Co-operation – my overseas ReLEx Smile laser eye surgery treatment

I had laser surgery performed on my eyes when we were in Kuala Lumpur.

Jeremy will testify that I’ve been banging on about getting it done for ages. Back in July 2007 I paid about $250-300 to the Lions Eye Institute to find out if I was eligible for the surgery – you have to pass a series of tests before any ophthalmic surgeon worth their salt will perform the surgery on you. The purpose of the surgery is to eliminate your need for glasses for about 10 years, so if the thickness of your cornea or the health of your eye is such that you won’t reach ten years before you need glasses again, you’d end up with what is termed an “unsatisfactory result”, and therefore you are not an eligible candidate for the surgery.

I remember calling up Lions to book the appointment, and phrasing it “I need to know if I have to gather up the courage to get the surgery” as there was no point in my saving my pennies only to discover that I wasn’t eligible at all. Of course the bottom fell out of the investment company that I had my savings in (thankfully my house deposit was invested elsewhere) and the money evaporated down to 10 cents in the dollar and my courage was not required for a while.

Recently it was sadly highlighted to Jeremy and I that if you want to do something and you have the means, then delaying the event until some far off date in the future could mean that you miss out entirely. So when my optometrist suggested that I appeared to be an excellent candidate for Lasik, and there were very good clinics overseas where I could have the surgery done for a fraction of the cost of having it done in Australia, Jez and I sat down and discussed the idea.

Saving up AUD8000 for elective eye surgery had always seemed a bit excessive when we could spend that money quite easily on house renovations or upgrading the car or heck, even a European holiday for the both of us. Factoring in that my glasses used to cost about AUD300 per year, the thought of spending about 25 times that amount for ten years of no glasses, it was clear that it wasn’t anything like a cost saving measure. The convenience of being able to use sports glasses was a fond distant memory from my second failed attempt at using contact lenses, but not worth that amount of cash. My prescription prevented me from wearing any glasses that had even a slight curve to them, so sports glasses were never possible unless I wanted to spend almost a thousand dollars on prescription Rudy Project sports glasses. And I was certainly never comfortable with that idea – what if I crashed my bike again and broke them?

I randomly googled “laser eye surgery medical tourism” and found a few reasonably reliable articles on the topic, and Malaysia was included in the list of places where you could have the surgery performed. We’d been to Malaysia for the Formula 1 twice before, so we felt comfortable there. I found a number of references to an eye specialist clinic, Optimax, so I started doing some research on them. Jeremy and I had the daft idea that we could go to KL for the Formula 1 again, and then stay a few days longer and I could have laser eye surgery.

One Saturday late last year I called up the clinic. I asked what the requirements would be for the surgery, what my options would be, and the likely cost. It would depend on my corneal thickness and prescription power as to whether I would be able to have femto-lasik custom laser surgery, at RM4000 per eye (the easy rule of thumb with Malaysian Ringgit to Australian Dollar conversion is to divide the Ringgit amount by three), or a newer surgery called ReLEx Smile at RM6300 per eye, and the eligibility tests beforehand would be RM195. I would be supplied with forms for a Perth optometrist to complete at 1 week after surgery, 1 month, 3 months and 6 months after surgery. I would then have to fax or email the forms to Optimax so that they could keep track of my progress after the surgery. If it was thought that I required further surgery, then it would be performed free of charge by Optimax, as long as I got myself to Kuala Lumpur.

Femto-lasik custom is performed by lasering a flap on the cornea, lifting the flap and then using a second laser machine to remove the excess corneal tissue. (Kimberly Low explains the process in an entry on her blog, Narcissism is Necessary).

ReLEx Smile is best described as keyhole laser surgery. A laser is shone through the front of the cornea, separating out a section of the corneal tissue called a lenticule. The lenticule is then excised from the eye via a 4mm long cut on the cornea.

Both techniques provide an excellent result on eligible patients. The femto-lasik custom is literally custom – your corneal tissue is excised according to a three dimensional image of the surface of your eye. This is the same concept with ReLEx Smile, but there is no need for a flap to be created. You will experience dry eyes after the surgery – there is no escaping that. My research unearthed a paper that looked at the results of a number of studies, and it stated that 96% of patients experienced dry eyes after surgery. You are disturbing the surface of the cornea, either through the creation of a flap or a slit in the cornea – this will effect tear production and the lubrication of the eye. However, the length of time that the patient experiences dry eyes is expected to be shorter with the ReLEx Smile technique.

The 2015 Formula 1 calendar had been released at this point, so I booked an appointment with Optimax for the Tuesday after the race; in the morning they would do the eligibility tests, and if I was OK for surgery, then in the afternoon they could perform it. I was able to email through my glasses prescription details and I contacted the Lions Eye Institute and they retrieved my records from their computer system and told me the corneal thickness that they’d measured back in 2007. Optimax replied and said that because of my hefty astigmatism there was a chance I was not eligible for ReLEx Smile surgery, but that decision would rely on the full battery of tests to confirm, however (not issuing a guarantee – see battery of tests) they believed that there would be no issue with femto-lasik custom.

The lady from the Lions Eye Institute had advised me that whilst it was unlikely that there had been a dramatic change in my corneal thickness measurement since 2007, she had heard of a significant change happening in some people over time. She thought that I should be fine and wished me luck. I felt 95% sure that I would be found eligible – technology and technique was sure to have improved over the past 8 years, and the only eye injury I’d incurred since then was a small amount of debris in my right eye after I cycled to work the day after that enormous hail storm a few years ago (the power had been out throughout the South East Metropolitan area, therefore no trains were running). My eye had healed from the debris extraction and there had been no significant change in my prescription for a number of years.

Back in 2007 the Lions Eye Institute people had advised me that I would end up needing reading glasses in the future (you can’t stop age related deterioration of sight, and at the age of 40 a significant number of people with previously apparently perfect vision suddenly find themselves nearsighted). I knew that my astigmatism could make the surgery difficult, and in my mind I was prepared for being told that if operated on the surgeon could only be able to produce a partial result – the continued need for vision correction with reading glasses, but the elimination of my distance vision problems.

We were booked into the same hotel we were in last time – the Parkroyal in Bukit Bintang, and we were flying Air Asia, all booked through Air Asia Go. It’s excellent value, because the flights from Perth to KL are only 5-6 hours, so you can deal with no leg room and no on-board entertainment for that long, and you get great deals on five star hotel rooms. If we were flying long haul to Europe then there is no way I’d fly on a low cost carrier, but when it’s only short haul like that Air Asia is perfectly adequate. (However, ask me again when I’m 70 and I’ll probably tell you I avoid low cost carriers). We were flying in the Thursday before the race, and flying out the following Friday.

A quick note: the only problem I’ve found with Air Asia Go is that it never includes the option of the hotel breakfast, and that is a pity. Few things are more fabulous than a multicultural hotel breakfast buffet. We usually start with the rendang, rice and roti canai, and then move on to French toast, or waffles, then omelette, or cold cuts of sausage and cheese, and pastries plus toast, fruit, and yoghurt all along with endless cups of tea and juice. After all that, you rarely need lunch.


The Formula 1 race, well; I’ll admit Vettel made a good choice when he went to Ferrari. I hope Renault comes good for Ricciardo and Infiniti Red Bull and I think that Alonso and Button are enjoying themselves in participating in the development of the McLaren Honda powerplant, but must hate seeing the track from the back of the grid like that.

Monday was a great decompress day – we went up to the Batu Caves (amazing, beautiful, and it is advisable to avoid getting bitten or scratched by the monkeys) and swam and sat by the pool. I made sure to make good inroads on my book because I was sure I wouldn’t be able to read much for a while.

Tuesday we got up early and went for a run, as a bit of a last hurrah. The Optimax preparatory instructions advised against swimming, tennis or tae kwon do for a month after surgery, but hadn’t specified anything regarding running, so Jeremy and I decided it was safer to assume no running for the same time period. We only had time to go out for about 4km but it felt more humid than it had been for any of our other runs in KL and made me finally decide against doing the Malaysian Women’s Marathon, because the prospect of running 10 times that distance plus a bit in potentially the same humidity did not appeal. Historically the event has lined up well with the Formula 1 weekend so it has always been in my mind as a possibility. (Maybe just the 10K race instead).

We ate the usual ridiculously large hotel breakfast, and then headed out to get a cab to Taman Tun Dr Ismail, where the main Optimax clinic is. Optimax have a number of clinics throughout Malaysia, including in Penang, but the Taman Tun Dr Ismail clinic in Kuala Lumpur is the HQ of the operation. The taxi costs about RM30-35 depending on the traffic of the day, and with a 10am appointment there was bound to be traffic. We gave it an hour to travel what Google Maps suggested should only take about 30 minutes, and they were fairly close in their estimation. With time to kill before my appointment I thought it wise to quickly withdraw some cash at a nearby bank ATM whilst I could still see to read the screen on the machine.

We went into the clinic and I got the standard medical history form to fill out. If you end up going to Optimax and you aren’t a Malaysian citizen with an identity card please note you will need your passport number for this form. Your passport number will also appear on your medical certificate as provided by Optimax if you choose to try and take some of your leave time as personal / sick leave instead of annual leave.

The staff quickly took me in to begin all the tests. They’re all the ones that you’ve probably had at some time at the optometrists – the glaucoma puff of air in your eye test (a measure between 1 and 20 is normal, mine was 9 at the time), the one where you look at the hot air balloon picture as it moves in and out of focus. There was a harlequin one and the slit lamp where you look every which way while they examine your eye. The slit lamp one was my favourite, because at one point due to the direction I was told to look combined with all the lights and mirrors I managed to see my own retina. Then there was the classic eye test: read this line, and this line, and now this line. Which is clearer? The red or the green? Which is sharper – 1, or 2? 3, or 4?

They took me back to the waiting area to Jeremy again, and put dilation drops in my eyes. I sent Jeremy off to investigate a running shoe shop and a bike shop that we knew was in the area of the clinic while I waited for the dilation drops to kick in. I sat for a while idly watching Sherlock on the television if I recall correctly until the staff took me back in to the slit lamp where they got to really look at my retina properly now that my pupils were dilated, and then they took me back to the eye examination room and tested that again.

Once they’d finished the tests, they took me into a counselling room and said that I yes I was eligible for laser eye surgery but I was eligible for both types – femto-lasik custom and ReLEx Smile. I was a bit flummoxed at this point. All my research had been into femto-lasik and the risks involved with that; I hadn’t even contemplated ReLEx Smile. The counselling session was solid; you are explained the procedure, what happens, etc. I decided to get Jeremy back to the building to discuss my options with him – I’d set aside the AUD3000 for femto-lasik custom surgery, and I wanted his – not approval as such, but agreement – regarding my choice of surgery. We finished the counselling session and I sat waiting for Jeremy in the reception area, whilst I read through the disclaimer form (sensibly printed in large font type). Oh and I was told that I’d only have to stop running for about a week. It was probable that it would be fine after 3 days, but it would be best to wait out the week, just in case.


When Jeremy returned and sat down with me he reminded me that the only thing I’d been particularly concerned about with femto-lasik was the flap creation and the fact that there are no stitches – there’s just a flap. And my tendency to rub my eyes was a concern for me; the fear that I’d accidentally forget and rub the flap open. There were also a few potential post-surgery issues with femto-lasik that would be generally avoided by using the newer technique and encouraged me to just go for the ReLEx Smile technique. The eligibility tests had noted that my eyes were naturally dry – a hazard of having a job that involves looking at a computer all day. ReLEx Smile could probably decrease the excessive dryness significantly compared to the femto-lasik. Whilst I hadn’t specifically put aside more savings, we did have savings to cover the extra expense. So I signed the disclaimer form for ReLEx Smile surgery for both eyes, and we paid. If you are reading this thinking about having laser eye surgery in Malaysia, please note that the day after my surgery was the day of the introduction of the Goods and Services Tax in Malaysia, so now all goods and services have a 6% government tax on them. I can’t confirm, but I suspect that medical procedures are not exempted from the tax.

We were told to head off and return at 1:30pm for surgery. We left the building and went to the Starbucks down the road. I wasn’t hungry, but I knew that I needed to eat, so we just had a coffee and tea each with a sausage roll and gave the free WiFi a bit of a flogging. I got a second enormous cup of tea to go and we went back to the clinic. Now, remember, I’d had pupil dilation eye drops given to me earlier, so my eyes looked like I was stoned and my sensitivity to light was huge. If you are ever pre-warned you are going to be given dilation eye drops, take enormous sunglasses with you – the drops were going to dilate my pupils for about 2 days, but yours might not dilate your pupils for as long. At this point I had terrible near vision, but my distance vision was being corrected by glasses. My prescription sunglasses were quite well tinted and polarized, but I still had trouble trying to deal with the brightness of outdoors at lunchtime.

Back at the clinic we sat in reception for a little while then they took me and another female patient to a surgery preparatory room. You had to take your shoes off and leave them outside the room, and occasionally surgical suited and booted people would wander in and read files and wander out again. We were advised on post-operative care by a staffer; which drops, how often, and when. I would have to use a combined steroid and antibiotic called Tobradex four times a day for a week, then I was to discard the bottle. I was to use Refresh Plus eye drops; I had a box of thirty single use containers and I would need to use them every two hours when awake. They supplied us with Ponstan, which most women remember for use against period pain but it is basically a non-steroidal anti-inflammatory painkiller. If I was uncomfortable enough to require pain relief it was recommended that I use that – but to take it with food.

Our blood pressure was checked and we were given the first of many anaesthetic eye drops at this point. We changed into a green sort of pair of cotton pyjamas (not scrubs) plus those paper hairnet things and put paper booties on our feet. I slid my glasses into the pocket of the pyjamas, and to be honest I didn’t really recognise that it had been the last time I would wear them.

We sat down with Stephen Chung, our surgeon. He was the guy who set up Optimax in back in 1995, and it has now expanded from one clinic in Taman Tun Dr Ismail to eight clinics throughout Malaysia. He went through the full ReLEx Smile procedure and explained that for the procedure to occur, and for it to be successful, it requires conscious participation from the patient – you have to follow instruction and you have to concentrate. It occurred to me that it’s not an operation, it’s a co-operation, between surgeon and patient.

Whilst being examined with the slit lamp we had dots painted on our eyes – whether this was on the cornea or the white of the eye I don’t know; I didn’t feel anything, as the local anaesthetic had well and truly kicked in at this point. We also had our eye areas cleaned ready for surgery.

The other patient went into the operating room first and I sat and tried to concentrate and remember all of the instructions I had been told. Not much time passed and I was ushered into the operating theatre.

The room was quite dim, and the machine had a bed that swung out on an arm underneath it. I was guided onto the bed and a quilt covered me. The bed then swung under the machine. A device was gently placed on my right eye and it held my eye open – you’d expect it to be uncomfortable but it wasn’t. Then something that smelt faintly like Contact book cover was stuck over my top and bottom eyelid, and then a surgical drape was stuck down over that. I slid under the machine and suddenly there it was, the green light that Dr Chung had said that I would see, the laser that was going to cut the lenticule in my cornea.

In retrospect, I was glad that they didn’t go through a bit of a dummy run, as I’d probably have panicked and it would have all been over, red rover. The co-operation requires the patient to look at the green dot, even if that green dot disappears, you keep looking at the spot where it was, and you do not move your eye in any manner. The dot isn’t big – think of the tip of the screw on the hinge of your glasses; it’s that small. And when you are told that you will see a green light, you actually see more than that: there is a startlingly white circle surrounding a green circle, and then the single green dot you need to focus on is in the centre of that circle. The white and green circle lowers onto your eye, disappearing out of your vision and is held there by a light suction. When the suction activates, a gentle female computer voice says “Suction on”.

Suddenly my biggest fear was moving. You see: with ReLEx Smile, there are no immediate second chances. On surgery day it’s a one shot deal. If you move your eye, and the laser loses its position it cuts out immediately, automatically. The placement is so careful and so fine that you can’t really try to start again where you stopped, so two months has to pass so that your eye can heal. Once your eye had healed, then they can try again to cut the lenticule. If you live in Malaysia, that’s an inconvenience, but it isn’t the end of the world. But if you’re me and you’ve flown 5-6 hours and are paying for a hotel, that’s a very expensive twitch.

I could hear someone count down from 25 – that’s how many seconds that you stare at that green dot. Sure enough, it disappeared and I just lay there, staring, concentrating and hoping that I hadn’t moved from where the dot had been and then suddenly it was over. The female computer voice said “Suction off”, the white circle reappeared and Dr Chung said “you moved just at the absolute end, but the laser didn’t lose you, and it is fine”. I was slid under another part of the machine which enabled Dr Chung to extract the lenticule that had been created in my cornea. You look at a white light this time, and there is no staring in one place; you swivel your eye chasing this light all over. That can’t have taken more than 15 seconds, and after a great gush of eye drops and saline solution on my right eye suddenly the drape was being removed. Now it was on to the left.

I was asked at the start if I wanted to hold the hand of a nurse, and I’d felt confident enough to say no, I’ll be fine. As my left eye was draped and I slid under the laser again, I felt a hand slide in next to my right, under the quilt. I grabbed it and hung on to it for dear life. I had no more than 40 seconds to one minute to go, and adrenalin was coursing through me. The white and green ring came down towards me, the green dot was there, and I stared and concentrated at it for 25 seconds, and when the computer voice said “Suction off” I think I started breathing so hard I nearly dislodged the drape. I was slid under the white light, and I chased that for a few seconds and that was it. I was done. Another gush of eye drops and saline solution and I was being led out of the theatre, into the change room and suddenly I was putting my trainers back on outside the preparatory room door.

I walked through the clinic to Jeremy, and he asked the staff to call a taxi for us, and then I sat there, in the reception area, slightly amazed that I’d finally done it. I’d had laser eye surgery.

When the taxi was due we went outside and I was massively pleased with my non-prescription sunglasses, one of my purchases from before we left Perth. I’d been emailed about a month beforehand a list of pre-surgery instructions and there were a few unexpected ones in there. Specifically an entreaty to not use any products that have alcohol as an ingredient, lest they affect the accuracy of the laser. Now, you’d have to read the ingredients panel of each product to discern what uses alcohol – Cetaphil gentle skin cleanser does, Oil of Olay moisturiser does too, but hurrah! My Dove cucumber and green tea deodorant is explicitly promoted as 0% alcohol, so whilst I was an un-moisturised patient, at least I wasn’t too sweaty. Some of the instructions were things that I fear have been an issue in the past, like “on surgery day, don’t drive yourself to the clinic, you will not be allowed to drive home”, and “bring non-prescription sunglasses for after the surgery”.

The taxi arrived, and I decided to try and curl up for a nap. The adrenalin was wearing off, and probably my anaesthetic too. I figured that sitting in the back of a taxi, unable to see properly and combined with the amazing driving of KL taxi drivers there was a reasonable chance of motion sickness, so it was best to combat it with sleep. Surprisingly I managed it, and I woke up as we went over the speedbumps of the Parkroyal driveway. We got out of the cab, and Jeremy guided me through the lobby and into the lift up to our floor.


I wore my sunglasses into the room, and went to remove them, and then put them straight back on. I faffed around filling the kettle for a cup of tea while Jeremy closed the blinds and prepared to go out. I gave him RM100 to get as many packets of Refresh Plus eye drops that he could find. I was intending on going straight back to sleep if I could, but my body requires a certain amount of caffeinating to function properly, and two grande Starbucks teas isn’t sufficient. In my research before the flight over I’d realised that my Buff (a sort of headscarf/headband/neckerchief thing) would be a perfect blindfold if I needed it to be darker than my sunglasses would allow. I’d taken it with me to the clinic in case I needed it in the taxi back to the hotel, and I fished it out of my bag and climbed into bed with it like a child’s blankie grasped in my hand. Jeremy headed out, and I hit the switch to turn off all the lights in our room and slept.

I woke up about an hour later, and discovered that the advice of “as little screen time as possible for a few days” was probably a very good idea as I checked Facebook. I dialled down the brightness setting on my phone, turned it away from my head so I was looking at it side on and typed a comment that yes, I’d just had eye surgery. I rolled over and went back to sleep again, but for a shorter time. When I woke up I felt very awake. I used the loo and then folded the Buff into a blindfold, put it on and then went over to the wardrobe with the room safe in it. The wardrobe has an automatic light in it, and I knew I could punch in the safe code blindfolded and dig out my iPod Classic and headphones, but the pain from the wardrobe light would be immense.

I bunged on the audio book for Harry Potter and the Deathly Hallows and made it about 10 minutes in before I felt massively tired and rolled over back to sleep. My eyes felt a bit irritated; like I’d been to the beach and had some grains of sand stuck in them. I knew that the Ponstan needed to be taken with a meal so I decided that when I woke up I’d have something to eat and take it then. When I woke up again my eyes had stopped hurting. It was late enough that I knew it would be night outside, I gently drew back the blinds and grinned madly as I looked out from the 17th floor and realised that the logos and directional arrows painted on the road below were in crystal clear focus. I looked at the right hand turn lane next to the hotel and I spotted a worker brushing leaves off the road onto the verge and marvelled that I could tell he was using a reed broom like the track marshals use at Sepang F1 Circuit.

I suddenly felt ravenously hungry for a massive slab of steak, so I found the room service menu, called them up and ordered a medium rare beef tenderloin in mushroom sauce with steamed vegetables. Not long afterwards Jeremy, Cathy and Greg came to the room and we sat chatting about their day, our day and the surgery while I ate.

The next day I went down to breakfast with Jeremy a touch earlier as my appointment at the clinic was at 9.30am not 10am. We scoffed as per usual, and went out and found a taxi driver who took us to Taman Tun Dr Ismail and we directed him to the clinic building. He was going to wait for us outside the clinic while I had my post-operative appointment. I had a mass of tests done including a ‘cover your left eye/cover your right eye’ test whilst I struggled to read some letters on the wall – I could work out some of them but not all of them (It’s either an O or a C or a D). I felt a bit sad and disheartened until the clinic worker said “OK, so you’ve got 20:20 vision, you’re fine to drive as of now”.

I had 20:20 vision. I don’t think I’ve ever had 20:20 vision before in my life. And those letters on the wall that I was struggling to read? Probably the size of my thumbnail.

I then went through to see Dr Chung who looked at my eyes through the slit lamp. He was really happy with the progress so far, and said that if I wanted I could use goggles in the hotel pool to protect from splashing, but to not put my head under water. He also said that I could rub my eyes without any concern and wash my own hair in the shower because the incision was healed enough that the fear of shampoo in the eyes was pretty small.

Jeremy and I left the clinic and went back to Bukit Bintang. We went shopping and wandered around a bit eventually heading back to the hotel. It would have been as if the previous day had not happened, except for the fact that I didn’t have any glasses on unless I was outside in sun (the dilation eye drops were just wearing off at this point) and I using the timer on my phone to remind me to apply eyedrops every 2 hours.

When we flew home on the Friday (actually Good Friday) I had my extensive supply of Refresh Plus eyedrops in case the plane trip caused a problem with dry eyes, but I was pretty OK. Over the week of using the Tobradex I learnt that five minutes after using the antibiotic/steroid you can taste the disgusting substance and looked forward to being able to throw the stuff out after my week 1 checkup.

On Tuesday morning I went to my optometrist for the first checkup. She was ecstatic that I’d taken her advice and gone for the surgery. She was hugely interested in what I thought of the clinic and whether I would recommend other people make the trip to KL for surgery and I said that I had no qualms whatsoever. If you hadn’t had to take a taxi in KL traffic to get there, and if outside it hadn’t been as humid as hell, then the clinic could have been in Subiaco or South Perth.

My vision is pretty good most of the time. I’ve noticed that at work my distance vision is almost always fine, it’s my near vision that gets blurry, but I think that the nearsightedness seems to clear up when I’ve had a lot of water to drink, so I’m going to experiment a bit with a sizable early glass of water before my normal immediate massive cup of tea. I’ve also dialled down the brightness on some devices and screens, and would recommend you do that before the surgery in preparation. Along with the brightness I’ve jacked up the default font size of my home and work computer to 125% instead of 100% to compensate for the occasional near sighted moments.  It will take about 1-3 weeks to settle down, and my final eyesight power won’t really be known for 6 months, but I can tell you already; it’s amazing.

Another thing I discovered during the process, – and honestly it should have occurred to me earlier – was that you can have different types of surgery on each eye. The pre-surgery instructions had specified that any vision impairment beyond -16 would have to be looked at on a case by case basis. As I was sitting in the preparatory room there were a couple of other patients brought in to have their post-operative care briefing. One was having femto-lasik custom on both eyes, but the other patient was having femto-lasik custom on one eye and the other eye was being operated on using a third laser surgery technique called Advanced Surface Ablation (ASA).

I don’t regret the delay between 2007 and 2015 when I first learnt that I could have the surgery and having it done in 2015; it took that long to gather the courage. If it weren’t for my optometrist, I probably would still wear glasses, and wouldn’t have even thought of having laser surgery done overseas.