Joel Hunter, MD Refractive Surgeon, Hunter Vision Updated 11/24/20 12:44 PM
Astigmatism is an extremely well-known, yet poorly understood phenomenon. It’s like the gluten intolerance of vision, except in this case pretty much everyone has it.
People are told at some point by someone wearing a white coat—either in a clinic or on a book cover—they’ve got this diagnosis and then, well, that’s that. You can’t do anything about it, except explain your condition to strangers if the opportunity arises.
In the case of gluten sensitivity, as far as I understand it, the only solution is to stay away from pasta and bread. That makes me sad. My hope is that many people have been given a wrong diagnosis, and they can one day enjoy Olive Garden’s never-ending breadsticks.
With astigmatism, however, there’s much more to say.
Gasp! What you know about LASIK and astigmatism might be wrong.
If you’ve been diagnosed with astigmatism, it’s positively certain you have it. Nearly everyone has some level of astigmatism. This includes most people who don’t need to wear glasses because they’ve always had good vision.
But the second point about it has a much more impactful upshot: the people who’ve been told their astigmatism means they have to stay away from LASIK have nearly all been relying on information that’s no longer relevant.
I too had the diagnosis of astigmatism from a young age. And I was told it meant my eye was shaped like a football. I’d like to think the optometrist who told me this did a poor job of explaining it, rather than admitting that I was such a nerd that I didn’t know what a football was.
The football analogy didn’t help me at all. I thought it did at the time, until I understood what astigmatism was. Only then was I able to work backward toward why eye doctors say, “Your eye is shaped like a football.”
It turns out what they mean is the curved part in the middle, not the pointy ends. So to get away from football, with all of its incomprehensible rules and ball shapes, let me explain astigmatism in a way that would have been easier for my young, un-athletic mind to understand.
Astigmatism = Distortion + Blur
You know how a contact lens is shaped like a dome? It’s shaped that way because it has to match the shape of the cornea, which is the dome-like window on the front of your eye.
The cornea is where astigmatism occurs, but to understand what that means, it’s easier to forget that it’s a dome for a moment.
Picture this instead: you’re holding a big square piece of flexible plexiglass with one hand on each side. When you’re holding it without applying any tension, that piece of plexiglass is flat: it has no astigmatism.
But if you squeeze your hands towards each other and flex that plexiglass, it isn’t flat anymore. It’s got a curve along the axis where you’re putting pressure. The shape of it looks more like the curve of a cylinder now.
You’ve given it astigmatism.
This situation is exactly what’s going on with the dome of your cornea when you’ve got astigmatism. Instead of a flat piece of plexiglass, it’s a small round dome, but the dynamics are the same.
If you imagine a tiny pair of hands applying some pressure to opposite sides of that dome, you’ve created astigmatism. This is the kind of astigmatism we’re talking about here.
The reason it’s so common is because it’s incredibly rare to find perfectly round, symmetrical corneas without even the slightest trace of squeeze in some direction. Those people who have astigmatism, but aren’t aware of it (and there are many), just don’t have enough distortion/squeeze to cause noticeable vision loss.
When astigmatism does cause a decrease in the quality of vision, it does so by distorting the image being focused through the corneal window.
If you imagine looking at someone through your piece of plexiglass, then squeezing the top and bottom of it, you’d see that they got shorter and wider as you squeeze. The same thing happens on the cornea, except that since the cornea is such a powerful lens, the blur from the distortion outweighs the funhouse mirror effect.
Not everyone knows what type of astigmatism they have.
What we often hear from people who have astigmatism is that they’re suffering from blurry vision. Your eye can have difficulty focusing light because of these two types of astigmatism: corneal astigmatism is a more common condition where the cornea has an irregular shape unlike a ball; or lenticular astigmatism when your lens is distorted.
On the other hand, one or both of your eye’s meridians can be nearsighted (myopic), farsighted (hyperopic) or one is nearsighted and the other is farsighted (mixed).
So what causes astigmatism then?
Well, medical experts can't really attribute a single factor as to what causes astigmatism. However, genetics is known to heavily influence its development. Studies indicate that first-degree relatives are prone to share such vision condition. So if your father has astigmatism, expect that there's a strong likelihood that you've inherited it from him.
If for some unfortunate reason you've encountered an eye injury, there's also a possibility that astigmatism may occur (even after surgery if you had one). That's because the cornea may have been scarred and damaged badly.
In some cases, patients may suffer from a degenerative disorder called keratoconus. This disease, when the bulging of the cornea has become severe, will initially develop into astigmatism and then cause visual discomfort but not necessarily lead to complete blindness.
Who are at risk for astigmatism? Will I suffer from it?
Anyone can develop astigmatism.
As mentioned, if you have it in your family history, your 2-year-old daughter may show symptoms of this condition. On the other hand, it may not manifest until someone is in their teens, early adulthood or even in their 40s.
I've also had patients who mentioned to me that they're not aware they have astigmatism because they haven't felt any symptoms at all. This is true, especially for children. It's only when they receive their eye exam treatment that they'll come to know about their true condition.
Bear in mind that certain factors can also contribute to its faster progression. For example, if you've undergone cataract surgery or have been diagnosed with keratoconus as stated earlier, the condition may develop at a more rapid pace.
What are the signs and symptoms of astigmatism?
Is your vision distorted, blurry or indistinct whether you're near or far from what you're seeing? Do you find it really difficult to see things clearly at night, especially when you're driving? Do you suffer from eye strain when you're browsing on your mobile phone or computer screen?
There's a strong possibility that you have astigmatism. Some of my patients also reported excessive blinking, frequent headaches and dizziness, and eye irritation. Others are surprised to know that they're already far-sighted or near-sighted.
Remember, however, that when you’re sensing any of these symptoms, do not skip your doctor’s appointment or you’ll jeopardize your vision. Most people nowadays have become overnight health experts just by reading an online article and not consulting a doctor.
So how do I find out if I have astigmatism?
Astigmatism is diagnosed through an eye exam by an optometrist or an ophthalmologist. Not sure of the difference between the two? This previous post will guide you on who to seek for expert opinion.
You may either undergo any of the tests that they use from visual acuity assessment (the basic eye test where you need to read letters from afar) to a refraction test where you need to read a chart while looking through the lens of an optical refractor called a phoropter.
Then more advanced tests may be needed. For instance, the astigmatic dial test evaluates if you can see a series of lines in similar thickness. If others are lighter or thinner, however, then you’re most likely to have astigmatism.
Then there’s the keratometer, which measures the radius of the light reflected on your cornea. It can identify if the curvature is distorted or not.
The Lenstar or IOLMaster, on the other hand, are recommended over the keratometer since they measure many more points of curvature closer to the center of the cornea.
Finally, there's corneal topography, which maps your cornea more accurately through a non-invasive imaging procedure.
How do we fix the astigmatism that causes noticeable blur?
A common question I often hear from patients is, “Can astigmatism still be corrected?”
When the doctor diagnoses very mild astigmatism, any immediate treatment won't be necessary. Otherwise, a pair of corrective lenses will be an immediate solution.
With corrective lenses, the goal is to neutralize the distortion of the image. If you’ve got a cornea with a top-to-bottom squeeze (making everybody the slightest bit shorter and wider, but mostly just blurrier), your glasses’ prescription will have lenses that squeeze in from the right and left side an equal amount (making everybody the slightest bit taller and skinnier, but mostly just clearer).
Another method on how to treat astigmatism is through orthokeratology or what you'd commonly hear as Ortho-K. Patients, especially those who fear astigmatism surgery, are glad to know that this method could reduce their dependence on eyeglasses. By wearing permeable contact lenses overnight, the cornea is reshaped by flattening the central epithelium. This contact lense covers parts that are thick or thin, forming an even surface. So upon waking up, the patient can see clearly without glasses or contact lenses for two days at the most.
That's clearly the downside of Ortho-K. Once you stop the treatment, your vision will revert to its blurry state. That's why it's best recommended only to patients with mild to moderate myopia because they may choose to wear their glasses when they can't have Ortho-K. Children with astigmatism are also ideal candidates for this procedure because they usually don't require surgery yet.
However, for mild, moderate, and severe cases, laser surgery for astigmatism may be recommended. The good thing about this treatment is it has a higher chance of a permanent solution with the use of state-of-the-art excimer laser energy. There are three popular procedures that use this technology.
Photo-refractive keratectomy, or PRK, is a method that removes the outer protective layer of the cornea and then removes the corneal tissue. While it only takes less than 15 minutes to complete the entire procedure, full healing of the surface takes a few days.
In addition, the operated eyes can turn watery for the next three days after the procedure. Medicinal and lubricating drops may also be required for the patient to ease the discomfort and reduce the risk of scarring.
Laser epithelial keratomileusis or LASEK (which is not to be confused with the more popular LASIK procedure), on the other hand, uses laser to correct the shape of the cornea. The cells on the surface area are diluted in an alcohol solution then set aside so that the excimer laser can be used to remove the tissue.
Full healing of the eyes takes about one to two weeks, with the first four days requiring the patient to wear bandage contact lenses as protection.
In addition, patients need to regularly use topical steroid drops and antibiotics for weeks to relieve the post-operative pain and discomfort. As visual rehabilitation may take much slower, patients also may notice haziness from time to time. For these reasons, LASEK is rarely recommended nowadays despite initial excitement about the procedure.
With LASIK, however, the effects are different.
LASIK, which has been around for more than 25 years, has received favorable reviews from astigmatism patients who have undergone such treatment. They profess about the speedy astigmatism correction (about a day after the surgery) since they no longer need their eyeglasses or contact lenses. As I’ve declared in my previous post, LASIK can let you see better than glasses or contact lenses.
While the process is complex, very few experience pain when a qualified and experienced surgeon handles the process. Should the patient require further vision correction as he ages (which is very rare by the way), adjustments using the same procedure can be made.
But while this procedure remains very popular today, it wasn't as accepted back then as many patients wondered if LASIK can fix or correct their astigmatism.
Here’s why people think LASIK and astigmatism don’t mix.
When LASIK first became popular, it became all the rage really fast. In the late ‘90s and early 2000s, around a million LASIK procedures were happening a year in the U.S. But when laser vision correction first got FDA approval, it wasn’t approved for astigmatism correction (which was wise because it couldn’t correct astigmatism at that time).
Over that first decade, the ability of LASIK to treat astigmatism evolved from “unable to fix astigmatism” all the way to “sometimes it can fix simple astigmatism.” So when people heard, “You shouldn’t get LASIK because you’ve got astigmatism,” most of the time, they were getting good information.
Although it seems off topic to point this out, in the early 2000s, it still sounded improbable that digital music would really take off or that any smartphone would ever dethrone the Blackberry.
Technology improves rapidly, and it’s easiest to recognize in those areas where we would have reason to stay updated. In the case of LASIK however, when patients and optometrists checked it out during its early, popular heyday, they found out it didn’t correct astigmatism.
That fact was the authoritative information they absorbed was the culprit. Somehow, a decade and a half later, that same information still abounds despite the fact that LASIK started to get really good at fixing astigmatism around the same time the original iPhone first debuted.
As the computers that control the laser responsible for LASIK became faster and more technologically advanced, the ability to correct astigmatism changed from “it’s possible” to “LASIK can fix astigmatism better than glasses or contacts ever could.”
And the reason for this has to do with the knee-deep astigmatism explanation we waded through a few paragraphs above. Instead of just looking through a lens with an equal and opposite astigmatism to that of your cornea (which is what glasses and contacts do), imagine you had the ability to get rid of the distortion altogether.
This is the satisfaction that patients have when they undergo LASIK for their astigmatism.
LASIK and astigmatism: BFFs – for real.
What if your eyes had wonderful, clear optics because they were distortion-free and didn’t need correction?
That’s what LASIK can now do for the overwhelming majority of people with astigmatism.
This fact has been true for years, but has remained oddly undiscovered by the majority of people who might benefit from it. I’m not a conspiracy theorist shouting, “Big Glasses is perpetuating a myth to keep you buying glasses!” But I do believe that when patients (and many optometrists) heard LASIK couldn’t fix astigmatism (which was around the same time that AOL was synonymous with email), they never had a good reason to circle back and stay updated as the technology evolved.
So yes, LASIK can fix astigmatism, and it can do it with incredible accuracy and ease. And while I hope this information is helpful to you, the genuine goal of this article is to dispel the pesky myth that LASIK can’t fix astigmatism.
I imagine if I worked at Apple and often heard people say, “My doctor says Apple doesn’t make mobile phones,” I would’ve written about how the iPhone exists. I don’t think I’d try to convince you to get an iPhone, I’d just want you to know the truth, especially if it might have an impact on your quality of life. I’m not saying you have to fix your astigmatism with LASIK. I just want you to know it can, because it’s something I care about, and I thought you might care about it too.
It may be superfluous info, but maybe you’re wondering how much LASIK costs in 2019?
How Much Does Lasik Cost for Astigmatism?
One of the frequent inquiries I get is about the price an astigmatism patient has to pay for LASIK.
Let me be frank about this: LASIK costs vary depending on your condition, your region, your clinic or hospital, the laser technology used in the procedure, your doctor's expertise and qualifications, and a host of other factors.
So if you have a severe case of astigmatism and would like to be treated in an upscale hospital in NYC offering the latest LASIK technology, expect around $6,000. And no, that's not a typo. If you want to know more about this, you can check my detailed calculation of LASIK costs here.
If you have extreme astigmatism, you're going to want a more customized treatment utilizing newer technology such as wavefront LASIK and bladeless LASIK (or femtosecond laser technology). Of course, your doctor's expertise in the field comes with a price. The most experienced surgeons have a higher fee compared to those just starting their career (which doesn’t come as a surprise at all).
Plus, some doctors have hidden costs that you'd only find out upon receiving your hospital bill. These include medications and disposable medical supplies, royalty fees for the laser equipment manufacturer, overhead cost for the surgery clinic or hospital, pre-operation consultancy fee, eye examination fee, and the list goes on.
Can Your Insurance Cover LASIK cost for astigmatism?
Most probably not (here’s a previous post that explains why). LASIK is considered an elective treatment no matter how necessary the medical procedure is for astigmatism. Insurance companies still consider it as a cosmetic process though. Funny how you've put in countless hours in front of the office computer screen only to find out that your company's health insurance plan only covers eyeglasses.
While patients demand to receive the best eye treatment available, not everyone can offer the service for the most affordable price.
But before you lose hope, think about this: Always beware of LASIK advertisements promising cheap prices. It's either you'd end up in my clinic to see if we can fix what the discount provider did to your eyes, or you'd be billed $2,000 more for the hidden costs, or you'd be coming back to your doctor for aftercare treatments and still end up not saving your dollars at all.
Here's what you should ask before paying for your LASIK
When talking to your surgeon, be sure to come in prepared. Whenever possible, read patient references and testimonials online (beware of fake feedback though) or ask from previous patients.
These questions can also help you assess whether the price you're paying for is commensurate to the quality of service you'll receive:
- Can you provide me with a detailed quote of the procedure?
- Does this include ALL charges?
- Do you offer flexible payment terms?
- What LASIK technology will be used?
- What kind of aftercare treatment will I receive?
- How much should I prepare for medications?
- Do I need temporary eyeglasses? How about contact lenses?
Is the cost for LASIK worth it then?
Astigmatism patients who have undergone astigmatism surgery through LASIK can best tell you why LASIK is a wise investment. When you're under the care of a competent eye surgeon, you'd be delighted by the extent of how your vision has been corrected by a procedure that lasted for about 15 minutes. In as short 24 hours, you'd be back to your regular routine with very minimal side effects.
Of course, a 20/20 vision isn't 100 percent guaranteed for all patients. However, full astigmatism correction is still the goal of any treatment and your doctor is best qualified to explain what the astigmatism surgery can attain.
Overall, in my opinion, the pros of LASIK outweigh the cons for good candidates.
While they say that not everyone is a candidate for LASIK, it’s still a great investment for those who are because it makes living without eyeglasses or contact lenses possible.
While they say that it is expensive, there are eye surgeons and no-interest financing plans already providing affordable LASIK treatment without compromising the quality of the service even in postoperative visits.
While they say that eventually you'll need LASIK again, this is exceptionally rare. Besides, modern LASIK treatments already create lasting, permanent results.
Author: Joel Hunter, MD is an Ophthalmologist, Refractive Surgeon, and the Founder of Hunter Vision, a LASIK Orlando Clinic in Florida.
A recognized and respected specialist in vision correction who has performed a countless number of refractive surgeries, Joel gives lectures across the country and trains fellow doctors in the newest LASIK surgery techniques.