Can myopia come back after LASIK or SMILE?

What long-term follow-up shows

LASIK now has more than twenty-five years of hindsight. We therefore know what becomes of operated eyes, well beyond the first few months.

A Spanish team re-examined patients ten years after LASIK for myopia of up to 10 dioptres. The myopia had come back slightly, by 0.12 dioptres per year on average, and this drift slowed down over time. At ten years, nearly three quarters of the eyes were still within one dioptre of the target. None had developed a deformation of the cornea.

SMILE is more recent. The longest study I know of followed patients for thirteen years: on average, the myopia had come back by only a quarter of a dioptre, and almost all eyes were still within one dioptre of the intended result. It covers only 29 eyes. That is few, and it should be read as an encouraging signal rather than a certainty.

A German review brought together the longest follow-up studies of PRK, LASIK and SMILE. Its conclusion is clear: within the recommended correction limits, there is no return of myopia that matters in daily life. It is mainly the very strong corrections that lost part of their effect over the years.

Why a slight return is possible

The cornea is not an inert material. After surgery, its surface layer, the epithelium, thickens slightly to fill in the treated area. A study comparing LASIK and SMILE measured this thickening: it occurs after both techniques, and it takes back a small part of the correction.

This is one of the explanations for the slight returns seen after surgery. The process then settles. This is why the refraction takes one to three months to stabilise, and why I never judge the result as final before then.

When the eye keeps growing longer

Myopia most often comes from an eye that is slightly too long. The laser corrects the cornea, not the length of the eye. If the eye keeps lengthening after surgery, the myopia comes back, however well the procedure was performed.

In adults, this lengthening is usually over. A Japanese study followed patients for four years after LASIK performed between the ages of 20 and 39: their myopia had not progressed noticeably, neither in the youngest nor in those in their thirties.

I nonetheless require two conditions before operating: being at least 21 years old, and having a prescription that has been stable for at least two years. This is not a formality. Operating on myopia that is still changing means taking the risk of seeing it come back. I check this stability at the pre-operative assessment, with your old prescriptions if you have kept them.

Who is most likely to need a retreatment?

The figures vary a great deal from one study to another. In a very large centre in Singapore, out of more than 53,000 eyes operated on over eighteen years, 2.55% needed a retreatment. In the ten-year Spanish follow-up, which involved stronger myopia and older lasers, this figure rose to one eye in five.

An American study looked at what increased this risk after LASIK. Three factors stood out: being over 40 at the time of surgery, myopia of more than 3 dioptres, and astigmatism of more than one dioptre. I tell you at the assessment if you are in one of these situations, so that you know before deciding.

How a retreatment works

When a retreatment is useful, it is discussed once vision has stabilised, generally from three months onwards. It requires enough corneal thickness to remain, which I measure before suggesting it.

After LASIK, it is the simplest kind of revision: the flap created during the first operation is lifted and the treatment is completed. After SMILE, there is no flap to reopen, and the retreatment is most often done on the surface. It is a little more delicate. This is one of the factors I take into account when choosing the technique, especially for high myopia. Any retreatment is included in the first year of follow-up.

Blurred vision that is not a return of myopia

Many patients operated on around 30 come back to see me at 45 thinking their myopia has returned. Most of the time, it has not. They still see well in the distance, but struggle to read up close: this is presbyopia, which affects everyone with age, operated on or not.

Later still, an early cataract can make the eye slightly short-sighted. Here again, it is not the laser surgery giving way, it is the natural lens changing.

There remains a rare but serious cause: ectasia, a progressive deformation of the cornea, which thins and bulges. A review of the literature estimated its frequency in patients who had no risk factor before surgery: about 90 cases per 100,000 eyes after LASIK, 20 after PRK and 11 after SMILE. These figures are low. They explain why the assessment measures the shape and thickness of the cornea so carefully: a fragile cornea is a reason not to operate, or to choose another technique.

What I tell you in consultation

If your myopia is stable, your cornea is healthy and the correction stays within reasonable limits, the result is lasting. A small return of a quarter or half a dioptre is possible over the years. Most patients do not notice it.

For high myopia, I am more cautious in what I predict, and I sometimes discuss solutions other than laser, such as the ICL implant. The choice between techniques is explained on the myopia surgery page.

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