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In terms of outcomes and risks, is laser-based or cornea-based refractive surgery or premium IOL implantation a better value for patients?
LASIK can offer better value, less risk
 Louis E. Probst |
While many surgeons believe that the refractive surgery option of LASIK vs. IOLs is about age, presbyopia, and the preservation or restoration of near vision, I would like to propose that safety, accuracy and convenience are the more important considerations. The patient who is interested in a refractive procedure does not have a medical problem; they are seeking a procedure that is going to offer them a better lifestyle. Therefore, they are totally unwilling to accept any surgical risk. While reading vision may be a concern for some presbyopic patients, all patients are mainly interested in achieving the best distance vision. Because many refractive patients are employed and busy, the convenience of the procedure is significant.
In terms of safety, the risks of the LASIK and IOL procedures are dramatically different. Schallhorn has shown that the risks with LASIK are somewhere in the 1 in 1,000 to 1 in 5,000 range. The risks with IOL technology are in the neighborhood of 1 in 100. IOL procedures are approximately one-fourth as accurate as LASIK in terms of the standard deviation of results achieving emmetropia. Astigmatism is broadly addressed in IOL technology by relaxing incisions or toric IOLs while LASIK treats astigmatism to 1/100 of a diopter with perfect alignment when iris registration is used. Finally, LASIK is routinely done as a bilateral procedure with topical anesthesia in a refractive clinic while IOL procedures require unilateral surgery, some type of medical evaluation, a surgical facility or hospital, and potential further refractive surgery to refine the results and address residual astigmatism.
In terms of cost, LASIK offers better value. Premium IOL procedures are generally priced at $3,000 per eye, while a competitive price right now for custom LASIK would be in the $2,000 range. So patients are getting a safer, more accurate and convenient procedure for a significantly lower cost. Yes, the presbyopic LASIK patient will need reading glasses if both eyes are corrected for distance; however, that compromise seams to be very acceptable to my patients when all the other advantages of LASIK are considered.
Louis E. Probst, MD, is the National Medical Director, TLC Laser Eye Centers, Chicago.
Choice depends on patient age and need
I believe this is a function of the patient’s age and the presence or absence of any cataract change.
 Alan B. Aker |
For patients younger than 40 years of age, LASIK or PRK is a better choice. These patients still retain accommodation, so if corrected for distance, they also have the ability to function well at near without spectacle correction. In addition, these patients have the blessing of youth. We know there will be ongoing refinement and improvement of the currently available presbyopia-correcting IOLs. These patients are young enough to benefit from future improvements, such as a toric presbyopia-correcting IOL when their cataracts develop.
For patients already in their presbyopic years, a refractive IOL is often a better choice. If these patients undergo LASIK, they lose their ability to see at near unless a modified monovision endpoint is chosen. This option compromises their depth perception, something that is often bothersome to golfers and patients involved in other sports. In addition, I have treated many patients for cataracts within 2 years of their having paid for a refractive procedure. Fortunately, many of the LASIK surgeons in our area recognize this and typically refer patients with early cataracts for consultation. These patients can then opt for a refractive cataract procedure. If they meet the criteria for cataract surgery, they wind up with emmetropia that is now covered by insurance or Medicare, depending on their age and coverage. If these patients opt for a premium IOL, they are not paying for this in addition to a LASIK fee. We have also seen patients who would opt for a premium IOL, but say they cannot afford it in light of what they paid for LASIK a year or two earlier.
Alan B. Aker, MD, is in private practice at the Aker Kasten Eye Center, Boca Raton, Fla.