LASIK & Contact Lenses
Reviewed by Leslie Doctor, M.D.
Contact lenses and LASIK have many similarities in that for the millions of patients who are nearsighted, farsightedness or have astigmatism, both vision correction options can help achieve independence from the hassles and limitations of wearing eyeglasses. Eyeglasses have come a long way in their cosmetic appeal in that frame manufacturers have dramatically improved the appearance of modern eyewear. However, glasses are glasses and still present a significant barrier and inconvenience for patients who like to swim or participate in water sports, go jogging or running, play tennis or racquetball, or play any sport or simply want to just be able to get up in the morning, get out of bed and not have to look for or depend on glasses to navigate around the house. For those patients who desire a more independent lifestyle, the vision correction options of contact lenses or LASIK are a good place to look.
If I Wear Eyeglasses, How Should I Choose Between Contact Lenses and LASIK?
Once you have made the decision to try and get rid of your dependence on eyeglasses, the choice between contact lenses and LASIK can be viewed in terms of a few major areas that are measured by how well you will be able to achieve your personal goals in a safe and effective manner.
There is little doubt that wearing glasses is not the optimal form of vision correction when it comes to vision performance. Contact lenses and LASIK both will correct your vision and eliminate a number of vision performance related issues induced by eyeglass correction. For example, nearsighted patients who wear eyeglass lenses to correct their myopia are subject to an effect called minification. Minification is the optical effect that glasses produce whereby objects actually appear smaller than they are. This may make them also appear farther away to some patients. While patients may adapt to this effect, it often creates a distorted sense of depth perception. This can be troubling for some patients who have occupations that require a good sense of depth perception. Tasks like operating heavy equipment or even other types of machinery can be a challenge with the minification effect. Think about the safety professional such as a police officer or firefighter who can't properly judge distances! Further, eyeglasses can compromise vision performance because they distort your peripheral vision. Depending on the frame you wear, eyeglasses can actually block your peripheral vision. You can imagine that the minification effect and distortion or blocking of your peripheral vision can wreak havoc on your performance if you play any type of sport! For this reason, contact lenses and LASIK will provide superior visual performance.
However, which option, contact lenses or LASIK provides better vision performance? The answer is that both contact lenses and LASIK eliminate the effect of minification and peripheral distortion because both contact lens correction and LASIK create their optical effect right at or on the surface of your eye, rather than in a plane in front of your eye-on your nose-as eyeglasses do. So, when we consider these aspects of vision performance, there is little if any difference between contact lenses and LASIK.
Convenience & Comfort
What about the differences in convenience between contact lenses and LASIK? In the past 20-25 years, contact lenses have undergone dramatic attempts to achieve the strong desire of patients to "wear no lenses at all." These changes began in the late 70's with the introduction of Extended Wear Contact Lenses which were marketed and prescribed for patients to be worn continuously for as long as 30 days. This was indeed a very convenient type of vision correction option for patients and one in fact that patients truly desire. The personal goal of almost all patients is to have the most convenient form of vision correction. Unfortunately, after several years of widespread patient acceptance Extended Wear Contact Lenses did not demonstrate that they could in fact be worn for 30 days or even for considerably lesser times on a continuous basis without a worrisome incidence of significant complications. As a result, the desired convenience of "wearing no lenses at all" could not be achieved with contact lenses. After the FDA requested that the Extended Wear Contact Lenses be removed from the market, almost all contact lenses prescribed were worn on a daily basis and required that they be cleaned, disinfected and reinserted in patients' eyes each and every day. This really did not meet the desire of most patients to "wear no lenses at all." In order to improve the convenience of contact lens wear, contact lens manufacturers began to first improve on the contact lens care systems and solutions so that there would be much less care involved in maintaining the lenses and thus they would be more convenient. This in fact was achieved with a number of care products reducing the number of steps necessary and the number of actual solutions necessary to maintain the lenses. These solutions, typically called "Multipurpose" Solutions provide the ability to clean, rinse and disinfect soft contact lenses with a single solution. Examples of these solutions are Allergan Complete Moisture Plus Multipurpose Solution, Alcon Opti-One Multipurpose Solution, and Bausch & Lomb Renu Multi Purpose Solution. Further, along with this, considerable improvements were made in the manufacture of contact lenses so that they could be produced at exceedingly low cost. Because they were able to be produced for literally pennies, the contact lens manufacturers were now able to offer the next step in contact lens convenience-"Frequent Replacement Contact Lenses."
The Frequent Replacement Contact Lenses allowed patients to purchase boxes of lenses that could be discarded frequently, on a planned basis in order to avoid contact lens complications. The ultimate planned Replacement Contact Lenses are Daily Disposable Contact Lenses which are worn for a day at time and then discarded, eliminating the need for any care products or disinfection-certainly more convenient in terms of care but not really any more convenient in terms of being able to wake up and just start your day. In addition, because Frequent Replacement Contact Lenses were made of a newer generation of polymers that contained a greater amount of water, they were in fact able to allow the cornea to "breathe" more efficiently so that they would allow them to be kept in for several days at a time if not perhaps a full week. The extended wear of Frequent Replacement Lenses once again offers the possibility of the desired convenience of "wearing no lenses at all" as they are simply removed each week and discarded and new ones inserted into the patients eye the following day. This is indeed an improvement in convenience for contact lens wearers. In the early 2000's, thanks to the further advances of even newer breathable polymers, called "silicone hydrogels", that have surfaces that are believed to stay clean and avoid adhesion by debris and microorganisms, a number of contact lens manufacturers have again resumed the marketing of "30 Day Lenses." Examples of these lenses include Bausch & Lomb PureVision, Acuvue Advance and Ciba Night & Day Lenses. These lenses are a bold attempt to bring patients the convenience and comfort they desire of "wearing no lenses at all." Certainly if contact lenses can be worn for 30 days at a time without removing them this would give patients about a month at a time of "convenience." Even with the introduction of 30 day contact lenses, of the 30-35 million contact lens wearers in the United States, only about 20% are actually wearing Extended Wear Contact Lenses. Time will tell if these more breathable Extended Wear Contact Lenses can in fact be worn safely for 30 days and approximate the convenience that patients are desiring.
What about comfort? Certainly having LASIK and wearing "no lenses at all" is the ultimate in comfort. But do contemporary contact lenses, even the most advanced lens materials such as silicone hydrogels, offer a comfort level that approximates "wearing no lenses at all?" According to an article by highly regarded contact lens research experts, Brien Holden, Ph.D, D.Sc. and Desmond Fonn, MOptom recently published in the April 2005 issue of Contact Lens Spectrum.
"Contact lenses really haven't made the grade yet. Some 2.5 billion spectacle wearers around the globe still outnumber contact wearers by a 25-to-1 ratio. As many as 500 million people need and can afford contact lenses, yet only 100 million wear them, according to data compiled in 2003 by the International Association of Contact Lens Educators."
These comfort issues with contact lenses seem to be responsible for a significant number of patients "dropping out" of contact lens wear and abandoning their contact lenses. Fonn, in his paper, "Preventing Contact Lens Dropouts" (Contact Lens Spectrum. 2002;17:26-32) reported that in the United States, an estimated 2-3 million people of drop out of contact lens wear each year. This represents up to 10% of the entire contact lens wearing population dropping out of lens wear each year, with the primary reason being unsatisfactory comfort. It is believed that the newer silicone hydrogels previously discussed may help address the contact lens comfort problem.
By far the main reason for discomfort with contact lenses does indeed seem to be related to dryness. According to the February 12, 2006 edition of CL Today, "of the 31 million soft contact lens wearers, 21 million, or 67%, self report that eyes feel dry during contact lens wear. There are nearly 2.7 million contact lens dropouts annually. Many of these dropouts say dryness was a major reason for discontinuing lens wear".
So then, which is more convenient and comfortable option, 30 day Contact Lenses or LASIK? There can be little doubt that LASIK offers a much more convenient lifestyle than contact lenses and one that actually achieves "wearing no glasses at all" for the ultimate comfort.
Let us assume that contact lenses are able to deliver a safe continuous 30-day wearing schedule to anyone who wishes to wear them. Will this then provide the complete lifestyle enhancement that patients have as personal goals? The answer simply is-NO! Contact lenses, even if they are breathable, even if they do not adhere debris and bacteria, and even if they provide adequate vision correction, are still limited in the lifestyle that they can deliver.
Environmental factors such as smoke and dryness considerably alter your ability to wear your contact lenses comfortably. It can hardly be a lifestyle improvement if you are unable to wear your contact lenses on the baseball field because there is just too much dust. Or, it can hardly be achieving your personal goals if you wanted to be able to wear your contact lenses at the beach and cannot do so due to all of the sand, or for that matter whenever small particles get under the lenses. Even with the best lens materials, contact lenses cannot provide the unlimited range of activities that you might wish to do without comfort or safety concerns. For this reason, LASIK offers a more consistent and predictable vision correction option in any and every type of lifestyle situation.
Safety and Risk Factors
An important consideration in whether you should have contact lenses or LASIK has to be based on the safety profiles of contact lenses compared to LASIK Eye Surgery. Over the past 25 years, contact lenses have been "consumerized" to where there are literally thousands of outlets where patients can buy contact lenses on line or by calling a toll free phone number without the direct dispensing and supervision of an eye care professional. Contact lenses are a medical device and regulated by the Food and Drug Administration (FDA). Even when prescribed by an eye care professional, minor as well as significant complications can occur in cases where hygiene and lens care has not been maintained or in cases where wearing schedules are not adhered to, typically involving sleeping in contact lenses, or extended wear. Even when things go well with contact lenses, annoying complications such as contact fit related problems, contact lens induced dry eye, giant papillary conjunctivitis can occur. Fortunately all of these complications are non-sight threatening.
Giant papillary conjunctivitis is an allergic type of inflammation that occurs on the inner surfaces of your eyelids, the "tarsal conjunctiva." It occurs most often in patients who have been wearing lenses for some number of years and who have not used the utmost in care in keeping their lenses clean. The buildup of protein on the contact lens surfaces causes an inflammatory process to occur whereby your lenses become itchy and your eyes actually begin to produce even more protein and mucous than normal. These secretions then cause even more irritation, itching and discomfort, ultimately causing you to have to stop wearing your contact lenses. There are anti-inflammatory and anti-allergic drops that can be prescribed by your eye care professional in order to alleviate the symptoms. However, even after using these drops and getting new contact lenses, and being absolutely meticulous in their care and wearing schedule, some patients are just unable to resume contact lens wear. While the complication of Giant Papillary Conjunctivitis is not sight threatening, it is inconvenient and troubling to those who desire the convenience, cosmetic and functional benefits that contact lenses can offer.
Contact lens induced dry eye occurs in some patients who may have had a marginally dry eye before they were fit with contact lenses or may actually be the result of contact lens wear. A normal and stable tear film is necessary in order to be a successful contact lens wearer who does suffer from symptoms of dryness and grittiness. To have good tear film stability means that the normal natural tear film is able to maintain itself in a fairly uniform layer on the cornea. Mother nature has provided us with a mechanism for achieving normal tear film stability in the form of certain anatomical features found on the outermost layer of the cornea, the corneal epithelium. The normal healthy corneal epithelium is covered with microscopic "hairlike" structures call microvilli. These microvilli act to provide a "roughened surface" for the normal tear film to adhere to and thus give it stability in between each time you blink your eyes. Unfortunately, over years of wearing contact lenses, it is believed that constant rubbing and movement of the contact lens across the surface of the cornea may in fact damage and deplete the presence of these epithelial microvilli resulting in a less stable tear film and contact lens induced dry eye symptoms. Again, this is not a sight threatening complication, but one that makes contact lens wear less comfortable and sometimes results in an inability to wear your contact lenses, even if you change lens materials and use lubricating eye drops. Once you have completely discontinued wearing your contact lenses, it is thought that the microvilli will resume their normal presence over some period of time and in most if not all cases, the tear film will return to normal.
According to the United States Food and Drug Administration, "The most serious safety concern with any contact lens is related to overnight use. Extended-wear (overnight) contact lenses--rigid or soft--increase the risk of corneal ulcers, infection-caused eruptions on the cornea that can lead to blindness. Symptoms include vision changes, eye redness, eye discomfort or pain, and excessive tearing."
James Saviola, O.D., Chief of the Vitreoretinal and Extraocular Devices Branch at FDA's Center for Devices and Radiological Health states, "The risk of corneal ulcers for people who keep extended wear lenses in overnight is 10-15 times greater than for those who use daily wear lenses only while awake." Dr. Saviola explains, "When the eyes are open tears carry adequate oxygen to the cornea to keep it healthy. But during sleep, the eye produces fewer tears, causing the cornea to swell." The swelling and lack of oxygen leaves your eyes vulnerable to infection.
Even though the FDA has approved extended wear contact lenses for overnight use, there are risks with use of extended-wear lenses, "even if it's just one night," says Dr. Saviola. Unfortunately, for those patients who are seeking convenient vision correction, extended wear or "30-Day" lenses may not provide a choice without certain safety concerns as indicated by the FDA's opinion. These safety concerns should be weighed carefully when considering LASIK and contact lenses as the conventional wisdom that contact lenses are a "simple on-line consumer purchase" may not reflect the reality. On the other hand, daily wear lenses that are removed daily for cleaning and are a safer choice, provided they aren't worn during sleep. Unfortunately, daily wear contact lenses do not provide the convenience LASIK can provide and so the decision needs to be weighed even further.
Another potential sight threatening concern is the infection Acanthamoeba Keratitis, caused by improper lens care and possibly bathing in hot tubs or even swimming. This difficult to treat parasitic infection's symptoms are similar to those of corneal ulcers. For patients considering whether to wear contact lenses or to have LASIK, if they need clear vision while swimming, they may wish to consider this potential serious infection in the risk profile. Or, they may wish to simply not wear contact lenses while swimming—but again this negates the benefits you are trying to achieve in terms of lifestyle, functioning and convenience.
So, while contact lenses have been reduced to being an on-line purchase implying a "care free, trouble free and risk free" form of vision correction, this may not be entirely correct. In fact, recent reviews and publications (Mathers, W.D., Archives of Ophthalmology, October 2006; Vol 124: pp1510-1511) of the safety and risks of wearing contact lenses as compared to having LASIK indicate that LASIK is indeed less risky over the long haul.
What about the risks and complications of LASIK? Doesn't LASIK raise an even greater list of safety concerns than contact lenses?
LASIK is surgery. Any and all types of surgery including LASIK have risks, complications, side effects and may be contraindicated for some patients,
According to the United States Food and Drug Administration:
Some patients may actually lose vision. That is that after LASIK, some patients may not be able see lines on the chart that they were able to previously see with their best eyeglass or contact lens prescription. This loss of correctable lines of vision on the vision chart cannot be corrected with glasses, contact lenses, or surgery. While this is unusual, it can happen. The importance of the skill of the LASIK surgeon and careful examination and consultation to be sure that you are a good LASIK candidate cannot be over emphasized in helping you obtain the best possible results.
Some patients may develop debilitating visual symptoms. Some patients develop glare, halos, and/or double vision that can seriously affect nighttime vision. Even with good vision on the vision chart, some patients do not see as well in situations of low contrast, such as at night or in fog, after LASIK as compared to before LASIK. Fortunately, the use of scanning-tracking Excimer Lasers deliver large optical treatment zones and provide good coverage of the pupil. This, along with custom wavefront guided LASIK protocols, so that higher order optical aberrations that cause night vision, glare, halo and decreased contrast can readily be treated has significantly minimized the incidence of these symptoms.
You may be under corrected or over corrected. While a very large percentage of patients achieve 20/40 vision and are able to pass a driver's test without correction, a lesser percent of patients achieve 20/20 vision without glasses or contacts. If you have some specific goals that you would like to achieve without being dependent on eyeglasses and contact lenses, then chances are a mild degree of under correction or over correction is not likely to impact your chances of a successful treatment. If you absolutely MUST have 20/20 vision you may require additional treatment, but additional treatment may not be possible. You may still need glasses or contact lenses after surgery. While specialized monovision LASIK may help you achieve your reading vision goals, if you used reading glasses before surgery, you may still need reading glasses after LASIK surgery.
Some patients may develop severe dry eyes. As a result of LASIK Eye Surgery, your eye may temporarily not be able to produce enough tears to keep the eye moist and comfortable. Dry eye cannot only cause discomfort, but can actually reduce the quality of your vision due to instability of the tear film which acts as an optical surface. It is important that during your LASIK consultation, the LASIK surgeon carefully and thoroughly evaluate your tear film and if necessary prescribe lubricating eye drops, prescription eye drops called Restasis, to help you make more of you own natural tears, and /or insert punctual plugs to help you retain more of your natural tears. Rarely, dry eyes after LASIK may be permanent.
Results are generally not as good in patients with very large prescriptions of any type. Patients with very high prescriptions do not have as good predictability and may often require a second treatment procedure to obtain the best possible results. By discussing your lifestyle goals and setting realistic expectations with your LASIK surgeon, you can have the best chance of achieving everything that you wish.
Only somewhat limited long term data is available. Whereas soft contact lenses have been available since the early 70's, LASIK is a relatively new technology. LASIK Eye Surgery globally has been performed since 1995, but the first Excimer Laser was approved by the FDA for LASIK in 1998. Therefore, the long-term safety and effectiveness of LASIK beyond 15 years is not yet known as compared to long-term safety and effectiveness of contact lenses being available for 30 years.
If I Wear Contact Lenses, How Should I Make the Decision to Have LASIK?
As you can see from the previous information, there are a number of considerations you must address. However, the biggest considerations are in the areas of understanding the risks of surgery as compared to contact lenses. As relayed above, the risks of Extended Wear contact lenses that meet the convenience and lifestyle factors of LASIK, may not be trivial.
Ask yourself the following questions about your contact lenses:
Can you wear your contact lenses, each and every day for as long as you would like comfortably?
Are there times after wearing your contact lenses for the entire day, that you "just can't wait to get them out?"
Do you wish that you just open your eyes and see the alarm clock and get to the bathroom without looking for your glasses?
Do you sometimes take a nap or even sleep in your contact lenses even though you know that it is really not safe?
Do you swim, or go in hot tubs or spas, while wearing your lenses even though you know this predisposes you to infection?
Do you have to instill lubricating or moisture drops to be able to wear your lenses as long as you need to?
After wearing your contact lenses for the entire day, do your eyes get red and irritated and need eye drops to "take the red out" or soothe them?
If any of these questions make you stop and think about your own contact lens wearing experiences, then maybe you are not as successful and happy a contact lens wearer as you thought.
Do I Need to Know Anything Special If I Am A Contact Lens Wearer, about to have LASIK Eye Surgery?
First, in order for the eye surgeon to get the most accurate measurements for any Laser Eye Surgery procedure, it will be necessary for you to stop wearing your lenses for some period of time. This period of time will depend on what type of lenses you have been wearing and over what period of time. Carefully follow the instructions given to you regarding not wearing lenses prior to your consultation. Contact lens wear alters the thickness and shape of your cornea &.even extended wear lenses worn for only daily wear may cause changes that can alter the measurements.
Second, you will be instructed to discontinue wearing of your contact lenses for some period of time prior to your actual surgery day &.make sure that you follow these instructions and leave your lenses out the proper time.
Third, if you have been wearing rigid lenses of any type, even extremely oxygen permeable Rigid Gas Permeable Lenses, your LASIK surgeon will require that you stop wearing them and monitor the shape and thickness of your cornea and your prescription over multiple visits in order to make sure that the measurements are stable. Rigid contact lenses of any type may cause significant changes in the shape of your cornea and thus your prescription. In order to be certain that the lenses are no longer causing these effects in your cornea, you must be compliant in leaving your lenses out and having the repeat measurements taken in order to confirm that the cornea has returned to its normal thickness and shape.
Fourth, as mentioned earlier, contact lenses may alter the microscopic structure of the surface of the cornea leading to contact lens induced dry eye symptoms. Make sure that you fully disclose to your LASIK surgeon any and all symptoms of dryness that you have experienced during your contact lens wearing history.
Last, if you have ever had any type of eye infection while wearing contact lenses, even if your doctor told you that the infection was NOT from the contact lenses, make sure that you bring this to your LASIK surgeon's attention.
As you can see, choosing contact lenses or LASIK is a personal matter and can only be made when you have a thorough understanding of each vision correction option and its risks and complications A complete discussion of LASIK risks, LASIK complications and LASIK contraindications is provided elsewhere in this site. The most effective way to obtain personal information and education is to schedule a consultation with an experienced LASIK surgeon who can answer your questions.