If you're looking for the right medical and financial fit for vision-correction surgery, you can go cross-eyed considering all the options.

Lasik is by far the most popular procedure that surgically corrects most kinds of nearsightedness, farsightedness and astigmatism, with traditional and "custom" Lasik accounting for 90% of vision-correction surgery.

But it isn't cheap, it's rarely covered by insurance, and some people aren't candidates for the procedure.

As workers with prescription eyewear take stock of the remaining balances in their pretax flexible-spending accounts, many are considering whether to have vision-correction surgery, what kind is right for them and whether it pays to delay action until next year.

Americans pay $3,570 on average to have Lasik surgery on both eyes, and they dig up to $800 deeper into their pockets to have the newer, wavefront-guided Lasik procedure, said Dave Harmon, president of Market Scope, an ophthalmology-industry research firm in St. Louis. Patients are typically in their late 30s and early 40s, he said.

When Lasik first received approval in 1996, "complication rates, though still low, were much higher than they are now," Harmon said, noting that doctors have become better at screening patients.

Those considering Lasik or other vision-correction surgery are wise not to put it off in hope of major advances just around the corner, he said: "I don't see dramatic improvements on the horizon. I see small, incremental improvements over time."

Cost versus benefit

Though the upfront fee can be substantial, surgery often drastically cuts spending on glasses and contacts over time, said Dr. Steven E. Wilson, corneal-research director and staff refractive surgeon at the Cleveland Clinic's Cole Eye Institute.

"There is a financial savings," Wilson said. "Usually people do this for quality of life, but as a side benefit you do reduce the cost of taking care of your eyes."

Americans spend about $2 billion a year on refractive surgery, according to Market Scope. They're expected to have 1.3 million procedures this year, up from 1.15 million last year, Harmon said.

As more people consider having laser surgery to shed their glasses and contact lenses, they'll find a host of variations. Here's a look at techniques on the market, their prices and how to tell which one's for you.

Lasik surgery, short for laser-assisted-in-situ keratomileusis, begins by using a microkeratome blade to peel back the outer layers of the eye so the doctor can reshape the cornea underneath with an excimer laser. This flap reattaches to the eye's surface.

The procedure, known as "flap and zap" among ophthalmologists, generally takes three minutes for each eye and requires several hours to recover your vision, said Dr. Paul Dougherty, a clinical instructor at UCLA's Jules Stein Eye Institute. "It's not painful when it's happening, but some people can get some discomfort within the first four to six hours," he said.

IntraLase refers to Lasik surgery that uses a laser, instead of a blade, to make the flap that lifts the outer eye layers during the first part of the operation. There is some conflicting research on this option.

Some studies suggest that patients who opt for IntraLase have fewer complications and less need to have a followup enhancement, Harmon said. Still, some patients have a higher incidence of inflammation under the flap after surgery, Dougherty said.

Perhaps the biggest benefit is psychological for patients squeamish about a blade, Wilson said. "In some cases, that's the major advantage of the procedure," he said. "It gets by a block that some patients have about laser vision correction."

Patients may prefer IntraLase, but they'll often pay a premium for it. "The major downside is it's more expensive," Wilson said. "We charge $300 more an eye for it."

Wavefront-guided or Custom Lasik is a more precise form of Lasik that involves measuring how the eye bends to 200 points of light as opposed to one point in the middle of the eye in conventional Lasik, according to Dr. Robert Maloney, spokesman for the American Academy of Ophthalmology.

"The pattern of visual impairment in your eye is as different as your fingerprint," Maloney said. "We can literally customize surgery, and that makes it more accurate." Custom Lasik patients are less likely to need a touchup and report better night vision than conventional Lasik patients, Maloney said.

Custom treatment isn't yet available for farsighted patients, but is expected to be approved by the end of the year, he said. People with thin corneas also may not be candidates.

The extra labor and equipment involved may drive up the price by an additional several hundred dollars per eye. Some doctors assure conventional Lasik patients concerned about having halos that custom treatment is available as a backup, Dougherty said: "I tell my patients we can use it as a safety net if you can only afford conventional."

VISX is the market leader in wavefront-guided Lasik surgery, accounting for 60% of lasers used compared with 20% provided by Alcon, Harmon said. The remaining 20% of custom lasers are supplied by Nidek, Bausch & Lomb, WaveLight Laser AG and LaserSight, he said.

Photorefractive keratectomy, or PRK, was available before Lasik and remains an alternative for many people, especially those with thin corneas and certain other eye conditions, Wilson said. A doctor removes the outer layer of the cornea with the help of eye drops and performs the corneal reshaping with a laser, though without creating a flap.

The downside is that PRK causes more pain and is slower to heal. It typically costs the same as conventional Lasik surgery. Another form of PRK is called Lasek, or laser-assisted subepithelial keratectomy.

Those who are over 40 and are farsighted or have presbyopia can have conductive keratoplasty, which uses radio waves to change the shape of the cornea through heat.

Designed to improve reading vision, CK is similar in price to Lasik or PRK, but the effect often disappears over time and some ophthalmologists don't offer it. Wilson and Dougherty, who said they had reservations about the procedure, are among them.

But don't expect perfection in any case. "The problem with any lens or surgery, including Lasik, is it's not perfectly accurate," Maloney said. "You're never sure you're going to get 20/20. You may still have a little nearsightedness or farsightedness or astigmatism."

Ultimately, patients need to consult with their doctors and take into account their prescriptions, their visual problems and needs, and their age to determine which correction makes the most sense to pursue, Dougherty said.

Those shopping for a surgeon are wise to choose one who does the pre- and postoperative exams as well as performing the surgery, Wilson said.

New-generation lenses

Patients with visual impairments outside the acceptable range for Lasik surgery or who have early cataracts may be candidates for implantable contacts lenses known as ICLs, or for intraocular contact lenses called IOLs, Dougherty said. The U.S. Food and Drug Administration is expected to approve the first of these implantable lenses soon.

One that's already been approved is Crystalens from Eyeonics, the first "accommodating" replacement lens to provide clear vision at all distances because it's flexible and works with the eye muscles, Dougherty said.

To be sure, the Crystalens procedure is pricey — Dougherty charges $5,000 per eye — and has to be done in a surgery center instead of in the doctor's office.

While recent trials suggest the lenses now have fewer complications than they did earlier, "I think we need much longer followup to know how safe this is for someone who's 20 years old," Wilson said. "We plan on approaching this with caution." Most accommodating and adjustable lenses, which will change shape by shining ultraviolet light on the lens, are still five to 10 years from becoming mainstream options, said Maloney of the American Academy of Ophthalmology.

Don't be afraid

Squeamishness about surgery shouldn't discourage people from seeking help for eye problems, said Dr. Amilia Schrier, assistant professor of clinical ophthalmology at Columbia College of Physicians and Surgeons. "Talking to the patient calms the patient tremendously," Schrier said. "In addition to that, we can administer medications such as Valium before the surgery for them to relax and feel more comfortable. Sometimes we can give medications IV, which will do the same thing. We give medications to the patient to relax during the procedure. Sometimes having someone there holding the hand, sometimes gentle talking, background music, as well as a good understanding of the procedure and a good relationship with the doctor, would all be things to calm the patient for this type of procedure.

"Depending on how motivated the patient is to have an eye surgery — this is elective surgery, this is nothing they have to do — if for some reason they feel they need to do this, and to overcome their fear, certainly there's hypnosis or counseling, which could also prepare them." - Jordan Lite

Reshaping the eye

New guidelines aim to help consumers tell if they're good candidates for laser eye surgery, or may be prone to a sight-hampering side effect. This Lasik procedure takes less than 15 minutes per eye.

1) A surgeon administers anesthetic drops and a thin flap of the cornea is lifted.

2) A laser reshapes the cornea. Each pulse removes a microscopic layer.

3) The flap is folded back over the eye and the cornea heals naturally.

How vision is corrected

1) Myopia, nearsightedness: cornea is flattened

2) Hyperopia, farsightedness: curve of cornea is steepened.

3) Astigmatism: curve of cornea is evened out.

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