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Refractive surgery
With the growth of refractive surgery and the lasers now available, millions of people each year stop wearing glasses or contact lenses.
I choose the technique after the examination, not before: every eye is different. Safety and clarity come first. I take the time to explain what I expect from the operation, and what, less often, can complicate it.
Principles
The cornea is the clear membrane at the front of the eye. It is a key part of the eye's optical system, and it is what refractive surgery modifies.
The outermost layer, made of protective cells. It shields the cornea from infection and drying out, and regenerates after injury.
The thickest layer, made mainly of collagen fibres and water. It gives the cornea its shape and structure.
The inner layer, made of cells that keep the cornea's water content in balance.
The cornea is too steeply curved or the eye is too long. Distance vision is blurred.
→ Flatten the corneaThe cornea is too flat or the eye is too short. Near vision is blurred and tiring.
→ Steepen the corneaThe cornea is unevenly curved. Vision is distorted at all distances.
→ Even out the curvatureAge-related loss of the eye's ability to focus up close (accommodation).
→ Make the curvature multifocalIt vaporises corneal tissue in a controlled way to change the curvature of the cornea. The tissue is removed without heat, so nearby structures are not damaged.
It cuts corneal tissue in a controlled way: it creates the flap for LASIK and the lenticule for SMILE.
The laser techniques
None is better than the others in absolute terms. Each has situations where it is the best answer, and the assessment shows which one applies to your eyes. Each technique has its own detailed page. I operate at the Institut Voltaire laser centre, in Paris 11th.
Transepithelial Photorefractive Keratectomy · surface laser
The laser itself removes the epithelium and then reshapes the cornea, with no deep cut and no contact with the eye. It is the standard technique for thin corneas and for eyes exposed to knocks. Recovery is longer: five to seven days.
Laser-Assisted in Situ Keratomileusis · corneal flap
A flap is cut with the femtosecond laser, the deeper layer is reshaped with the excimer laser, and the flap is laid back without stitches. Twenty-five years of experience behind it, recovery in 24 to 48 hours, and a simple enhancement by lifting the flap again.
Small Incision Lenticule Extraction · no flap
The femtosecond laser shapes a lenticule, which is removed through a micro-incision, with no flap cut. The cornea's biomechanics are better preserved and dry eye is less marked. It has treated hyperopia since 2024 on the VisuMax 800.
Under-correction or regression remains possible, whatever the technique. A second treatment, called an enhancement, is included in the first year of follow-up. How feasible it is, however, depends a great deal on the original technique. This is a factor in the choice that is rarely raised beforehand.
The existing flap is lifted again and the excimer laser completes the correction. This is the simplest and quickest enhancement.
The enhancement is done on the surface, like the first operation, provided enough corneal thickness remains.
SMILE leaves no flap to lift. The CIRCLE technique gets round this: the femtosecond laser makes a circular incision at the periphery and a hinge around the old cap, turning it into a LASIK flap. The flap is lifted, the excimer laser corrects what remains, and the flap is put back in place.
Recovery is quicker than after PRK, but the procedure calls for great precision to avoid overlapping incisions and epithelial complications.
Key point: this should not put you off SMILE, since an enhancement is still possible. It does matter for high corrections, where the likelihood of a second treatment is greater.
I have been performing refractive surgery since 2016, at the Institut Voltaire laser centre: the Zeiss VisuMax 800 for the femtosecond step and the Schwind Amaris 750S for the excimer laser. Training and equipment
Recovery
It is the question I am asked most often, and the one most poorly answered, because it hides three questions. Seeing "well enough" to go back to work, seeing "really well" with sharp contrast and no halos, and being stable: these are three separate milestones, several weeks apart. The chart compares them for the six techniques.
Good enough to work, read a screen and get around. This is when normal life resumes. Driving also depends on the visual acuity measured at the check-up, not only on the time that has passed.
Contrast is back, and halos and glare at night have faded. This is what is still missing when you see 20/20 but find your vision "less crisp" than you hoped.
The correction no longer changes. Only at this stage can an enhancement be considered: offering one earlier would mean correcting a refraction that is still shifting.
Non-linear scale. Times are a guide only and vary with the correction, the quality of the tear film and individual healing.
Trans-PRK removes the epithelium, which has to grow back: it takes three to five days on average to heal completely, and this sets the pace. LASIK and SMILE leave the surface intact, so recovery is much faster. Between those two, LASIK keeps a lead over the first week; the difference in quality of vision between LASIK and SMILE usually closes after a month.
PresbyLASIK works differently: the cornea is made multifocal, and the brain has to learn to sort the images. This neuroadaptation explains a longer recovery that, above all, varies more from one patient to another.
Lens implants follow a third pattern. The phakic lens does not touch the cornea: recovery is among the fastest, 24 to 72 hours, with stability in two to six weeks. PreLex replaces the natural lens: vision becomes useful again in two to seven days, but if the implant is multifocal or EDOF, neuroadaptation delays high-quality vision by several weeks, sometimes several months.
The times given for PreLex and PresbyLASIK are based on the usual course of lens surgery and on clinical experience: direct comparative data are limited.
The quality of the tear film, above all. Dry eye or an unstable tear film delays sharp vision and, even more, contrast vision. Corneal sensation can also take several months to return, at a different pace depending on the technique.
There is always an identifiable cause: corneal oedema, dry eye or a residual correction. The approach is to find it and treat it, for example with anti-inflammatory eye drops for oedema. An enhancement is only considered once the refraction is fully stable.
Comparison
Each technique draws a different shape. Click a legend item to show or hide a technique and read its profile on its own.
The higher the value, the more favourable the criterion · scale from 0 to 5
Beyond the laser
The laser removes corneal thickness, and that thickness is limited: beyond a certain point, more would have to be removed than the cornea can spare. Two solutions then exist, and neither touches the cornea at all: a lens is added in front of the natural lens, or the natural lens itself is replaced.
A soft lens is inserted between the iris and the natural lens, which stays in place. The cornea is not touched: this is the solution for high myopia and for corneas too thin for laser. The implant can be removed.
Clinique Les Martinets, Rueil-MalmaisonThe natural lens, which stiffens with age, is replaced by a multifocal lens implant that restores near and distance vision. The procedure is the same as cataract surgery, performed before a cataract develops, and it means a cataract can no longer form afterwards. It is considered from the age of 55.
Clinique Les Martinets, Rueil-MalmaisonThe pre-operative assessment
It does not only determine whether you are eligible: it tailors the procedure to give the best chance of success while keeping the risk of complications as low as possible.
On the day
At the Institut Voltaire laser centre, in Paris 11th: the operation takes 10 to 20 minutes depending on the procedure, as a day case, under anaesthetic eye drops.
Schwind Amaris 750s
About 30 seconds of laser per eye, while you look at a point of light. A bandage contact lens is placed at the end. Details →
Visumax 800 + Schwind Amaris
7 seconds of cutting, then about 30 seconds of photoablation per eye. The flap is laid back at the end. Details →
Visumax 800
14 seconds to cut the lenticule in each eye, then painless removal. A single laser. Details →
Practical matters
This surgery is not reimbursed by French national health insurance. Some top-up health insurers (mutuelles) cover part or all of it, on presentation of a quote.
The fee depends on the technique chosen for your eyes, which is only decided after the pre-operative assessment. You are then given a detailed quote to send to your top-up health insurer to request cover.
Full post-operative follow-up and any enhancement during the first year are included. Payment can be made on the day of the first post-operative check-up, and you are given an invoice for your top-up health insurer.
Operations are booked through the secretariat at the Rueil Ma Vision practice. Operating sessions take place every other Wednesday morning, and the wait is usually a few weeks.
TransPRK: on day 5, then at 1 month and 6 months. LASIK and SMILE: on day 1, then at 1 month and 6 months. Further appointments are possible if needed, and at your request.
What it costs
None of these techniques is covered by French national health insurance (Assurance Maladie). The amounts below are all-inclusive: the surgeon's fees, clinic and laser centre costs, consumables and post-operative follow-up. The assessment determines the right technique, and the amount follows from it; it is not something you choose.
| Technique | Both eyes | Per eye |
|---|---|---|
| Trans-PRK | €2,600 | €1,300 |
| LASIK | €3,000 | €1,500 |
| SMILE | €3,300 | €1,650 |
| PresbyLASIK | €3,300 | €1,650 |
| ICL phakic lens | €5,000 | €2,500 |
| PreLex | €4,500 | €2,250 |
Many top-up health insurers (mutuelles) include a set allowance for refractive surgery. All fee information
No commitment
Waiting times, arrangements, cost, time off work: write to the practice. You will receive a reply by email, within five working days on average. A question about your own eyes, however, can only be answered in a consultation. You can also take the eligibility test in three minutes, or look at the fees.
The button prepares an email in your mail app. Please do not include any health information.
Getting here
Everything before and after the operation happens at the practice in Rueil-Malmaison. Only the laser treatment itself takes place in Paris.
Before and after
96 avenue Albert 1er, 92500 Rueil-Malmaison
Appointments, consultation, pre-operative assessment, decision consultation and all post-operative follow-up.
On the day of the operation
5 rue la Vacquerie, 75011 Paris
This is where the laser treatment takes place, and nothing else. You only come here once, on the day of the operation.
SFO information leaflets (in French)
These leaflets are published by the French Society of Ophthalmology (Société Française d'Ophtalmologie, SFO) and the French national union of ophthalmologists (Syndicat National des Ophtalmologistes de France). They describe the operation, its results, its risks and the consequences of declining treatment. They form the basis of informed consent, but do not replace the consultation.
Getting here
The practice is in Rueil-Malmaison, five minutes' walk from the RER A (the regional express train line), where the Hauts-de-Seine and Yvelines départements meet. It is easy to reach from Paris, La Défense and the whole of western Paris. I see patients from Rueil and the neighbouring towns, and people who come from further afield.
For refractive surgery, some patients also come from elsewhere in France or from abroad: the pre-operative assessment and the operation can be arranged on two consecutive days, and part of the follow-up can be done with your usual ophthalmologist. Let us talk about it before you travel.
RER ARueil-Malmaison station, five minutes' walk. Direct trains from La Défense, Nanterre, Chatou, Le Vésinet, Saint-Germain-en-Laye or Paris.
By carVia the A86 and the N13. Three public car parks close by: avenue Victor Hugo, avenue Alsace-Lorraine and avenue Albert 1er.
Where operations take placeCataract surgery, ICL phakic lenses and PreLex at Clinique Les Martinets, in Rueil-Malmaison. Refractive laser surgery at Institut Voltaire, Paris 11th.
The questionnaire gives you a first indication in three minutes. The pre-operative assessment gives the definitive answer.
Dr Emmanuel Halimi
Ophthalmic surgeon · RPPS 10100555084 · Medical Council of Hauts-de-Seine no. 92/23003
Page written and approved by the surgeon.
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