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
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Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts2
Coastal Vision Medical Group, Irvine, California3
UW Medicine Eye Institute, University of Washington, Seattle, Washington4
Stuart 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, California5
Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland6
Francis I. Proctor Foundation, Department of Ophthalmology, University of California, San Francisco7
Division 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).
Refractive Surgery PPP - 2022 - Literature Search