eye are naturally clear and help focus light, but may contain higher-order aberrations.

The light reflects off your retina, which is the tissue lining the back of your eye. Then, the aberrometer measures the reflected wavefront as it travels back to the front of your eye.

The wavefront aberrometer uses this information to generate a 3D wavefront map, which includes any aberrations. A wavefront map is as unique as your fingerprint. 

Wavefront Aberrometry

Your eye surgeon uses this map to customize your LASIK treatment. Wavefront-guided LASIK will correct your vision while minimizing any existing higher-order aberrations in your corneas. 

The wavefront-guided LASIK procedure may take slightly longer than a conventional LASIK surgery, but the recovery time is similar.

How Much Does Wavefront-Guided LASIK Cost?

Wavefront-guided LASIK usually costs more than conventional LASIK. If your surgeon combines wavefront-guided LASIK with a bladeless LASIK procedure, this can increase the cost further. An average range for LASIK is $4,000 to $5,000 for both eyes. A conventional, non-bladeless LASIK procedure may cost less. 

Pros & Cons

Wavefront-guided LASIK is excellent technology that many patients are eligible for. However, there are some drawbacks to consider.

Pros of Wavefront-Guided LASIK:
  • Higher-quality vision. Wavefront-guided LASIK minimizes higher-order aberrations, giving patients sharper vision after surgery, compared to conventional LASIK.
  • Suitable for larger pupils. A common concern with conventional LASIK is that patients with larger pupils may experience more night vision problems. The symptoms include halos, glare, and reduced contrast sensitivity. Studies find that with wavefront-guided technology, pupil size does not have a significant impact on these side effects.
  • Suitable for subtle visual distortions. For patients who have existing higher-order aberrations before LASIK, wavefront-guided technology is an excellent option. These patients may have subtle corneal irregularities that glasses or contacts cannot correct.
Cons of Wavefront-Guided LASIK:
  • May not suit older patients. Your cornea and lens are clear structures in your eye that help focus light. As we age, the lens develops into a cataract. The wavefront aberrometer may then pick up aberrations in the lens as opposed to the cornea. This is not ideal for a wavefront-guided LASIK procedure since the goal is to correct irregularities in the cornea.
  • Requires accurate aberrometer results. Since a wavefront-guided procedure requires exact measurements, not everyone is a candidate. For example, the aberrometer may not capture a high-quality measurement on someone with a corneal scar or who has lens implants from cataract surgery. If the aberrometer cannot take accurate readings, this error can cause more higher-order aberrations.
  • May leave less possibility for touch-ups. Since the procedure adjusts for corneal irregularities, you may have thinner corneas after surgery than with conventional LASIK. This means a lower potential for a second LASIK procedure in the future.
  • Limited treatment range. Diopters (D) are the units used to measure your eyeglass prescription. Wavefront-guided technology is approved to treat about 7.0 D of myopia, 3.0 D of astigmatism, and 3.0 D of hyperopia. The majority of patients fall into this prescription range and can receive wavefront-guided treatment. However, patients with higher prescriptions require an alternative form of LASIK, such as wavefront-optimized.

Wavefront-Optimized

Wavefront-optimized LASIK is similar to conventional LASIK, but with some enhancements. Both are laser vision correction surgeries that treat refractive errors. Your refractive error corresponds to the numbers on your eyeglass prescription. However, custom wavefront LASIK delivers better quality vision. 

One concern with conventional LASIK surgery is that some patients experience light-related distortions after surgery. These side effects occur because the laser flattens your cornea, which is the clear covering in front of your eye. These distortions are the higher-order aberrations discussed earlier.

Wavefront-optimized surgery prevents higher-order aberrations better than conventional LASIK. This means clearer vision, particularly at night. 

Wavefront-Optimized LASIK Procedure

Before surgery, your eye doctor will check your prescription, which is called a subjective refraction. You may be familiar with this part of the eye exam when you must choose which lens looks clearer. 

The laser will use your prescription as the basis for your LASIK treatment, just like conventional LASIK.

The laser also uses special wavefront software. The program directs the laser to treat not just the center, but also the periphery of your cornea. This allows your cornea to maintain its natural shape, which minimizes any postoperative higher-order aberrations.

Conventional LASIK flattens your cornea, which can cause glare, halos, and difficulty seeing at night. Wavefront-optimized LASIK maintains the natural curve of your cornea, creating fewer side effects.

How Much Does Wavefront-Optimized LASIK Cost?

Wavefront-optimized LASIK may cost slightly more than traditional LASIK. However, wavefront-optimized procedures may cost less than more advanced types of LASIK, such as wavefront-guided or topography-guided LASIK.

If your surgeon combines wavefront-optimized LASIK with a bladeless LASIK procedure, this can increase the cost further. LASIK typically ranges between $4,000 to $5,000 for both eyes. A conventional, non-bladeless LASIK procedure may cost less.

Pros & Cons

Pros of Wavefront-Optimized LASIK
  • Higher-quality vision. Wavefront-optimized LASIK gives you sharper vision versus conventional LASIK. Because wavefront-optimized procedures create fewer higher-order aberrations, patients experience less night vision problems.
  • Wide range of treatment. Diopters (D) are the units used to measure your eyeglass prescription. Wavefront-optimized LASIK is approved to treat up to 12.0 D of myopia, 6.0 D of astigmatism, and 6.0 D of hyperopia. This range is wider than other custom LASIK treatments.
  • A great alternative to other customized LASIK treatments. With other customized procedures, like wavefront-guided and topography-guided LASIK, obtaining reliable measurements is more complicated. Unreliable measurements can happen for a variety of reasons, including eyelid interference, poor eye alignment, or dry eyes. In these situations, the surgeon may perform wavefront-optimized LASIK instead.
Cons of Wavefront-Optimized LASIK
  • Does not correct pre-existing corneal irregularities. Wavefront-optimized surgery mainly prevents higher-order aberrations that occur during the procedure but does not treat pre-existing aberrations. If you have irregular corneas, wavefront-guided LASIK may be more suitable for you.
  • May not suit post-cataract surgery patients. Occasionally, patients who receive cataract surgery need LASIK to correct any residual prescription. Depending on the type of lens implant the patient selected for the cataract surgery, wavefront technology may not produce high-quality measurements. The surgeon may perform conventional LASIK in these cases.

Wavefront-Guided vs. Wavefront-Optimized

Though the names are similar, wavefront-guided and wavefront-optimized are two different LASIK procedures. Wavefront-guided technology is more sophisticated and customized.

You can think of wavefront-optimized as an improved conventional LASIK procedure. Just like conventional LASIK, wavefront-optimized LASIK relies mainly on your eyeglass prescription to correct your vision. However, wavefront-optimized surgery uses advanced computer software to deliver a better visual outcome compared to conventional LASIK. 

Here are some important points to know about wavefront-guided and wavefront-optimized LASIK:

  • Wavefront-guided and wavefront-optimized LASIK both use advanced software, which guides the laser to reshape the periphery of your cornea. This helps to minimize post-surgical aberrations.
  • Studies find most patients have minimal amounts of higher-order aberrations, especially at a younger age. These patients would do well with either a wavefront-guided or wavefront-optimized procedure.
  • If a patient does have pre-existing higher-order aberrations, wavefront-guided LASIK is the better option. 
  • You can think of wavefront-guided LASIK as minimizing pre- and post-surgical aberrations, while wavefront-optimized LASIK mainly prevents post-surgical aberrations.
  • Wavefront-optimized procedures are faster than wavefront-optimized LASIK.

Overall, research shows both wavefront-guided and wavefront-optimized LASIK deliver excellent visual outcomes. However, wavefront-guided LASIK generally yields better vision results, with fewer aberrations post-surgically.

Topography-Guided (Contoura® Vision)

Contoura® Vision is a topography-guided LASIK surgery. It is an FDA approved and customized laser vision correction surgery. Currently, this custom LASIK technology is the most advanced form available in the United States. Contoura eye surgery can deliver higher quality vision than conventional LASIK.

Topography-guided LASIK was FDA-approved in 2013 and became widely available in 2015.

Contoura Vision Procedure

All LASIK surgeries involve the cornea, which is the clear covering on the front of the patient's eye. Conventional LASIK eye surgery corrects your vision by taking your prescription and the overall shape of your cornea into account. Contoura topography-guided LASIK is much more detailed.

First, your surgeon uses an instrument called a topographer. Then the topographer takes thousands of measurements across your entire cornea. These measurements provide a detailed map that includes any irregularities on your cornea’s surface. 

corneal topography

Overall, the procedure and recovery process for Contoura Vision LASIK is very similar to conventional LASIK. The main difference is that the surgeon needs to take more pre-operative measurements into account. Though there is more planning on the surgeon’s part, the patient does not experience any differences during the surgery itself.

Contoura Vision Cost

Since the technology is more sophisticated, topography-guided LASIK often costs more than conventional LASIK. If your surgeon combines Contoura Vision treatment with a bladeless LASIK procedure, this may add to the cost as well. 

An average range for LASIK is $4,000 to $5,000 for both eyes. If your quoted price is significantly lower, chances are you will receive a conventional LASIK procedure instead of a customized or bladeless surgery. Ask your surgeon which option is best for you.

Pros & Cons

Pros of Contoura Laser Eye Surgery
  • Higher-quality vision. As mentioned above, Contoura Vision minimizes distortions in your vision. LASIK patients experience sharper vision after surgery, often better than with glasses or contacts. 
  • Fewer side effects. Studies show Contoura Vision causes less glare, light sensitivity, and difficulty seeing at night versus other LASIK procedures.
  • Removes less tissue. Since the procedure is more precise than conventional LASIK, the laser does not need to remove as much corneal tissue. Patients with thinner corneas might be a better candidate for topography-guided versus conventional LASIK.
  • Suitable for patients with astigmatism. Patients with astigmatism often have irregularly shaped corneas. Contoura topography-guided LASIK may deliver better results for these patients than conventional LASIK.
Cons of Contoura Laser Eye Surgery
  • Not approved for touch-ups. Contoura Vision is not FDA approved to treat patients who previously had other refractive surgery such as PRK (photorefractive keratectomy), RK (radial keratotomy), or Contoura Vision. If you need a second “touch-up” procedure, your surgeon will recommend a different type of LASIK treatment for you. Surgeons in other countries may use Contoura LASIK on patients who have had refractive surgery in the past.
  • Limited treatment range. Diopters (D) are the units used to measure your eyeglass prescription. Contoura topography-guided LASIK is FDA approved to treat up to 8.0 D of myopia, up to 3.0 D of astigmatism, or 9.0 D of myopia and astigmatism combined. The majority of patients fall into this prescription range and can receive topography-guided treatment. However, patients with hyperopia or higher prescriptions require an alternative form of LASIK, such as wavefront-optimized.

Contoura Topography-Guided LASIK for Abnormal Corneas

Though Contoura topography-guided LASIK is only approved in the U.S. to correct normal, untreated corneas, surgeons are finding other uses for topography-guided technology. 

Topography-guided technology is useful for corneal conditions such as:

  • Keratoconus and pellucid marginal degeneration. These are corneal diseases that cause abnormal corneal thinning (ectasia).
  • Post-surgical complications. Patients with a history of refractive surgery such as LASIK, PRK, or RK may develop irregularities in their corneas, including irregular astigmatism. 
  • Corneal scars. Scarring can also cause corneal irregularities.
  • Penetrating or lamellar keratoplasty. These are different types of corneal transplant procedures. After surgery, some patients experience significant amounts of irregular astigmatism.

Internationally, many LASIK surgeons have been successful in using topography-guided technology to treat the conditions above. In the U.S., some surgeons are adapting this technique as an off-label use. 

Additionally, these surgeons use topography-guided PRK as opposed to Contoura topography-guided LASIK to treat these corneal conditions. Many surgeons believe PRK is safer for patients with irregular corneas since there is no corneal flap involved. 

In patients with keratoconus, LASIK surgeons are performing topography-guided PRK along with a procedure called corneal cross-linking. When combined, these procedures help stabilize the cornea and reduce irregularities.

After surgery, many patients have enhanced visual acuity and quality of vision. In the future, the use of Contoura topography-guided technology on abnormal corneas may become widely available in the United States.

Resources
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El-Awady, Hatem E., et al. “Wavefront-Optimized Ablation Versus Topography-Guided Customized Ablation in Myopic LASIK: Comparative Study of Higher Order Aberrations.” Ophthalmic Surgery, Lasers, and Imaging, vol. 42, no. 4, 2011, pp. 314–320., doi:10.3928/15428877-20110421-01.

Jain, Arun Kumar, et al. “Outcomes of Topography-Guided versus Wavefront-Optimized Laser in Situ Keratomileusis for Myopia in Virgin Eyes.” Journal of Cataract & Refractive Surgery, 1 Oct. 2016, www.sciencedirect.com/science/article/pii/S088633501630325X.

Kanellopoulos, Anastasios J., and George Asimellis. “Keratoconus Management: Long-Term Stability of Topography-Guided Normalization Combined With High-Fluence CXL Stabilization (The Athens Protocol). Journal of Refractive Surgery, vol. 30, no. 2, Feb. 2014, pp. 88–93., doi:10.3928/1081597x-20140120-03.

Kent, Christopher. “Topo-Guided Ablation & Irregular Astigmatism.” Review of Ophthalmology, 6 July 2017, www.reviewofophthalmology.com/article/topoguided-ablation-and-irregular-astigmatism.  

Kent, Christopher. “Topo-Guided LASIK in Refractive Practice.” Review of Ophthalmology, 5 Feb. 2019, www.reviewofophthalmology.com/article/topoguided-lasik-in-refractive-practice.  

Ozulken, Kemal, et al. “Comparison of Wavefront-Optimized Ablation and Topography-Guided Contoura Ablation With LYRA Protocol in LASIK. Journal of Refractive Surgery, vol. 35, no. 4, 1 Apr. 2019, pp. 222–229., doi:10.3928/1081597x-20190304-02.

Machat, Jeffery J. “Evolution of the Wavefront-Guided Laser.” Cataract & Refractive Surgery Today, May 2015, www.crstoday.com/articles/2015-may/evolution-of-the-wavefront-guided-laser/.

McCabe, Cathleen M. “PRK Versus LASIK After Cataract Surgery.” Cataract & Refractive Surgery Today, July 2016, www.crstoday.com/articles/2016-jul/prk-versus-lasik-after-cataract-surgery/.

Moshirfar, Majid, et al. “Meta-Analysis of the FDA Reports on Patient-Reported Outcomes Using the Three Latest Platforms for LASIK.” Journal of Refractive Surgery, vol. 33, no. 6, 1 June 2017, pp. 362–368, doi:10.3928/1081597x-20161221-02. 

Perez-Straziota, Claudia E., et al. “Visual Acuity and Higher-Order Aberrations with Wavefront-Guided and Wavefront-Optimized Laser in Situ Keratomileusis.” Journal of Cataract & Refractive Surgery, vol. 36, no. 3, Mar. 2010, pp. 437–441., doi:10.1016/j.jcrs.2009.09.031.

Roe, Joshua R., and Edward E. Manche. “Prospective, Randomized, Contralateral Eye Comparison of Wavefront-Guided and Wavefront-Optimized Laser in Situ Keratomileusis.” American Journal of Ophthalmology, vol. 207, 4 June 2019, pp. 175–183, doi:10.1016/j.ajo.2019.05.026.

Stephenson, Michelle. “Wavefront-Guided VS. Wavefront-Optimized Laser Treatments.” EyeWorld Online, ASCRS Ophthalmic Services, 30 June 2017, www.eyeworld.org/wavefront-guided-vs-wavefront-optimized-laser-treatments.

Chan, Annie, and Edward E. Manche. “Effect of Preoperative Pupil Size on Quality of Vision after Wavefront-Guided LASIK. Ophthalmology, vol. 118, no. 4, Apr. 2011, pp. 736–741., doi:10.1016/j.ophtha.2010.07.030.

Machat, Jeffery J. “Evolution of the Wavefront-Guided Laser.” Cataract & Refractive Surgery Today, May 2015, www.crstoday.com/articles/2015-may/evolution-of-the-wavefront-guided-laser/.

Moshirfar, Majid, et al. “Meta-Analysis of the FDA Reports on Patient-Reported Outcomes Using the Three Latest Platforms for LASIK.” Journal of Refractive Surgery, vol. 33, no. 6, 1 June 2017, pp. 362–368, doi:10.3928/1081597x-20161221-02. 

Roe, Joshua R., and Edward E. Manche. “Prospective, Randomized, Contralateral Eye Comparison of Wavefront-Guided and Wavefront-Optimized Laser in Situ Keratomileusis.” American Journal of Ophthalmology, vol. 207, 4 June 2019, pp. 175–183, doi:10.1016/j.ajo.2019.05.026.

Stephenson, Michelle. “Wavefront-Guided VS. Wavefront-Optimized Laser Treatments.” EyeWorld Online, ASCRS Ophthalmic Services, 30 June 2017, www.eyeworld.org/wavefront-guided-vs-wavefront-optimized-laser-treatments.

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