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A Las Vegas LASIK and cataract vision correction Center of Excellence lead by ophthalmologist Dr. Matthew Swanic, MD.
Las Vegas Eye Institute - LASIK
5 REASONS TO CHOOSE LAS VEGAS EYE INSTITUTE FOR LASIK
LASER Vision correction is an amazing procedure and there are many excellent places to get it done. However, we know that when it comes to your eyes that it’s not only normal, but expected, to be nervous about getting this procedure done. We want to put you at ease and let you know what we would look for in a refractive surgery practice.
An experienced and well-trained surgeon. Notice that we didn’t just say experienced. We find that many practices talk about how many “cases” they have done. However, what you really care about is how many they have done right. At Las Vegas Eye Institute Dr. Swanic has been doing LASIK procedures for 10 years since he began his Cornea and Refractive surgery fellowship at UCLA. He is certified to use both the Visx and Wavelight platforms but this does not mean he just did a weekend course (that is actually all it takes to become certified.) He did a year of fellowship training with Rex Hamilton M.D. at UCLA where he not only learned the best techniques to perform the procedure but more importantly the best way to evaluate people BEFORE performing the procedure. At a tertiary care facility like UCLA, that sees patients from all over the world, he was able to see the very rare complications of refractive surgery and learn how to avoid them.
Up to date preoperative testing equipment. People sometimes feel our screening for LASIK can be a bit exhaustive, but of course, when something is as important as your eyesight you don’t want shortcuts. All patients at Las Vegas Eye Institute undergo an extensive evaluation of the shape and curvature of their cornea (the structure where LASIK is performed). We no longer use conventional corneal topography as we find it can give variable results that can be hard for even the most experienced surgeon to properly evaluate.
We utilize the Cassini system that uses up to 700 multicolored LEDs to detect even the most subtle abnormalities in the way light reflects off of your cornea. We then carefully evaluate the structure of the cornea with our Zeiss Cirrus 6000 OCT that measures the eye at a rate of 100,000 scans a second. It is able to measure the thickness of your cornea at thousands of points in just a fraction of a second. We further evaluate the epithelial thickness of the cornea with this same device to make sure the epithelium (surface layer) is not masking any underlying significant shape changes. Lastly, we utilize the iDesign system to measure your refractive error, the size of your pupils, the centration of your pupils, the topography of the cornea (a second time in addition to the Cassini), and lastly your whole eye’s wavefront which is a detailed map of the way light is bent in your eye.
The latest in LASIK technology. LASIK technology has advanced significantly since the excimer LASER was FDA approved in 1995. We are celebrating 25 years of LASIK in the United States this year! This is great because it shows that the procedure is stable and safe, but it highlights that you want to make sure your surgeon has the latest tools to get you the best vision possible. We are proud to offer the latest in Wavefront-guided ablations utilizing the Johnson & Johnson Visx iDesign platform. This device measures your prescription to 1/100th of a diopter. It also utilizes over 1250 data points to provide our excimer laser with a sophisticated wavefront-guided plan to treat the most subtle abnormalities of your eye. Prior to performing this wavefront-guided ablation we utilize the exquisitely precise Zeiss Visumax femtosecond laser to create your LASIK flap. The Visumax laser utilizes low energy pulses fired at 500,000 times per second to create a flap of any size and depth that Dr. Swanic chooses. If you have a thin cornea and we need a flap as thin as 80 microns (a human hair is 75 microns thick) we can deliver this result with remarkable precision.
The advantage our patients notice though is its comfort. The Visumax is low suction which means that your vision will not blackout at any point during your procedure and you are very unlikely to be left with unsightly red spots. Dr. Swanic loves this feature as he has gone through many different flap creation platforms in his career and none have been this comfortable or this gentle on the eye.
Evaluation by your surgeon BEFORE and AFTER your treatment. Dr. Swanic takes great pride in his outcomes and that means that even with the best technologies he wants to double-check all of his preoperative and postoperative data personally. He will be seeing you for your LASIK consultation, he will perform your procedure, and he will see you after your procedure. You will likely find this very different than most practices. You may pay slightly more for this luxury but we think it’s valuable to have access to a surgeon with extensive knowledge and experience in refractive surgery.
A surgeon who has had the procedure performed on his own eyes. It’s not great when you walk into your refractive surgery evaluation and see your doctor wearing glasses. You will notice that Dr. Swanic doesn’t wear glasses and that is because he had Laser Vision Correction performed on his eyes 10 years ago and still enjoys 20/20 vision. This means that he knows what its like to have this done not only because he has performed it countless times but because he has gone through it himself. He believes strongly in refractive surgery and loves giving his patients the gift of clear vision that he enjoys every day.
WHAT DOES MY LASIK COST INCLUDE AT LAS VEGAS EYE INSTITUTE?
When selecting a LASIK provider, it is important to understand what your LASIK cost includes. Some providers advertise for a low initial cost, only to charge more for “add-ons” which result in a much higher cost of LASIK than the price that was initially quoted. At Las Vegas Eye Institute we do not have a multiple tiered pricing programs like you may find at other LASIK providers. This means that whether you opt for PRK or LASIK or need some mild dry eye treatment after your procedure, you will not incur any additional costs for any necessary post-operative treatments. At Las Vegas Eye Institute, we strive to provide a premium LASIK experience which includes transparency in pricing. We do not want people to find out after the fact that any additional services they may need to get the optimal visual results are not included in the price they paid. At Las Vegas Eye Institute, our standard LASIK price for all patients includes:
Wavefront Guided Excimer LASER treatment utilizing the Visx iDesign 2.0 Topography integrated treatment algorithm (also known as Custom LASIK)
Femtosecond LASER flap creation with the Zeiss Visumax 500 kHz platform
Enhancements of all procedures (Wavefront Guided if appropriate) for the first 2 years if needed (generally enhancements are not needed due to high accuracy of the iDesign 2.0 platform)
PRK Procedures with advanced alcohol assisted epithelium removal and MMC placement
Punctal plug placement if indicated (permanent or 3 month or 6 month dissolvable) to alleviate temporary eye dryness
At Las Vegas Eye Institute, Custom LASIK is included with each LASIK procedure at no additional cost. With Custom LASIK, specific data points unique to your eyes are taken into consideration when planning your LASIK procedure. Small abnormalities in your eyes are measured with the advanced technological device called the iDesign 2.0. The iDesign 2.0 was FDA approved in 2018 and can capture over 1,200 data points to design your LASIK treatment while older technology can only capture about 250. With this device, treatments are customized to patients individual eyes and provide better visual results than that offered by older technology.
You will notice that at Las Vegas Eye Institue, Dr. Swanic does not offer LASIK procedures that are performed with a blade (known as a microkeratome). Although the microkeratome is an excellent device that Dr. Swanic previously utilized, he feels that with recent advances in technology, the new Visumax femtosecond platform which is a bladeless, all-laser platform, provides for a significant improvement in the safety of LASIK. The Visumax platform, in particular, is also remarkable in that the flap thickness can be programmed to any depth that Dr. Swanic customizes for your case and it is accurate to a 3-micron standard deviation. This means that most flaps should be within 3 microns of target and nearly all flaps should be within 10 microns of target. To give you a frame of reference one strand of human hair is 75 microns in thickness.
The accuracy of modern all-laser LASIK is truly marvelous. Some patients may experience a temporary period of eye dryness that can make vision initially slightly less clear than targeted or provide mild discomfort in the weeks following the LASIK procedure. The good news is that at Las Vegas Eye Institute, we treat your case according to your individual needs and provide punctal occlusion at no additional cost if we find that it may be helpful after the procedure. Prior to Dr. Swanic starting his own ophthalmology practice in 2013, he worked at other ophthalmology practices where patients are told to pay for punctal occlusion at the time they sign up for their LASIK procedure as an add-on to the initial LASIK cost. We do not do this at Las Vegas Eye Institute because this is not necessary for many patients and it is not easy to predict prior to the LASIK procedure who will need this service. Regardless, patients of Las Vegas Eye Institute can rest assured that punctal occlusion, if necessary, is an included portion of your procedure. Some patients may benefit from very short-acting plugs that dissolve in 3 months or 6 months. These are simple to place and you will not feel them at all. Dr. Swanic also utilizes permanent plugs that are made of silicone, but we don’t use them often for our LASIK patients. The reason is that the dryness of LASIK is temporary and is usually fully resolved by 6 months. Also, permanent plugs can be felt by a small percentage of patients after placement for about the first week, so we would prefer to only use them for patients that really need them.
Our treatments all include 2 years of LASIK enhancements if needed. Fortunately, with the new Visx iDesign 2.0 platform our current enhancement rate is well under 5%. Again we feel asking patients to pay for some form of “assurance” enhancement package doesn’t make sense because the vast majority of patients will never need it. Ultimately, when choosing the right doctor to perform your LASIK surgery, finding the right surgeon is more important than price. Dr. Swanic completed his ophthalmology residency at Tufts, his refractive surgery fellowship at UCLA and is dedicated to providing the highest and most technologically advanced level of care to all his patients.
AM I A CANDIDATE FOR LASIK OR REFRACTIVE SURGERY?
This is a common reason for consultations at Las Vegas Eye Institute. Here we attempt to discuss some of the key elements of a thorough examination for refractive surgery. Some of the things that we evaluate at our office you may already know, such as your glasses or contact lens prescription. However, you may not be aware of conditions like irregular corneal shape or subtle eye dryness. An evaluation at Las Vegas Eye Institute is the best way to find out about your LASIK candidacy.
What is your Refractive Error?
This is the most important question for helping to determine if you are a candidate for LASIK. The good news is that with modern LASER Vision correction technologies most patients presenting for refractive screening will be candidates for refractive surgery. At Las Vegas Eye institute the Visx iDesign 2.0 system is FDA approved for correction of myopia (nearsightedness), astigmatism, and hyperopia (farsightedness.)
The above video is a great primer on astigmatism and how it is treated.
Our Visx iDesign Laser is FDA approved for treatments up to 12D of nearsightedness; however, due to restraints on how much tissue we can safely remove, most surgeons will limit LASIK to corrections of -8.00 to -9.00 diopters. Our laser is approved to also correct up to 5 diopters of astigmatism when using its iDesign Wavefront guidance and as long as we feel that you are an appropriate candidate we can attempt to correct that full amount. Lastly, for people that are farsighted the Wavefront Guidance program allows corrections up to +4.00 diopters, but we generally try to limit our corrections to patients with +3.00 diopters or less. The reason for this is that Dr. Swanic has found with most LASER platforms, even including our advanced iDesign 2.0 system, it is difficult to successfully correct over +3.00 diopters and have it remain stable long term. We have had patients get excellent correction of +4.00 or even +5.00 diopters of farsightedness, but unfortunately we have seen it regress back to about +3.00 diopters over the first few years after original treatment.
The above video helps explain the condition of Hyperopia or Farsightedness.
Have you ever been told that you have any eye diseases?
One of the things that LASIK consults focus on is the detection of eye diseases that you may not even be aware that you have. The one that we focus most heavily on is Keratoconus. Our testing is focused on making sure that you don’t have keratoconus or a predisposition to developing keratoconus (this is referred to as forme fruste keratoconus.) People with Forme Fruste Keratoconus should not undergo LASIK eye surgery because it can lead to a condition called corneal ectasia.
The above video gives more information on the disease Keratoconus.
Subtle abnormalities of the eye can be detected by one of our advanced diagnostic devices. We actually use 2 different corneal topographic devices at Las Vegas Eye Institute for this purpose. The first is the infrared topography built into the iDesign 2.0 platform. Although you can’t see them, hundreds of infrared lights are reflected off of your cornea and create a precise map of your eye. This map is later used during your LASIK treatment to improve its accuracy but we also use this data to evaluate the shape of your eye for any subtle disease. Next, we use the Cassini topographer to which uses 679 multicolored LEDs to create a GPS like map of your corneal shape. This gives us incredible corneal detail to detect even the subtlest of disease.
Starting in November of 2019 we are excited to be adding epithelial thickness mapping with the Zeiss Cirrus 6000 OCT. Optical Coherence Tomography (OCT) is amazing Laser technology that scans your eye at 100,000 times per second to create a detailed map of your cornea. We have been using OCT technology for years at Las Vegas Eye Institute for corneal analysis prior to LASIK but we are proud to add detailed analysis of the corneal epithelium (the 50 micron surface layer of the eye). Studies have shown that subtle findings of early Keratoconus can be masked by our epithelium but with this technology we now have the capability to spot them wear other devices would have missed them. We are proud to be on the cutting edge at Las Vegas Eye Institute, all of this technology comes at a cost, but we are confident that you will agree that your vision is priceless.
Have you been told that you have dry eye? Do you have trouble wearing contact lenses?
Contacts can be rough on the eyes, especially in the dry Las Vegas heat. The good news is that even if your contacts bother your eyes this often does not mean that you have dry eye that would prevent you from undergoing LASIK or PRK. Dr. Swanic used to have extreme difficulty wearing contacts. In fact, he only wore glasses for the two years leading up to his PRK procedure because his eyes would turn very red after just two hours of contact lens wear. Fortunately, his eyes were carefully evaluated for signs of dryness (none were found) and the decision was made to proceed with PRK.
People with severe dry eye should not undergo LASIK as this is likely to make their dryness worse, maybe not permanently, but possibly for several months to a year. At Las Vegas Eye Institute all LASIK patients are evaluated for dryness preoperatively. If signs of dryness are found we will attempt to address them preoperatively. If we cannot get them under control adequate control then we will regretfully recommend avoiding Laser vision correction. For patients over the age of 40 they may still be a good candidate for Refractive Lens Exchange which is discussed elsewhere on our website.
I have more questions. How can I learn more?
We have lots of great information on our website covering LASIK, Cataract Surgery, and other treatment options on our website, but truly the best way to get your Laser vision correction questions answered is to come in for a complimentary LASIK screening exam.
By: Matthew Swanic M.D.
Cornea and Refractive Fellowship Trained Surgeon
Las Vegas Eye Institute
HOW COMMON IS DRY EYE AFTER LASIK?
I often get asked about LASIK and dry eye, especially being a LASIK surgeon in the very dry city of Las Vegas, Nevada. Let me be straight with you. Yes, LASIK can make dryness worse, but the good news is that the dryness is typically temporary. In my experience, the dryness takes about a week to kick in, and is the most prevalent for the first month after the procedure. This is part of the reason it is very important to see a LASIK doctor that has a lot of experience in treating dry eye. You will find that doctors who have completed fellowships in Cornea and Refractive surgery tend to treat a larger volume of dry eye patients than doctors who have not. This also means that we tend to be very proactive in treating it early.
Be Wary of the Internet When Researching LASIK and Dry Eye
I remember a few days before I had PRK performed on my own eyes while I was a resident in ophthalmology, I stumbled upon a website that warned that LASIK and PRK caused serious eye dryness that was devastating and irreversible. At the time, I was still a resident at Tufts and had not yet started my fellowship in Cornea and Refractive Surgery at UCLA at that point. Since residency training in ophthalmology focuses more on the core areas or ophthalmology such as glaucoma, cataract surgery, retinal disease, and eyelid disorders more than it does on refractive surgery, I actually had not seen that many LASIK or PRK patients at that earlier point in my training. So, when I stumbled on this website claiming LASIK was dangerous, just days before my procedure, I was concerned.
Fast forward 10 years and I have experienced zero issues with dryness after my PRK procedure. There are some people who develop serious dryness after LASIK, but my experience has been that most of these people had serious dryness issues before the procedure that may have gone undiagnosed. All patients at Las Vegas Eye Institute and other quality LASIK practices are screened for pre-existing dry eyes. It is important to realize that LASIK has been performed on millions of patients throughout the US since the FDA first approved the excimer laser in 1995, and the vast majority of these patients have experienced either short-lived dryness or no dryness at all.
Why do people experience initial eye dryness with LASIK?
Doctors and researchers are quite certain that the reason patients get dryness with LASIK has to do with cutting of corneal nerves during the LASIK procedure. It is important to remember that with modern thin-flap femtosecond LASIK (the only kind performed at Las Vegas Eye Institute) we are cutting far fewer nerves than we did with LASIK performed in with a blade back in the 1990s and 2000s.
Now it’s time for some eye anatomy. Our cornea on average is 540 microns thick. The original LASIK performed with a blade cut 160 microns deep into the cornea. Our Visumax Laser is programmed to create flaps that are only 110 microns thick – a reduction of approximately 31%! Even with the thinner flap, nerves are still being cut even if it is a huge improvement over the procedures of the past. The good news is that corneal nerves do regrow. Studies looking at recovery of corneal sensation after the procedure show over 50% recovery in sensation by three months, approximately 80% recovery at six months, and essentially a return to baseline at one year. Interestingly this mirrors my clinical practice where most dryness symptoms are completely gone by six months after the procedure.
Video of creation of femtosecond LASIK flap
Why Might PRK Be Better for People with Pre-Existing Dryness?
In contrast to LASIK, the PRK procedure does not require the creation of a flap in the cornea. Instead, a very thin layer of the cornea is removed using a very dilute alcohol solution. This means that the only nerves cut during this procedure are those that are removed during what is known as the advanced surface ablation. This advanced surface ablation generally affects only the central 6mm of the cornea. In comparison, the flaps created by the Visumax LASIK laser are typically about 8mm in diameter for myopic ablations (our cornea is on average 12mm in diameter.) Because of the smaller amount of nerves being cut with the PRK procedure, the dryness I see in my practice from PRK is typically minimal or nonexistent. PRK, however, does have longer recovery time and is not right for everyone so please read our LASIK page to find out more. You can discuss whether you are a better candidate for PRK or LASIK during your initial consultation.
What Can I Expect After LASIK?
Most people will develop some level of dryness after LASIK but interestingly patients rarely report to me that their eyes “feel dry”. The most common presentation of dry eye is a slight drop in the crispness of vision during the first month after the procedure. On examination, we see tiny dots on the surface of the eye that we refer to as punctate epithelial erosions which are essentially tiny dry spots. The typical treatments for this temporary dryness include:
Punctal plug placement (very tiny devices that retain your natural tears)
Preservative-free artificial tears (we like Refresh Plus for this)
Prolonged topical steroid therapy (eye drops)
High dose Omega-3 supplements
Which Patients Are More Likely to Have Issues with Eye Dryness After LASIK?
During your LASIK consultation, we will ask you some basic questions about your eye general health, as we do see an increased incidence of dry eye in patients with autoimmune diseases such as Sjogren’s Syndrome, Rheumatoid Arthritis, and Lupus. Certain medications have also been associated with dry eye – in my experience, the biggest offenders tend to be antihistamines. The acne medication Accutane can also cause severe dryness during its use and it is not recommended to undergo LASIK while on Accutane (however LASIK can be performed after the course is completed.) Other known risk factors for dry eye include:
Age over 50
Post-menopausal females
Patients with diets low in vitamin A or Omega-3 fatty acids
Want to Know More About LASIK? What Is the Next Step?
We recommend completing a complimentary LASIK screening evaluation. During this evaluation, we will examine your eyes to determine not only if you are a good candidate for LASIK but also to evaluate if you have any pre-existing issues with eye dryness. Some patients are concerned about dry eyes because they find wearing contacts uncomfortable. Fortunately, most of the time this discomfort is not due to pre-existing eye dryness but rather more often due to the irritation that comes from poor oxygen and nutrient penetration caused by wearing contact lenses. If you would like to schedule a complimentary screening evaluation please click here.
WHAT IS THE REAL COST OF LASIK?
You may have seen some LASIK practices run ads offering LASIK at prices that seem too good to be true. There are LASIK practices out there that offer prices such as $995 per eye, or even as low as $299 an eye. The purpose of this article is to help consumers make informed decisions and identify bait and switch pricing tactics when choosing a LASIK provider. When prices seem too good to be true, they usually are. These “low cost” LASIK providers often charge additional fees for add-ons that would normally be included by a quality LASIK surgeon who provides the highest standard of care. When choosing a surgeon to operate on something as precious as your eyes, you shouldn’t feel like you have walked into a car dealership.
What is the LASIK Provider’s Cost to Perform LASIK?
There are several components of the LASIK provider’s cost to perform LASIK that this article will explain:
The cost of the Femtosecond laser (the laser that creates the flap)
The cost of the Excimer laser (the laser that reshapes the cornea)
“Click fees” paid to the laser manufacturer for each of the above
The cost of the surgeon (and his/her years of training)
The cost of the postoperative care
The cost to run the practice and including overhead and marketing expenses
The Carl Zeiss Visumax Femtosecond Laser at Las Vegas Eye Institute
What is the Cost of an Excimer LASIK Laser in 2019?
After the flap is created by the Femtosecond laser, an Excimer laser will then be used to reshape the cornea and correct your vision. The big LASIK laser manufacturers in the United States charge well over $100,000 for an Excimer laser. The typical range is between $150,000 at the low end to nearly $300,000 at the high end. The manufacturers of the Excimer lasers (except for the Nidek laser which is not commonly used today) also charge a click fee each and every time the laser is used. The click fee charged by most modern laser manufacturers is between $200 and $300 dollars PER EYE. Excimer lasers also are true LASERs (Light Amplification by Stimulated Emission of Radiation) which create ultraviolet energy by exciting Argon and Fluorine gas. This gas that is used to operate the lasers typically costs ver $1,000 per tank and needs constant replacement. Even disregarding the cost of the gas to operate the laser, the total cost in click fees alone to operate the femtosecond laser to create the flap and Excimer laser to reshape the cornea totals approximately $350 per eye ($150 for flap creation + $200 for Excimer laser), and $700 for both eyes, on the low end. So when you see an advertisement for LASIK for $299 per eye, it is highly unlikely that $299 per eye is what you will be actually paying since at that price, a practice would probably lose money on each and every case performed.
Dr. Swanic using the Visx iDesign 2.0 wavefront guided Excimer Laser
What kind of training does a LASIK surgeon undergo? How much education do they typically have?
LASIK is only performed by ophthalmologists. An ophthalmologist is a Medical Doctor (M.D.) that has gone to four years of medical school after he or she has graduated from college. This procedure is never performed by technicians and it is not performed by optometrists (optometrists go to optometry school but not medical school like ophthalmologists). In 2019 the average cost of college tuition is $20,770 per year for public colleges and $46,950 per year for private colleges (tuition, books, and room and board). The average cost of medical school in 2019, on the other hand, is $36,755 per year for public medical schools and $59,076 per year for private medical schools per year. After medical school, an ophthalmologist completes an additional one-year internship, typically in Internal Medicine or Surgery. After this internship, an ophthalmologist begins his or her residency training in ophthalmology which requires another three years of specialized training. Lastly, most of the highly skilled ophthalmologists performing LASIK today have completed an additional one-year fellowship in refractive surgery where they further hone their surgical skills and learn about the finest details of refractive surgery. Dr. Swanic, at the Las Vegas Eye Institute, obtained his undergraduate education at the Honors College at UNLV at the top of his class, completed his medical school education at the University of Nevada School of Medicine, his internship at University Medical Center in Las Vegas, his residency at Tufts Medical Center in Boston, and finally his Cornea and Refractive Surgery fellowship at UCLA’s Jules Stein Eye Institute. That is a total of 13 years of education and training!
Additional Costs of LASIK and Why You Should Avoid Low-Cost LASIK Promises
As discussed above, LASIK procedures performed at a reputable LASIK practice normally include at least six to twelve months of post-operative care which are included in the cost of your procedure. Many successful LASIK practices also tend to spend a lot of money on marketing – the estimate is that each LASIK patient comes at a cost of about $600 worth of marketing. Yup, all those ads that you hear on the radio and see your phone and computer screen cost a lot of money. After considering all of the above costs, it becomes clear why one should be skeptical of practices advertising prices as low as $299 or even $995 per eye. Even at $995 per eye, the LASIK practice would likely only break even after Laser equipment costs, Laser finance costs, excimer click fees, femtosecond click fees, and advertising costs. Often times, these low-cost promises are used to lure patients in who are then charged add-on fees for additional services such as post-operative care or for the use of more advanced LASIK lasers. If the price seems too good to be true, it usually is. To find out more about the LASIK procedure please visit the LASIK section of our site.
The LASIK Suite at Las Vegas Eye Institute
UCLA Fellowship Trained Refractive Surgeon
Las Vegas Eye Institute
MONOVISION LASIK FAQ
I have wanted to write this FAQ for a while because I get asked these questions a lot in my clinic when I am seeing patients for a cataract consultation or a LASIK consultation. Monovision has a lot of myths surrounding it, so I hope this article can help get some misconceptions cleared up.
What is Monovision LASIK?
Monovision LASIK is when we determine which of your eyes is dominant and then target that dominant eye for good distance vision. We then target the other non-dominant eye for good near vision.
The amount of correction for near vision is typically determined by your surgeon based on your age and desires. I can discuss these considerations for your corrective eye surgery and personal preferences during your Free LASIK Consultation at Las Vegas Eye Institute.
What is the success rate of monovision LASIK?
This is a great question that we finally have a good answer for due to the recent Visx iDesign 2.0 FDA Monovision LASIK trial. As a refractive surgeon, I have performed a considerable amount of LASIK and cataract surgery targeting “monovision” and found it incredibly well-tolerated in my patients. I was taught during my residency that achieving monovision with contact lenses is only tolerated by about 60% of patients, so this data hasn’t necessarily matched up with my real-world experience. The FDA trial with iDesign 2.0 LASIK had 160 patients enrolled and at 6 months postoperative they found the following results:
88% with binocular vision of 20/20 or better (looking at the eye chart with both eyes open)
<1% reported always having to wear glasses (down from 88%)
97% reported overall satisfaction with vision
These are very good and reassuring numbers (and keep in mind that about 5% of people aren’t happy in any given survey)! One main factor to point out, however, is that this FDA trial was for iDesign 2.0 LASIK, which is not the same as regular LASIK. iDesign 2.0 LASIK is far more technologically advanced in that it corrects astigmatism, integrates topography into its treatment plans, and attempts to decrease wavefront errors that other LASIK platforms may not. That being said, we’ve also had great results with wavefront optimized treatments on the Alcon Wavelight platform, so that can also provide great outcomes depending on the patient and the case.
What is the cost of Monovision LASIK?
At Las Vegas Eye Institute in 2019 our price varies between 3750 and 4250 for both eyes. This vision correction procedure(s) is with iDesign 2.0 and the Visumax Femtosecond Laser to create the flap. The price is the same for PRK (Photorefractive Keratectomy) or ASA (Advanced Surface Ablation.) Postoperative visits and necessary enhancements are included with this price. Call us or request an appointment online today if interested in a free LASIK consultation.
Will I still see in 3-D after monovision LASIK?
The short answer is a resounding YES! Our brains and how we see the world are obviously very complex, but our brain essentially determines an object’s position in space based on a few key ways: 1. Perspective (image size,) 2. Motion Parallax (movement against stationary objects), 3. Stereopsis, and 4. Shadows.
The key thing to realize is that much of our depth perception is not actually based on the use of both of our eyes together but is based on monocular clues. Perspective, shadows, and motion parallax can all be seen with only one eye. You can tell that you have reasonably good 3-D vision simply by closing one eye and looking around the room. You will notice that things don’t “feel” as 3-D but you have a pretty good idea of how far away the door is and I don’t think you will have much difficulty picking up a pen off the table in front of you even with one eye closed. Also, it is quite amazing how the brain adapts to one eye being set for good distance vision and the other eye for good near vision.
When may I not like Monovision LASIK?
Stereopsis does have its value or we wouldn’t all have two eyes. Its value is that when we have both eyes open, our brain can triangulate objects. This is VERY important for tasks where objects are coming at you fast and you need to quickly respond to them. The example I use for this is professional baseball players trying to hit a curveball and people who play tennis – they really do need this function. However, this function isn’t needed for all tasks and for many tasks we use steropsis only minimally. For instance, I know doctors that perform surgical procedures using monovision (again note that things aren’t typically moving fast in this environment).
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For this reason, I do tell my patients that are interested in monovision that if they engage in these types of tasks which require tracking fast-moving objects, they may want to temporarily reverse their monovision when doing so. How can they do this? For tennis, they can put in a contact lens in the eye that is set for near vision so that they have sharp distance vision again. Then when they are off the court, they can take the contact out and enjoy near vision again. During the majority of their daily lives, they often find that monovision still affords them good stereoscopic vision as well as good near vision for tasks like reading their phone or using a computer.
We also recommend reading our patients’ Monovision LASIK reviews to understand their experience with the procedure, our staff, and aftercare.
I like to read will monovision work for that?
Yes – the monovision correction at the levels I typically target will allow you to read. That being said, at Las Vegas Eye Institute we don’t set near vision targets for very high powers because that will decrease the quality of your distance vision, increase haloes at night time, and decrease the quality of your stereoscopic vision (yes stereoscopic vision is still present with monovision but reduced mildly). Because we don’t set the near eye that high, you will find monovision easy to adapt to, however, it can make reading for prolonged periods of time tiresome. You also may have difficulty reading very fine text like that found on pill bottles. This can often be overcome with regular over the counter reading glasses but a custom pair of reading glasses can be made.
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Does Monovision LASIK cause haloes at night?
This is variable with vision correction surgery. Nearly all patients will see haloes initially after having one eye set for monovision. Fortunately for many patients, their brain adapts to this and shuts off the haloes over the course of the next few weeks. I have had some patients where the halos do not diminish sufficiently over time. The good news is that the haloes typically are visible ONLY at night or in dim lighting conditions and if truly bothered by them my patients will buy a custom pair of glasses to keep in the car for night driving.
I’m 35 years old should I get my eyes set for monovision anticipating the onset of presbyopia?
Surprisingly I have gotten this question during several LASIK consultations and my answer is “NO.” The reason I say no is that without any problems with your near vision at this age, you will see zero benefits to this and only downsides. You would likely get haloes from this and some level of eye strain. Most LASIK candidates will not be significantly bothered by presbyopia until about the age of 42 (this can vary person to person.) And even then, it usually is more of an annoyance and they can adapt to it by holding things further out to get them into focus. This is variable but most patients that I have seen don’t succumb to carrying reading glasses until the age of 45.
REVIEW: THE DIFFERENCE BETWEEN DIFFERENT LASIK OPTIONS IN 2019
Patients often know that LASIK has changed considerably since the excimer laser was approved in 1995 but they aren’t sure exactly what has changed. The following post is designed to help clear up some confusion.
What is LASIK eye tracking?
Laser eye tracking was the first major advancement in LASIK surgery and it was an important one, because it is instrumental to the implementation of further technological advancements that followed it. Eye tracking essentially allows the laser to follow the eye. Many people don’t realize this but the original LASIK lasers actually didn’t have any of the advanced eye tracking technology that is available today. In fact, the older lasers didn’t have any eye tracking, period. That isn’t to say they were just firing randomly, but they essentially relied on having the patient fixate on a light and not move their eye during the surgery. If the patient moved their eye, the surgeon could stop the laser and remind them to fixate on the light. This may sound primitive, and to some extent it was, but we need to realize that the original LASIK lasers did not fire at as a high a rate as the ones we have today, meaning that the surgeon had more time to stop the laser if eye movement was detected. Also, the only LASIK ablation profile available on the first lasers was for myopia, or nearsightedness, which is a treatment that essentially flattens the central cornea. If this type of treatment is mildly decentered, it often doesn’t affect a patient’s vision substantially, especially if only a small fraction of the spots is off target. This is not the case for hyperopia or farsighted treatments where lasers are fired in a ring around the center of the visual axis instead of just firing in the center of the cornea. If the patient keeps moving their eye during a farsighted treatment without tracking, then the central zone, what we refer to as the optical zone, can become very distorted and uneven which will induce astigmatism and affect visual quality.
One thing I can tell you, and often reiterate to all of my patients, is that all modern lasers have eye tracking. If a patient moves their eye during the procedure the most common thing that occurs is that the laser will simply shift its firing pattern to the eye’s new location. However, if the patient moves their eye too far, then the laser will simply stop firing. If this occurs, I will stop and reassure the patient, let them find the fixation light again, and then the procedure can proceed normally. The laser utilized at Las Vegas Eye Institute, called the Visx S4 IR, not only has active eye tracking, it also has a technologically advanced feature called “iris registration”. This technology is linked to the preoperative testing machine at our practice called the Visx iDesign. The iDesign takes an infrared picture of your eye that is transferred to the laser prior to your procedure. Then when you are under the laser, I personally capture a new picture of your eye that is matched to your preoperative picture. Why do I do this? The reason is our eyes are known to rotate when we lie down on our back, this can be a negligible amount (say 1-2 degrees) but it can also be a more significant amount (such as 6-10 degrees) that will make astigmatism correction less accurate. The “iris registration” technology that we have at Las Vegas Eye Institute coupled with the high resolution “wavefront guided” LASIK ensures that the precise treatment we captured before the procedure is properly lined up when your eye rotates even a fraction of a degree when under the LASER, which leads to more optimal outcomes.
What is Wavefront?
This image is an iDesign wavefront capture of my eye. You can see the high definition image of my iris used for iris registration on the top left and the wavefront capture of my eye on the bottom left). The other two images pertain to the topographic shape of my cornea.
Wavefront is a key topic to understand when we are discussing modern LASIK because nearly all of the procedures done these days are either “wavefront guided” or “wavefront optimized”. A wavefront is simply a light beam that is analyzed after it exits your eye. Our iDesign device specifically sends an infrared beam (that you cannot see) through your eye and then an advanced sensor picks up and analyzes the infrared beam when it exits your eye. A wavefront is unique to your specific eye and when it is captured it shows us precisely how your eye tends to distort light. A nearsighted patient will have a completely opposite wavefront capture compared to that of a patient that is farsighted. Astigmatism is also captured up on a wavefront. Of course, we don’t capture wavefronts merely to determine if a patient is nearsighted, farsighted, or has astigmatism. All of those things can be determined with a much more basic device called an autorefractor and then confirmed by a doctor or technician using the typical “which is better 1 or 2” device called a phoropter. The reason we actually began to capture wavefronts was that in the early 2000s we were aiming to give patients “superhuman” vision by correcting things beyond what glasses were capable of correcting. Nearsightedness, farsightedness, and astigmatism (things that can be corrected with glasses) are referred to as “lower order aberrations.” Wavefront goes beyond this to try to correct more subtle optical abnormalities called “higher order aberrations” which primarily include things called coma, trefoil, and spherical aberration.
OK, I think I understand what a wavefront is, now what is wavefront optimized LASIK?
Wavefront optimized LASIK is a great technology that was popularized by a laser originally called an Allegretto but is now utilized in the United States primarily on the Alcon Wavelight Platform. I was trained using this technology during my fellowship at UCLA and have used it for many years with great results. However, its “wavefront” terminology doesn’t have anything to do with a wavefront capture device. It only has to do with the way all treatment plans are created with the laser. The treatment plan is initially input into the laser in the form of nearsightedness or farsightedness with or without astigmatism. This treatment plan is actually written just like your glasses or contact lens prescription. Wavefront optimized LASIK then takes into account the typical preexisting amount of “spherical aberration” in the general population of patients along with the amount of spherical aberration that LASIK normally induces. With Wavefront optimized LASIK, the laser is programmed to fire additional pulses to correct for this typical preexisting and induced spherical aberration which is also known as “wavefront error”. Accounting for and correcting this wavefront error was a great advancement in LASIK technology. Patients get great outcomes and this is the reason I’ve used wavefront optimized LASIK technology on countless patients with both the Wavelight 400 and the newer Wavelight EX500 platform.
What is Wavefront guided LASIK?
Wavefront guided LASIK is LASIK that corrects “higher-order aberrations” along with “lower order aberrations”, i.e., nearsightedness, farsightedness, and astigmatism. Wavefront guided LASIK can go a step beyond wavefront optimized LASIK because it is actually attempting to correct several other “higher-order aberrations” other than just spherical aberration that was discussed above. Higher order aberrations known as coma and trefoil cannot be corrected using general population data because coma and trefoil by their very nature are unique to each individual patient’s eyes. So if you want to correct these higher order aberrations, it is necessary to test for them with a wavefront capture device on each patient you want to treat. The original wavefront capture device (the device that was used to perform LASIK on my own eyes in 2010) was called the Visx Customvue. It was an amazing device at the time and consisted of something known as a Hartmann-Shack aberrometer that was able to detect things like trefoil, spherical aberration, and coma. The Customvue then took this data and created a treatment plan to correct these aberrations along with the lower order aberrations of nearsightedness, farsightedness, and astigmatism. It was very advanced for its time and even captured an iris image that was transferred to the laser for “iris registration” as discussed above. There has since been a further advancement in technology with the iDesign 2.0 which is the device used to capture each patient’s individual data at Las Vegas Eye Institute.
The image above is a patient seated for capture in the iDesign device.
What is new in wavefront guided LASIK?
The company Visx received FDA approval for the iDesign capture device in 2015. This device then underwent further refinements that allowed it to integrate corneal topography into treatments with iDesign 2.0 that received FDA approval in 2018. This amazing new device was created to replace the Customvue capture device. The Customvue was a great device (as I mentioned, it was used on my own eyes) but its Hartmann-Shack aberrometer had limited resolution. This was just what you would expect for the time period it came out. If you think about the resolution of cell phones in the early 2000s it is nothing compared to your modern iPhone or Android phone. The Visx iDesign LASIK capture device is exactly the same way. iDesign now has a high-resolution Hartmann-Shack sensor that is over 5 times that of Customvue. We used to get about 250 data points and now get 1250! This increased resolution has produced better results with iDesign than I’ve seen with any other platform since I began performing LASIK in 2010. We often had people get 20/20 and usually even 20/17 vision with the Customvue and Wavelight platforms. Now with the iDesign, we have seen even patients achieve 20/13 vision. This technology along with all of the other state-of-the-art equipment we have at Las Vegas Eye Institute make me proud to say that there has never been a better time to consider getting LASIK.
Cornea and Refractive Fellowship Trained Surgeon
Las Vegas Eye Institute
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Las Vegas Eye Institute
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