Refractive Surgery Preferred Practice Pattern®

Secretary for Quality of Care
Timothy W. Olsen, MD
Academy Staff
Andre Ambrus, MLIS
Meghan Daly
Flora C. Lum, MD
Medical Editor: Susan Garratt
Approved by: Board of Trustees
September 9, 2022
Copyright © 2022 American Academy of Ophthalmology®

English Summary :

Keratorefractive surgery can be used for a wide range of refractive errors, but intraocular procedures may be considered in some cases. A comprehensive medical eye evaluation should be performed before any refractive surgery procedure. Excimer laser ablation using wavefront aberrometry information can limit the induction of higher-order aberrations (HOAs) and even reduce pre-existing HOAs in some cases. The most common complaints from patients dissatisfied with refractive surgery include blurred vision, glare, dry eyes, and night-vision problems. Intraocular refractive surgery can be considered for patients who wish to reduce their dependence on eyeglasses or contact lenses. Potential complications of refractive lens exchange for myopia include retinal detachment, infectious endophthalmitis, intraoperative suprachoroidal hemorrhage, cystoid macular edema, corneal edema, and intraocular lens dislocation.

中文摘要:

角膜屈光手術可用於廣泛的屈光不正，但在某些情況下，可能會考慮使用眼內手術。在進行任何屈光手術之前，應對患者進行全面的眼科檢查評估。使用Excimer laser ablation using wavefront aberraometry可以限制高階像差（HOAs）的產生，並在某些情況下減少現有的HOAs。對屈光手術不滿意的患者最常見的抱怨包括視力模糊、眩光、眼睛乾燥和夜間視力問題。對於希望減少對眼鏡或隱形眼鏡依賴的患者，可以考慮進行眼內屈光手術。近視屈光晶狀體置換術的潛在併發症包括視網膜脫離、感染性眼內炎、手術中超脈絡膜出血、囊樣黃斑水腫、角膜水腫和人工晶狀體脫位。

HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE

Contraindications to refractive surgery include the following:

• Unstable refraction

• Abnormalities of the cornea (e.g., keratoconus or other corneal ectasias, thinning, edema, interstitial or neurotrophic keratitis, extensive vascularization)

• Insufficient corneal thickness for the proposed ablation depth

• Visually significant cataract

• Uncontrolled glaucoma

• Uncontrolled external disease (e.g., blepharitis, dry eye syndrome, atopy/allergy)

• Uncontrolled autoimmune or other immune-mediated disease

• Uncontrolled mental illness, including anxiety or depression

• Unrealistic patient expectations

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It is recommended that corneal refractive surgery patients be provided with a record listing diagnosis, preoperative keratometry readings, and refraction, as well as postoperative refraction.

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It is recommended that the refractive surgeon maintain a record including preoperative keratometry and refraction as well as postoperative refraction and provide that data if needed for future eye care, including cataract surgery.

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As part of the informed consent process, it is recommended that the refractive surgeon review common adverse effects such as dry eye and eventual presbyopia with patients considering corneal refractive surgery.

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Excimer laser ablations that result in very thin residual stroma increase the risk for ectasia. For laser in situ keratomileusis (LASIK) procedures, a minimum of 250 µm is suggested as a safe residual stromal bed thickness. There is no absolute value that guarantees ectasia will not occur. Abnormal topography and percentage of tissue altered (PTA) higher or equal to 40% are also associated with higher ectasia risk.

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Published studies have failed to demonstrate a relationship between pupil size and the quality of postop vision, minimizing the importance of pupillometry in the preoperative workup.
Persistent diffuse lamellar keratitis (DLK) unresponsive to corticosteroids should prompt consideration of microbial keratitis or interlamellar fluid due to increased intraocular pressure (IOP) measured peripheral to the LASIK flap, intraocular inflammation, or endothelial decompensation. For extensive DLK, the interface should be irrigated to minimize stromal loss and changes in refractive correction.

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Surgical management of presbyopia includes keratorefractive surgery, corneal inlays, and intraocular lens implantation (multifocal, accommodative, and extended depth of focus lenses).