Before choosing a technique, there is more to understand than the eye. Yet most of the questions I am asked begin with the technique.
When patients come to see me hoping to be free of their glasses, their first question is almost always about the technique: “Am I a candidate for laser?”, “Would SMILE be better?”, “I’ve heard about implants — what do you think?”. This is a natural way into the subject: it is how people talk about it among themselves, on forums and on social media. But it is not how a surgical decision is made. In practice, the reasoning has to run the other way: starting from your eye, your visual needs and what the literature establishes; the technique only comes at the end. This is what the principle that guides all my work sums up: the indication comes before the technique.
No technique is better “in absolute terms”
LASIK, transPRK, KLEx, the phakic implant (a lens placed inside the eye without removing the natural lens), refractive lens exchange (RLE), and any new technique that may emerge in the future cannot be ranked on a single scale, from least to most effective. Each of these approaches is the right answer for a given eye and way of life, and the wrong answer for others. A technique that works very well for one patient may be inadvisable, or even contraindicated, for the person sitting next to them in the waiting room — even when the prescription on their glasses looks identical. The question “what is the best technique?” therefore has no answer until we know which eye, and which patient, we are talking about.
An indication arises where three elements meet
What I call an indication is not a choice from a catalogue. It is the point where three sources of information converge.
- The measurable characteristics of your eye. Thickness and regularity of the cornea, size of the error to be corrected, anterior chamber depth, clarity of the natural lens, quality of the tear film: objective data gathered during the preoperative assessment.
- Your visual needs. Your age, your work, your leisure activities, how often you drive at night, how much compromise you are personally willing to accept. A 25-year-old software developer and a 55-year-old teacher do not have the same needs, even if their myopia is identical.
- What the scientific literature establishes. Which techniques work, for which profiles, and with which limits. This is the evidence base on which each of my recommendations rests.
An indication is the place where these three elements meet. When they do not meet, I do not propose surgery. It also happens, and often, that they converge on several techniques: the choice then rests on their practical aspects and on your preferences.
The reasoning runs from the eye to the technique, never the other way round
I do not first decide that “this patient will have LASIK” and then check that the boxes are ticked. I analyse your eye, I define with you the visual goal to aim for, and the appropriate technique emerges from that reasoning. Sometimes a test result rules out an option straight away: a cornea too thin for the correction required, for example, excludes laser. Sometimes two approaches remain possible, and we discuss their respective trade-offs together. The technique is a consequence of the analysis, not its starting point.
“Not operating” is also an answer
The most honest recommendation is sometimes not to operate, or to wait. A fragile cornea, a prescription that has not yet stabilised, presbyopia about to change the whole picture, or expectations that do not match what the technique can actually offer: these situations exist, and naming them is part of the care. Deciding not to operate, or to postpone, is not a missed opportunity: it is the direct application of the principle of transparency. I would rather see a well-informed patient leave without surgery than operate on a fragile indication.
A decision that is shared
Neither you nor I make this decision alone. My role is to set out clearly what is possible, what is not, and what each option involves, including its limits and trade-offs. Your role is to tell me who you are: your life, your priorities, what you are and are not prepared to accept. The end of the preoperative assessment is there precisely for this: to take the time for this shared decision, without haste.
Finally, the indication does not end on the day of the procedure. Vision continues to change with age, and follow-up accompanies that change. Getting the indication right also means anticipating, from the outset, what will become of your vision in the years that follow.
This page presents general guidance drawn from my practice and current scientific literature. Each situation is assessed individually in consultation, on the basis of a complete preoperative assessment. It is not a substitute for personalised medical advice. — Dr Alexandre Balon, ophthalmic surgeon, Clinique Saint-Pierre Ottignies.