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  • AAO PPP Refractive Management/Intervention Panel, Hoskins Center for Quality Eye Care
    Refractive Mgmt/Intervention
    By the American Academy of Ophthalmology Preferred Practice Pattern Refractive Management/Intervention Panel: Deborah S. Jacobs, MD, MSc, Chair,1 Jimmy K. Lee, MD,2 Tueng T. Shen, MD, PhD,3 Natalie A. Afshari, MD,4 Rachel J. Bishop, MD, MPH,5 Jeremy D. Keenan, MD, MPH,6 Susan Vitale, PhD, MHS, Methodologist7

    As of November 2015, the PPPs are initially published online-only in the Ophthalmology journal and may be freely downloaded in their entirety by all visitors. Open the PDF for this entire PPP or click here to access the PPP on the journal's siteClick here to access the journal's PPP collection page.

    1Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
    2Coastal Vision Medical Group, Irvine, California
    3UW Medicine Eye Institute, University of Washington, Seattle, Washington
    4Stuart I. Brown Chair in Ophthalmology in Memory of Donald P. Shiley, Professor of Ophthalmology, Chief of Cornea & Refractive Surgery, Vice Chair of Education, Shiley Eye Institute, University of California, San Diego, California
    5Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
    6Francis I. Proctor Foundation, Department of Ophthalmology, University of California, San Francisco
    7Division of Epidemiology and Clinical Applications, National Eye Institute, NIH, Bethesda, Maryland

    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

    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.

    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.

    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.

    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.

    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.

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

    Literature Search

    Refractive Surgery PPP - 2022 - Literature Search