Jeff Varrella will not soon forget the burning smell as the laser carved a flap on the surface of his cornea, or the bright, white light that preceded his sudden—though brief—vision loss.
But with a reassuring hand on his shoulder and hope that his 57 years of very poor vision would soon end, he remained calm as the surgeon reshaped his cornea, transforming his vision from severe nearsightedness to close to 20/20. When it was over, Varrella peered through the tiny holes in the protective patches covering his eyes and nearly cried.
“I could see the whole room for the first time in my life,” he says. “I looked up at the doctor, and I could see her clear as day.”
Varrella recently traded out his too-thick glasses and suboptimal contact lenses for laser-assisted in situ keratomileusis, or LASIK. He made the decision only after traditional corrective lenses began to fail him and he found a well-established surgeon who would perform the surgery at a reasonable price.
LASIK can correct nearsightedness, farsightedness and astigmatism, but it is not a good choice for everyone, such as those with unusual curvatures to their corneas or degenerative eye conditions, and complications from the surgery still occur. Still, the procedure has stood the test of time, and about 95 percent of patients say they are satisfied with their results. Area ophthalmologists agree that, thanks to technical innovations, the refractive eye surgery is safer and more effective than ever for up to 85 or 90 percent of people who need corrective lenses.
In 2021, an estimated 800,000 Americans chose LASIK for vision correction, according to Dr. Stephen Wilmarth, medical director of Horizon Vision Center. While LASIK’s popularity waxes and wanes, the COVID-19 pandemic brought a noticeable uptick in LASIK surgeries, as people tired of their glasses fogging up when they wore a mask. In addition, business closures and travel cancellations meant more money in the bank, so some people who for years put off the elective surgery could now afford it.
“I have been doing LASIK for 20-plus years,” says ophthalmologist Nilu Maboudi of Griffin & Reed Eye Care, who performed Varrella’s surgery. “It’s really an elegant procedure. I still come home after doing this surgery and say, ‘That is so darn amazing.’”
FROM BLADES TO LASERS—The first refractive surgery, approved by the FDA in 1995, was called photorefractive keratectomy, or PRK, in which ophthalmologists use a blade or brush to remove the outer layer of cells on the surface of the cornea, then an excimer laser to reshape the cornea and correct the vision. Surgeons place a temporary contact lens on the eye to reduce pain and aid in healing, which can take three to four days followed by gradual improvements for a month. Dr. Peter Wu of Sacramento Eye Consultants says PRK is still used for some patients with high corrective prescriptions or for athletes or military service men and women who are at greater risk of cornea damage.
LASIK was the next generation, approved by the FDA in 1999. LASIK is different because surgeons cut a flap on the surface of the cornea, leaving a hinge on its edge. As with PRK, they use a laser to reshape the cornea, changing the way light focuses on the retina to improve vision. They lay the flap back onto the eye and leave it to heal naturally. Maboudi says most patients feel comfortable enough to drive the next day.
In 2001, Sue Christian was a busy private-practice attorney. Very nearsighted, she was at the point where she was wearing both contact lenses and glasses. She longed to be rid of them. She studied the data on LASIK, knew the potential risks and side effects like dry eye, halos and glare, and talked to others who’d had success with LASIK before taking the plunge.
It was late August, just days before the World Trade Center attacks. She found a surgeon she liked with several years of experience. The procedure seemed to go as planned. She went home to rest, assuming she would wake up with good vision. But that’s not what happened. Her vision was cloudy and her eyes very painful.
Back at the eye center, her surgeon told her that both flaps had wrinkled. Surgeons say this typically happens if the patient rubs their eyelids after surgery, but Christian hadn’t touched them as they had been covered, and when the covers were removed, she couldn’t see. She says her surgeon was stumped. To correct it, he saw her over several weeks, each time gently massaging and smoothing the wrinkles in the flap (technically called striae) over the cornea.
Unable to return to work for weeks, Christian was at home on the morning of the World Trade Center attacks and remembers struggling to witness the events of 9/11 unfold on live television.
“I had to sit two feet from the TV to see it,” she recalls.
After about four treatments, Christian’s vision returned—without the need for glasses or contacts. Exuberant, she wrote her surgeon with gratitude.
“It was horrible not knowing if I would ever get my vision right,” says Christian, now 72. “But it meant so much to me to not have to wear contacts or glasses anymore.” Christian’s surgeon was Wilmarth, one of the region’s first to perform LASIK. He says that while the incidence of striae was relatively rare 20 years ago, these days the complication requires follow-up treatment in fewer than 1.5 percent of cases. That’s thanks to newer technology, specifically the Femto laser, which in most cases has replaced the blade for creating the corneal flap with short, infrared pulses.
Wilmarth uses a kitchen-gadget analogy to describe the difference in technique. Think of the eye as a cantaloupe with a round edge, he says. When you use a knife to cut the fruit, your piece will have varying degrees of thickness. The laser works more like a cookie cutter, slicing a disk shape with a constant depth across the cornea.
“This means that when we put the flap back down, it’s recessed and can’t move around,” he says. “This is why we don’t see the striae that we used to see sometimes.”
Innovative diagnostic and treatment planning devices have further improved LASIK. The Pentacam gives the doctor a 3D image of the patient’s cornea and measures its thickness,\ which makes choosing good candidates for LASIK more accurate.
“It takes 22,000 data points of your eye, which helps us look for any weak points in the front or back of the eye that might make the outcome of the procedure unpredictable,” says Maboudi. “In that case, we don’t do the surgery.”
In addition, ophthalmologists now use programmable treatment lasers that tailor each treatment to the individual patient. This is known as wavefront technology, approved for use in 2003.
“With wavefront, we can scan the whole optical system and determine even minor variations in the prescription that normally are not corrected with glasses, but that we can correct with the laser, such as an asymmetric astigmatism,” says Dr. Jeffrey Caspar, director of Cataract and Refractive Surgery at the UC Davis Eye Center. “We can also correct corneal curvatures that cause glare at night.”
WHY LASIK ISN’T MORE POPULAR—Why more people don’t get LASIK is both simple and complicated. One is the cost; LASIK isn’t covered by insurance. At reputable eye centers in the Sacramento region, a patient can spend upward of $2,600 per eye. In the Bay Area, Varrella was quoted $4,000 to $5,000 per eye. Misinformation also contributes to fewer people choosing LASIK. Optometrists, for example, might tell a patient they are not LASIK candidates when they are.
“There is pushback from other eye care professionals because they don’t want to lose their contact lens or glasses business,” Wilmarth says. “The most common lie is that LASIK doesn’t correct an astigmatism. We have been able to do that for over 20 years.”
Fear may be the biggest obstacle, especially in light of controversial new draft guidance by the Food and Drug Administration describing dry eyes, visual disturbances and other possible side effects of LASIK.
“People are nervous about their eyes,” says Wu. “Vision is precious. You don’t want to take chances with it. But this is a very safe procedure.”
Adds Maboudi: “My observation is that the more blind they are, the more trepid they are. They don’t believe it works, and they don’t think they’re a good candidate. I find patients do best when they have a lot of information on board.”
By the same token, says Caspar, LASIK is not appropriate for patients with unrealistic expectations.
“LASIK can greatly reduce or eliminate the need for glasses for most,” he says. “For those who see great with glasses, it’s great. But if you are looking for better vision, it’s not likely going to happen. LASIK only does what glasses do.”
Caspar adds that LASIK can’t prevent the loss of focusing ability as patients get older, so many will require readers at some point. And LASIK doesn’t prevent cataracts and can complicate cataract surgery later. Christian says she started wearing reading glasses about five years ago and had cataract surgery in recent years, as well.
SELECTING A SURGEON—When selecting a surgeon or surgery center for LASIK, longtime providers urge people to choose a board-certified ophthalmologist whose standard approach is to perform custom LASIK, who performs thorough tests to determine whether you are a good candidate for the procedure, and who provides any needed follow-up care.