Published in Refractive Surgery

Top 5 Pearls for Choosing Refractive Surgery Procedures

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13 min read

Familiarize yourself with five clinical pearls for choosing refractive surgery procedures to optimize surgical outcomes.

Top 5 Pearls for Choosing Refractive Surgery Procedures
Refractive surgery has provided millions of people with the ability to live life without glasses and contact lenses. Emerging as a revolutionary field in ophthalmology, many of our patients now have a safe and effective opportunity to shed the constraints of glasses and contact lenses.
The diversity of available procedures can be both a boon and a challenge, necessitating a thoughtful and individualized approach when matching patients with the most suitable refractive surgery option.
I dedicated my post-residency training in refractive surgery at the Cleveland Eye Clinic to immerse myself in the latest and greatest technologies available to provide my patients with amazing vision.
Drawing from my experience and perspective, I present five pearls that can guide ophthalmologists, especially residents and fellows, in making informed decisions that prioritize patient outcomes and satisfaction.

Types of refractive surgery

Before delving into the pearls, it's essential to have a foundational understanding of refractive surgery, its types, and the conditions it aims to address.

LASIK

Laser-assisted in situ keratomileusis (LASIK) is a widely performed procedure that involves the creation of a corneal flap and reshaping of the cornea with an excimer laser to correct refractive errors.
Corneal flap creation can be made via the time-honored method with a microkeratome, which uses a fine blade, or the newer advanced method using a femtosecond laser.1
LASIK correction of myopia flattens the central corneal surface, thus correcting the focal plane on the retina. In contrast, to correct for hyperopia, LASIK sculpts the cornea to make a steeper central area.

PRK

Photorefractive keratectomy (PRK) requires the removal of the corneal epithelium and directly treats the corneal stromal surface with the excimer laser, eliminating the need for a corneal flap. PRK is best suited for individuals at risk of flap-related complications or those with thinner corneas.

SMILE

Small incision lenticule extraction (SMILE) is a minimally invasive procedure that involves the removal of a small corneal lenticule to reshape the cornea and correct refractive errors.2 The incision geometry of the SMILE procedure is four-fold.
First, the lenticule cut is performed on the underside of the lenticule. This is followed by the lenticule sidecuts. Next, the cap interface is created on the upper side of the lenticule. And, finally, a 2 to 3mm small incision is created superiorly. The lenticule interfaces are dissected using a flap separator, and the lenticule is extracted manually, all via the small incision.2

Refractive lens exchange

Often recommended for patients with presbyopia or significant lens changes, in refractive lens exchange (RLE), an artificial intraocular lens (IOL) replaces the eye's natural lens to correct refractive errors. This is a good alternative for patients who are not good candidates for corneal-based procedures.
There are various types of IOLs available. The most common IOLs used for RLEs are multifocal IOLs, extended depth of focus (EDOF) IOLs, toric IOLs, and accommodating IOLs. The multifocals come in bi- and tri-focal varieties, providing near, intermediate, and distance vision. The EDOF IOLs provide distance and intermediate vision, and toric IOLs correct astigmatism.
Accommodating IOLs are able to provide distance with some near vision; however, they have fallen out of favor among most surgeons for lack of helpful near vision.

ICL

Implantable collamer lens (ICL) involves the insertion of a lens between the natural lens and the iris, providing vision correction for patients with moderate to high refractive errors. This is generally used for patients who have not reached presbyopia and are not good candidates for corneal-based procedures.

Ideal candidates for refractive surgery

Refractive surgery is particularly beneficial for addressing common refractive errors such as regular astigmatism, hyperopia (farsightedness), myopia (nearsightedness), and presbyopia (age-related decline in near vision).
The ideal candidates for refractive surgery are generally individuals with stable vision prescriptions (ideally no spherical change greater than 0.5D in the last 2 years), good overall eye health, and realistic expectations regarding the outcomes of the procedure.
It is important to review the relative and absolute contraindications of all refractive surgery procedures before proceeding with any patient.3

5 pearls for choosing refractive procedures

Now, let's delve into the top five pearls for matching refractive patients with the most suitable procedures.

1. Conduct a thorough pre-operative evaluation.

A comprehensive pre-operative assessment forms the bedrock of a successful refractive surgery outcome. Residents and fellows must delve into various aspects of the patient's ocular health and vision profile.
This includes evaluating corneal thickness, assessing corneal topography, and examining the quality of the tear film. Understanding the patient's lifestyle, visual demands, and expectations is equally crucial.
Corneal thickness, for example, is a critical factor in determining a patient's eligibility for LASIK. Thinner corneas might not withstand the creation of a corneal flap, making alternatives like PRK or ICL more suitable. Topography maps help identify irregularities in corneal shape, guiding the choice of procedure that will yield the most predictable outcomes.
Additionally, a thorough examination should consider the patient's general health, as certain systemic conditions or medications may impact the suitability of refractive surgery. Contraindications for LASIK include uncontrolled autoimmune conditions such as rheumatoid arthritis or lupus.

2. Develop individualized treatment plans.

Just as each patient is unique, their refractive surgery plan should be personalized to address their specific visual characteristics. Residents and fellows should tailor the procedure to individual parameters such as corneal thickness, pupil size, and the degree of refractive error.
For instance, a patient with a high degree of myopia might benefit from a procedure like ICL, which can offer stable and predictable outcomes and leave the cornea untouched. On the other hand, a patient with presbyopia seeking vision correction might be more suited for procedures like RLE, where the natural lens is replaced with a multifocal intraocular lens.
Other options to consider include monovision LASIK, where the dominant eye is corrected for distance vision and the non-dominant eye is left for near vision. Depending on the patient's age and occupation, the near eye may be more suitable for an intermediate target (mini-monovision) than the traditional near target.
Sometimes, when troubleshooting with monovision, it is best to have the patients have a contact lens trial to demonstrate to them how their results will be. By customizing treatment plans, ophthalmologists enhance the likelihood of achieving optimal visual outcomes and reduce the risk of complications.

3. Educate patients and manage their expectations.

Patient education is an integral part of the refractive surgery journey. Ophthalmologists must effectively communicate the potential benefits and risks associated with each procedure. Managing patient expectations is critical to fostering satisfaction and minimizing post-operative concerns.
Discussing the possibility of visual disturbances post-operatively, such as glare or halos, is essential; 20% of patients will report some form of visual change.4 Some patients may suffer from visual changes such as glare, halo, or star-bursting patterns around lights, haze, and decreased contrast sensitivity.
The FDA reports that visual disturbances tend to stabilize 3 to 6 months after the procedure.4 These symptoms are often transient and part of the healing process, but informing patients about them in advance contributes to a more positive post-operative experience.
One of the most common transient side effects of LASIK is dry eyes due to a lack of tear production. This is due to the interruption of the lacrimal reflex as a result of nervous tissue being severed during the procedure.4,5,6,7
Various studies have shown dry eyes to occur in 85% to 98% of patients 1 week after surgery.6,8,9 This number drops to around 60% at 1 month.9 Conservative treatments like artificial tears and/or punctal plugs are most commonly applied until the nerves regenerate.
Taking the time to address patient queries and concerns helps establish trust and transparency, fostering a collaborative approach to decision-making. Patients are always more concerned if they have surprises after surgery. However, with strong communication, patients can be well prepared to expect any side effects and tolerate them better if they are informed prior to surgery.

4. Stay current with technological advances within the field.

The field of refractive surgery is dynamic, with continuous technological advancements shaping the landscape. Staying abreast of the latest tools and techniques is paramount for ophthalmologists aiming to provide patients with cutting-edge and effective options.
Advancements in laser technology, diagnostic equipment, and surgical techniques contribute to faster recovery times, improved safety profiles, and enhanced visual outcomes. Residents and fellows should engage in ongoing professional development, attending conferences, and participating in training programs to integrate new technologies into their practice.
For those residents and fellows looking for real expertise in the refractive realm, it is recommended to pursue a refractive surgery fellowship that will provide extensive exposure and experience to the different modalities so you are the best trained.
By leveraging the latest advancements, ophthalmologists can offer patients state-of-the-art solutions that align with their expectations for both safety and efficacy.

5. Consider the patient’s long-term vision goals.

Refractive surgery is a long-term investment in a patient's visual well-being. When recommending a procedure, it's crucial to consider the patient's long-term vision goals. This involves contemplating potential lifestyle changes, age-related vision alterations, and the need for potential enhancements.
For example, LASIK may be an excellent choice for a young patient with stable vision seeking freedom from glasses, but it might not be the ideal option for an older patient with evolving presbyopia. In such cases, procedures like RLE, which accommodate the aging process, might be more appropriate.
Thinking ahead and aligning the chosen procedure with the patient's evolving visual needs contributes to sustained satisfaction and reduces the likelihood of secondary interventions.

Final thoughts

In the ever-evolving landscape of refractive surgery, the art lies in the intersection of technological expertise and a personalized approach to patient care. These five pearls encapsulate essential principles for residents and fellows navigating the complexities of refractive surgery.
A thorough evaluation, personalized treatment plans, patient education, technological acumen, and a focus on long-term goals collectively contribute to successful outcomes and satisfied patients.
As refractive surgery continues to advance, this guidance serves as a compass, ensuring that ophthalmologists navigate with precision, providing clarity and vision to those seeking a life free from the constraints of corrective lenses.
  1. Bashir ZS, Ali MH, Anwar A, et al. Femto-lasik: The recent innovation in laser assisted refractive surgery. J Pak Med Assoc. 2017 Apr;67(4):609-615.
  2. Moshirfar M, Bennett P, Ronquillo Y. Laser In Situ Keratomileusis (LASIK) [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
  3. Reinstein DZ, Archer TJ, Gobbe M. Small incision lenticule extraction (SMILE) history, fundamentals of a new refractive surgery technique and clinical outcomes. Eye Vis (Lond). 2014 Oct 16;1:3. doi: 10.1186/s40662-014-0003-1. PMID: 26605350; PMCID: PMC4604118.
  4. Wilkinson JM, Cozine EW, Kahn AR. Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK. Am Fam Physician. 2017 May 15;95(10):637-644.
  5. Toda I. Dry Eye After LASIK. Invest Ophthalmol Vis Sci. 2018 Nov 01;59(14):DES109-DES115.
  6. Xie W. Recent advances in laser in situ keratomileusis-associated dry eye. Clin Exp Optom. 2016 Mar;99(2):107-12.
  7. Toda I, Asano-Kato N, Komai-Hori Y, Tsubota K. Dry eye after laser in situ keratomileusis. Am J Ophthalmol. 2001 Jul;132(1):1-7.
  8. De Paiva CS, Chen Z, Koch DD, et al. The incidence and risk factors for developing dry eye after myopic LASIK. Am J Ophthalmol. 2006 Mar;141(3):438-45.
  9. Yu EY, Leung A, Rao S, Lam DS. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000 Dec;107(12):2131-5.
M. Amir Moarefi, MD
About M. Amir Moarefi, MD

M. Amir Moarefi, MD, is a board-certified ophthalmologist in Los Angeles, California, specializing in laser vision correction (LASIK, PRK, SMILE) and anterior segment surgery (cataracts, glaucoma, pterygium, eyelids). He completed a refractive surgery fellowship at the Cleveland Eye Clinic, with a focus on advanced-technology lens implants, clear lens exchange and other delicate procedures. Dr. Moarefi completed his residency in ophthalmology at Case Western University – University Hospitals, and interned at UC Irvine Medical Center and the Long Beach Veterans’ Hospital. He earned his Doctor of Medicine degree from Chicago Medical School, after completing two Master’s degrees in biomedical sciences and healthcare management and administration.

M. Amir Moarefi, MD
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