Laser eye surgery is the world's most commonly performed elective procedure — more than 30 million laser surgeries are carried out each year. It is also one of the safest operations available, with a very high likelihood of success and an extremely low risk of complications.
In terms of medical history, however, laser refractive surgery is a relatively young field. Nearly 40 years have passed since the first laser eye surgery was performed. Freedom from glasses and contact lenses became widely popular among the general public around 30 years ago.
Patients often ask, quite reasonably, whether enough data has been gathered over that time to know what a person's vision will be like years after a laser procedure. Is the result truly lasting? Do the eyes and vision of someone who has undergone a laser procedure change with age in the same way as someone who has not? We discussed these questions with KSA Silmakeskus eye surgeon Dr Ants Haavel.
History and Development of Laser Eye Surgery
Could you give a brief overview of the history of laser eye surgery — how long procedures have been performed and how it all began?
The first lasers used in eye surgery were excimer lasers, which had previously been used only for industrial purposes, such as manufacturing microchips. Lasers were first used in eye surgery in 1987, when German eye surgeon Theo Sailer and Columbia University researcher Stephen Trokel collaborated to perform the first corneal (the eye's clear front layer) operation — a photorefractive keratectomy, known as PRK.
The name LASIK was first introduced in 1991 by the legendary Greek eye surgeon Ioannis Pallikaris, who is also credited with performing the world's first LASIK operation.
Laser refractive surgery began in Estonia in the early years of the 21st century. The first laser procedure at KSA Silmakeskus was performed in 2005. Until 2010, LASIK was the predominant method at KSA; after that, we moved exclusively toward blade-free procedures.
Blade-Free Procedures vs LASIK
KSA has performed both LASIK and blade-free procedures. When comparing blade-based and blade-free procedures, is the outcome the same years later? Or does the blade-free procedure have advantages?
We can only draw conclusions based on the specialist literature and our own experience. At KSA, we have been monitoring our results for 18 years, having performed over 30,000 procedures and hundreds of thousands of examinations.
Our conclusion is simple and straightforward — the more gently the cornea is treated during and after the procedure, the safer the procedure, the better the quality of vision, and the more lasting the effect. That is why we stopped performing blade-based procedures in 2010, even though at that time we were the clinic carrying out the highest number of LASIK procedures in Estonia and the Baltic states.
I should emphasise that this reflects KSA Silmakeskus's perspective, as there are thousands of clinics around the world that continue to perform blade-based procedures and are satisfied with their results.
How Long Do the Results of a Laser Procedure Last?
How long do the results of a Flow3 laser procedure last? Are they lifelong?
When patients ask whether the result is permanent and lifelong — meaning they will never again need minus-power glasses — we can say that once the cornea and the eye have fully recovered from the procedure, the effect of the procedure on the cornea is indeed lasting.
On rare occasions, a small degree of minus prescription can return, creating a need for a repeat procedure. In the early years of laser surgery, the rate of repeat procedures was 30–40%, but with advances in technology, accumulated experience, and patient selection criteria, procedures have become considerably more precise and safe. At KSA Silmakeskus, the rate of repeat procedures today is under 1%.
It is worth keeping in mind, however, that laser surgery does not protect the eye against age-related changes or the development of more complex eye conditions. It is precisely for this reason that it is critically important for the clinic to select patients for the procedure with the utmost care.
We at KSA are very selective — if during the pre-procedure examination we notice any doubt at all about a patient's suitability, we place them on hold and do not proceed with the procedure. We invest significant sums each year in diagnostic technology, continuously train our staff through international and domestic programmes, and work closely with patients during pre-procedure examinations. When patients are very carefully selected, the results are also very good and lasting.
Reading Glasses and Age-Related Changes
Does long-sightedness develop, and why? Is it related to the laser procedure or not?
Hyperopia (long-sightedness) is caused by several factors and is in no way dependent on having undergone a laser procedure. It can arise because the diameter of the eye is smaller than average. For example, many young children have hyperopia, and as they grow and the size of the eye increases, their long-sightedness decreases or disappears entirely. This change in refraction (the way the eye bends light) is called emmetropisation.
Another cause is a change in the light-bending properties of the lens inside the eye. This is the reason most adults or older individuals develop hyperopia.
Age-related long-sightedness, known as presbyopia (the need for reading glasses), occurs because the structures of the eye — including the eye muscles, connective tissue, and lens — lose their elasticity and can no longer focus light rays onto the cornea when looking at close objects. This is not unique to the eyes; as a rule, many people find that after the age of 45 their joints and back begin to stiffen as well. Those who manage to keep the whole body supple tend to retain the ability to focus at close range for longer. So — a healthy body means a clear mind and good vision!
Corneal Recovery After a Laser Procedure
Is it true that the manipulation involved in a laser procedure is so minimal that, after recovery, it is impossible to tell under a microscope that anything has been done to the eye?
Indeed, in the ideal case, after full recovery — which takes a few months — there should be nothing visible under a microscope. The cornea should be perfectly clear, with no trace of the laser procedure visible. This means that an eye doctor should not be able to tell that any manipulation was performed on the eye.
Diagnostic devices, however, can detect that a procedure has been carried out, as they establish that the cornea is slightly thinner and flatter than that of the average person. A standard sheet of printer paper is 100 micrometres thick. If a person has, for example, 6 dioptres of myopia (short-sightedness), which represents quite a significant degree of short-sightedness, the laser reshapes the cornea to eliminate that short-sightedness by thinning it by approximately 100 micrometres.
You can see how little the properties of the eye need to be changed to produce a life-changing improvement in vision. Performing such microsurgical manipulation would be unthinkable without laser technology.
Vision Outlook 25 Years After the Procedure
Finally, what is the likely vision outcome for a person who had a laser procedure at KSA at the age of 25, by the time they are 50 or older?
We are now able to see, speak with, and receive feedback from our patients for whom nearly 18 years have passed since their laser procedure. Given that many of them are now over 50, the most typical scenario based on our patients' results is that a person who had the procedure at 25 still has many decades of excellent distance vision ahead, and will not need to think about minus-power glasses again during their lifetime.
At some point, depending on the individual, a need for reading glasses for close vision will likely arise. However, this is also something that awaits people who have not had a laser procedure. In my view, the outlook for that 25-year-old is excellent — they can spend their best and most active years with very good vision.
What is the current state of vision among KSA Silmakeskus patients for whom more than 10 years have passed since their laser procedure? Has their vision remained good, or have any concerns or complaints arisen? Are they glad they had the procedure done all those years ago? It is precisely this topic that will be covered in our next blog article. Stay tuned!
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