Joel Hunter, MD Refractive Surgeon, Hunter Vision Updated 11/21/19 12:32 PM
It used to be that qualifying for LASIK surgery was very strict since doctors, limited by the technology available at the time, would try to contain the risks involved in the treatment. However, with the improvement in LASIK technology, the procedure can accommodate more interested patients.
For instance, in 1998, it was excellent advice to avoid LASIK if you have astigmatism. In 2019, though, even high amounts of astigmatism can be cured with LASIK better than with contacts or glasses. The improvement in technology in 21 years has been enormous.
A simple example of the fact that we can do things now that we couldn't back then would be the concerned looks you'd get telling the 1998 LASIK researcher they could find the answer by "using their phone to google it." But many doctors—including eye doctors—stick with guidelines created when LASIK was in its infancy.
Still, not everyone can undergo LASIK even if one thinks they’re a good candidate for refractive surgery. To begin with, a patient must meet the criteria that eye surgeons use during the consultation process.
LASIK candidacy checklist: are you qualified?
To find out if you’re qualified to undergo LASIK, eye doctors use a checklist of criteria to determine if you fit the standards of a qualified patient.
Appropriate Age for LASIK
One’s eyesight changes frequently during childhood, which also re-occurs (although for a different reason) late into adulthood. Because of refractive instability, eye surgeons recommend performing LASIK only to patients after turning 18 when the eyes are at ocular maturity (or have completed growing).
Eyeglass or contact lens prescription
Your eye doctor will conduct an eye exam during the consultation to determine if your prescription has changed. Remember that the “+” sign refers to the presence of farsightedness, while the “-“ sign is for nearsightedness. Your prescription must fall within ideal treatable limits (for what is considered a stable eye prescription) to qualify for LASIK.
The first number in your eyeglasses or contact lens prescription (i.e., sphere) must be between +2.00 and -10.00. If you’re more severely nearsighted, you’re likely not a candidate for LASIK.
The second number (i.e., cylinder), on the other hand, measures the extent of your astigmatism. To qualify for LASIK, it should be between 0 and -6.00. The more you have the more distortion you’ll have pre-operatively. Remember too that if the cylinder number is at “0” or “sph,” your astigmatism cannot be measured because it is too insignificant to blur your vision.
Eyesight with eyeglasses or contact lenses on
Are you able to see well with your eyeglasses or contact lenses? This is one criterion that doctors consider since your eyesight needs to be in good condition while keeping either your glasses or contacts on.
Corneal thickness and shape
Because LASIK involves creating a corneal flap, the cornea’s thickness needs to be assessed first. If the cornea is too thin, other refractive surgeries such as PRK are more suitable as this would leave more tissue after the procedure.
If you have keratoconus (a condition were corneal thinning and bulging into a cone-like shape occurs), performing LASIK is not recommended as it will lead to further complications.
If you have any existing serious eye conditions or health-related problems, your doctor may discourage you from pursuing LASIK.
These are just some of the criteria as doctors vary when it comes to the standards that they follow.
Why you can be disqualified for LASIK
About once a week I will see a patient who was told that he’s a good candidate for LASIK, but actually should probably avoid getting it. The candidacy diagnosis was wrong. Several times a week, however, I'll see a patient that was told that they wouldn't be a good LASIK candidate, but is actually a great candidate. Again, the candidacy diagnosis was wrong. Most commonly, the person told they shouldn't have LASIK was given "astigmatism" as the reason.
So what makes someone a non-candidate for LASIK?
There are a lot of special cases that require a consult to address, but the vast majority of non-candidates are advised against LASIK for one or more of three reasons:
- The cornea, clear dome on the front of the eye, that is treated by laser is too thin to safely treat with laser.
- The cornea has a shape to it that is too steep, too flat, or too lumpy of a dome to have predictable good results.
- The lens inside the eye, not the cornea, is too cloudy to justify doing LASIK to fix the prescription.
There are other reasons someone might not be a good LASIK candidate. As an example, if you are pregnant or breastfeeding, it is usually best to wait. But all of those reasons combined end up being only a fraction of one of these three. We have a lower candidacy rate at Hunter Vision than other LASIK centers because I'm pretty neurotic about every factor being perfectly aligned for someone to love their vision after LASIK.
Who should not get LASIK?
What this means is that I probably tell a few people they shouldn't have LASIK that would have done well with it. But believe me, that is a way, way better situation than being told you were a good candidate when you weren't.
The last thing that you want to happen is to have LASIK-related complications that may result in permanent loss of vision. As a responsible medical practitioner, I’m bound to exercise proper and exhaustive pre-operative screening during consultation first and foremost. It’s the same priority I give when performing sensitive surgical techniques, using state-of-the-art medical equipment, and making sure that follow-up treatments are made.
But you may argue that different eye doctors have different opinions. You may qualify for LASIK in one clinic, but be denied in another. An eye doctor in Florida may let you pass the screening, but another practitioner in a different state may not. So who should you follow then?
Differing opinions from different eye doctors
Why would one doctor say you’re a candidate for LASIK, and another say you’re not? The quick answer here is that one of those doctors is probably wrong. It doesn’t help us much though, because now we’ve got to figure out which one.
It’s kind of like that old logic puzzle of the twins at a fork in the road where one always lies while the other always tells the truth, and you’ve got to figure out what question to ask to find the correct path to take.
I believe the solution to that one was, “Which isn’t the opposite of the path I shouldn’t not decide to not take?” Or something like that. People rarely find themselves in that situation so I haven’t had any practice to keep that answer straight. LASIK candidacy, however? I keep up with that riddle. It’s quite often I’ll meet someone who was told they were or were not a candidate for LASIK when in fact the opposite is true.
The way to know whether or not you’re a LASIK candidate, or why one doctor would say you were and another not, isn’t as quick as saying one doctor is wrong. That doesn’t mean it isn’t straightforward, though.
The vision diagnostics and conversation with your doctor that are necessary for finding out your true LASIK candidacy take time. Those two examples—diagnostics and conversation—aren’t chosen at random. They are the cornerstones to the truism that LASIK is 95% knowing what to do and 5% doing it.
First up is diagnostics. This means the testing of your eye function and imaging of your eyes involved in deciding if LASIK would be safe and effective in your case.
A refraction (“better one or better two?”) is the centerpiece of the eye testing. It has to be done to perfection because it will have influence on the decision-making process and ultimately, your vision after LASIK.
How do you know if it was done right? You start with autorefraction (using a machine that does this automatically). This gets checked against your previous glasses and contacts prescriptions.
Next, a very carefully performed refraction gets you significantly closer to the true final number. That refraction is important enough that it is performed in its entirety again the day of surgery to ensure it matches.
And finally, there is one other crucial component of the exam: dilation.
Dilating drops aren’t necessary for the reason you may think (to get big pupils). They are necessary because they paralyze the focusing muscle in your eye. That focusing muscle is, by a landslide, the primary reason for a refraction coming up with the wrong prescription.
A cycloplegic refraction (which is medicalese for “refracting after dilation”) ensures a refraction is honest, and it often shows where it wasn’t. I describe a cycloplegic refraction as “having the key to the test” because it lets us know if the other vision testing—including your current glasses—is missing something.
The imaging done requires more description than is necessary or helpful in an article like this. Luckily, the idea behind it doesn’t. The scans of your cornea (where LASIK will happen) must give an idea of the architecture and curvature that makes your cornea unique.
Knowing the thickness of the cornea only is like measuring someone for a suit by just asking how tall they are. There are literally thousands of data points that can (and should!) be acquired by the imaging diagnostics of your cornea.
How would you know if that’s what’s happening in your LASIK consult? Great question! And the answer sums up the rest of what we have to talk about here.
The rest of our conversation is about the conversation. It’s the conversation your LASIK doctor has with you during your consult. If you’re talking to a doctor who you feel like you can trust on their verdict about why you can or can’t have LASIK, you should feel like you know why you trust it.
If it isn’t explained clearly why the testing and imaging shows if LASIK is a good choice for you, there’s a reason. It’s usually one of these three: they didn’t do enough of it, they don’t know enough about it, or they don’t care enough to take the time to explain it. None of those three should earn enough trust from you to make it the final call on whether you can have LASIK.
The takeaway here is that if you don’t feel like you’ve got a clear answer, then you don’t have a clear answer. Keep looking. There are LASIK doctors out there who are like that twin who always tells the truth.
Maybe you clicked on this blog thinking, “I bet this will have some real Old West gun-slingin' words. I reckon this feller says optometrists’ words are none too welcome around these parts.” If so, I’m sorry to disappoint you. But also, wow would I like to hang out with you! Your internal monologue is delightful. And it’s on point with the typical optometry vs. ophthalmology “this town ain’t big enough for the both of us” mindset of conflict.
That conflict often (this is true!) dominates the conversation in the world of eye medicine, which is hilarious because almost no one cares about it in the real and normal world where we all live. I imagine even finding out about this now must feel like visiting a small town and finding out that the citizens of it are bitterly divided and identify themselves based on whether they are associated with the local Moose Lodge or the Elk Lodge.
Optometrist vs. Refractive Surgeon on LASIK candidates
Anyway, one area that you might assume some conflict could arise would be in the opinion of an optometrist vs. a refractive surgeon on the idea of LASIK. Oftentimes, based on the information shared with me during LASIK consults, optometrists will tell a patient whether or not they are a candidate for LASIK.
This doesn’t bother me. For a lot of people, their optometrist is the only eye doctor they’ll ever see, so it seems silly to expect they’d never speak on a relatively well-known eye procedure. As you’d imagine, this means sometimes an optometrist will tell a patient they’re not a candidate for LASIK when, in fact, they’re actually a great LASIK candidate. It’s bound to happen, and I’ve seen it multiple times.
There are only two options available to us as to why an optometrist would give a patient the wrong information about their LASIK candidacy. One, the optometrist sees a lifetime of glasses and contact lens prescriptions’ revenue going down the drain.
“I prescribe glasses and contacts, so when this patient doesn’t need them, they’ll break up with me. I won’t let that happen. I will lie to them so that we can be together forever.” I want to be clear on this—that is almost never the case. People are better than that, and optometrists are wonderful people. Has an optometrist ever willfully withheld the information that LASIK could help a patient? I’m sure.
Also, one time a guy came to fix our garage when I was a kid and then left town after my dad gave him the down payment. Some people just aren’t nice. But that doesn’t change the fact that most people are.
That leaves us with option two. An optometrist gave the best advice they could, based on the information available to them. This, in my opinion, is probably the case almost every time there is a discrepancy between what an optometrist and refractive surgeon advise about LASIK.
Part of why I believe this is that I’ve had several instances where an optometrist has told a patient they are a candidate for LASIK, only for me to tell them they aren’t. And now seems like as good of a time as any to point out the likely obvious, but still necessary, fact that this only works if the refractive surgeon is also honest and meticulous.
If you feel like you got less certain information from your refractive surgeon than your optometrist about your LASIK candidacy, you’ve at least figured out one key piece of information. You can know you shouldn’t get LASIK from that guy, anyway, even if you are a candidate.
In a world where the professionals you look to for help are honest and want the best for you—which I believe is most of the world, most of the time—it comes down to specialization.
When a patient asks me what type of contacts will work best for them (that actually happens on a regular basis), I say something like, “Gosh. I’d like to help you, but it’s almost like asking the guy behind you in line at the grocery what contacts you should wear. I know an optometrist who knows more about that than I could ever hope to. You should see her.” I’m not an expert on that. I’m an expert on LASIK, so I can offer really specific reasons for whether or not LASIK is a good idea.
If your optometrist says you’re not a LASIK candidate, but you wonder if you actually might be, then you should see an expert on LASIK who you feel like you can trust. Your optometrist is giving you the best information they’ve got and they want the best for you, but sometimes the best for you in this specific case just requires a little more information.
LASIK and a patient’s lifestyle
What about lifestyle? Lifestyle always seemed like a kind of useless word to me—like it is a little off-the-mark of what it is trying to describe. It seems like a compound word that has less meaning than the two words that compose it. Usually it’s the opposite: workflow, doorknob, toothbrush—those are good compound words. It saves time because in those cases a double-word like that gives a very narrow description of a specific idea better than each word on its own.
Lifestyle on the other hand... I don’t even know what I’m describing. The style of life for someone? The word style doesn’t narrow down what we’re talking about at all. If anything it just adds more questions. It can’t mean personality or interests or careers. There are words for all those things.
I’ll come right out and say it: lifestyle is a big stupid non-word. If you’ve read any of these blogs, you may think, “Good golly, this guy is usually upbeat! I wonder what happened to his whimsy.”
Well, I’ll tell you. I’ve spent three hours (this is true) writing and rewriting this article and deleting all of it because I can’t wrap an explanatory structure around the question. I feel like I’ve been trying to write an answer to the question, “Is energymood a factor?”
So, in breaking with tradition of answering the exact question—since it’s like trying to answer if yellow is round or square—I’m going to answer a different question. Hopefully it also answers questions about lifestyle for people smarter than me who know what that word means. It also just occurred to me that maybe I don’t have a lifestyle, and that’s what’s prevented me in writing this. Nonetheless, here’s the answer to LASIK candidacy based on career and hobbies.
Your job and LASIK
There are only two cases I can think of where LASIK candidacy might be determined by the specifics of what you do in your daily life. The first is folks who rely on extreme near vision. This would include fine jewelry design, circuit board soldering, creating tiny model replicas, etc...
In those cases, being myopic may be better than not. The handicap of having no distance vision without glasses can come with one singular perk of incredible, supernormal near vision. When you correct myopia with LASIK, near vision still works for reading and other activities associated with up close vision. But the best “perfect” vision can’t compete for easy near vision when it is up against myopia.
Being myopic means your eyes naturally, at rest, are perfectly in focus at a very close distance. It requires zero work from your focusing muscles in your eyes. Your eyes are built to use those focusing muscles when needed, but if you never need to use them at all then you are accomplishing the same near vision task with zero effort.
You may not be able to see who walks into your office, but you can stare in perfect focus a few inches in front of your face all day without effort. That’s a nice feature to have if most of your day is spent dealing with extremely close and small objects.
The other category where LASIK may not necessarily be best is for pilots over the age of 45. There are different rules for distance and near vision with different pilot licenses. In some cases, glasses may still be necessary when flying. Having performed LASIK on pilots over the years, I can say it’s not been a problem before. But there’s probably some selection bias in that sample group because the pilots who chose to have LASIK were folks that knew what I just wrote here. It’s because I told them directly, since this article wasn’t written yet.
In either of these two scenarios, it’s possible that LASIK is still going to be a good choice. It’s just important to know all the factors specifically related to you when you’re making that choice. If “lifestyle” means something different to you than what we talked about here, I’d love to answer questions about it at a consult. And the motivation there is almost entirely selfish because I really want to learn what we’re talking about when we use the word lifestyle.
How much does LASIK surgery cost
When you’re qualified to have LASIK, the final question comes down to one thing: Can I afford LASIK?
But before you consider how much LASIK costs, I’d like to ask you first instead: What’s your vision worth?
My patients who have successfully undergone refractive surgeries are always delighted by the results in terms of restoring their eyesight. There’s no denying that LASIK can be expensive but for them, there is no better investment they’ve made in their lives – not even the new car they bought – than going to my clinic to have their eye issues fixed. (As a side note, if you want to learn more about it, read about the top 8 reasons why people choose us for vision correction.)
But who ever thought that something that’s expensive can still be affordable? In all honesty, getting an eye surgery won’t require you to empty your bank account these days.
We have payment plans available that make vision correction surgeries affordable for almost everyone. We know tight budgets make it tough to come up with a “chunk” of money rather than paying over time in bite-sized bits.
Our affordable payment plans for vision correction surgeries including LASIK can fit your tight budget. That's why we offer payment plans for as low as $130 per month - yes, that's not a typo - so you can start and end your day without your eyeglasses.
Author:Joel Hunter, MD is an Ophthalmologist, Refractive Surgeon, and the Founder of Hunter Vision, a LASIK Clinic in Orlando, 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.