Ah, a great battle between two competing vision correction surgeries. On the field we have lasik: the most well known laser eye procedure. In the visitor's dugout we have ICL: a relative newcomer to the vision correction scene (despite the fact that it's been around for a few decades). Let's put both of these procedures through the tests to determine who wins out as the optimal way to correct your vision. We got nine innings ahead, so settle down and grab some peanuts and Cracker Jack.
First inning - who is a candidate?
The competition starts out close. Many people can qualify for either ICL or lasik.
How much prescription can be treated
At first glance, it may seem that ICL is able to accommodate a wider range of prescriptions. The ICL is a physical lens that corrects prescription. This physical lens gets placed within the eye. You can theoretically make a lens of any prescription and place it within the eye to correct vision. This is a huge advantage to ICL. For patients who have very large prescriptions, ICL is capable of correcting their vision.
Lasik may not work for these large prescriptions. To correct prescription, lasik causes a small amount of thinning to the cornea. Correcting vision with lasik requires a certain amount of thickness to the cornea. If the cornea is too thin, you run the risk of lasik weakening the cornea and causing it to change shape & blur vision over time - something called corneal ectasia. The larger the prescription, the more cornea thickness you need. Eventually you reach a point where the prescription is too large to be safely treated with lasik. But ICL is capable of treating these prescriptions. The ICL can completely eliminate up to -16 in prescription!! The ICL becomes the perfect choice for the patients with high amount of nearsightedness.
But ICL is incapable of treating certain prescriptions (at least in the United States). ICL cannot treat prescriptions smaller than -3. ICL also can't treat patients who are farsighted (prescriptions that start with a "+" sign). Laser eye surgery, however works very well for these prescriptions.
The space in the front of the eye
Somewhat similar to how lasik is limited by how thin the cornea is, ICL is limited by how much space exists within the front part of the eye - called the anterior chamber. The anterior chamber must be a certain size for the ICL to safely fit.
Anterior Chamber of Eye, image by File:Three Internal chambers of the Eye.png: Artwork by Holly Fischer derivative work: Pixelsquid, CC BY 3.0, via Wikimedia Commons / cropped from original
The ICL sits just behind the iris (the colored part of the eye) and vaults over the natural lens inside the eye. This vaulting of the lens pushes the iris forward just a little.
The front of the eye is also filled with a fluid called aqueous humor. This aqueous is constantly being produced and drained out of the eye at the angle of the cornea. If there isn't enough space in the anterior chamber, the ICL lens can push the iris forward enough and cause it to block the angle. This will cause the pressure inside the eye to go up and cause problems. Thus, ICL requires a certain amount of space in order to make sure it has minimal impact within the eye.
Irregular corneas and keratoconus
But not only can the ICL treat thin corneas, it can also treat irregular corneas. Irregular corneas have an increased risk of becoming weak over time. As discussed above, a weak cornea can develop ectasia or change shape. A condition called keratoconus exists in which this exactly happens. As the cornea changes shape, it blurs and distorts the vision. By thinning the cornea more with laser eye surgery, it will only make everything worse.
But ICL doesn't thin the cornea. With certain irregular corneas and for certain patients with keratoconus, ICL is able to correct vision when lasik cannot. (see also Can You Correct Vision With The ICL For Keratoconus?)
At the end of the first inning, ICL was able to sneak a double past lasik and take a small lead. While there is a gap of patients that ICL cannot treat, a huge benefit to ICL is that it can treat those larger prescriptions and make a significant difference for the people who really really can't see without any glasses or contacts.
- ICL up 1-0
Second inning - extra visits before surgery
With both ICL and lasik, there is frequently another measurement of the prescription of the eyes prior to the procedure. This is almost certainly the case if you are a contact lens wearer and wore contact lenses to your consultation appointment. (Contact lenses can cause a slight temporary change in the shape of your cornea and cause a change in your vision. To get both of these procedures as accurate as possible, it's important to go out of the contact lenses for some time to get the most accurate prescription).
With lasik, this second measurement check is frequently done on the day of the surgery. It makes things more convenient. Afterwards, your correction is programed in the laser.
The ICL lens, however, is individually ordered for your particular eye. As this lens is a physical item, it must be ordered in advance. This lens not only contains your prescription but the lens is actually sized for your eye as well. It's a very customized solution, but it does require extra visits prior to the procedure in order to get all the necessary measurements of the lens.
While not a too large of a difference, lasik has the slightly less-involved pre-surgery process compared with ICL. In a quick inning, lasik is able to bring a runner home and tie up the competition.
- ICL and lasik tied 1-1
Third Inning - Cost $$
In the bottom of the third, lasik hits a two run homerun to pull ahead of ICL.
Lasik boasts a huge advantage over ICL in the cost of the procedure.
ICL surgery has some additional costs that lasik does not have. Because the ICL has a physical lens, this lens adds to the cost of ICL surgery. While lasik does have some fees for each patient to use the lasik laser, these fees are much smaller than the cost for the ICL lens.
ICL surgery is also frequently done in a surgery center. Surgery centers require more staffing and materials. In general, having a surgery in a surgery center will be more expensive than having the same surgery done within an office setting. In almost all cases, lasik is done within the office. Lasik doesn't need any of the requirements of a surgery center. This further reduces the cost of lasik.
The average cost for lasik is around $4,500 for both eyes. ICL, on the other hand, can sometimes be double that price and ranges from $7,000 - $10,000 for both eyes. Check out more at How Much Does Lasik Eye Surgery Cost? and What Does ICL Surgery Cost?
- Lasik up 3-1
Fourth Inning - Elegance of the correction
ICL and lasik eye surgery correct vision through two completely difference processes.
The lasik laser remodels the cornea. For people that are nearsighted, this means making their cornea more flat. Changing the shape of the cornea allows lasik to change how light is focused in our eye and gets our vision in focus. But this change is permanent. To make the cornea more flat, laser energy is applied to the cornea. Each laser pulse removes a very small precise amount of cornea. This is the reason why the cornea has to be a certain thickness with lasik. Lasik will make the cornea more thin in the process.
But ICL is completely different. ICL doesn't involve the cornea. ICL involves placing a lens inside of the eye. Just as how this lens can be placed in the eye, this lens can also be removed from the eye. Thus, the ICL correction can be reversed! But typically you wouldn't want it reversed; that would mean going back into glasses and contact lenses. Note: the main situation where the ICL is removed is during cataract surgery. With today's ways of measuring and calculating the cornea, individuals who have had lasik done have slightly less accuracy in getting their prescription perfectly on target after cataract surgery. While this is expected to improve over time, individuals who have ICL don't have that issue.
By placing a high quality lens within the eye, ICL can have better night time vision than lasik. While both can lead to improved low-light vision, ICL comes out ahead of lasik when compared directly. ICL preserves and can even improve our ability to make out fine details at night-time.
On top of that, ICL also has built in UV protection. While it's still recommended to wear sunglasses to protect the surface of the eye, it's nice to know that you have extra built-in protection for your retina and natural lens inside your eye.
Lasik still is a good procedure, but ICL has some really cool nifty features. ICL hits a solo homerun to narrow the gap.
- Lasik ahead 3-2
Fifth Inning - The surgery
Who would have thought that it would not be until the fifth inning before we actually got to the surgery part...
What are the commonalities between ICL surgery and lasik?
- In both procedures, both eyes are typically done on the same day. You don't need to wait a few weeks later to get the second eye done. This has the benefit of having a quicker recovery time as well as reducing the number of doctor appointments.
- Both procedures are quick. You show up, get prepared for surgery, get the surgery done and before you know it, you are going home. You may only spend 2-3 hours at the eye center for the complete process (but the surgery time itself is only about 15-30 minutes of that time). Lasik does have the advantage of being slightly quicker than ICL. While each eye for ICL takes about 10-15 minutes with some extra time between the two eyes, lasik can be done for both eyes in about 15 minutes.
- Both surgeries are painless. Anesthetic or numbing drops work really really well on the eyes. They take care of all pain. You will still notice weird sensations such as pressure sensations and if you squeeze your eyelids real hard the blink protector used for both can be uncomfortable, but technically the surgery doesn't have any pain due to the anesthetic drops used prior to the procedure.
- You are awake for both surgeries. While this sounds scary, it is actually beneficial because you don't have to worry about getting medically evaluated for anesthesia prior to the surgery nor have to worry about recovering from the anesthesia. As the surgery is painless, you mainly just experience weird and bizarre sensations.
Both surgeries are very similar. They are both very easy to go through. But lasik is just a little bit easier to go through than ICL.
- Lasik goes up 4-2
Sixth Inning - Recovery after surgery
The first day
After both lasik eye surgery and ICL surgery, you will have some blurred vision. This blurred vision does heal up very quickly within the first day.
Because the eye is dilated for ICL surgery (and not for lasik), it can take just a little bit longer for the vision to sharpen up after ICL surgery as it takes a little bit longer for the dilation to wear off.
After both ICL surgery and lasik, you will have some scratchiness and discomfort. With both of these procedures, this discomfort will go away within the first 2-6 hours after the procedure. Occasionally the scratchiness with ICL can be just a little shorter than with lasik.
Both procedures have a very similar first day.
Beyond the first day is where these two procedures diverge
But there are still some similarities between the two procedures: Both procedures will still have some element of night-time vision symptoms to adjust to. This includes halos around lights at night. For lasik, these symptoms are often prescription dependent; high prescriptions can cause more of these symptoms. While the modern lasik lasers today have dramatically improved these symptoms, some people can notice them within the first few months. Gradually over the course of the first few months, these symptoms fade away as the brain adjusts to your new vision through a process called neuroadaptation.
But also for the first few months after lasik you will have some extra dry eye. This dry eye from lasik is due to the fact that lasik affects more of the cornea. Within the cornea are small nerves which regulate the production of natural tears on our eye. These nerves are disrupted after lasik; subsequently, we can't produce the same level of tears after lasik. But as these nerves gradually heal up overtime, this dry eye improves until you return back to your normal level.
As ICL doesn't really affect the cornea, you don't have this same amount of dry eye. You will still have some dry eye irritation with ICL within the first week. After all, you still had a surgery and you still will have some inflammation on the surface of the eye. The eye drops used after ICL surgery will also cause a little bit of irritation. But all of this heals up pretty quickly within the first week or two.
Once you get past the first day, ICL has a much shorter recovery than with lasik. You are pretty much all recovered.
That line drive by ICL starts to narrow the lead.
- Lasik up 4-3 over ICL
Seventh Inning - Short Term risks
Ok, we passed the normal course of the surgeries. But unfortunately in life, nothing is ever perfect. Both ICL and lasik will have some short-term risks or roadblocks on the road to recovery. When treated, however, these short-term risks can be resolved.
One large concern for lasik patient is the risk of having a lasik flap. After surgery, there is a chance that this lasik flap can shift out of position and cause issues. And this is a real risk; but in reality its biggest risk is within the first day or two after lasik. Once you get past this time-frame, the odds of you having a lasik flap dislocation drop quite a bit. (See also Everything You Need To Know About Flap Dislocation After Lasik)
For ICL, there biggest short-term risk is having a high eye pressure after the surgery. This high eye pressure typically happens within the first day or two after the surgery. This high eye pressure can also be quite uncomfortable and cause a headache. Typically this eye pressure is treated with medication in the short term but resolves on its own within the first 24 hours. Its rare that this high eye pressure needs additional treatment after ICL surgery (See also What Causes a Headache After ICL Surgery?)
Nothing in life is risk free, but in the short term, ICL and lasik have similar short-term risks
- Lasik still up 4-3
Eighth Inning - Longevity
The biggest concern after lasik is developing additional prescription or regression. And while the regression rate after lasik has improved quite a bit in the past two decades, it still exists. Higher prescriptions treated with lasik increase the risk of the regression. Some of the reasons why the prescription can change with high prescriptions comes from the fact that sometimes highly near-sighted patients can gradually get more near-sighted with time. This prescription happens regardless of getting lasik done or not.
But beyond high prescriptions getting worse, there are other reasons why prescriptions can wear off after lasik. The cornea itself can change shape. The epithelium on the surface of the cornea can thicken and change the curvature of the cornea. The treatment can also alter the natural equilibrium tension in the cornea. This can also lead to the cornea changing shape (especially with larger treatments). Both of these effects can cause the prescription to have a small amount of regression.
ICL is also used to treat these highly near-sighted individuals. While ICL can't eliminate regression that would naturally occur just from having a very high prescription, ICL doesn't affect the cornea and eliminates any cornea change causing regression. The prescription corrected by the ICL doesn’t wear off over time.
ICL ties it up with one inning to go! This is getting exciting!
- Tied 4-4
Ninth Inning - Long Term Risks
Can either lasik or ICL break the tie in this ninth inning? Let's discover how each surgery pans out in the long-term.
First lasik
As discussed way earlier in the first inning, there is a condition called keratoconus. Keratoconus causes a progressive change in the shape of the cornea causing blurred and distorted vision. Now, patients with keratoconus or those with irregular corneas are not candidates for lasik. Lasik can make this condition worse.
But there is a very small percentage of patients who may look entirely normal on scans and still go on to develop weakening of the cornea - post-lasik ectasia.
As technology has improved and as surgeons have learned more about risk factors for post-lasik ectasia (such as large lasik treatments on thin corneas), this condition has become rare. The chances of this occurring is around 0.1% or less. And also, if caught and treated early through a procedure called cornea cross-linking, one can avoid losing vision.
Now ICL
ICL avoids the risk of post-lasik ectasia by preserving the cornea. But ICL does a have risk that lasik doesn't have. This is the risk of getting a cataract after ICL surgery. A cataract is a clouding of the natural lens inside our eye. The lens can become cloudy for a wide variety of reasons. The most common way is through the natural aging process of the lens. But if the lens is stressed in any way, it can develop some clouding.
Just like any living cell in our body, the lens needs nutrients to survive. It gets these nutrients from the aqueous fluid surrounding the lens. The ICL sits directly in front of our own natural lens. If the ICL sits too close to the lens, it can impede the flow of nutrients to the lens. This can potentially cause a cataract.
The risk of a cataract is low (studies estimate less than 0.5% to 3.0% depending on age and prescription). And fortunately cataracts are treatable with cataract surgery. But it still can be annoying to need cataract surgery.
Before cataract surgery, our lens is soft and flexible. This flexibility allows our lens to change our focus and see things off in the distance and up close when our vision is corrected. Over time, in a natural process called presbyopia, the lens becomes inflexible and we lose our ability to focus up close. People start to need reading glasses or progressive glasses to see up close. In order to see up close we need a flexible lens.
After cataract surgery, the new artificial lens placed is inflexible. This means that after cataract surgery you will have a harder time seeing up close (at least in one eye). There are special artificial lenses called multifocal lenses or lifestyle lenses that can restore that up close focus. And while these lenses work great, the ideal scenario is to not need cataract surgery until the lens naturally changes on its own.
These two risks are rare, but between the two conditions, the risk of post-lasik ectasia is smaller than the risk of developing cataracts after ICL.
In the bottom of the ninth, lasik lays down a sacrifice bunt to drive home a run!
- Lasik wins 5-4
Lasik wins!!, image by Arturo Pardavila III from Hoboken, NJ, USA, CC BY 2.0, via Wikimedia Commons
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The Post-Game
It was a close match between ICL and lasik in this very comprehensive look. Both of the two procedures really have some amazing technology. But by a narrow margin, lasik still comes away as the preferred treatment to correct vision (for those that qualify for lasik). But for those in which lasik wouldn't work, ICL is also an awesome option.
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