• AAO PPP Refractive Management/Intervention Panel, Hoskins Center for Quality Eye Care
    Refractive Mgmt/Intervention
    Compendium Type: I

    By the American Academy of Ophthalmology Preferred Practice Pattern Refractive Management/Intervention Panel: Roy S. Chuck, MD, PhD,1 Deborah S. Jacobs, MD,2 Jimmy K. Lee, MD,3 Natalie A. Afshari, MD,4 Susan Vitale, PhD, MHS,5 Tueng T. Shen, MD, PhD,6 Jeremy D. Keenan, MD, MPH7

    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 site. Click here to access the journal's PPP collection page.

    1 Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, New York
    2 BostonSight, Needham, Massachusetts 
    3 Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, New York
    4 Shiley Eye Institute, University of California, San Diego, California
    5 Clinical Trials Branch, Division of Epidemiology and Clinical Applications, National Eye Institute/National Institutes of Health, Bethesda, Maryland
    University of Washington Eye Institute, Seattle, Washington
    7 Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California


    In the United States and other industrialized societies, the prevalence of myopia is increasing. Increased time spent outdoors appears to be protective against myopia in children. Increased levels of near work are less of a risk factor than previously believed.

    Studies from around the world have confirmed that that the incidence of microbial keratitis has not been reduced with the introduction of new lens types (including the newest highly gas-permeable silicone hydrogel lenses), and that overnight wear of any contact lens is associated with a higher risk than daily wear.4-7

    Overnight wear, regardless of contact lens type (including the newest highly gas-permeable silicone hydrogel lenses), increases the likelihood of corneal infection.4, 8-14 Although there are lenses approved by the FDA for extended wear, this and other risks, benefits, and alternatives should be presented to patients for whom this mode of contact lens wear is being considered.

    Environmental risk factors and hygiene practices, such as no-rub cleaning, topping off (reuse) of solutions, contaminated lens cases, exposure to tap water, wearing contact lenses in hot tubs, and changes in water supply are risk factors for the increases in Acanthamoeba and fungal keratitis in association with contact lens wear in the past decade.15-36

    Hydrogen peroxide systems may be superior to preserved disinfecting solutions in reducing pathogen binding and in cysticidal disinfection, but they require more complex care regimens.21, 25, 28, 37-40

    Daily disposable contact lenses are a good option for reducing the likelihood of complications associated with soft contact lens wear.5

    Presbyopia can be managed by using eyeglasses or contact lenses (soft, rigid gas-permeable, aspheric bifocal or multifocal). Surgical management of presbyopia includes keratorefractive surgery, corneal inlays, or intraocular lens implantation (multifocal, accommodative, and extended depth of focus lenses).

    As data from published studies fail to demonstrate a relationship between pupil size and the quality of postoperative vision, the importance of pupillometry in the preoperative workup remains controversial.

    It is recommended that keratorefractive surgery patients be provided with a record (K Card) or that the ophthalmologist maintain a record that lists information about the patient’s eye condition, including preoperative keratometry readings and refraction as well as stable postoperative refraction. The K Card should be available if the patient requires cataract surgery or future eye care. (See Appendix 8.)

    Excimer ablations that result in very thin residual stroma increase the risk for ectasia. For LASIK procedures, 250 μm has been suggested as a safe residual stromal bed thickness, but there is no absolute value that guarantees that ectasia will not occur. Although surgeons do not agree on a figure, they do agree that when ectasia risk is assessed, many factors should be considered. Abnormal topography is the most significant risk factor for postoperative ectasia. In the context of normal preoperative topography, percentage of tissue altered (PTA) higher or equal to 40% has been associated with higher ectasia risk.297 Other hypothesized risk factors include thin preoperative central corneal thickness, younger patient age, and higher attempted corrections.

    Persistent diffuse lamellar keratitis (DLK) that is unresponsive to corticosteroids should prompt consideration of microbial keratitis or interlamellar fluid due to increased intraocular pressure (IOP), intraocular inflammation, or endothelial decompensation. For moderate to extensive DLK, the interface should be irrigated sooner rather than later to minimize stromal loss and changes in refractive correction.

    Contraindications to corneal laser refractive surgery include:

    • 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
    • Unrealistic patient expectations

    Adverse events related to FDA-approved products (i.e., contact lenses) and procedures should be reported to MedWatch. MedWatch (www.fda.gov/medwatch) is the Safety Information and Adverse Reporting Program for drugs and other medical products regulated by the FDA. MedWatch is the first, and most crucial, step for doctors and patients to take when reporting adverse events.

    Literature Search

    Refractive Errors & Refractive Surgery PPP - Literature Search - 2017.pdf

    Cochrane Eyes and Vision Supplements

    We thank our partners, the Cochrane Eyes and Vision US Satellite (CEV@US), for identifying reliable systematic reviews and for developing the evidence tables that we cite and discuss in support of the PPP recommendations.

    Literature Search.pdf

    Inclusion and Exclusion Criteria.pdf

    Evidence Table.pdf