Is "Bladeless LASIK" or "i-LASIK" the Best?

Safer LASIK!
Is “Bladeless LASIK" or "I-LASIK” the best?

By Scott Grealish MD
EyeHealth Northwest Lasik Specialist
Portland, Oregon

Many LASIK patients are doing research online to help them make good decisions about their vision. The natural fear of going blind leads many patients into an in depth technical analysis of Lasik in an effort to find reassurance from “experts” online or from the community at large. Anyone searching Lasik currently is going to quickly encounter clinics promoting the “superior safety” of their “latest” technology, especially “Bladeless LASIK”. I’d like to review the pro’s and con’s of “Bladeless LASIK” and share my experience with this technology. Since 1998 I’ve used many different lasers and techniques to correct vision. It’s amazing how sophisticated our LASIK techniques have become since the FDA approved LASIK in 1995. However, it’s easy for patients to assume that any new technology is better than the “old” one it replaces, and that logic runs contrary to my personal experience as a LASIK surgeon. I’d like to point out a few issues with this line of thinking and share some of our experience at EyeHealth Northwest regarding the safety of Lasik surgery.

LASIK is Safe

First and foremost I’d like to convey the message that Lasik surgery is indeed quite safe and effective at this point in time. Like any surgery, it has potential side effects. It always will. Better technology will never fully eliminate the human side of the surgery; the surgeon and clinical staff play a big role in the outcome, and to a greater extent than most patients realize, they themselves play a role in the outcome. Despite these pitfalls, the fact remains that on a national level the risks of losing vision from Lasik surgery appear to be about 3-4 times less than the risk of losing vision from a contact lens complication. Since most of our patients come to Lasik from wearing contacts, they are in fact decreasing the risk to their eyes in most cases. At EyeHealth Northwest we have never had an infection or serious loss of vision from Lasik since our center opened in 1999.

Marketing is Marketing

Secondly, I think we all realize that commercial interests often bias the information we get through the internet. For several years now there has been a big marketing push for “Bladeless LASIK”. The “Bladeless” part refers to how surgeons begin the Lasik procedure by making a thin “flap” of corneal tissue once the eye is numbed with drops. Many clinics advertise the “Bladeless” Intralase laser (also called i-lasik by the manufacturer in an attempt to appeal to Apple fans) as being “superior, safer, more modern technology” as opposed to the alternative “blade” or “microkeratome” method of creating the flap. Patients should know that worldwide there have been over one million surgeries done with the Intralase laser. It’s no longer new, having gone through many improved models since 2003. It is now considered by most surgeons to be an excellent technology. However, the “old” blade based microkeratome technology has been used in over 15 million surgeries and has undergone development since the 1950’s. It remains the preferred technique for the majority of surgeons to date. I think patients should realize that in my searching of the internet I find almost exclusively biased commercial information on the intralase, with no real mention of potential downside. In contrast, searching our specialty medical journals and chat groups I find great diversity of opinion amongst surgeons and publications both supporting the safety of the laser as well as those pointing out new and serious complications from the laser.

When surgeons choose equipment they weigh factors of safety, efficacy, track record, ease of use, and yes even cost (which they may not be able to pass along to their patients). No wonder there is an active healthy debate amongst experts in this field as to which technique is “best”. I’d like to share my experiences and beliefs on this issue having used both “Bladeless” and “Blade” techniques.

Experience Counts

I have used a microkeratome called the Amadeus 2 with a special order medlogics blade since 2005. In that time, my partners and I have not experienced a single serious “blade” related complication over thousands of surgeries. The accuracy of the device in my hands is equivalent to the best published data for the intralase device.

In 2009 I performed a limited number of LASIK procedures with the “Bladeless” Intralase technique. My experience was favorable in terms of excellent outcomes and no complications, however, my patients were clearly less comfortable both during and after the surgery than my microkeratome patients. This finding was true for every patient and quickly led me to abandon the technique. I am not alone in making this observation, I have confirmed my experience with other surgeons who have broad experience with both techniques. It appears that patient comfort can vary from laser to laser using the “Bladeless” technique. While I fully appreciate the potential advantages of the Intralase technique, I am not prepared to use it in my surgery until further advances refine the comfort of the technique for all patients and surgeons. My surgical staff was truly relieved to go back to our “old” technique using the microkeratome which is so easy for our patients and gives such consistent and excellent results in my hands.

If the intralase (or indeed it’s formidable German competition) improves safety or efficacy substantially in the future compared to the latest microkeratomes (which also continue to improve) then we at EyeHealth would utilize a laser to create the flap. That decision would be independent of cost in our case. Until that time, we remain committed to using our current device with it’s proven track record in our hands.

Lastly, I’d like to point out a serious flaw in the argument that “Bladeless” LASIK is safer than any other LASIK. First, be aware that “Bladeless” LASIK still makes a cut on the eye, creating what we call a “flap”. In the majority of cases, a “flap” related complication is exactly that, related to the presence of a flap rather than how it was created. These should be rare complications (less than one in a thousand) in the hands of an experienced surgeon no matter which device is used. If surgeons are really concerned in a particular case that a complication may occur making a flap, they don’t use the Intralase, they simply use a no cut, no flap technique. This is done directly on the corneal surface and known as PRK or Lasek. It is routinely performed at EyeHealth (indeed it accounts for 20% of all “LASIK” surgery nationally) and is immune to flap complications simply because no “flap” is created! This is actually the safest "Bladeless", "All Laser" way to fix vision and it's an important part of my practice.

The best advice I can offer patients considering LASIK is to meet personally with an experienced surgeon and ask for detailed answers about their results, techniques, and complication rates. Any LASIK surgeon with experience and integrity should easily be able to answer your questions and make specific recommendations about your best options based on their experience and their preferred techniques independent of any marketing hype or commercial bias.