Eye Surgery Options: Laser, Lens, Cataract, Glaucoma and Retina

Eye surgery has changed enormously in the last few decades. Procedures that once required long hospital stays are now usually done as day cases under local anaesthetic, often in less than half an hour. Millions of people each year have their vision restored by cataract surgery, freed from glasses by laser correction, or protected from blindness by glaucoma and retinal operations.

Surgery is still surgery, though. Every procedure has specific candidacy criteria, recovery requirements and risks, and the right choice depends on your eyes, your age, your work and your expectations. This guide gives you a clear, balanced overview so you can have an informed conversation with an ophthalmologist. It does not replace an individual assessment.

Refractive surgery: correcting focus

Refractive surgery changes how light is focused in the eye to correct myopia, hyperopia and astigmatism. It works either by reshaping the cornea, the clear front window of the eye, or by adding or replacing a lens inside the eye. It does not treat the underlying anatomy of a long or short eye, so a person with high myopia still has the same risks of retinal problems after surgery and still needs regular check-ups.

LASIK

In LASIK (laser-assisted in situ keratomileusis), the surgeon creates a thin hinged flap in the cornea with a femtosecond laser or a blade, folds it back and reshapes the underlying tissue with an excimer laser before replacing the flap. Vision usually improves within a day or two, and discomfort is mild. The flap means the cornea is slightly more vulnerable to a hard blow, and LASIK requires a cornea of adequate thickness. Dry eye after LASIK is common for several months and occasionally persists.

PRK and surface treatments

In PRK (photorefractive keratectomy) and related techniques such as LASEK and transepithelial PRK, the thin surface layer of the cornea (epithelium) is removed and the laser reshapes the surface directly. There is no flap. Recovery is slower and more uncomfortable: the epithelium takes several days to heal and vision can fluctuate for weeks. In exchange, more corneal tissue is preserved, which makes PRK a good option for thinner corneas and for people in contact sports or professions where eye trauma is likely.

SMILE

In SMILE (small incision lenticule extraction), a femtosecond laser creates a thin disc of tissue inside the cornea, which is removed through a small keyhole incision. There is no large flap, and some studies suggest slightly less dry eye early on than with LASIK. SMILE is mainly used for myopia and astigmatism; options for hyperopia are more limited and still developing. Results are broadly comparable to LASIK for suitable patients. Read our comparison of LASIK, PRK and SMILE for a deeper look.

ICL (implantable collamer lens)

An implantable contact lens, or phakic intraocular lens, is placed inside the eye in front of your natural lens, which stays in place. ICLs can correct higher prescriptions than laser can safely treat, and they are an option for people whose corneas are too thin or irregular for laser surgery. Because the lens can be removed, the procedure is in principle reversible. Risks include raised eye pressure, cataract formation over time, infection and, rarely, damage to the corneal lining cells, so regular follow-up is required.

RLE (refractive lens exchange)

Refractive lens exchange is technically the same operation as cataract surgery, but performed on a clear lens to correct focus. It is mostly considered for people over about 45 to 50 with high hyperopia or significant presbyopia, who would develop cataract eventually anyway. Multifocal or extended-depth-of-focus implants can reduce dependence on reading glasses, but they may cause halos and glare at night. In younger, highly myopic eyes RLE carries a higher risk of retinal detachment.

Who is a good candidate for refractive surgery?

A responsible surgeon turns down a significant proportion of people who ask for laser surgery. That is a sign of good practice, not bad luck. Typical requirements include:

• Age at least 18, and often older, with a prescription that has been stable for at least one to two years.
• Healthy corneas of sufficient thickness and regular shape. Signs of keratoconus are a strong reason to avoid LASIK.
• No active eye disease such as uncontrolled dry eye, uveitis, significant cataract or poorly controlled glaucoma.
• Not pregnant or breastfeeding, as hormones can change the prescription.
• Good general health; some autoimmune diseases and uncontrolled diabetes may affect healing.
• Realistic expectations: the aim is to reduce dependence on glasses, not necessarily to achieve perfect vision for life. Reading glasses will still be needed after about 45 in most cases.

Risks of refractive surgery

Serious complications are uncommon, but you should understand them before deciding: dry eye, glare, halos and starbursts at night, under- or over-correction needing an enhancement, regression over time, flap complications after LASIK, infection, corneal haze after PRK and, rarely, progressive corneal weakening (ectasia). Thorough screening with corneal topography and thickness measurements reduces these risks but cannot eliminate them.

Cataract surgery

A cataract is a clouding of the natural lens, usually with age. It cannot be cured with drops, diet or exercises; surgery is the only effective treatment. In modern phacoemulsification, the surgeon makes a tiny incision, breaks up the cloudy lens with ultrasound, removes it and inserts a clear artificial lens (intraocular lens, IOL). The procedure usually takes 15 to 30 minutes under local anaesthetic and you go home the same day.

Choosing a lens implant

• Monofocal: clear vision at one distance, usually far; reading glasses are then needed. The standard choice in many public health systems.
• Toric: corrects astigmatism as well.
• Multifocal or trifocal: aims to give distance and near vision, at the cost of possible halos, glare and slightly reduced contrast.
• Extended depth of focus (EDOF): a compromise with good distance and intermediate vision and fewer halos than multifocals.
• Monovision: one eye set for distance and the other for near; works well for some people, not for others.

Candidacy and timing

There is no need to wait for a cataract to be ripe, as was once taught. Surgery is generally recommended when the cataract affects your daily life, driving, reading or safety. Biometry measurements before the operation determine the implant power.

Risks

Cataract surgery is very successful, but complications can occur: posterior capsule opacification (a common, easily treated clouding behind the implant, cleared with a quick YAG laser procedure), inflammation, raised pressure, swelling of the macula, retinal detachment and, rarely, a serious infection inside the eye (endophthalmitis). See what to expect before, during and after cataract surgery.

Glaucoma surgery

Glaucoma damages the optic nerve, usually in connection with eye pressure. Most patients start with pressure-lowering drops, but laser and surgery play an important role. All of them aim to lower pressure and slow or halt further damage; none can restore vision that has already been lost.

Risks depend on the procedure and include pressure that becomes too low or rises again, infection, bleeding, cataract progression and the need for further surgery. Lifelong monitoring continues after any glaucoma treatment.

Retina procedures

The retina is the light-sensitive layer at the back of the eye. Retinal treatments are often urgent, and timing can make the difference between keeping and losing vision.

• Intravitreal injections: anti-VEGF medicines are injected into the eye to treat wet macular degeneration, diabetic macular oedema and retinal vein occlusion. They are done under anaesthetic drops and usually repeated over months or years.
• Laser photocoagulation: seals leaking vessels or treats abnormal vessel growth in diabetic retinopathy, and can secure a retinal tear before it becomes a detachment.
• Pneumatic retinopexy: a gas bubble injected into the eye pushes a detached retina back into place, combined with freezing or laser.
• Scleral buckle: a silicone band sewn onto the outside of the eye supports the retina.
• Vitrectomy: the gel inside the eye is removed to repair detachments, macular holes, epiretinal membranes or bleeding. A gas or silicone oil bubble may be left inside, sometimes requiring specific head positioning for days. You must not fly or travel to high altitude while a gas bubble is present.

Risks include infection, raised pressure, cataract after vitrectomy, re-detachment and bleeding. The benefit is usually substantial because the untreated conditions often lead to severe sight loss.

Preparing for and recovering from eye surgery

• Bring a complete list of medicines; tell the team about blood thinners and medicines for prostate problems (some can affect the iris during cataract surgery).
• Arrange for someone to take you home.
• Use the prescribed drops exactly as instructed; your surgeon decides which ones and for how long.
• Avoid rubbing the eye, swimming and dusty environments for the period your surgeon advises.
• Wear the protective shield at night if given one.
• Keep all follow-up appointments, even if you feel fine.

When to contact your surgeon urgently