Wavefront-Optimized versus Wavefront-Guided

All surgeons tout some form of wavefront LASIK. However, not all are custom LASIK. All doctors have a preference for one laser over another. Since they are human, bias are built into their thinking. All of the modern lasers have a per click charge for each use. For example, the Allegretto laser charges about $250 per eye. Additionally, the cost of the system cost about $300k to purchase. Add in maintenance fees of $25-$50k a year, and you can see why LASIK with modern technology cost so much. For all laser LASIK, the cost is even higher because femtosecond lasers also adds in a per click cost per eye. In general, the wavefront-guided solution cost on average of $250-$500 per eye more. (Update 1/4/12: I cannot find corroborating evidence of this.) (Update 1/9/12: I knew I didn't just pull the numbers out of my nether region; I have found references on wavefront-guided as being more expensive:

Cost. Custom wavefront treatments add significantly to the costs of performing LASIK. These increased costs lead patients to expect more from their treatments, and we know that unmet expectations are a significant factor in litigation. The higher costs of custom treatments is not justifiable if the aberrometers are simply acting as autorefractors, or if improvements can be traced to better lasers and better nomograms

the VISX laser is, objectively:the most expensive to buythe most expensive to operate/usehas the greatest market share by far (more than all other brands combined in the USA

There is no getting around the fact that wavefront-guided LASIK uses much higher technology and is more expensive. It would be the same as saying that a computer is higher technology and more expensive than an abacus or slide rule. We would all agree that a computer is well worth the extra expense.

Therefore, don't compare optimized with guided and pick the cheaper one as if they are all equal. Wavefront-guided tend to cost $500 to $1000 more than optimized for both eyes! (Ditto)

Most studies indicate that for low myopia, wavefront-optimized and wavefront-guided differences are statistically insignificant. Both lasers provide equally excellent results.  However, wavefront-guided is slightly better to correct higher order aberrations. Guided also has a higher percentage of 20/16 vision.

 The percentages of eyes that achieved 20/16 or better vision in the groups that underwent wavefront-guided and wavefront-optimized LASIK, respectively, at 3 months was 40.2% and 20% for –0.75 to –2 D; 35% and 17.4% for –2.01 to –4 D; 28% and 15.7% for –4.01 to –6 D; 22.5% and 17.6% for –6.01 to –8 D; and 16.3% and 19% for greater than –8 D.

The higher your prescription, the lower the chance of achieving 20/16 vision. However, the chances of achieving it using wavefront-guided is almost 100% higher for myopia between between -75 to -6 than optimized! That is statisticaly significant!

If your wavefront report shows an RMS error of .3 or higher for HOA, the wavefront-guided method is supposedly superior based on various clinical studies. So make sure you ask for the wavefront report from your consultation before you make a decision! Studies after studies have shown that wavefront-guided is superior for eyes with RMS error of HOA of .3 microns or higher. Additionally, for myopia between -2 and -4, optimized and guided provide statistically insignificant differences in the results. However, higher than -4 and the guided technique proves superior.

Update (12/29/11): Dr. Bindi Emailed me this study by Dr. Kezirian which compares very favorably for the wavelight. It is dated 2004 and many studies have been done since. Keep in mind that Dr. Kezirian is paid a consultant for Alcon which is the parrent company of the the wavelight. All FDA studies performed by the manufacturer are biased to the manufacturer. Studies by Dr. Manche is more current and his facility owns both the Wavelight and the VISX S4. Dr Manche prefers the guided solution for eyes with higher HOA and myopia.

The FDA does not currently approve any laser for correcting HOA even though clinical studies have shown that wavefront-guided does just that. Furthermore, all eyes have some form of HOA and certain HOA actually improves the vision due to the particular of those eyes. The studies have shown that wavefront-optimized and guided limits creation of HOA. Guided wavefront actually attempts to correct HOA. This is the reason why the recommendation is to use guided if you already have high existing HOA. Furthermore, All LASIK procedures have a tendency create HOA as a result of the surgery. Standard LASIK creates far more HOA than newer wavefront-optimized, while wavefront-guided does an even better job than wavefront-optimized in limiting the HOA.

So if you ask the doctor what is the best solution and he answers wavefront-guided, don't immediately think he wants to rip you off. It is not because it cost the most, but it is because studies have proven that it is the best solution money can buy. It is up to you if the differences in a few percentage points is worth the additional cost.

Finally, the thing to remember is that LASIK is not forever. Even people with normal eyesight, their eyes will eventually get worse as they reach age 40 and higher. However, for my wife whose eyes are in the 5.25 range, a regression of -.5 to -1 after ten years is still far better than her current practical blindness right now.

References:
http://www.ncbi.nlm.nih.gov/pubmed/21946784.
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/LASIK-outcomes-compared/ArticleStandard/Article/detail/698223
http://www.la-sight.com/los-angeles-lasik-prk-eye-surgery/allegretto-technology/wavefront-lasers-compared.aspx (updated 12/29/11)
(Updated 1/9/12)
http://www.lasiksurgerynews.com/news/what-is-lasik-surgery.shtml
http://www.realself.com/question/allegretto-wave-compare-laser-eye-options-in-terms-effectiveness-source-answers
http://www.allaboutvision.com/askdoc/custom-lasik.htm