Refractive Surgery and Frivolous Lawsuits

Exciting new technologies set to improve visual outcomes as curtain comes down on 7th Winter Refractive Surgery Meeting

THE 7th ESCRS Winter Refractive Surgery Meeting in Rome, held in conjunction with the sixth National Meeting of the Italian Association of Cataract and Refractive Surgery, highlighted the significant advances in refractive surgical techniques and technologies.
The large attendance at this year’s meeting, surpassing last year’s event by more than a third, reflected its increasing success as an important forum for ophthalmologists from around the world to discuss significant advances and issues at the beginning of each year.
Laser corneal recontouring has been the most frequently performed elective ophthalmic procedure since the first ESCRS Winter Refractive Surgery Meeting in 1997 and it dominated the programme again this year.
Three-quarters of the symposia highlighted innovations in Lasik, Lasek and PRK. The ongoing improvements in technology, techniques and functional visual results have been indisputable.
The evolution of customised laser refractive surgery has been evaluated annually at the winter meetings. Increased experience with different customisation approaches have led to more realistic expectations, a better understanding of current limitations and less controversy regarding necessary components.
There was agreement among most surgeons experienced in both wavefront-guided and non-wavefront-guided ablations that they currently prefer not to use wavefront guidance for primary procedures.
There was consensus, also, that improvements in laser systems unrelated to wavefront guidance have provided excellent results, and that many components of diagnostic and laser delivery systems need to be refined before wavefront guidance can be expected to provide real benefits to most patients.
The organisers of the meeting devoted a whole symposium to eye tracking. The importance of proper centration and alignment cannot be overstated. Surgeons, engineers and industry representatives now agree on many basic concepts. No one laser system incorporates all the necessary components to ensure accurate and consistent centration and alignment throughout all the steps, from patient data acquisition to laser delivery.
Attempts to precisely correct astigmatism and higher order optical aberrations while delivering smaller and smaller spots at higher and higher frequencies require eye trackers with very high total acquisition, processing and response rates.

Tracking systems must correct all positional errors. The contributory roles of different eye movements — saccadic, vestibular, optikinetic, vergence, miniature — must be understood and controlled. Errors related to illumination and angular projection must also be prevented.
During the early development of far-ultraviolet laser large-area corneal recontouring, both excimer and solid state lasers were investigated for far-UV radiation delivery. Excimer lasers have so far dominated the field. Discussion of solid state laser replacement of excimer gas lasers for far-UV corneal sculpting returned in a presentation in Rome. Although proponents of solid state technology announced the obsolescence of excimer lasers more than a decade ago, solid state UV-laser development has been struggling for almost two decades to overcome major technical hurdles and achieve successful clinical application.
Some of these challenges included the difficulty obtaining adequate energy density and very high speed accurate scanning. Current capabilities will need to be assessed.
Satisfying refractive surgery patients can be very challenging. Highly motivated patients who are suitable candidates with realistic expectations are often happy after refractive surgery.
As discussed at a symposium in Rome, proper patient selection based on adequate preoperative evaluation as well as meticulous attention to detail during preoperative planning and surgery reduce the risk of complications.

Nonetheless, many factors are still beyond the surgeon’s total understanding and control.
Advances in diagnostic technology are allowing surgeons to analyse more accurately and understand more completely how anatomical, biomechanical, wound healing and optical factors affect refractive surgical results.
Visual problems related to pupil size, decentration, laser ablation profiles, ectasia and IOL calculations after refractive surgery can be disabling for patients.
The speakers agreed that, although there is increasing knowledge of some of the causative factors, these complications are still not totally controllable. Surgeons must be cautious and inform patients completely.

Refractive IOLs
The consensus at this year’s meeting was that the current niche for refractive IOLs is in the correction of errors beyond the limits of Lasik, Lasek and PRK.
Although some surgeons previously predicted that corneal refractive surgery would by now be outdated by refractive IOLs, the benefits and risks of available phakic IOLs and refractive lensectomy techniques do not suggest that they will replace laser corneal recontouring procedures for most refractive patients in the near future.
Speakers at the symposium on refractive IOLs addressed the continuing evolution of IOL technology and increasing options for the refractive patient.
Although sizing and positioning problems related to angle-supported and posterior chamber phakic IOLs have not been completely eliminated, current designs reduce the risk of pupillary ovalisation from angle-fixated IOLs, and the risk of cataracts and glaucoma from posterior chamber IOLs.
Recent innovations in phakic IOL technology provide surgeons with easy insertion of foldable IOLs which are capable of correcting both spherical and astigmatic errors without IOL rotation after insertion.
As the curtain came down on the ESCRS Winter Refractive Surgery Meeting for another year, participants shared their common thoughts — an excitement about the availability of improved techniques and technologies and the hope that the world situation will stabilise and accelerate global economic recovery to allow more patients to benefit from increasingly satisfying visual results after refractive surgery.

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