A note to readers: This is a personal story of transition. It does not list publications or statistics because everyone has access to the same data, which have been available for years. What has been lacking from the available studies is the human element of transitioning from one technology to another. If reading peer-reviewed articles were enough, this article would not exist. Personal transition stories with emotions are necessary to facilitate change.

Refractive surgery has always been at the cutting edge of medical technology and continually evolving to offer patients better outcomes. As someone who grew up in a family deeply entrenched in the field, I have witnessed and been a part of this evolution firsthand. My father was a pioneer who brought the first excimer laser for PRK to the former Yugoslav region in 1998. The ensuing years brought the rise of LASIK. I firmly believe that laser-assisted lenticule extraction (LALEX) is the future of refractive surgery.

A FAMILY LEGACY OF INNOVATION

In 1998, when I was 9 years old, my father acquired the first excimer laser for PRK in our region. His dedication to advancing eye care was unwavering. I still remember that machine and the first procedures. In 2006, he underwent LASIK for oblique astigmatism and later opted for refractive lens exchange. These experiences were milestones in our family’s commitment to the field.

Growing up in this environment, I was naturally drawn to refractive surgery. From a young age, I was fascinated by the transformation of vision correction from a novelty to a routine procedure. My personal journey with LASIK in my left eye, performed with a microkeratome, was a testament to our belief in this technology. My wife, friends, and the employees and doctors who work for our family also underwent LASIK. If my children were older and had refractive errors, I would not hesitate to perform refractive surgery on them. We believed, and still believe, that refractive surgery is safe and effective.

THE STRUGGLES AND TRIUMPHS OF TRANSITION

Our first foray into LALEX with the VisuMax 500 (Carl Zeiss Meditec) was far from smooth. The speed of patients’ visual recovery was disappointing, and transitioning from a technology we knew well to something entirely new was daunting. In hindsight, if we had known how to set up the laser properly, we could have had amazing outcomes even then. Many of my colleagues with a VisuMax 500 are getting excellent results by changing the laser’s programming and decreasing the laser energy applied to the cornea, thus increasing the speed of visual recovery.

In 2020, we tried again with the Schwind ATOS (Schwind eye-tech-solutions), but challenges persisted. Transitioning from wavefront-guided LASIK to LALEX was not just a technical adjustment; it was a fundamental shift in our approach to eye surgery. Despite initial setbacks, we persevered. The real hurdle was not the complexity of the procedure but our reluctance to step outside our comfort zone. On December 31, 2022, I resolved to treat LASIK as an alternative to LALEX and dedicate a full year to the latter. The results were transformative.

ADVANTAGES OF LALEX

As I delved deeper into LALEX, I discovered its numerous advantages. The procedure involves creating a small incision, preserving the corneal structure better than LASIK. Minimal invasiveness reduces the rate of complications, such as dry eyes and nerve damage. Once I mastered the technique and optimized our equipment, our patients experienced rapid visual recovery comparable to LASIK.

The biggest change was how I communicated with my patients. I explained, “This procedure is different. Tomorrow, you will see many lines on the chart, but they might be a bit blurry. However, you can go back to your life right after the follow-up exam.” Today, with many small optimizations, the results of LALEX in my practice are comparable to LASIK at day 1 and week 1. At 1 month, outcomes with all lasers and types of refractive surgery are similar, but the first few days are key to driving business.

COMMITMENT: THE KEY TO MASTERY

The transition to LALEX reminds me of the shift from extracapsular cataract extraction to phacoemulsification. Both require surgeons to leave their comfort zones and commit to mastering new techniques. My journey underscores the necessity of fully embracing LALEX for several months to achieve success.

The biggest issue lies with surgeons who have extensive experience with PRK and LASIK. It is even more challenging if they remember how easy it was to lift a flap created with a microkeratome. These physicians tend to compare their surgical experience with a new technique to their experiences with older techniques. Unless the experiences match up, it is difficult for them to understand why they should change their approach when it seems good enough.

FINDING IKIGAI IN SURGERY

The Japanese concept of ikigai, meaning a reason for being, resonates deeply with my experience. For eye surgeons, this means committing to techniques that offer the best outcomes for patients, even if the techniques are initially more challenging. Embracing LALEX has become my ikigai. It brings me immense satisfaction to see patients enjoy improved vision and a higher quality of life just 24 hours after surgery. This fulfillment fuels my commitment to continually refine my skills and stay abreast of advances in LALEX technology.

Mastering LALEX is akin to the dedication seen in the documentary Jiro Dreams of Sushi.¹ Jiro Ono’s relentless pursuit of perfection and meticulous attention to detail elevate sushi-making to an art form. His apprentices spend years honing their skills before handling anything important. Similarly, surgeons must continuously refine their techniques and view each procedure as an opportunity to achieve excellence. This commitment transforms surgery from a skill to a craft, improving patient outcomes and advancing the field of refractive surgery.

THE EVOLUTION OF CHOICES: FROM ONE DEVICE TO MANY

When LALEX first emerged, only one device was available: the VisuMax 500. Surgeons had to decide whether to adopt LALEX or stick with LASIK. Today, multiple devices are available, including the Elita (Johnson & Johnson Vision), the Femto LDV Z8 (Ziemer), Schwind ATOS, and the VisuMax 800 (Carl Zeiss Meditec).

The question is no longer whether to adopt LALEX but which device to use. Each offers unique features and advantages, allowing surgeons to select the best tool for their practice and patients. The availability of multiple devices also signals broader acceptance of and trust in the efficacy of LALEX.

EMBRACING THE FUTURE

The future of refractive surgery is bright, and LALEX is at the forefront of this evolution. The journey from PRK to LASIK and now to LALEX reflects a pursuit of excellence in eye care. Each advance builds on the successes and lessons of its predecessors.

For surgeons, embracing this future requires a willingness to learn and adapt. The transition to LALEX demands dedication and a commitment to mastering the technique. It is not enough to simply add LALEX to the list of available procedures; it must become the primary focus.

THE POWER OF COMMUNITY

One of the most valuable aspects of my journey has been the support I have received from the refractive surgery community. Sharing experiences and learning from the successes and challenges of fellow surgeons have led to collective growth. By working together and sharing our insights, physicians can continue to push the boundaries of what is possible in refractive surgery.

I invite readers who are on the fence about adopting LALEX to join me for 2 days at our clinic in Zagreb, Croatia. The first day will be dedicated to performing LALEX cases, and the second day will be for postoperative visits. If the experience doesn’t convince the visitor to switch, nothing will.

1. Gelb D. Jiro Dreams of Sushi. Los Angeles, CA: Magnolia Pictures; 2011.