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Refractive surgery is a procedure that corrects common vision problems resulting from refractive errors. Refractive errors occur when your eyes cannot focus images accurately onto the retina, which is the sensory tissue lining the back of your eye. As a result, refractive errors cause blurry vision.
Types of refractive errors include:
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There are several forms of refractive surgeries. Although LASIK (laser in-situ keratomileusis) is one of the most popular options, not everyone is a candidate. Your ophthalmologist can determine which surgery is the best choice for you.
LASIK eye surgery corrects your vision by reshaping the clear surface of your eye, called the cornea. The surgeon uses either a femtosecond laser or microkeratome blade to create a flap on your cornea.
Once the flap is lifted, an excimer laser reshapes the corneal tissue underneath. If you are nearsighted, the laser flattens the curvature of your cornea to reduce your eye’s focusing power. If you are farsighted, the laser steepens your cornea to increase focusing power. For those with astigmatism, LASIK evens out the irregular shape of your cornea so that it is more symmetric. After this step, the flap is replaced, which acts as a bandage to reduce recovery time.
There are custom LASIK procedures that deliver more precise and personalized visual results, including wavefront-guided, wavefront-optimized, and topography-guided LASIK.
PRK is also performed with a laser, but unlike LASIK, the surgeon does not create a corneal flap. Instead, the surgeon applies an alcohol solution or uses surgical instruments to remove the cornea's outer layer (epithelium). Then, the surgeon applies the excimer laser to reshape your cornea. Because there is no flap, the surgeon applies a bandage contact lens, which protects your eye as the epithelium heals.
The healing time is also longer than LASIK. With LASIK, some people go back to work the next day. With PRK, many people choose to take a week off work to recover.
LASEK includes a combination of LASIK and PRK techniques. An alcohol solution loosens the epithelium, but instead of removing the tissue, the surgeon creates a flap in the epithelium. This flap is thinner than the one created during LASIK, making this a suitable choice for thin corneas.
Epi-LASIK also creates a thin epithelial flap with a microkeratome blade. This procedure does not involve using an alcohol solution, so it is less damaging to the cornea than LASEK.
SMILE primarily corrects myopia and some astigmatism. SMILE uses a femtosecond laser to create a circular piece of tissue in the inner layer of your cornea, called a lenticule. Then, the surgeon creates a small incision on your cornea and removes the lenticule through this incision.
Although this is a newer procedure, some studies show that SMILE is a promising alternative to LASIK. Benefits include less dry eye and a more stable corneal structure after surgery.
RLE is similar to cataract surgery, only it is performed before one develops a cataract, which is a clouding of the natural lens inside the eye. During the procedure, the surgeon removes your natural lens and replaces it with an intraocular lens (IOL). This surgery is particularly beneficial for people with high prescriptions who may not be eligible for laser refractive surgery.
The surgeon selects the type of IOL depending on the vision correction you need, which may include:
Phakic IOL is a lens implant that corrects high levels of myopia. Instead of removing the natural lens like RLE procedures, the natural lens stays in place. A phakic IOL can be removed or replaced later on.
Two types of phakic IOLs include:
In general, refractive surgeries are considered safe and effective. Of course, all surgeries come with some risk, and the rate of complications varies depending on the type of procedure.
Some potential risks of refractive surgery include:
A review of several LASIK studies published between 2008 and 2015 found that over 98% of patients were satisfied with their LASIK outcome. The rate of complication ranges from 0.7% to 6.6%, which is considered low.
Lens implant surgeries are more invasive than laser refractive surgeries and generally carry a higher risk of complications. For example, the risk of retinal detachment is higher with an RLE procedure (about 1.5% to 8.1% in those with high myopia) versus laser refractive surgery (about 0.05% to 0.19% among LASIK patients).
The effects of refractive surgery are permanent. However, the surgeon can replace phakic IOLs if your vision changes or remove them if you need cataract surgery. With RLEs, the implant is permanent.
Because laser refractive surgeries remove tissue from your cornea, the effects cannot be reversed. However, your vision can change after surgery for other reasons, for example, if the focusing power of your natural lens changes.
With many options for refractive surgery, choosing the right procedure can be overwhelming. Here are some areas to consider:
Ultimately, you should consult your ophthalmologist to determine which procedure is best for you.
Arevalo, J. Fernando. “Managing Retinal Detachment After Refractive Surgery.” Retina Today, retinatoday.com/articles/2017-apr/global-perspectives-managing-retinal-detachment-after-refractive-surgery.
Moshirfar, Majid, et al. “LASIK Complications.” EyeWiki, 20 Jan. 2015, eyewiki.aao.org/LASIK_Complications.
Sandoval, Helga P., et al. “Modern Laser in Situ Keratomileusis Outcomes.” Journal of Cataract & Refractive Surgery, vol. 42, no. 8, Aug. 2016, pp. 1224–1234., doi:10.1016/j.jcrs.2016.07.012.
Schallhorn, Steven C., et al. “Refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes.” Clinical ophthalmology (Auckland, N.Z.) vol. 11 1569-1581. 28 Aug. 2017, doi:10.2147/OPTH.S143201