Laser Eye Surgery: An Overview of Methods, Risks, and Costs for a Life Without Glasses or Contact Lenses

People with nearsightedness see nearby objects clearly, while distant objects appear more or less blurry.

In nearsightedness, the eye’s focal point lies in front of the retina. This means that, relatively speaking, the eye is too long for the refractive power of the cornea, or the cornea is too curved for the eye’s anatomy.

There are various surgical procedures for treating nearsightedness. If nearsightedness is not too severe, it can be corrected through laser refractive surgery.

In cases of very severe nearsightedness, artificial lenses can be implanted into the eye. These are usually inserted in addition to the eye’s natural lens.

People with farsightedness see distant objects clearly, while nearby objects appear blurry. To see nearby objects clearly, the eye must accommodate the lens. This means that the eye muscles reshape the lens and “focus” it on the closer objects.

As a result, farsighted people often find seeing to be tiring. Young people can often compensate for farsightedness through accommodation.

If the lens’s ability to focus on nearby objects decreases over the years, a blurry visual impression develops that must be corrected. This is why farsighted people often notice their farsightedness little or not at all until well into adulthood.

In hyperopia, the eye’s focal point is mathematically located behind the retina, which is why a blurred image forms on the retina. Relatively speaking, the eye is too short, or the cornea is too flat for the length of the eye.

Refractive surgery can also be used to treat farsightedness. Hyperopia is corrected using lasers or lens surgery at laser eye centers.

In astigmatism, the curvature of the cornea (and sometimes the lens) is unevenly stronger in one direction than in another. Nearly every eye has some degree of astigmatism.

In some people, however, this irregularity is so severe that incoming light rays are focused on multiple points on the retina. As a result, they have difficulty seeing both up close and at a distance.

Astigmatism can be corrected using

• laser corneal surgery,
• special corneal incision techniques, or
• lens surgery

.

Presbyopia refers to the age-related loss of the eye’s ability to focus on near objects.

In youth, the eye’s lens is soft and flexible and can easily change its shape, allowing the eye to focus sharply on objects both near and far. Starting around age 50, the eye’s lens loses its elasticity, and the eye finds it increasingly difficult to focus on nearby objects.

Initially, difficulties arise in dim lighting; later, they occur even in well-lit conditions.

Presbyopia cannot be completely corrected through laser refractive surgery. However, a condition known as “monovision” can be achieved. This means that one eye is optimized for near vision and the other for distance vision.

If clouding of the lens (cataract) accompanies the loss of elasticity, it may be advisable to implant an artificial lens. To do this, the eye’s natural lens is completely removed. However, these artificial lenses are typically set for a specific distance. Multifocal lenses, on the other hand, can be adjusted for multiple focal ranges.

The cornea accounts for the majority of the eye’s total refractive power. The strength of this refractive power depends on the curvature of the cornea’s surface. The steeper the surface, the more the incoming light is refracted; the flatter the surface, the less the light is refracted.

Nearsightedness and farsightedness and their correction © bilderzwerg / Fotolia

Laser eye surgery procedures make use of these physical principles. The procedure involves altering the surface curvature of the cornea to positively influence the eye’s refractive power.

To do this, the surgeon uses special laser systems to remove fine layers of the cornea according to a precisely calculated pattern. In the process, tissue is vaporized in fractions of a second. If the curvature is too steep, it is reduced; if it is not steep enough, the radii of curvature are made steeper.

Structure of the cornea © bilderzwerg / Fotolia

The tissue ablation described above can take place at different levels or depths within the cornea. Depending on the procedure used, these layers are located

• be located immediately beneath the outermost surface of the cornea, or
• the treated tissue layers are located deeper within the cornea.

Laser surgical procedures include

• LASIK (Laser in situ Keratomileusis),
• FemtoLASIK (laser in situ keratomileusis using a femtosecond laser system),
• LASEK (laser-assisted subepithelial keratomileusis), and
• PRK (photorefractive keratectomy), the predecessor to LASEK.

LASIK Eye Surgery

LASIK stands for Laser in situ Keratomileusis, which means reshaping the cornea using laser energy.

Since a laser allows for extremely precise tissue ablation, it can be used to reshape the curvature of the cornea.

First, a thin superficial flap is created. A device called a microkeratome can be used for this purpose. It uses a rapidly oscillating blade to cut a flap on the front surface of the cornea. The lamella is not completely separated but remains attached to the cornea on one side. The lamella, also known as a “flap,” is folded aside so that the inner layer of corneal tissue is exposed.

An excimer laser is then used to vaporize the desired amount of corneal tissue with short flashes of light. This changes the refractive power and corrects the vision defect. The flap is then folded back into place so that the corneal surface remains intact.

Laser Eye Surgery Using Femto-LASIK

The corneal flap can also be created using a femtosecond laser system (fs-laser or Femto-LASIK).

This laser device emits short flashes of infrared light that are focused with the highest precision on pre-calculated points on the cornea. Each flash creates a separation point in the corneal layers. Thousands of such light pulses are focused into the cornea according to a computer-controlled pattern, ultimately forming a flap.

Compared to the flap that can be cut using a microkeratome, the “femtosecond laser flap” is even more precise. The rest of the procedure is as described for LASIK.

Laser Eye Surgery Using LASEK

LASEK stands for laser-assisted subepithelial keratomileusis. As with LASIK, this refers to reshaping the cornea through the application of laser energy. Here, too, as with LASIK, an extremely fine amount of tissue is removed using a laser to reshape the curvature of the cornea.

In LASEK, a special alcohol-based solution is applied to the surface of the eye for a few seconds. It loosens the epithelium from its firm attachment to the corneal surface, exposing the underlying corneal tissue.

The layer can then be lifted from the surface as a thin flap and pushed aside. Once the surface of the corneal tissue is exposed, the desired tissue ablation can be performed by exposing it to short laser pulses.

The laser pulses are computer-controlled. This ensures that exactly the amount of tissue necessary for correcting the curvature is removed. Afterward, the epithelial flap is slid back over the surface, acting as a natural bandage.

In addition, a protective contact lens is applied and left in place for a few days to allow the surface to heal. During the first few days after the procedure, you may experience some discomfort, and your eyes may water.

Laser Eye Surgery: PRK

Photorefractive keratectomy (PRK) is the predecessor to LASEK.

In this procedure, the epithelium is not loosened with alcohol; instead, this outermost layer of the cornea is directly ablated. The resulting wound heals within a few days as the cell layer regrows. Long-term results are already available for this procedure, as it has been in use since 1984.

Other refractive surgery procedures include

• special corneal incision techniques,
• corneal implants, and
• lens surgery involving the implantation of artificial intraocular lenses.

Special corneal incision techniques

If a patient has mild astigmatism, it can be corrected in certain cases using special relieving incisions (fragmentation). These special relieving incisions can also be performed as part of cataract surgery to optimize the refractive outcome.

Corneal implants

Some corneal diseases lead to a “bulging” of the cornea (known as keratoconus). Under certain conditions, it may be beneficial to stabilize the cornea by inserting tiny support elements.

This can at least partially compensate for the reduced visual acuity caused by the deformation of the cornea.

Lens Surgery with Implantation of Artificial Intraocular Lenses

Not all degrees of nearsightedness or farsightedness can be treated with laser procedures. If, for example, too much corneal tissue is removed with the laser, there may not be enough tissue left. This can cause the eye to lose its stability.

For this reason, it may be advisable for people with severe nearsightedness or farsightedness to correct their vision by implanting an artificial lens. In this procedure, either an additional artificial lens (intraocular contact lens—ICL) is inserted into the eye, or the natural lens is replaced with an artificial one.

Lens Surgery: Implants for Severe Refractive Errors

If an artificial lens is inserted into the eye in addition to the natural lens, this is referred to as a phakic intraocular lens. This procedure is primarily used for very severe nearsightedness, possibly in combination with high astigmatism. For farsightedness, however, it is used less frequently.

The additional lens can be positioned in the anterior chamber of the eye (between the cornea and the iris) or attached to the iris itself.

Lens Surgery: Implants to Replace the Natural Eye Lens

Replacement of the natural lens with an artificial lens is typically performed to treat cataracts.

You can find out whether correcting your vision with refractive surgery is possible and advisable by consulting with your ophthalmologist.

Favorable conditions include:

• Your refractive error (eyeglass prescription) has remained stable over an extended period.
• There are no other eye conditions present.
• There are no systemic diseases, such as diabetes or rheumatism.
• For women: You must not be pregnant.

Every decision to undergo refractive surgery is highly individual. It is based on the patient’s wishes and needs, as well as the options and recommendations of the ophthalmologist. Some reasons to consider laser eye surgery include:

• Eliminating the need for glasses and/or contact lenses: When nearsightedness is corrected with glasses, the image projected onto the retina is reduced in size—the more severe the nearsightedness, the greater the reduction. This is why people with nearsightedness often prefer contact lenses. For some patients, however, even contact lenses are not a viable option. In these cases, refractive surgery can be used to eliminate the need for glasses and contact lenses.
• For astigmatism exceeding 10 dpt cyl., the refractive error can no longer be corrected with glasses but only through refractive surgery.
• Use of custom-made implants: This allows the refractive error to be largely corrected, enabling patients to regain vision in an eye that was previously unable to participate in the visual process due to refractive error.
• For myopia of -30 diopters and hyperopia of +10 diopters: Custom-made intraocular lenses can free patients from the need for thick eyeglass lenses, which results in improved visual acuity and quality of life for those affected.

In refractive surgery, the doctor tests visual acuity using reading charts. During this test, patients attempt to recognize letters or symbols from a specific distance.

A person with normal vision (visual acuity = 1.0) can distinguish objects with a resolution of one arcsecond. This measurement is subjective.

The ophthalmologist determines which treatment is most likely to be successful © peopleimages.com | AdobeStock

Skiascopy is used for the objective measurement of the eye’s refractive power (refraction). This procedure can be performed even on young children and infants. The unit of measurement for the eye’s refractive power is the diopter.

Refraction can also be measured using an autorefractometer. This is a device that uses photosensors and image processing to project and focus the image.

In addition, the doctor can determine what correction is needed to compensate for astigmatism. To do this, the doctor holds toric lenses in front of the eye. These lenses correct the distortion in the image.

Anyone who decides to undergo laser eye surgery should thoroughly research the methods and costs involved. Many people planning to have laser eye surgery hope to be able to do without glasses and contact lenses permanently. Laser eye surgery offers an effective solution for this, particularly for nearsightedness and astigmatism. However, such laser eye treatment always involves risks and costs that must be weighed on an individual basis.

The cost of laser eye surgery can vary depending on the method and clinic. The cost of the laser eye treatment itself, as well as the total cost of the procedure, also varies, with the exact cost depending heavily on the individual’s specific circumstances. As a rule, neither public health insurance plans nor private insurers cover the full cost, although some health insurance providers may cover part of the expenses. It is therefore important to have a transparent overview of the costs, as the cost of the procedure, the cost of vision aids beforehand, and the cost of laser eye surgery itself should be factored into your budget realistically.

In laser eye surgery, both eyes are usually treated in a single session. A thorough eye examination is performed beforehand, as eye health is crucial. Potential risks can arise during laser eye surgery—such as dry eyes or other side effects—which is why the procedure carries certain risks. Therefore, especially when it comes to laser eye surgery, all questions regarding the procedure should be clarified in advance.

Today’s laser eye surgery methods offer many options, but cost remains an important factor. Many people initially perceive the costs of laser eye surgery as high, since they always involve expenses and can sometimes be substantial. However, the actual costs are often put into perspective when compared to long-term expenses for glasses or contact lenses. Anyone deciding to undergo laser eye surgery should be aware that costs can vary significantly and depend on the method, clinic, and individual circumstances.

Overall, laser eye surgery can significantly improve vision and enable a life without visual aids; nevertheless, the costs and risks should be carefully weighed. Anyone considering laser eye surgery should seek comprehensive advice to make the best decision for themselves and their eyes.

What happens during laser eye surgery?
During laser eye surgery, the cornea is reshaped using a laser to correct refractive errors. Procedures such as LASIK or Femto-LASIK reshape the eye’s refractive power.

Are there risks associated with laser eye surgery?
Like any eye procedure, laser eye surgery carries a certain degree of risk. Possible side effects include dry eyes, sensitivity to glare, or rare complications.

Who is a good candidate for laser eye surgery?
Laser eye surgery is suitable for patients with stable refractive errors such as nearsightedness, farsightedness, or astigmatism. Sufficient corneal thickness and healthy eyes are prerequisites.

How much does laser eye surgery cost, and does health insurance cover the costs?
Depending on the method and clinic, the costs for laser eye surgery are usually on the higher end. Statutory health insurance plans generally do not cover the costs, as this is an elective procedure.

Can you see without glasses after laser eye surgery?
Many patients can see clearly without glasses or contact lenses after the procedure. In some cases, however, a mild visual aid may still be necessary, for example, in cases of presbyopia.