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