benc's blog

Unorganized thoughts on LASIK

January 23, 2021 • ☕️☕️ 9 min read

I got LASIK recently. I have a few thoughts on the experience and its technology/economics.

Holy fuck, it works

The science of LASIK is very cool. The reason (most) (younger) people have vision problems is their cornea (the front of the eyeball) isn't bending light perfectly: imagine using a camera where the glass is weirdly bent. LASIK seeks to change the shape of the cornea by burning away tissue.

There are two lasers used: one laser creates a flap on your eye, making the tiniest possible cut as far from the center of the eye as possible (imagine peeling an apple in the most minimal way possible) to grant access to the cornea and the other laser alters your cornea by burning away tissue. This is where most of the risk comes in: we currently do not have the technology to restore burned away tissue and the eye is so complex (there's a reason there are two separate medical professions dedicated to it!) the body will not heal it. If the surgeon fucks up... well it's bad.

But it actually works! LASIK was first approved in the FDA the same year I was born (1998) and has been remarkably successful. Stories of it not working are the minority (see "Even good medical resources are bad").

Moreover, its improvement is tied to the relentless progress of technology in the way most medicine is not. As our laser technology improves, we can aim at the correct area of the cornea more accurately. The machine also uses eye-tracking (so it's always aiming at the correct part of the eye) and the processors and algorithms that enable the tracking have improved immensely since 1998. One could easily imagine LASIK being as common as optometrists someday as the cost of lasers go down.

FWIW, besides my left eye being unusually dry, I've suffered no side effects and have something between 20/15 and 20/20 vision now.

It's still a laser pointed at your eye

It's one thing to know all the science and quite another to have the laser pointed at your eye. There's also a scary moment after they open the flap in your eye when you can't really see (just black with some flashes of light) and you're really hoping that this shitty beige medical room isn't the last thing you ever saw. Surgery is still surgery and surgery is very annoying, at best.

Still! It's fucking wild this works! We went millennia without any vision correction, figured out eyeglasses around 13001, took another 600 years to figure out contacts and figured out how to avoid corrective devices in most cases just 100 years later. The results of science are cool. My hope is the progress on vision correction accelerates enough that by the time my vision starts deteriorating again in my 40s (the lens - the thing in your eye you change the shape of to change where you're focusing on starts to become less flexible around then), there's some process to fix that 2.

It's weirder being able to see than I expected

I hadn't realized how much of my life is centered around this seeing/not-seeing dichotomy. A few days ago I was going to sleep and felt guilty that I hadn't taken my contacts out because I could still see - but, of course, that was just the LASIK-improved-eyes. I've needed glasses since the 1st grade so I probably should have expected more changes to my life than I did.

The economics are fucked: the petty complaint

Of course, it wouldn't be the American medical system if extraordinary, almost mythological science wasn't backed up by an economic model of incredible stupidity that benefits nobody except a few monopolistic companies.

I paid $4,000 for LASIK. It's usually $5,000 (they had a sale) but that's also because I went to a place with the best laser. I probably could have saved around half if I went with an older - but still FDA-certified and everything - laser. I originally projected LASIK to save me money in the long run (I've wanted it for about 4 years). I was spending around $400 a year in daily contacts. LASIK is estimated to last around 20 years (that's around when non-corneal vision problems start cropping up) so I would have saved around $4,000 over that time-span and avoided the downsides of contacts3.

However, I recently started a job and got vision "insurance". Insurance is a misnomer there, they don't actually insure your eye (in general, if you develop an eye disease or hurt your eye, that's the purview of your general health insurance). They're basically vision coupon plans that companies offer employees because the government offers tax breaks on compensation that's in the form of insurance because the American healthcare system is spectacularly poorly designed. The one I'm currently on (VSP Vision Care) will pay for frames every other year plus eyeglass lenses/contacts... but nothing for LASIK.

This changes the economics of LASIK to be squarely negative. Of course, as promised, this is a very petty complaint: people born with 20/20 vision go and work for companies that offer vision insurance all the time and they don't whine about it. Still, this is one of many examples of where the American healthcare system is bad. The total cost of contacts is cheaper than LASIK is but the structure of how each is paid leads to more total spending being the most logical one for the consumer.

It ends up like this is because vision insurance plans typically own or are owned by larger corporations that acquire optometry chains and even glasses/contact lens makers. This sort of vertical integration gives them more control over a consumer's dollars (John Oliver does a good overview of the funhouse mirror nightmare that is American optometry). The higher LTV of a contacts consumer, combined with the fact that there are very few makers of glasses/contacts leads to bad incentives.

The economics are fucked: a better complaint

A better complaint of the economics LASIK is that the time it's most logical to do and the time most people find it most affordable to do are very different. LASIK makes sense to do as soon as someone's vision stops changing. It's a one-time investment that has a relatively fixed deprecation date (the patient's 40s). The squares out to the most logical time to perform LASIK as most people's 20s.

I don't know if you, dear reader, have seen the news lately but young people are not doing so hot economically right now. There's a lot of reasons why 4 but the point is that most young people would probably struggle to meet a $400 expense, let alone a $4,000 one5.

This is, of course, shitty in a broad sense but, bringing it back to LASIK, it's particularly shitty for that. The optimal medical window to get LASIK does not align with a time when most people can afford it - I'm very lucky that I was able to. The result is that most people get LASIK when they're older and thus get fewer years of good vision + have a harder recovery. Not great.

Even good medical resources are bad

The meme that WebMD will tell you literally any symptom is cancer is well deserved. But WebMD is trying to ride the SEO dragon and get clicks so whatever, good on them for finding a business model, I guess. On the other hand, Mayo Clinic brands itself as a serious online medical resource. However, if you go to their page on LASIK, you're treated to (after a good explanation of how it works, to be fair), a large enumeration of the risks with absolutely no context on how likely they are. Buried at the end is that the surgery works for more than 8/10 people (itself, a very conservative estimate). This page looked a lot like the consent form I had to sign for the surgery where they're covering their ass by enumerating every possible thing that could go wrong.

Without knowing the legal risks that Mayo could subject themselves to - because I'm sure they're real and I certainly wouldn't want to run a site that has to deal with them - I think this is a bad model for informing patients. A patient that has a precise-ish measure of the chance of success and knows nothing about the risks (except there's a bunch and they're all >0) is just a patient that has been successfully scared. I think a better model would seek to quantify the risks, and would at least mention that the procedure being FDA approved means they have to be relatively small for an optional procedure. America has plenty of entities trying to confuse us about healthcare; we really don't need the neutral ones contributing to the confusion. I suspect that lack of good patient resources leads to the well-known phenomenon where patients blindly listen to doctors even when that leads to suboptimal outcomes.

Good Lord, the American medical system is bad

I was actually surprised at how bad the patient experience was during this process. It wasn't worse than normal but the same QoL nonsense that pervades the rest of American medicine - difficulty getting someone on the phone, irritating pharmacy delays, etc; all of that was here too. I didn't expect that for an optional luxury procedure that presumably has a quite high-profit margin in a competitive area (eyeballing Google Maps, it looks like there are about 10 places around Chicago that do LASIK). All the typical Republican talking points about the free market really should apply here and they really don't. As a particular example of this, I called and requested a receipt (not automatically sent to me, because of course not) and my options were snail-mail and fax. I hardly need to point out here that the ability to fax probably implies the ability to scan which implies the ability to email; the lack of an option to do so implies they don't give a shit6.

I don't really know what to do with this - and the people reading this, myself included, probably don't need to be persuaded about this - but with the caveats of N=1 in mind - it seems clear to me that if the free market doesn't get this procedure right, it's not going to get much right with respect to healthcare7. Universal healthcare, whether single-payer (Canada), single provider (U.K.), or some sort of regulated and subsidized free market system (Germany), doesn't have to be very good to represent a massive improvement. Maybe the equivalent of Ben Nelson (US Senator, D-NE, one of the deciding votes to pass Obamacare but also make it worse) in 20 years will believe this and won't pussyfoot around with complicated exchanges and shit and just pass something straightforward and good.

  1. The discovery is officially credited to an Italian. As with many discoveries, the usual arguments on whether the Arabs or Chinese figured it out first and didn't document it apply.

  2. You know, assuming America and this planet are still around.

  3. Glasses would have been much cheaper. I estimate around $2,000 cheaper but they're also a clearly worse product in terms of vision compared to contacts. Glasses leave blindspots, contacts do not.

  4. I have some controversial takes here but let's just blame Baby Boomers and all be happy.

  5. That report doesn't break down the $400 unexpected expense by age (itself an example of the natural myopia - get it, "myopia" - democracies have towards the lower voting young population, in my opinion) but if 40% of adults would struggle, young people who are worse off then the aggregate population and since COVID has hit, I'm comfortable characterizing it as "most".

  6. When I finally received the receipt (one week later), it was a printed piece of paper in a hand-addressed envelope. Everyone involved in the design and execution of the process of procuring that receipt should feel bad.

  7. I should note here that Obamacare tried to create a system of electronic medical records which was a spectacular failure. Maybe someday.