CLEAR Eye Surgery: Lenticule Extraction Explained

Short answer: CLEAR is a type of laser eye surgery in which a femtosecond laser shapes a thin disc of tissue, called a lenticule, inside the cornea; the surgeon then removes it through a small incision. Removing the lenticule reshapes the cornea to correct short-sightedness, with or without astigmatism, and no flap is created. CLEAR is Ziemer’s femtosecond-only lenticule extraction, in the same family as SMILE, and in published one-year series its outcomes are comparable to SMILE and femtosecond LASIK (J Refract Surg, 2024). At Focus Vision it is from $4,250 per eye, all-inclusive.

Focus Vision co-founder Dr David Gunn was the first surgeon in Australia to perform CLEAR. This guide explains how it works, how it compares with the other types of laser eye surgery, who it suits, recovery, risks and cost.

What is lenticule extraction?

Laser eye surgery has developed in three main steps, each a different way of reshaping the cornea:

1. PRK: the thin surface layer of the cornea is removed and an excimer laser reshapes the surface. TransPRK is the modern no-touch version.
2. LASIK: a flap is created, lifted, and the tissue underneath is reshaped with an excimer laser (AAO).
3. Lenticule extraction: a femtosecond laser shapes a lenticule inside the cornea, which is removed through a small incision, with no flap and no excimer laser (AAO).

Lenticule extraction is sold under several brand names, including CLEAR (Ziemer), SMILE (Zeiss), SmartSight (SCHWIND) and SILK (Johnson & Johnson). SMILE was the first: it was first reported in 2008 and approved by the US FDA in 2016 (SMILE review).

CLEAR compared with LASIK and TransPRK

	CLEAR	LASIK	TransPRK
How it works	Lenticule shaped by a femtosecond laser, removed through a small incision	Femtosecond flap, excimer laser reshapes underneath	Laser removes the surface layer and reshapes the surface
Flap	No	Yes	No
Early recovery	Misty for about a day; vision fluctuates for about a week	Most see well the next day	Sore for a few days; vision settles over weeks
Time off work (Focus Vision guide)	A few days	About 2 days	About 1 week
Used at Focus Vision for	Short-sightedness, with or without astigmatism	Short- and long-sightedness, astigmatism	Short- and long-sightedness, astigmatism
Price per eye (all-inclusive)	From $4,250	From $4,250	From $3,500

Prices are from our costs page and exclude prescribed medications and eye drops.

Outcomes. In published one-year series, outcomes after CLEAR are comparable to SMILE and femtosecond LASIK (J Refract Surg, 2024). CLEAR is not a safer or more precise version of SMILE or LASIK; it is a different way of reaching the same goal, and suits some eyes better than others.

Dry eye. Because no flap is cut, fewer corneal nerves are disrupted. A meta-analysis found dry eye in the early months was less common after SMILE-type lenticule extraction than after femtosecond LASIK (Shen et al., 2016). That can make lenticule extraction a good option if you have borderline dry eyes. See dry eye, glare and halos after LASIK for what LASIK patients report a year on.

No flap. With no flap to dislodge, lenticule extraction and TransPRK are often considered for contact sports and for pilots, defence and police.

Who is CLEAR suitable for?

CLEAR may suit you if you:

• are 18 or over with a prescription that has been stable for at least a year (FDA);
• are short-sighted, with or without astigmatism (the prescriptions Focus Vision uses CLEAR for);
• have healthy corneas of adequate thickness;
• prefer a flap-free procedure, for example because of contact sports or your job.

If you are long-sighted, LASIK or TransPRK is usually used instead. CLEAR is also not the right choice if your corneas are thin or irregular. Corneal conditions such as keratoconus usually rule laser vision correction out; keratoconus is assessed and treated separately (drbrendancronin.com.au). For very high prescriptions, an implantable contact lens may be better. Your surgeon recommends a procedure after measuring your eyes at your assessment.

What happens on the day

• Plan on two to three hours at the day hospital; the procedure itself takes about 25 minutes.
• Your eye is numbed with drops and a small clip holds your eyelids open. You are offered medication to relax you, or you can choose to be asleep, sedated by an anaesthetist in our accredited day hospital, currently at no extra charge. See Can I be asleep for laser eye surgery?
• The laser lowers onto your eye. You feel firm pressure and your vision goes dark for about a minute while the lenticule is shaped.
• Under a microscope, your surgeon separates the lenticule and removes it through the small incision. You may feel gentle pressure, but most people feel no pain.
• Clear plastic shields go over your eyes, and you need someone to take you home.

Recovery after CLEAR

• First day: vision is usually misty for about 24 hours. Wear your shields overnight and start your drops when you get home.
• First week: vision can fluctuate noticeably; this is normal and settles. Try not to rub your eyes for 7 days, and wear the shields when you sleep for two nights.
• Follow-up: visits at one day, one week and three months, within a year of follow-up appointments included in the price. If you live outside Brisbane, your last check can be with your local optometrist.

As a guide at Focus Vision, after CLEAR you can usually fly after 1 day, drive after 1 to 7 days, swim, surf or ski after 1 week, use a sauna after 2 days, and return to contact sports after 4 weeks. See the full return-to-activity table in Types of laser eye surgery and our recovery timeline.

Risks

Lenticule extraction is surgery and carries risks, which your surgeon will go through with you:

• Dry eye, usually temporary, though less common in the early months than after femtosecond LASIK (Shen et al., 2016).
• Glare, halos and starbursts, especially at night and in the early months (FDA PROWL).
• Slower visual recovery in the first week than LASIK, while vision fluctuates.
• Under- or over-correction. If your vision needs fine-tuning once it is stable, enhancements are free for two years under our enhancement policy.

Cost and cover

CLEAR at Focus Vision is from $4,250 per eye, all-inclusive: pre-operative assessments, the procedure and a year of follow-up appointments, with no surcharge for higher prescriptions. Prescribed medications and eye drops are extra (costs page). For how this compares with SMILE pricing in Australia, see SMILE laser eye surgery cost. Medicare doesn’t cover laser eye surgery, but some top-tier health insurance policies do (Bupa, Medibank); see also Paying for laser eye surgery.

To find out whether CLEAR suits your eyes, book a free optometrist assessment or call (07) 3239 5005.

References

1. Keratorefractive Lenticule Extraction Using the Ziemer FEMTO LDV Z8 Platform (CLEAR): One-Year Results. J Refract Surg. 2024. doi:10.3928/1081597X-20241016-01. journals.healio.com/doi/full/10.3928/1081597X-20241016-01
2. American Academy of Ophthalmology. LASIK — Laser Eye Surgery. EyeSmart. aao.org/eye-health/treatments/lasik
3. American Academy of Ophthalmology. What Is Small Incision Lenticule Extraction (SMILE)? EyeSmart. aao.org/eye-health/treatments/what-is-small-incision-lenticule-extraction
4. Small incision lenticule extraction (SMILE) history, fundamentals of a new refractive surgery technique and clinical outcomes. PubMed Central PMC4604118. ncbi.nlm.nih.gov/pmc/articles/PMC4604118
5. Shen Z, Zhu Y, Song X, Yan J, Yao K. Dry eye after small incision lenticule extraction (SMILE) versus femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for myopia: a meta-analysis. PLoS One. 2016. doi:10.1371/journal.pone.0168081. pubmed.ncbi.nlm.nih.gov/27992482
6. U.S. Food and Drug Administration. When is LASIK not for me? fda.gov/medical-devices/lasik/when-lasik-not-me
7. U.S. Food and Drug Administration. LASIK Quality of Life Collaboration Project (PROWL studies). fda.gov