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Refractive Surgery
Third Edition

Dimitri T. Azar, MD, MBA

Distinguished University Professor and B.A. Field Chair of Ophthalmic Research, University of Illinois at Chicago,
Chicago, IL, USA;
Senior Director and Ophthalmology Lead
Verily Life Sciences (formerly Google)
San Fransisco, CA, USA

Associate Editors

Damien Gatinel, MD, PHD

Head
Department of Anterior Segment and Refractive Surgery, Rothschild Foundation
Paris, France

Ramon C. Ghanem, MD, PHD

Director of Cornea and Refractive Surgery Department
Sadalla Amin Ghanem Eye Hospital
Joinville, Brazil

Suphi Taneri, MD
Director, Center for Refractive Surgery
Department of Ophthalmology at St. Franziskus Hospital
Münster, NRW, Germany;
Associate Professor of Ophthalmology
Eye Clinic, Ruhr University
Bochum, NRW, Germany

For additional online content, visit expertconsult.inkling.com

First edition 1997 © Appleton & Lange
Second edition 2007 © Elsevier Inc.

Copyright © 2020, Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.

ISBN: 978-0-323-54769-7

E-ISBN: 978-0-323-55116-8

Content Strategists: Russell Gabbedy, Kayla Wolfe

Content Development Specialists: Trinity Hutton, Joanne Scott
Publishing Services Manager: Deepthi Unni
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Illustrators: David Gardner, Danny Pyne, Paul Kim, MS, CMI, Matrix Art Services
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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Video Table of Contents

8.1 IntraLase Femtosecond Laser LASIK 15.12 Removal of Epithelial Ingrowth Island After
Ramon C. Ghanem Femtosecond Laser LASIK
8.2 LDV Femtosecond Laser-Assisted LASIK Ramon C. Ghanem
Ramon C. Ghanem 15.13 Treatment of Flap Folds After LASIK
8.3 Microkeratome-Assisted LASIK (Moria SBK) Dimitri T. Azar and Ramon C. Ghanem
Ramon C. Ghanem 16.1 Standard SMILE Technique Using Double-Ended
13.1 Excimer Laser Ablation Patterns Dissector With Taneri Spoon Tip
Ramon C. Ghanem Suphi Taneri
14.1 Topography-Guided PRK for Hyperopia After 17.1 Preparation of Lenticule With SMILE
Radial Keratotomy Double-Ended Dissector With Taneri
Ramon C. Ghanem Spoon Tip
14.2 Topography-Guided Transepithelial PRK for Suphi Taneri
Keratoconus Regularization 17.2 Epithelial Abrasion on Cap Surface at the
Ramon C. Ghanem Sidecut
14.3 Topography-Guided Transepithelial PRK for Suphi Taneri
Central Scar After Foreign Body 17.3 Suction Loss Before Preparation of
Ramon C. Ghanem Sidecut. Manually Performed Incision With
15.1 Free Cap in Microkeratome-Assisted-LASIK, Diamond Knife
Ablation, and Flap Repositioning Suphi Taneri
Ramon C. Ghanem 17.4 Incomplete Lenticule Preparation by the Laser
15.2 Reposition in Slit Lamp of Early Flap Dislocation Due to Conjunctiva Sucked Into the Interface
After LASIK Between Cornea and Action Cone
Ramon C. Ghanem Suphi Taneri
15.3 Anterior Chamber Gas Bubbles After Corneal 17.5 Suction Loss Before Preparation of Sidecut
Flap Creation With a Femtosecond Laser Suphi Taneri
Dimitri T. Azar, José de la Cruz, Ramon C. Ghanem 17.6 Epithelial Abrasion on Cap Surface
15.4 Suction Loss During Flap Creation With a Suphi Taneri
Femtosecond Laser 17.7 Epithelial Cells Within SMILE Interface
Dimitri T. Azar and Ramon C. Ghanem Suphi Taneri
15.5 Incomplete LASIK Flap Due to Suction Loss 18.1 PRK for Hyperopia With Mechanical Epithelial
Ramon C. Ghanem Removal and MMC
15.6 Flap Tear After Suction Loss Due to Mechanical Ramon C. Ghanem
Block in Microkeratome LASIK 18.2 Alcohol-Assisted PRK Retreatment After LASIK
Ramon C. Ghanem Ramon C. Ghanem
15.7 Flap Adhesions in Femtosecond Laser LASIK + 18.3 Topography-Guided Transepithelial PRK for
Alcohol-Assisted-PRK After 3 Months Irregular Astigmatism and Central Corneal
Ramon C. Ghanem Scarring After Foreign Body Accident
15.8 Buttonhole Flap Ramon C. Ghanem
Dimitri T. Azar and Ramon C. Ghanem 19.1 LASEK Technique
15.9 Transepithelial PTK With Prophylactic MMC After Suphi Taneri
Buttonhole LASIK Flap 19.2 Epi-LASIK
Dimitri T. Azar and Ramon C. Ghanem Suphi Taneri
15.10 Treatment of Epithelial Ingrowth With Fibrin 20.1 OCT-Guided Trans PTK + PRK for Granular
Glue Adhesive Dystrophy
Vinícius Coral Ghanem Ramon C. Ghanem
15.11 Treatment of Epithelial Ingrowth 20.2 PTK in Recurrent Epithelial Erosion Syndrome
Dimitri T. Azar and Ramon C. Ghanem Ramon C. Ghanem

v
vi Video Table of Contents 

20.3 PTK for Epithelial Erosion Syndrome Due to 30.2 Artiflex Implantation With Enclavation Needle in
EBMD in a Patient With Previous LASIK a Patient With Keratoconus
Ramon C. Ghanem Ramon C. Ghanem
20.4 Focal PTK for Apical Leucoma Syndrome 30.3 ARTISAN for Hyperopia After Radial Keratotomy
Vinícius C. Ghanem Ramon C. Ghanem
20.5 Manual Keratectomy and PTK for Corneal Scars 31.1 Posterior Chamber Phakic IOL Implantation in
After Pterygium Surgery High Myopia
Ramon C. Ghanem Jean L. Arne
20.6 Transepithelial PTK in Avellino Dystrophy 32.1 Traumatic Dislocation and Successful
Dimitri T. Azar and Ramon C. Ghanem Re-enclavation of an ARTISAN Phakic IOL
22.1 Epi-off Cross-linking Ramon C. Ghanem
Ramon C. Ghanem 33.1 ARTISAN Bilensectomy
24.1 Radial Keratotomy Veronica Vargas Fragoso and Jorge L. Alió
Emir A. Ghanem 33.2 Phakic IOL Exchange
25.1 Conductive Keratoplasty “Light Touch Veronica Vargas Fragoso and Jorge L. Alió
Technique” 33.3 Bilensectomy
Dimitri T. Azar and Ramon C. Ghanem Veronica Vargas Fragoso and Jorge L. Alió
26.1 Keraring Implantation for Keratoconus 38.1 KAMRA Corneal Inlay
Regularization—Manual Technique Damien Gatinel
Ramon C. Ghanem 39.1 Diffractive Trifocal Intraocular Lens Implantation
26.2 LDV Z8 Femtosecond Laser-Assisted 300 Ramon C. Ghanem
Degrees Cornealring Implantation for 39.2 Toric Extended Depth of Focus Intraocular Lens
Advanced Keratoconus Implantation
Ramon C. Ghanem Ramon C. Ghanem
26.3 Intralase Femtosecond Laser-Assisted INTACS 42.1 Femtosecond Laser Arcuate Keratotomy for High
Implantation Astigmatism After DALK
Dimitri T. Azar and Ramon C. Ghanem Ramon C. Ghanem
26.4 Ferrara Ring ICRS for High Astigmatism 42.2 Manual Arcuate Keratotomy for High
After Keratoplasty Astigmatism After DALK
Ramon C. Ghanem Ramon C. Ghanem
26.5 ICRS Explantation 42.3 Femtosecond Laser-Assisted Wedge Resection
Ramon C. Ghanem After Penetrating Keratoplasty
30.1 Artisan for Myopia With VacuFix Enclavation Ramon C. Ghanem and Dimitri T. Azar
Ramon C. Ghanem
Foreword
Richard Wagner worked for nearly 30 years to complete
the tetralogy of The Ring—from 1848 to 1876 until the
premiere in Bayreuth, starting in Dresden and continuing
in Switzerland and Bayreuth, the hometown of my grand-
father. You may ask what The Ring has in common with
Dimitri Azar’s book on refractive surgery. First, Dimitri
and I share the passion for Wagner’s music. Second, it
also took nearly 30 years to make refractive surgery, espe-
cially laser vision correction, an accepted subdiscipline in
ophthalmology—30 years seems to be an acceptable time
to create a masterpiece. Third, many of the primers in
modern refractive surgery happened also in Germany and
Switzerland (e.g., phototherapeutic keratectomy [PTK],
wavefront-optimized treatments, wavefront-guided treat-
ments, topography-guided ablation, small-incision lenticule
extraction [SMILE], corneal cross-linking, and customized
cross-linking).
When laser refractive surgery commenced by the end of
the 1980s, it was considered “the dark side of ophthalmol-
ogy”—by the way, for good reasons. Meanwhile, refractive
success rate and complication rate has outperformed soft
contact lenses. Typical refractive success rates (± 0.5D) of
myopic LASIK are around 94%, comparable or better with
the 95% confidence interval of spherical refraction. This
means that we can’t make the success rate any better; it is
as good as the refraction that needs to be corrected. Regard-
ing complications, the paper of Masters et al. showed clearly
that, at the latest, after 3 years the risk of microbial keratitis
is higher with contact lenses compared to LASIK. But it
took refractive surgery 30 years to appear at the bright side
of ophthalmology!
This book arrives, therefore, at the right time. The list of
the authors reads like a “who’s who” of refractive surgery,
and each of the chapters is worth reading. In addition, it
covers the whole spectrum and includes new techniques
(SMILE, customized cross-linking) as well as traditional
procedures, such as PRK and keratotomies.
Thank you, Dimitri, for writing and collecting so many
original articles, and thus creating a standard book on
modern refractive surgery!
Theo Seiler, MD, PhD
Institut für Refraktive und
Ophthalmo-Chirurgie (IROC)
Stockerstrasse, Zürich
2018
vii
Foreword to the First Edition
Evolution of medical information progresses inexorably,
though sometimes unpredictably. The lifetime of a major
new clinical concept often lasts no longer than one to three
decades and then, new or revitalized ideas emerge, and
like juggernauts, vigorously plow ahead, casting aside pre-
existing beliefs that stand in their way. Their rate of growth,
interestingly, is akin to that of a new colony of microorgan-
isms (i.e., an S-shaped curve with an initial slow phase,
followed by exponential and sometimes explosive growth,
finally terminating in a plateau, or, in some case, a final
steep descent and even extermination). For example, the last
quarter of the 20th century may reasonably be considered
the golden age of vitreous surgery, at least as we now know
it. This is not to say that we have seen the final innovative
ideas in this arena; indeed, we are about to enter the impor-
tant derivative activities utilizing vitreoretinal surgical tech-
nique, such as submacular surgery, retinal cell transplants,
drug delivery, and hopefully, gene transfer. The age of initial
revolutionary ideas, however, occurred in the early 1970s,
and many of the later concepts and techniques should be
considered important refinements instead of epiphanies.
Now, with the passage of time, the field of refractive
surgery rises and glows, piquing our interests and chal-
lenging our priorities. These refractive ideas promise to
rejuvenate both therapeutic and cosmetic approaches to
ocular problems that, according to conventional wisdom,
have previously been considered technically, economically,
or ethically insurmountable. As in the case of most such
innovations involving human health and its associated com-
mercial enterprises, there is a spectrum of opinion, with
enthusiastic advocates and their understandable hyperbole
recognizable at one end and died-in-the-wool naysayers at
the other extreme. Of course, the “truth” lies somewhere
in the middle. With history in mind, one can predict that
ingenious ideas, instruments, and surgical procedures will
rather quickly and dramatically proliferate in this emerg-
ing field. Darwinian natural selection influenced, some-
times regrettably but unavoidably, by the marketplace will
have its say and, within a decade or so, refractive surgery
will evolve more completely. Eventually, the public will
become well served by a combination of properly evalu-
ated surgical procedures and superbly trained eye surgeons.
This process requires a continual sifting of new concepts
and techniques. Through repeated trial and error that are
enhanced by ethical, objective, and wise evaluation of sci-
entifically obtained clinical data, a mature discipline will
emerge that benefits patients who are carefully selected,
informed, treated, and followed up.
In the early stages of its evolution, now about to enter
the exponential phase of growth, the field of refractive
viii
surgery needs to undergo some periodic respites that allow
both the evaluation and teaching of new ideas and data that
have become available to date. Herein lies the value of
Dimitri Azar and his welcome book. During his several
years at the Wilmer Eye Institute, Dr. Azar displayed the set
of attributes required of an editor and author of a compen-
dium whose goals include promulgating new surgical ideas
for the therapists of both today—tomorrow; namely, highly
developed ethics, communicative skills, intellectual prowess,
and technical virtuosity. He is also well endowed with the
combination of exuberance and perseverance that are neces-
sary both for proselytizing favorable principles and practices
and simultaneously promoting the caution that is essential
whenever patients are subjected to revolutionary interven-
tions that have not been wholly vindicated. Indeed, as
pointed out by the author:
We must continue to validate refractive surgical procedures
by ensuring their predictability and reproducibility through
controlled and well-designed scientific investigations.
Dr. Azar’s imprimatur is evident throughout this book—
his ideas, his original writings and illustrations, and, of
course, his selection of outstanding American and inter-
national authors. Importantly, the authors represent both
younger and older refractive surgeons—gay blades and
experienced savants, so to speak. Both groups have much to
offer, and, as they themselves would be quick to admit, their
valuable offerings represent information which is state-of-
the-art, but which, of necessity, is in dramatic flux. Future
editions (and one hopes there will be several) will reflect the
result of careful clinical scrutiny; some current ideas that are
fervently propounded will die, and better ones will evolve.
Perhaps the very vigilant among us would wish to be
clairvoyant before embarking on this journey, utilizing a
crystal ball to predict what the future of this field foretells;
on the other hand, the excitement and much of the value
of unpredictable and presently unfathomable new ideas
would be lost. We should look to the future, therefore, with
pleasure and bated breath, but also with judicious circum-
spection. There will be many opportunities for appropriate
mid-course corrections. For the moment, however, this
book is an outstanding contemporary summary of refractive
surgery for both the neophyte and the sophisticate. It is the
forerunner of an epoch of eye surgery that will occupy our
minds and our operating rooms for years to come.
Morton F. Goldberg, MD
Director and Chairman
The Wilmer Ophthalmological Institute
Baltimore, Maryland
September 1996
Preface
The original idea of publishing a comprehensive multi-
author “Refractive Surgery” textbook materialized in 1996,
while I was on the faculty of the Wilmer Institute, witness-
ing and documenting, the renaissance of the field. More
than two decades later, refractive surgery is still advancing,
with the development of more precise and sophisticated
applications.
As in previous editions, the third edition of this book
maintains the essential backbone of the refractive surgery
story. Advancements in technology have expanded the
options for refractive surgical vision correction and improved
clinical outcomes. Correspondingly, the number of proce-
dures performed has continued to increase. This third
edition describes the principles and practice of refractive
surgery. We describe advances in various surgical tech-
niques, their indications, patient selection, limitations, and
complications. We have abridged the introductory and
corneal healing, corneal inclusions and orthokeratology sec-
tions, and we have updated the Optics chapters and included
an overview of anterior segment optical coherence tomog-
raphy (OCT) in refractive surgery. The lamellar surgery
section now encompasses laser in situ keratomileusis
(LASIK), Q-based and wavefront-guided custom LASIK,
TopoLink and small-incision lenticle extraction (SMILE).
We added a collagen cross-linking section and expanded the
sections of refractive intraocular lenses (IOLs), phakic IOLs,
and presbyopia surgery. Many chapters continue to benefit
from illustrative surgical and educational videos as well as
high-resolution representative photographs and illustra-
tions. Emphasizing the visual nature of refractive surgery,
several figures representing comprehensive themes are com-
posites, often presented in single illustrations.
This textbook would not have been possible without
the contributions of the associate editors, Drs. Damien
Gatinel, Ramon Ghanem, and Suphi Taneri. Their contri-
butions have broadened the scope of this book and have
provided an international, world-wide perspective of refrac-
tive applications. Nor would it have been possible without
the continued energy and commitment of Joanne Scott,
Nayagi Athmanathan, Trinity Hutton, Russell Gabbedy,
and the publishing team at Elsevier, who approached the
third edition with unfailing enthusiasm, keeping up with
our constant revisions to incorporate and update new topics
and techniques, as rapid developments in the field of refrac-
tive surgery showed few signs of abating.
As we dedicate this textbook to our families and teachers,
we express our gratitude to the contributors who gave their
valuable time, writing and revising manuscripts with dedi-
cation. The breadth and the depth of this edition are attrib-
utable to the collective expertise of more than 75 refractive
surgeons and researchers who contributed chapters, gener-
ously sharing their knowledge and expertise, and made
helpful suggestions throughout the process of producing
this volume.
I would also like to acknowledge the valuable assistance
of Pushpanjali Giri. Her relentless communication with the
publisher and with contributors was paramount in keeping
the project on schedule.
When I wrote the closing coda to the second edition, I
was transitioning from the Massachusetts Eye and Ear Infir-
mary and the Schepens Eye Research Institute at Harvard
Medical School to the Department of Ophthalmology and
Visual Sciences, and the Lions of Illinois Eye Research
Institute, at the University of Illinois at Chicago (UIC). I
write this preface, more than a decade later, as I start a new
chapter in my career assuming new responsibilities in San
Francisco as Senior Director of Ophthalmic Innovations
and Ophthalmology Lead at Alphabet Verily Life Sciences.
I am indebted to my many colleagues, fellows, residents,
and students at UIC for their friendship and unwavering
support while I was engaged in the production of this book.
Dimitri T. Azar, MD, MBA
San Francisco, CA, 2019
ix
List of Contributors

The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without
whom this new edition would not have been possible.

Elena Albé, MD Dimitri T. Azar, MD, MBA

Consultant Distinguished University Professor and B.A. Field Chair
Eye Clinic, ISTITUTO CLINICO HUMANITAS, of Ophthalmic Research
Rozzano, MI, Italy University of Illinois at Chicago, Chicago, IL, USA;
Senior Director and Ophthalmology Lead
Jorge L Alió, MD, PhD Verily Life Sciences (formerly Google), San Fransisco, CA,
Professor and Chairman of Ophthalmology USA
Vissum Alicante, Spain
Miguel Hernández University of Alicante, Spain Richard E. Braunstein, MD
Miranda Wong Tanga Associate Professor of Clinical
Norma Allemann, MD Ophthalmology
Adjunct Professor, Head of Discipline Harkness Eye Institute, New York, NY, USA
Department of Ophthalmology, Federal University of São
Paulo—UNIFESP Salim I. Butrus, MD
Clinical Volunteer Faculty in Ophthalmology— Clinical Professor
Department of Ophthalmology & Visual Sciences— Department of Ophthalmology, Georgetown University
University of Illinois at Chicago—UIC and George Washington University, Washington, DC,
USA
Mazen Amro, MD
Ophthalmologist Florence Cabot, MD
Université Libre de Bruxelles, Brussels, Belgium International Clinical Cornea Fellow
Erasmus Hospital, Brussels, Belgium Anne Bates Leach Eye Hospital and Ophthalmic
Biophysics Center, Bascom Palmer Eye Institute,
Jean-Louis Arné, MD University of Miami, Miller School of Medicine, Miami,
Professor Emeritus FL, USA
Head of Ophthalmology Department, Paul Sabatier
University, Toulouse, France Jonathan Carr, MD, MA(Cantab), FRCOphth
Medical Director
M. Farooq Ashraf, MD, FACS Lasik Plus—Paramus, Paramus, NJ, USA
Medical Director
The Atlanta Vision Institute, Atlanta, GA, USA Fábio H. Casanova, MD, PhD
Director, Memorial Oftalmo Recife Eye Center, Brazil
Janine Austen Clayton, MD
NIH Associate Director for Research on Women’s Health Wallace Chamon, MD
Director Professor
NIH Office of Research on Women’s Health, Bethesda, Department of Ophthalmology and Visual Sciences,
MD, USA Escola Paulista de Medicina, Universidade Federal de São
Paulo (UNIFESP), São Paulo, SP, Brazil;
Nathalie F. Azar, MD Clinical Volunteer Faculty
Clinical Professor and Director of Pediatric Department of Ophthalmology and Visual Sciences,
Ophthalmology University of Illinois at Chicago, Chicago, IL, USA
University of Illinois at Chicago, Department of
Ophthalmology, Chicago, IL, USA

x

Philippe Chastang, MD
Corneal and Refractive Surgical Specialist
Chirurgie Oculaire Et Réfractive
Consultation Cabinet;
Formerly, Fondation Ophthalmologique A. de Rothschild,
Paris, France
Pauline Cho, PhD, FAAO, FBCLA
Professor
School of Optometry, The Hong Kong Polytechnic
University, Hong Kong, SAR, China
José de la Cruz, MD
Cornea Fellow
UIC Department of Ophthalmology and Visual Sciences,
The University of Illinois Eye Center, Chicago, IL, USA
Roberto Fernández-Buenaga, MD, PhD
Consultant Ophthalmologist
Vissum Madrid, Spain
Jorge Alió-del Barrio, MD, PhD
Consultant Ophthalmologsit
Vissum Alicante, Spain
Ana Mercedes García-Albisua, MD
Second-Year Cornea Fellow, Chief Resident
Cornea and Refractive Surgery, Asociación Para Evitar la
Ceguera en México “Hospital Dr. Luis Sánchez Bulnes”,
Mexico City, México
Damien Gatinel, MD, PHD
Head
Department of Anterior Segment and Refractive Surgery,
Rothschild Foundation, Paris, France
Emir Amin Ghanem, MD
Ophthalmologist
Sadalla Amin Ghanem Eye Hospital, Joinville, SC, Brazil
Marcielle A. Ghanem, MD
Refractive Surgery Department, Sadalla Amin Ghanem
Eye Hospital, Joinville, SC, Brazil
Ramon C. Ghanem, MD, PhD
Director of Cornea and Refractive Surgery Department
Sadalla Amin Ghanem Eye Hospital, Joinville, Brazil
Vinícius Coral Ghanem, MD, PhD
Ophthalmologist and Medical Director, Department of
Ophthalmology Sadalla Amin Ghanem Eye Hospital,
Joinville, SC, Brazil
List of Contributors xi
Pushpanjali Giri, BA
Research Specialist
Department of Ophthalmology, University of Illinois at
Chicago, Illinois Eye and Ear Infirmary, Chicago, Illinois,
USA
Andrzej Grzybowski, MD, PhD, MBA
Professor of Ophthalmology
Department of Ophthalmology, University of Warmia
and Mazury, Olsztyn, Poland
Foundation Ophthalmology, Poznan, Poland
Shilpa Gulati, MD
Department of Ophthalmology and Visual Sciences,
Illinois Eye and Ear Infirmary, University of Illinois at
Chicago, Chicago, IL, USA
Rosario Gulias-Cañizo, MD, MSc
Research Coordinator
Research Department, Universidad Nacional Autónoma
de México, Asociación Para Evitar la Ceguera en México
“Hospital Dr. Luis Sánchez Bulnes”, Mexico City,
CDMX, Mexico
Joelle Hallak, PhD
Assistant Professor
Executive Director
Ophthalmic Clinical Trials and Translational Center,
Department of Ophthalmology and Visual Sciences,
University of Illinois at Chicago, Morgan, Chicago, IL
Rola N. Hamam, MD
Assistant Professor of Ophthalmology
Department of Ophthalmology, University of Beirut,
Beirut, Lebanon
David R. Hardten, MD
Director of Refractive Surgery
Minnesota Eye Consultants
Adjunct Associate Professor of Ophthalmology
University of Minnesota, Minneapolis, MN, USA
Everardo Hernández-Quintela, MD, MSc, FACS
Chief of Service
Department of Cornea and Refractive Surgery Services,
Universidad Nacional Autónoma de México Asociación
Para Evitar la Ceguera en México, Hospital Dr. Luis
Sánchez Bulnes, Mexico City, CDMX, Mexico
Peter S. Hersh, MD, FACS
Cornea and Laser Eye Institute—Hersh Vision Group
Professor of Clinical Ophthalmology, Director of Cornea
and Refractive Surgery
Rutgers Medical School Visiting Research Collaborator
Princeton University, Princeton, NJ, USA
xii List of Contributors 
Arthur Ho, MOptom, PhD, FAAO
Chief Scientist and Innovation Officer
Brien Holden Vision Institute, Sydney, NSW, Australia;
Visiting Professorial Fellow
School of Optometry and Vision Science, University of
New South Wales;
Voluntary Professor of Ophthalmology
University of Miami, Miller School of Medicine, Miami,
FL, USA
Thanh Hoang-Xuan, MD
Professor of Ophthalmology
University of Paris, American Hospital;
Formerly, Fondation Ophthalmologique A. de Rothschild,
Paris, France
Brien A. Holden, PhD, DSc, OAM
Formerly Deputy CEO
Vision Cooperative Research Centre, The University of
New South Wales, Sydney, NSW, Australia
Sandeep Jain, MD
Professor of Ophthalmology
Cornea Service
Director, Cornea Translational Biology Laboratory
Director, Dry Eye Service and oGVHD Service
University of Illinois at Chicago, Department of
Ophthalmology, Chicago, IL, USA
Elias F. Jarade, MD
Ophthalmologist, Cornea and Refractive Surgeon
Beirut Eye & ENT Specialty Hospital, Beirut, Lebanon
Joel Adrien D. Javier, MD
Clinical Consultant
Bausch & Lomb, Singapore
James V. Jester, PhD
Professor of Ophthalmology and Biomedical Engineering
University of California, Irvine, Irvine, CA, USA
Piotr Kanclerz, MD, PhD
Medical Doctor
Department of Ophthalmology, Medical University of
Gdańsk, Gdańsk, Pomorskie, Poland
Vikentia J. Katsanevaki, MD, PhD
Head of Refractive Department
Vardinoyannion Eye Institute, University of Crete Medical
School, Crete, Greece
Johnny M. Khoury, MD
Assistant Professor of Ophthalmology
Director, Refractive Surgery Division
American University of Beirut Medical Centre, Beirut,
Lebanon
Michael C. Knorz, MD
Professor of Ophthalmology
FreeVis LASIK Center, Klinikum Mannheim, Mannheim,
Germany
Jeffrey C. Lamkin, MD
Private Practice
Akron, OH, USA
François Malecaze, MD, PhD
Professor of Ophthalmology
Hospital Purpan, Toulouse, France
Fabrice Manns, PhD
Professor of Biomedical Engineering and Ophthalmology
Ophthalmic Biophysics Center, Bascom Palmer Eye
Institute, University of Miami
Miller School of Medicine, Miami, FL;
Chairman of the Department of Biomedical Engineering,
University of Miami College of Engineering, Coral
Gables, FL
Marguerite B. McDonald, MD, FACS
Clinical Professor of Opthalmology
NYU School of Medicine;
Tulane University School of Medicine, New Orleans, LA,
USA
Françoise C. Abi Nader, MD
Optometrist
Laser Eye Medical Center, Dubai, United Arab Emirates
Ioannis G. Palliakaris, MD, PhD
Dean and Professor of Ophthalmology
Vardinoyannion Eye Institute of Crete/Institute of Vision
and Optics, University of Crete Medical School, Voutes,
Crete, Greece
Jean-Marie Parel, IngETS-G, PhD, FAIMBE,
FARVO
Henri and Flore Lesieur Chair in Ophthalmology
Ophthalmic Biophysics Center, Bascom Palmer Eye
Institute, University of Miami
Miller School of Medicine, Miami, FL;
Vision Cooperative Research Center, University of New
South Wales, Sydney, Australia
Kévin Pierné, MD
Practitioner in Ophtalmology
Hospital Purpan, Toulouse, France
Antony M. Poothullil, MD
Kaiser Permanente, Ophthalmology, Portland, OR, USA
 List of Contributors xiii

Ana Belén Plaza-Puche Walter Stark, MD

Optometry Office of the Research Development &
Innovation Department, Vissum Alicante, Spain
Cynthia J. Roberts, PhD
Professor of Ophthalmology & Visual Science and
Biomedical Engineering
Martha G. and Milton Staub Chair for Research in
Ophthalmology
The Ohio State University, Columbus, OH, USA
Renan Rodrigues, MD
Ophthalmologist, Post-doctoral Student
Department of Ophthalmology/Cataract and Refractive
Surgery Division, Federal University of São Paulo
(UNIFESP)/ São Paulo Hospital/ UNIFESP, São Paulo,
SP, Brazil;
Co-founder of CONUS—Keratoconus Center
Mark Rosenblatt, MD, PhD
Professor and Head of Ophthalmology and Visual
Sciences in the UIC College of Medicine
Chicago, IL, USA
Boone Pickens Professor of Ophthalmology
The Director of the Stark-Mosher Center for Cataract and
Corneal Services
The Wilmer Eye Institute, The Johns Hopkins Hospital,
Baltimore, MD, USA
Mario Antonio Stefani, PhD
R&D Board Chairman
R&D Medical Division, Opto Eletrônica S/A, São Carlos,
SP, Brazil
Leon Strauss, MD, PhD
Instructor
The Wilmer Eye Institute, The Johns Hopkins University,
School of Medicine, Baltimore, MD, USA
Suphi Taneri, MD
Director, Center for Refractive Surgery
Department of Ophthalmology at St. Franziskus Hospital,
Münster, NRW, Germany;
Associate Professor of Ophthalmology
Eye Clinic, Ruhr University, Bochum, NRW, Germany

Mirwat Sami, MD, FACS Vance Thompson, MD

Houston Eye Associates, Houston, TX, USA Director of Refractive Surgery
Vance Thompson Vision
Valeria Sánchez-Huerta, MD, FACS Professor of Ophthalmology
Head of Academics University of South Dakota Sanford School of Medicine,
Department of Cornea and Refractive Surgery Services, Sioux Falls, SD, USA
Universidad Nacional Autónoma de México
Asociación Para Evitar la Ceguera en México “Hospital Josep Torras, MD
Dr. Luis Sánchez Bulnes”, Mexico City, CDMX, Mexico Department of Ophthalmology, Mutua Terrassa Hospita,
Barcelona, Spain
David J. Schanzlin, MD
Partner, Gordon Schanzlin New Vision Institute Kazuo Tsubota, MD
Professor of Clinical Ophthalmology (Emeritus) Professor and Chairman
University of California, San Diego, San Diego, CA, USA Department of Ophthalmology, Keio University School of
Medicine, Tokyo, Japan
Theo G. Seiler, MD
Department of Ophthalmology, University of Bern, Bern, Veronica Vargas
Switerland Refractive Surgery Fellow
Department of Investigation, Development and
Theo Seiler, MD, PhD Innovation at Vissum Alicante, Alicante, Spain
Professor and Chairman
Institut für Refraktive und Ophthalmo-Chirurgie Frédéric Vayr, MD
(IROC), University of Zurich, Zurich, Switerland Corneal and Refractive Surgical Specialist
Institut Laser Vision, Noémie de Rothschild;
Ashish G. Sharma, MD, FACS Formerly, Fondation Ophthalmologique A. de Rothschild,
Retina Consultants of Southwest Florida Paris, France
Fort Myers, Florida, USA
Steven M. Verity, MD
Professor
Department of Ophthalmology, Cornea/External Disease
and Keratorefractive Surgery, University of Texas
Southwestern Medical Center at Dallas, Dallas, TX, USA
xiv List of Contributors 

Jayne S. Weiss, MD Sonia H. Yoo, MD

Associate Dean of Clinical Affairs Professor of Ophthalmology
Chair, Department of Ophthalmology Anne Bates Leach Eye Hospital and Ophthalmic,
Herbert E Kaufman MD Endowed Chair Biophysics Center, Bascom Palmer Eye Institute,
Professor of Ophthalmology, Pathology and Pharmacology University of Miami, Miller School of Medicine, Miami,
Louisiana State University School of Medicine, LSUHSC, FL, USA
New Orleans, LA, USA
Bavand Youssefzadeh, DO
Albert Chak-Ming Wong, MBChB (CUHK), Ophthalmology Associate Physician
MRCSEd, MMedSc (HK), MMed (Ophth), Cornea/Refractive Department, Gordon Schanzlin New
FCOphthHK, FHKAM (Ophth), FRCSEd (Ophth) Vision Institute, San Diego, CA, USA
Clinical Assistant Professor (Honorary)
The Jockey Club School of Public Health and Primary
Care, Faculty of Medicine, The Chinese University of
Hong Kong;
Director
Department of Ophthalmology, Albert Eye Centre, Tsim
Sha Tsui, Kowloon, Hong Kong
 Dedication

To Lara, Nicholas, and Alexander;

To Nathalie,
for sharing my profession with dedication and excellence,
my long days with patience and assistance,
my leisure with cheerfulness and laughter,
and my happy moments with affection and optimism;
and for providing Alexander, Nicholas, and Lara with wonderful roots
and magnificent wings;
To all my fellows and residents for being the source of my learning and inspiration;
To Ilene, Fred, Mort, Claes, Bob, Michael, and Andy for their friendship
and mentorship;
And in memory of my loving parents; I can no longer see them with my eyes, but I see
the light they have brought to the world still shining, long after they have gone.
Dimitri T. Azar, MD, MBA

To my teachers, students, family, and friends.

To the curious minds.
Damien Gatinel, MD, PHD

I dedicate this work to my dear family for their constant inspiration and support.
With reverence to my grandfather, Sadalla Amin Ghanen, in memoriam;
to my beloved parents, Emir Amin Ghanem and Cleusa Coral-Ghanem, models of
wisdom, courage, dedication, and professional ethics;
to my brother Vinícius, a friend at all times, a professional colleague, and an example
to be followed.
to Marcielle, my great love and mother of our sons, Nicolas, Henrique, and Gabriel;
and, finally, to two great mentors, Professors Newton Kara-José and Dimitri T. Azar.
Ramon C. Ghanem, MD

To my father and mother for their unconditional love,

to Anneanne, Remziye Teyze, Ertug Amca in memoriam, and Ufuk Hala for their
loving support,
to Nicola for passionately sharing her life with me,
to Mavi-Nur and Sinan for adding fun and excitement,
and to Heinrich Gerding, Kunibert Krause in memoriam, H. Burkhard Dick, and
Dimitri T. Azar
Suphi Taneri, MD
1
Terminology, Classification, and
History of Refractive Surgery
SHILPA GULATI, ANTONY M. POOTHULLIL, AND DIMITRI T. AZAR
Introduction: Why Do Patients Choose
Refractive Surgery?
Patients desire refractive surgery for a variety of reasons.
For patients seeking laser in situ keratomileusis (LASIK)
or surface ablation, the most common motivation is a
desire to decrease contact lens or spectacle use.1–3 Some
individuals require improvement in their uncorrected visual
acuity (UCVA) because of their careers. Others have ocular
or medical conditions that make contact lens wear dif-
ficult or dangerous. Some prefer to be free of glasses or
contacts when engaging in sports and recreation. Presby-
opic patients may want to be able to read clearly without
glasses. Still others have anisometropia or spectacle-related
anisophoria such that corrective spectacle lenses result in
prominent eyestrain and an unacceptable degree of dis-
comfort. Cosmetic appearance may also be a reason for
surgery.
The number of refractive surgical procedures available to
patients has increased dramatically since the early days of
radial keratectomy (RK) and keratomileusis. Recent devel-
opments are discussed in this textbook, including custom-
ized LASIK, small-incision lenticule extraction (SMILE),
presbyopic implants, and multifocal IOLs. Patients who
have had LASIK for the correction of myopia are generally
very happy. In a survey by Miller et al., approximately 85%
were at least “very pleased” with their refractive outcome
and 97% said they would decide to have the procedure
performed again.4 Factors that correlated well with patient
satisfaction were postoperative improvements in UCVA,
decreased cylindrical correction, and absence of side effects,
such as dry eye. While this may be comforting, it is impor-
tant to remember that the vast majority of refractive surgery
is performed on patients with excellent corrected visual
acuity and a decrease in quality of vision is ultimately unde-
sirable. With continued advancements of refractive proce-
dures, we can minimize complications, improve outcomes,
and educate our patients and ourselves.
2
Emmetropia, Ametropias, and Presbyopia
The successful performance of refractive surgery demands a
thorough understanding of the optics of the human eye.
The refractive power of the eye is predominantly deter-
mined by 3 variables: the power of the cornea, the power
of the lens, and the length of the eye. In emmetropia, these
3 components combine in such a way as to produce no
refractive error. When an eye is emmetropic, a pencil of
light parallel to the optical axis and limited by the pupil
focuses at a point on the retina (i.e., the secondary focal
point of an emmetropic eye is on the retina; Fig. 1.1). The
“far point” in emmetropia (defined as the point conjugate
to the retina in the nonaccommodating state) is optical
infinity.
Eyes with refractive errors can have abnormalities in one
or more of the above variables, or all variables can be in the
normal range but incorrectly correlated, resulting in a
refractive error. For example, an eye with an axial length in
the upper range of normal may be myopic if the corneal
variable is also in the steeper range of normal. In a myopic
eye, a pencil of parallel rays is brought to focus at a point
anterior to the retina. This point, the secondary focal point
of the eye, is in the vitreous. Rays diverging from the far
point of a myopic eye will be brought to focus on the retina
without the aid of accommodation.
The hyperopic eye, on the other hand, brings a pencil of
parallel rays of light to focus at a point behind the retina.
Accommodation of the eye may produce enough additional
plus power to allow the light rays to focus on the retina.
Rays converging toward the far point farther behind the
eye will be focused on the retina while accommodation is
relaxed.
For full correction of myopia and hyperopia, a distance
corrective lens placed in front of the eye must have its sec-
ondary focal point coinciding with the far point of the eye
so that the newly created optical system focuses parallel rays
onto the retina.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery
F2
Far point = x
(A) Emmetropia
Far point
(B) Myopia
F2
(C) Myopia
F2
(D) Hyperopia
• Fig. 1.1 Schematic diagrams of emmetropia, myopia, and hyperopia.
(A) In emmetropia, the far point is at infinity, and the secondary focal
point (F2) is at the retina. (B and C) In myopia, the far point is in front
of the eye and the secondary focal point, F2, is in the vitreous. (D) In
hyperopia (bottom), the secondary focal point, F2, is located behind
the eye. (Modified with permission from Azar DT, Strauss L. Principles
of applied clinical optics. In: Albert D, Jakobiec F, eds. Principles and
Practice of Ophthalmology. Philadelphia: WB Saunders; 1994.)
Astigmatism may be caused by a toric cornea or, less
frequently, by astigmatic effects of the native lens of the eye.
Astigmatism is regular when it is correctable with cylindrical
or spherocylindrical lenses so that pencils of light from
distant objects can be focused on the retina. Otherwise, the
astigmatism is irregular. Visual acuity is expected to decline
for the different degrees of astigmatism. Astigmatism of
0.50 to 1.00 diopters (D) usually requires some form of
optical correction. An astigmatic refractive error of 1.00 to
2.00 D decreases uncorrected vision to the 20/30 to 20/50
level, whereas 2.00 to 3.00 D may decrease UCVA to the
20/70 to 20/100 range.5
Presbyopia is the age-related loss of accommodation.
Onset of presbyopia will vary with the refractive error and
its method of correction. For example, myopes corrected
3
TABLE Classification of Lenticular and Scleral
1.1 Refractive Procedures
M MyA H HA MxA A P
CLE + +
PIOL + +
Bioptics + + + + + +
Multifocal + + +
Accommodative IOL + + +
Phaco-Ersatz +
Scleral relaxation, ±
expansion
A, Aphakia; CLE, clear lens extraction; H, hyperopia; HA, hyperopic
astigmatism; IOL, intraocular lens; M, myopia; MxA, mixed astigmatism;
MyA, myopic astigmatism; P, presbyopia; PIOL, phakic intraocular
lenses.
with spectacles can simply remove their glasses for improved
reading vision. Latent hyperopes, on the other hand, use
their accommodative reserve for clear distance vision; as the
amplitude of accommodation wanes with age, reading dif-
ficulties emerge.
Classification of Refractive Procedures
Refractive surgery procedures are undergoing constant
development and modification. In the late 1990s, LASIK
has essentially replaced RK as the preferred treatment for
patients with myopia. More recently, SMILE and multifocal
IOLs have gained increasing popularity and phakic intra-
ocular lenses (PIOLs) have undergone numerous modifica-
tions for the treatment of higher degrees of myopia or
hyperopia. With an expanding repertoire of options, it is
important to have an organized understanding of the surgi-
cal techniques that are available to the refractive surgeon.
Refractive surgery procedures for the correction of
myopia, hyperopia, presbyopia, and astigmatism achieve
emmetropia by modifying the optical system of the eye. In
this chapter, we have divided surgical techniques into 2
broad categories: keratorefractive (corneal-based) and len-
ticular or scleral surgical procedures. Keratorefractive tech-
niques surgically alter the cornea without entering the
anterior chamber and are the main type of refractive surgery
performed today. The lenticular or scleral refractive proce-
dures include intraocular techniques, such as the insertion
of multifocal, accommodating, and adjustable lenses, and
extraocular methods, such as scleral relaxation or expansion
procedures for presbyopia (Table 1.1).
Keratorefractive Surgery
Keratorefractive surgeries rely on at least five major methods
to reshape the corneal surface: lasers, incisions, corneal
implants, thermal procedures, and nonlaser lamellar surgery.
4 se c t i o n I Introduction

All procedures induce corneal changes by affecting the More commonly, the laser is used to perform corneal
corneal stroma. Excimer lasers are used to subtract tissue stromal ablation under a lamellar flap, termed laser in situ
from the stroma and modify corneal shape. With incisional keratomileusis (LASIK).
surgery, a blade is used to make precise cuts into the stroma.
These incisions result in wound gape, altering the corneal Laser Procedures for Myopia
surface contour, resulting in changes in the refractive power In PRK, the excimer laser is applied to the anterior surface
of the cornea. Corneal implants can be placed into the of the cornea for reshaping (Fig. 1.2). The laser may be used
corneal stroma to change corneal shape. Thermal techniques
cause focal changes in stromal collagen architecture in order
to change corneal contour. At present, thermal methods are
limited to the correction of hyperopia or presbyopia. Non-
laser lamellar surgeries add or subtract tissue from the
cornea in order to reshape it. With lamellar addition pro-
cedures, donor corneal tissue is transplanted to the host
cornea. Lamellar subtraction procedures involve two stages:
(1) lamellar stromal dissection and (2) removal of stromal
tissue. Many of these procedures have the unintended side
effect of reducing corneal tensile strength. Our understand-
ing of corneal biomechanics has increased and has allowed
us to develop safer keratorefractive procedures for our indi-
vidual patients.6–9

Keratorefractive Procedures: Myopia and

Myopic Astigmatism
Myopia is the most common visually significant refractive
error, with a rising prevalence of 25% to 40% in Western
countries.10,11 In the United States, the prevalence of myopia
has doubled in the last 30 years and pathologic myopia
(over 8.00 D) has risen eightfold.12 Numerous procedures
have been developed to treat myopia by altering the corneal
curvature. The cornea is responsible for 60% of the eye’s
refractive power; small changes in curvature can produce
significant refractive changes. Corneal procedures correct
myopia by flattening the anterior curvature or changing the
index of refraction of the cornea. All keratorefractive pro-
cedures for the treatment of myopia modify the corneal
thickness to produce anterior curvature alterations except
for RK, in which the corneal curvature is flattened by tec-
tonic weakening without changing the central thickness.13

Laser Procedures
The excimer laser, a 193-nm argon fluoride (ArF) beam,
has become the technology of choice for keratorefractive
surgeons worldwide. A major advantage of the laser is its
ability to precisely ablate tissue with submicron pulses. The
excimer laser-ablated surface has the potential of being
smoother than that obtainable by other surgical techniques.
Since its introduction in 1983 by Trokel and Srinivasan for
linear keratectomy, the excimer laser procedure has under-
gone a rapid evolution.14 Myopic excimer laser treatments
achieve their effect by flattening the central cornea. The
• Fig. 1.2 Schematic illustration of myopic photorefractive keratec-
laser can reshape the cornea by ablating the anterior corneal tomy. The shaded area refers to the location of tissue subtraction.
surface, as in photorefractive keratectomy (PRK) or laser- More stromal tissue is removed in the central as compared to the
assisted subepithelial keratectomy (LASEK or epi-LASEK). paracentral region.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 5

to remove the corneal epithelium. Alternatively, the epithe- Myopic LASIK

lium may be removed by scraping with a surgical blade or
by using dilute ethanol and a cellulose sponge. For myopia
of 1 D to 7 D, PRK has been shown to result in a high
rate of preservation of best corrected visual acuity (BCVA)
and minimal complications. In most series, 90% of patients
achieve 20/40 or better uncorrected acuity and are within
1 D of emmetropia. In this moderate myopia group, the
initial overcorrections generally regress toward emmetropia
over several months, with stabilization after 6 to 12 months.
Highly myopic patients often regress 6 to 12 months after
surface PRK, presumably because of stromal regeneration
and/or epithelial hyperplasia, which cause resteepening of
the ablated zone.15 Dense subepithelial haze occurs rarely
but is greater in PRK treatments exceeding 6 D and may
reduce the BCVA. Mitomycin C has been applied during
PRK treatments in order to decrease the incidence of haze
formation.16 Artola et al. found that induced corneal aber-
rations after PRK for myopia created a multifocality that
enhanced near acuity, which may delay the onset of pres-
byopic symptoms. However, this multifocality also reduced
the quality of the retinal image for distance at low contrast.17
LASEK and epi-LASIK are modifications of the PRK
procedure in which the corneal epithelium is preserved,
displaced prior to surface ablation, then replaced after laser
application. Advantages over PRK include decreased post-
operative discomfort, reduced postoperative scarring, and
faster visual recovery. Prior to laser application, the epithe-
lium is treated with 15% to 20% ethanol. This treatment
weakens hemidesmosomal attachments between the corneal
epithelium and the underlying Bowman membrane. The
epithelial sheet can then be easily displaced and protected
by moving it outside of the ablation zone. Following stromal
ablation, the epithelial sheet is returned to its original loca-
tion, covering the ablated area.18 Pallikaris et al. have • Fig. 1.3 Schematic illustration of myopic and hyperopic laser in situ
keratomileusis. A superficial corneal flap is raised. The shaded area
described epi-LASIK, using an automated blade to remove refers to the location of tissue subtraction under the flap. After treat-
the corneal epithelium mechanically, without the applica- ment, the flap is repositioned.
tion of alcohol. They suggest that this technique should
provide improved comfort and decreased haze formation
compared to PRK, and histologic studies show better pres- used to photodisrupt the corneal stroma with a preset depth
ervation of the corneal epithelial sheet when compared to and pattern. When used for LASIK, the laser creates the
LASEK.19,20 corneal flap prior to excimer laser application.21
LASIK is a two-stage procedure that combines lamellar Customized corneal ablations use Q-based or “wave-
surgery with laser application. It has become the most front” aberrometers to detect and treat both spherocylindri-
widely performed refractive procedure in the United States. cal error and higher-order aberrations (HOAs) that can
Its main advantages over surface ablation procedures include affect visual acuity. At the time of publication, these devices
faster visual recovery, less postoperative discomfort, and are approved in the United States for the treatment of
decreased incidence of postoperative corneal scarring or myopic and astigmatic refractive errors. These custom lasers
haze in patients with higher refractive errors. During LASIK, offer the possibility of improved vision compared to tradi-
an anterior corneal flap is created and then is lifted, the tional excimer lasers because they address additional factors
excimer laser is applied to the stromal bed, and the flap is that may be contributing to blur in an individual’s optical
returned to its original position (Fig. 1.3). The corneal flap system.22 A study of 132 eyes undergoing LASIK using the
can be created with either a microkeratome or an intrastro- NIDEK Advanced Vision Excimer Laser (NIDEK) showed
mal laser. Microkeratomes are affixed to the globe via a that fewer HOAs were induced when compared to non-
suction device and the blade is passed via a manual or custom LASIK, and 93% achieved uncorrected vision of at
automated mechanism. The femtosecond (FS) laser is a least 20/20. Preoperative sphere and cylinder ranged to
solid-state laser with a 1053-nm wavelength that can be −8.25 D and −3 D, respectively.22
6 se c t i o n I Introduction
• Fig. 1.4 Small-incision lenticule extraction (SMILE).
SMILE is a refractive procedure in which an FS laser is
used to create a corneal stromal lenticule, which is extracted
whole through a 2- to 3-mm incision (Fig. 1.4). Outcomes
have been noted to be similar to those of LASIK: in a meta-
analysis by Zhang et al.23 comparing SMILE and FS-assisted
LASIK (FS-LASIK) in 1101 eyes, no significant difference
was found in refractive outcomes. SMILE was found to
result in higher postoperative corneal sensitivity but fewer
dry-eye symptoms than FS-LASIK. The biomechanical sta-
bility after SMILE surgery is expected to be greater than
that after LASIK and may be comparable to PRK and
LASEK. Fig. 1.5 compares RK, PRK, LASIK, and SMILE
corneal biomechanics. Long-term follow-up has demon-
strated a reduction in HOAs and minimal refractive regres-
sion, though some potential advantages, such as improved
biomechanical stability and postoperative inflammation,
have yet to be established.
Laser Procedures for Myopic Astigmatism
Compound myopic astigmatism can be treated with nega-
tive or positive cylinder ablation. Negative cylinder ablation
flattens the central cornea in both the flat and the steep
meridians. Positive cylinder ablation may allow a larger
optical zone with no change in the central depth of abla-
tion.24 One study examined 74 eyes with compound myopic
astigmatism treated with the Meditec MEL 10 G-Scan
(Zeiss) excimer laser. Patients were followed for 1 year and
had myopia from −4.50 D to −9.88 D and astigmatism up
to 4.00 D. At 1 year, mean postoperative spherical equiva-
lent was −0.49 and mean cylinder refraction was 0.59.25
Incisional Procedures: A Historical Perspective
In the early 1970s, RK was performed by ophthalmologists
in the Soviet Union, including Beliaev,26 Yenaliev,27 and
Fyodorov and Durnev.28–31 RK was performed for the first
time in the United States in 1978.32,33 The RK procedure for
myopia places deep, radial, corneal stromal incisions, which
weaken the paracentral and peripheral cornea and flatten
the central cornea. Refractive power of the central cornea
is reduced and myopia is decreased (Fig. 1.6). The surgeon
can control the refractive effect by adjusting three variables:
central optical zone, incision number, and incision depth.
Incisional Procedures for Myopia
RK achieves the best results in patients with low and moder-
ate degrees of myopia (up to 5 D). In patients with higher
amounts of myopia (6–10 D), the response to surgery is
much more variable34–43 and undercorrection is more
common. The age of the patient partially determines the
upper limit of attainable correction. Older patients achieve
a greater correction by approximately 0.75 D to 1.00 D per
10 years of age exceeding 35 years.44 Other patient variables
may affect outcomes but are difficult to quantitate. For
example, reports show that a premenopausal female with a
flat cornea, low intraocular pressure, and a small corneal
diameter may achieve less correction than would be gener-
ally predicted for a particular RK technique.45–47
RK has been studied thoroughly, most notably by the
National Eye Institute (NEI)–funded, multicenter Prospec-
tive Evaluation of Radial Keratotomy (PERK) study, a col-
laborative effort of 9 clinical centers. Predictability of results
remains problematic.35–45 Early studies of predictability
showed that about 70% of eyes have a residual refractive
error within ±1 D of the predicted result and 90% within
±2 D.45–49 Later studies, with a staged approach, report
80% to 90% of eyes within 1 D of emmetropia.49–51 Stabil-
ity of refraction after radial keratotomy is also inade-
quate.52–54 The 10-year PERK results revealed long-term
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 7

A B

C D
• Fig. 1.5 Simulated displacements in corneal shape on the surface resulting from the four refractive surgi-
cal procedures at a normal intraocular pressure of 15 mm Hg. The dark-red areas involve maximum
displacements (>0.5 mm) outwards (body expansion), and the dark-blue areas involve zero displacement
near the constrained boundary of the models. The “preoperative surface” is displacement of the normal
cornea. (A) Radial keratectomy: maximum displacements located at middle incisions; (B) photorefractive
keratectomy: maximum displacement at central cornea; and (C) LASIK and (D) SMILE: maximum displace-
ments located around the central cornea (unit: mm). (From Shih P-J, Wang I-J, Cai W-F, Yen J-Y. Bio-
mechanical simulation of stress concentration and intraocular pressure in corneas subjected to myopic
refractive surgical procedures. Sci Rep. 2017;7(1):13906. doi:10.1038/s41598-017-14293-0.)

instability of refractive errors; 43% of eyes changed refrac-
tive power in the hyperopic direction by 1 D or more
(hyperopic shift) between 6 months and 10 years.52
RK has essentially been replaced by newer excimer laser
keratorefractive procedures. In 2003, one survey showed
that 4% of cataract and refractive surgeons performed RK,
down from 46% in 1996.53
Incisional Procedures for Myopic Astigmatism
Naturally occurring astigmatism is very common and up
to 95% of eyes may have some clinically detectable astig-
matism in their refractive error.55 Between 3% and 15% of
the general population has astigmatism greater than 2 D.56
Although there is some variability, approximately 10% of
the population can be expected to have naturally occur-
ring astigmatism greater than 1 D, where the quality of
UCVA might be considered unsatisfactory.9,57 Surgically
induced astigmatism can occur following cataract surgery.
The incidence of astigmatism following extracapsular cata-
ract extraction greater than 2 D is approximately 25% to
30%.58,59 With clear corneal incision phacoemulsification
procedures, the incidence of astigmatism is much less. Bel-
trame et al. showed 0.66 D to 0.68 D of surgically induced
astigmatism 3 months after phacoemulsification through a
3.5-mm clear cornea incision.60
Astigmatic keratotomy (AK) involves performing trans-
verse (also called tangential, or T) cuts in an arcuate or
straight fashion perpendicular to the steep meridian of astig-
matism (Fig. 1.7A). AK offers the patient a very good
chance of significant improvement by correcting astigmatic
errors.61–63 In general, patients with greater than 1.5 D of
astigmatism may be candidates for AK. Deeper and longer
incisions closer to the center of the cornea produce greater
effect, but cuts beyond 75 degrees are not recommended.
Effects of cuts increase dramatically with age. This proce-
dure is now performed with the femtosecond laser and,
rarely, with a diamond blade.
Relaxing incisions in the steep meridian were developed
by Troutman (Fig. 1.7B). These decrease astigmatism in the
steep meridian, but the results can be unpredictable.64,65
This procedure may be combined with wedge resection or
suturing in the flat meridian. These techniques have been
used to correct postkeratoplasty astigmatism and surgically
induced astigmatism at the time of cataract surgery.65–67
A study of 52 eyes showed a mean astigmatic change of
−0.8 D in patients who had clear cornea cataract surgery
with placement of limbal relaxing incisions (LRIs). The
control group of 47 eyes had a mean astigmatic change of
+0.50 D.68
The Ruiz procedure, now rarely used, employs trapezoi-
dal cuts, four transverse cuts inside two radial incisions
(Fig. 1.7C). Although important in its time, stacking mul-
tiple rows of astigmatic incisions is no longer felt to be
prudent because of poor predictability. A pair of tangential
8 se c t i o n I Introduction
• Fig. 1.6 In radial keratotomy, radial incisions are placed in the cornea
(top), resulting in forward bowing of the midperipheral cornea and
compensatory flattening of the central cornea (middle). Postoperative
appearance of radially symmetric spokes can be appreciated (bottom).
or arcuate incisions achieves significant correction. Addi-
tional incisions have minimal added benefit.
Nonlaser Lamellar Procedures for Myopia:
A Historical Perspective
Lamellar procedures for myopia involve corneal lamellar
dissection combined with the addition or subtraction of
corneal stromal tissue to result in overall flattening of corneal
curvature. Nonlaser lamellar techniques include keratomi-
leusis, automated lamellar keratoplasty, and epikeratophakia.
5mm 7mm
C
• Fig. 1.7 Correction of myopic astigmatism. (A) Astigmatic keratot-
omy. (B) Limbal relaxing incision. (C) Ruiz procedure.
Keratomileusis refers to carving or chiseling the cornea.
The first reported clinical results were published in 1964 by
Jose Barraquer, and keratomileusis was first performed in
the United States in 1980 by Swinger.69–71 For myopia,
keratomileusis involves excision of a lamellar button (lenti-
cule) of the patient’s cornea with a microkeratome, reshap-
ing the lamellar button such that the central corneal
curvature is flattened, and replacing it in position with or
without sutures. Automated lamellar keratoplasty (ALK),
also called keratomileusis in situ, was initially developed for
higher myopia (Fig. 1.8). ALK uses a mechanized micro-
keratome to remove a plano lenticule (corneal cap) or to
create a hinged corneal flap. A second pass of the micro-
keratome in the stromal bed resects a disc of central corneal
stroma, and the corneal cap or flap generally is replaced on
the stromal bed without sutures. The lenticule, at the time
of the first pass, can be secured by a small residual hinge of
tissue (flap) to minimize the possibility of losing the cap.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery
• Fig. 1.8 Automated lamellar keratoplasty. Schematic illustration of in
situ automatic corneal reshaping of the keratomileusis bed. The shaded
area refers to the location of tissue subtraction. A corneal button is
raised using a microkeratome (top). A second pass modifies the stromal
bed to allow corneal flattening after replacing the cap (middle).
9
The procedure enables correction of large degrees of myopia
(5 D to 18 D), but major problems include irregular astig-
matism, unpredictability, and long visual recovery time
(freezing damages tissue).72–75 Corrections beyond 18 D
require greater tissue resections, resulting in instability and
unpredictability.71,72 Clinically significant irregular astigma-
tism can occur in 10% to 15% after ALK, but this may
decrease with time.73,76,77
Epikeratoplasty (also known as epikeratophakia and onlay
lamellar keratoplasty) was introduced by Kaufman, Werblin,
and Klyce at the LSU Eye Center in the late 1970s and
early 1980s.78,79 It involves removal of the epithelium from
the patient’s central cornea and preparation of a peripheral
annular keratotomy. No microkeratome is used. A lyophi-
lized donor lenticule (consisting of the Bowman layer and
anterior stroma) is reconstituted and sewn into the annular
keratotomy site (Fig. 1.9).80 Theoretical advantages of epik-
eratophakia are its simplicity and reversibility.81 This proce-
dure is capable of correcting greater degrees of myopia than
keratomileusis, but irregular astigmatism, delayed visual
recovery, and prolonged epithelial defects are common.77,82
Corneal Implants for Myopia
Synthetic materials can be embedded between corneal
stromal lamellae to correct myopia. Intracorneal rings can
be threaded into a peripheral midstromal tunnel or placed
in a peripheral lamellar microkeratome bed to effect flatten-
ing of the central cornea.83,84 Their advantage lies in the
avoidance of manipulation of the central cornea and visual
axis (Fig. 1.10). Studies have also examined synthetic intra-
corneal lens implants that are placed in a centrally dissected
corneal stromal pocket for the correction of aphakia and
myopia (Fig. 1.11).85 These lenses have high indices of
refraction and are made of materials such as polysulfone.86–88
Hyperopia and Hyperopic and
Mixed Astigmatism
Although hyperopia affects approximately 40% of the adult
population,89,90 it is much less visually significant than
myopia. The great majority of young hyperopes regard their
eyes to be optically normal. They may experience early pres-
byopia and manifest hyperopia in their mid- to late thirties.
Hyperopia may also be the result of overcorrection following
radial keratotomy for myopia. This may require surgical
intervention, but a waiting period of approximately 1 year
may be necessary.91 Many of the keratorefractive procedures
used for hyperopia are similar in design to those used to
treat myopia but act to increase the cornea’s refractive power.
Laser Procedures
Excimer laser techniques—such as PRK, LASEK (or epi-
LASEK), and LASIK—can be used to treat hyperopia. An
ablation pattern allows for maximum ablation in the mid-
periphery for an overall steepening of the optical zone. At
present, custom corneal ablations are not approved for
hyperopic corrections in the United States.
10 se c t i o n I Introduction
• Fig. 1.9 Schematic illustration of epikeratoplasty. A preshaped donor lenticule (bottom) is sutured to the
recipient stromal bed to correct myopia (left) and hyperopia (right). The shaded areas refer to the locations
of tissue subtraction.
Laser Procedures for Hyperopia
Patients with low degrees of hyperopia treated with LASIK
achieve more predictable results and achieve refractive sta-
bility more quickly than those with higher amounts of
hyperopia (> 5 D).92,93 Stability with hyperopic LASIK is
usually reached by 3 months.14 One study has compared
LASEK and PRK for the treatment of hyperopia of up to
5.0 D. LASEK patients experienced less postoperative pain,
decreased haze, faster visual recovery, and greater refractive
stability compared to patients with hyperopic PRK.94
Laser Procedures for Hyperopic and
Mixed Astigmatism
Hyperopic astigmatism occurs when both meridians are
focused behind the retina. Patients with this profile can be
treated in minus-cylinder or plus-cylinder format. When
treating in minus-cylinder format, both meridians are flat-
tened centrally, with the steeper meridian being flattened
more. In plus-cylinder format, both meridians undergo
peripheral steepening, with the flatter meridian being steep-
ened more. Azar and Primack showed that plus-cylinder
ablations spare more tissue when treating hyperopic astig-
matism.95 A study of 124 eyes with hyperopic astigmatism
treated with the Alcon LADARVision excimer laser showed
results similar to those with hyperopic spherical treatment,
with 53.1% achieving 20/20 uncorrected visual acuity at 12
months with a small overcorrection of the cylinder.96
In patients with mixed astigmatism, one meridian must
be flattened and the other must be steepened because one
meridian is in focus in front of the retina and the other
behind the retina. Treatments that combine hyperopic
sphere with myopic cylinder treatments or hyperopic cylin-
der with myopic cylinder treatments spare the most tissue.95
In a study by Salz and Stevens,96 65 patients with mixed
astigmatism were treated with the Alcon LADARVision
excimer laser. Uncorrected visual acuity was 20/20 in 52%
at 12 months.
Incisional Procedures for Hyperopia
Hexagonal keratotomy, devised by Mendez in 1985, is an
incisional treatment for hyperopia consisting of circumfer-
ential connecting hexagonal peripheral cuts around a clear
4.5-mm to 6.0-mm optical zone. This procedure allows the
central cornea to steepen, thereby decreasing hyperopia
(Fig. 1.12).97 A second procedure using nonintersecting
hexagonal incisions was described by Casebeer and Phillips
in 1992.98 A study in 1994 of 15 eyes reported complica-
tions that included glare, photophobia, polyopia, fluctua-
tion in vision, overcorrection, irregular astigmatism, corneal
edema, corneal perforation, bacterial keratitis, and end-
ophthalmitis.99 These authors concluded that hexagonal
keratotomy was unpredictable, unsafe, and had high rates
of complications.99
Nonlaser Lamellar Procedures for Hyperopia
ALK, keratophakia, and epikeratophakia have been used
to treat hyperopia. In hyperopic ALK (also known as ker-
atomileusis), a deep lamellar keratectomy is performed
with a microkeratome, elevating a corneal flap. The stromal
bed subsequently develops ectasia under the flap, which
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery
B has been performed to hyperopia from 4 D to 10 D. In
• Fig. 1.10 Corneal intrastromal ring segments. (A) The ring is placed
in the stroma (top) resulting in central flattening (middle); the central
cornea is not manipulated (bottom). (B) Photograph of intrastromal
segments (arrows).
11
• Fig. 1.11 Schematic illustration of an intracorneal lens inlay. The
synthetic lens is placed in the corneal stroma after creation of a lamellar
flap (illustrated here) or within a lamellar pocket (not shown).
• Fig. 1.12 Conductive keratoplasty (CK). Spot algorithm used to
predict the effect of CK. A greater effect is obtained with neutral-
pressure CK.
is replaced without additional surgery. Alternatively, the
stromal side of the resected disc is remodeled into a convex
hyperopic lenticule that, when placed in the original
stromal bed, results in steepening of the central cornea.
Hyperopic ALK has poor predictability and the risk of
progressive ectasia limits its usefulness. Homoplastic ALK
this procedure, the microkeratome removes a small disc
(80–100 mm in thickness, 5–7 mm in diameter) that is
discarded and replaced by a 350- to 400-µm thick donor
lenticule (generated using the microkeratome). The safety
12 se c t i o n I Introduction
and efficacy of hyperopic and homoplastic ALK have not
been fully established.100
Keratophakia is a technique developed by Barraquer for
treating high hyperopia or aphakia. A lamellar keratectomy
is first performed on the patient’s cornea using a microkera-
tome. Donor corneal tissue is then shaped into a lens after
removal of the epithelium, Bowman layer, and anterior
stroma. This donor lens is placed intrastromally within the
recipient and the anterior lamellar cap is sutured in place.
This process creates a steeper anterior cornea and increases
refractive power. Synthetic intracorneal lenses have also
been developed for implantation in the lamellar bed but are
investigational. Hyperopic epikeratophakia uses a prepared
donor lenticule without microkeratome removal of tissue.
Although theoretically safer than keratomileusis, it lacks
predictability and may induce irregular astigmatism.101
Thermal Procedures for Hyperopia
Thermal energy can be used to shrink collagen of the corneal
stroma and increase central corneal power. When applied
to the paracentral or peripheral cornea, these techniques
result in increased central corneal curvature and peripheral
corneal flattening. Three methods are described: radial
intrastromal thermokeratoplasty, laser thermokeratoplasty,
and conductive keratoplasty.
Radial intrastromal thermokeratoplasty shrinks the
peripheral and paracentral stromal collagen, producing a
peripheral flattening and a central steepening of the cornea
to treat hyperopia. Radial thermokeratoplasty (hyperopic
thermokeratoplasty [HTK]) for the correction of hypero-
pia was developed in the then Soviet Union in 1981 by
Fyodorov. A retractable cautery probe tip produces a series
of preset-depth (≈ 95%) stromal burns in a radial pattern
similar to that used in RK.41,102–105 Although an initial
reduction in hyperopia was observed, lack of predictability
and significant regression are problems.41,102–105 However,
there may be less induced astigmatism with radial ther-
mokeratoplasty than with hyperopic ALK or hexagonal
keratotomy.106
Solid-state infrared lasers, like the holmium:yttrium alu-
minum garnet (Ho:YAG) laser, have been used in a periph-
eral intrastromal radial pattern (laser thermokeratoplasty
[LTK]) to treat hyperopia of 4 D and less.107 LTK works
by causing thermal shrinkage of stromal collagen in the
paracentral cornea, with a resultant steepening of the central
corneal curvature, thereby reducing hyperopia. Recent work
on human eyes has demonstrated appropriate topographic
changes with at least short-term stability.108 This laser energy
can be delivered by a handheld probe or slit beam system and
appears most useful for limited amounts of hyperopia
and hyperopic astigmatism. However, the long-term effects
and refractive stability of Ho:YAG LTK are unknown.
Conductive keratoplasty (CK) is a technique that has
been recently approved by the US Food and Drug Admin-
istration (FDA) for the treatment of hyperopia and presby-
opia. CK uses a special probe to deliver radiofrequency wave
energy to the deep stroma of the midperipheral cornea,
causing focal shrinkage of collagen fibers, steepening the
central cornea and flattening the periphery (see Fig. 1.12).
Applications are made in concentric 6-, 7-, or 8-mm circles;
the amount of effect depends on the number of spots placed.
At the present time, CK has been approved for the treatment
of hyperopia (0.75–3.25 D, with no more than 0.75 D of
astigmatism) and presbyopia in emmetropes and hyperopes
(by induction of myopia, −1.00 D to −2.00 D).107,108
Aphakia
Most aphakic patients who are intolerant of contact lenses
or simply desire refractive correction undergo secondary
intraocular lens placement. Aphakic patients who are at
high risk for intraocular procedures may benefit from kera-
torefractive surgery. These procedures for the treatment of
aphakia are similar to nonlaser lamellar techniques, such as
keratophakia and epikeratoplasty or corneal implants for
high hyperopia. As described before, keratophakia involves
the intrastromal placement of donor stromal tissue that has
been shaped into a lens. The donor tissue lens is thicker in
the center than in the periphery. Epikeratophakia has been
described previously for myopia and hyperopia and involves
sewing a donor lenticule to the anterior surface of the pre-
pared cornea. Widespread use of epikeratophakia is limited
because of problems with epithelial healing and graft clarity.
Its main use is in the correction of aphakic children aged 1
to 8 years who are spectacle and contact-lens intolerant, in
order to avoid amblyopia. The highest success rates in epi-
keratophakia have been reported in the treatment of 8- to
18-year-old patients with aphakia.109
Intracorneal lens implants are under investigation.
Advantages include improved refractive quality and predict-
ability and faster visual recovery when compared to nonlaser
lamellar techniques for aphakia. In addition, corneal
implants eliminate the risks associated with the use of
human donor tissue. Materials such as hydrogel85 or fenes-
trated polysulfone,110 with a high index of refraction, have
been studied. Steinert et al. reviewed the use of a hydrogel
implant (lidofilcon A) in patients with aphakia, followed
over 2 years. A total of 88% of these patients had a refrac-
tion within 3 D of plano. Complications included loss of
BCVA, irregular astigmatism, and irregular microkeratome
resections in some patients.111
Presbyopia
Near vision correction is an especially important consider-
ation when planning refractive surgery in the presbyopic age
group. Myopic patients may experience difficulty with near
vision if their refractive error is fully corrected. Undercor-
rected myopes may experience less-than-optimal distance
vision but may retain some of their ability to see clearly at
near distances. Keratorefractive procedures for presbyopia
include monovision, a procedure that leaves a residual
myopic correction in one eye, and multifocal corneal abla-
tion, a procedure that is still in development.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery
Monovision
Monovision improves near vision by giving one eye a
slightly myopic correction, usually −1 D to −2 D. The
other eye is corrected fully for distance. Myopia remain-
ing in the dominant eye is called uncrossed monovision,
and myopia remaining in the nondominant eye is called
crossed monovision. Monovision treatments can be applied
to myopes, hyperopes, and emmetropes. For patients with
myopia, the “near” eye is not treated for the full amount
of myopic refractive error; rather, it is left with a residual
myopic correction. In hyperopes, myopia must be created
by “overcorrecting” the near eye. Keratorefractive options to
achieve monovision have expanded in the past decade and
include PRK, LASIK, and conductive keratoplasty. One
challenge to creating monovision with laser and conductive
procedures is irreversibility.
Following monovision treatment, patients must adapt to
its effect. Monovision patients have been found to perform
relatively worse with low levels of illumination, near-
threshold levels of stimuli, and tasks requiring good depth
perception.112,113 However, among patients who underwent
PRK and LASIK monovision correction, between 88% and
96% were satisfied with their visual outcome.114,115
Conductive Keratoplasty
While conductive keratoplasty was approved in the United
States for the treatment of presbyopia in emmetropes, the
advantages that it offers being a nonincisional, nonablative
approach are limited by a high rate of refractive regression.
In a retrospective consecutive single-surgeon study, Ayoubi
et al.116 compared FS-LASIK and conductive keratoplasty
for monovision treatment of the nondominant eye in pres-
byopic emmetropic patients. FS-LASIK monovision pro-
vided stable correction with less induced astigmatism and
HOA; the retreatment rate was 3% after FS-LASIK com-
pared to 50% after CK (P <.0001). Stahl et al.117 evaluated
long-term follow-up for unilateral CK performed in the
nondominant eyes of near-plano presbyopic patients. The
postoperative refraction for these eyes eventually stabilized,
with no statistically significant change in mean manifest
spherical equivalent or keratometry between 1 and 3 years.
Multifocal Corneal Ablation and PresbyLASIK
Multifocal corneal ablation is still an experimental process
in which the excimer laser is used to produce different
optical zones within the cornea that can serve distance or
near vision (see Fig. 1.12). PresbyLASIK, a multifocal
corneal ablation procedure based on traditional LASIK,
creates a multifocal surface able to correct any visual defect
for distance while reducing the near spectacle dependency.
This multifocal cornea produces simultaneous images on
the retina, and the patient processes the appropriate image
when performing distance or near tasks. For example, when
looking at a distance target, the image produced by the
optical zone(s) for distance will be in focus while light
passing through the near optical zone(s) will create blur.
13
• Fig. 1.13 Differences between ablation patterns. In peripheral pres-
byLASIK, the center of the cornea is treated for distance vision and
the periphery for near. In central presbyLASIK, the center of the cornea
is treated for near vision and the periphery for distance vision. (Modified
from Vargas-Fragoso V, Alió JL. Corneal compensation of presbyopia:
PresbyLASIK: an updated review. Eye Vis. 2017;4:11.)
Side effects include postoperative glare, halos, ghost images,
and monocular diplopia.118–124 Treatment may be limited by
pupil size and the degree of refractive error.110
Pseudo-accommodative corneas may take on two pos-
sible patterns: peripheral presbyLASIK creates a peripheral
concentric near zone, while central presbyLASIK creates
a central near zone (Fig. 1.13).125,126 A recent study of
presbyLASIK in myopes and hyperopes found that pres-
byLASIK induced significant changes in spherical aberra-
tion. In myopes, this yields the advantage of an increased
depth of focus relative to LASIK; in hyperopes, the spheri-
cal aberration is more consistent, independent of refractive
change.127,128 Alió et al. demonstrated predictability, stability,
safety, and good visual outcomes with central presbyLASIK
in presbyopic patients with hyperopia.129,130 PresbyLASIK
has also been combined with micro–monovision to allow
for better intermediate vision stereoacuity than monovision
alone.131
Corneal Inlays
Corneal inlays are lenticules that are inserted into an FS-
created corneal stromal pocket for the treatment of presby-
opia. There are currently 3 types of corneal inlays available:
the KAMRA (AcuFocus) inlay uses a pinhole effect; Presby-
Lens (ReVision Optics) is based on corneal shape changes;
and Flexivue Microlens (Presbia) has a central plano zone
surrounded by peripheral ring segments of different refrac-
tive indices. These inlays differ from monovision by preserv-
ing distance vision in the implanted eye. The KAMRA inlay
was the first FDA-approved implant in this class; long-term
studies demonstrate good uncorrected near and intermedi-
ate vision, without an unacceptable decrease in distance
vision. However, the KAMRA inlay restricts entering light
with the small aperture; in a small percentage of patients,
this causes glare, halos, and reduced contrast and night
14 se c t i o n I Introduction
vision.132–135 Compared to ablative procedures, inlays carry
the benefit of reversibility. Complications are uncommon;
the most common complication of a decentered inlay may
be corrected with recentration.135
Hybrid
Hybrid techniques combine the benefits of these approaches
and intend to suppress their drawbacks. Laser-blended
vision provides moderate multifocality in both eyes com-
bined with a small degree of monovision in the near eye).
In Supracor and PresbyMAX, reduced multifocality in the
distance eye is combined with full multifocality and mono-
vision in the near eye. Supracor is an aberration-optimized
algorithm that creates a 3.0-mm hyperpositive area of
+2.00 D for near vision, with either symmetric or asym-
metric surrounding distance correction. Presbymax creates
a biaspheric multifocal corneal surface with a central hyper-
positive area of +0.75 D to +2.50 D for near vision correc-
tion, surrounded by an area of distance correction.136
Intracor uses FS laser to create several concentric intrastro-
mal rings at different depths to steepen the central cornea
of the nondominant eye and is used in low hyperopic,
emmetropic, and low myopic eyes. Since Intracor requires
no ablation, it protects the integrity of the cornea with a
stable gain in uncorrected near visual acuity (UNVA).137
A systematic review of presbyopic correction of the
cornea by Mosquero and Alió131 concluded that Presby-
MAX provided excellent UNVA and distance corrected near
visual acuity, with high predictability and a 1% reversal rate.
KAMRA provided similarly excellent uncorrected distance
visual acuity with a 1% retreatment rate but a 6% reversal
rate. In contrast, presbyLASIK, laser-blended vision and
Supracor all had high subsequent retreatment rates. Nearly
all forms of presbyLASIK yield a loss of at least two lines
of distance visual acuity, generally caused by dry eye or
the induction of HOAs. Intracor was found to have a high
(9%) loss of two or more lines of corrected distance visual
acuity. Subsequent reports on corneal ectasia and concerns
regarding retreatment and reversibility have raised safety
concerns.138,139
Lenticular and Scleral Refractive
Surgical Procedures
The majority of refractive procedures performed today are
of the keratorefractive type. There may be absolute or rela-
tive contraindications, however, that make keratorefractive
procedures unacceptable in certain individuals. For example,
patients with high ametropias—high myopia, high hypero-
pia, or high degrees of astigmatism—may not be appropri-
ate candidates for laser keratorefractive procedures because
treatment might ablate too much corneal tissue or because
the degree of refractive error exceeds the approved treatment
ranges of available excimer lasers. Keratorefractive proce-
dures are also limited in their ability to provide good dis-
tance and near vision in the same eye. Refractive surgical
techniques that are not cornea based provide an alternate
method of decreasing dependence on spectacles or contact
lenses for these patients and offer the benefit of a more
stable refraction. Lenticular procedures rely on the place-
ment of intraocular lenses for the correction of ametropias
and have been used to treat myopia, hyperopia, astigma-
tism, and presbyopia. Scleral techniques described later are
used for the treatment of presbyopia.
Clear Lens Extraction
Clear lens extraction (CLE) involves the removal of the
clear crystalline lens using techniques routinely employed in
cataract surgery. These patients typically have high degrees
of myopia or hyperopia; refractive error is corrected by
placing an intraocular lens at the time of the procedure.
Some patients with high degrees of myopia may be left
aphakic. Surgical risks include those of routine cataract
surgery although the risk of retinal detachment is increased
in high myopes undergoing CLE. Fernandez-Vega et al.
reviewed 190 cases of CLE in patients with an axial length
greater than 26.00 mm. In these patients, the risk of retinal
detachment was 2.10%, with a mean follow-up time of
4.78 years.140
Phakic Intraocular Lenses
PIOLs have become an option for the treatment of high
ametropias or presbyopia. PIOLs are inserted between the
cornea and the natural lens. They are attractive because
they preserve accommodation, yield predictable results, and
have a lower risk of retinal detachment than CLE.112 Lens
designs are of 3 basic types: anterior chamber IOLs, iris-
fixated IOLs, and posterior chamber IOLs that are placed
between the iris plane and the natural lens. These lenses
have been inserted for the treatment of high myopia, high
hyperopia, and astigmatism (toric PIOL). Complications of
PIOLs include endothelial cell loss, cataract formation, risk
of synechiae or atrophy, and retinal detachment.141
Long-term follow-up for toric PIOLs has demonstrated
high patient satisfaction as well. Guell et al. reported 5-year
follow up of 299 iris-fixated PIOLs, including 84 toric
PIOLs. Mean spherical equivalent of −6.82 D was reduced
to −0.09 D, mean preoperative cylinder of −3.24 D was
reduced to −0.83 D, and endothelial cell count was reduced
by only 3.6%.142,143 Dick et al. found a statistically signifi-
cant increase in mean contrast sensitivity 3 months after
toric PIOL implantation in 195 eyes.144
Bioptics
Bioptic procedures combine intraocular methods with
corneal refractive procedures to correct refractive errors
with predictability and stability. High levels of ametro-
pia may not be successfully treated with corneal refrac-
tive procedures alone. Intraocular surgery such as CLE or
PIOL placement is usually performed first, followed by
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery
keratorefractive surgery to correct residual error. Zaldivar
et al. reviewed the results of bioptics procedures performed
in myopes. Patients were treated with LASIK at least 1
month after either phakic or pseudophakic intraocular lens
placement. Patients with PIOLs and LASIK had a mean
preoperative spherical equivalent refraction of −5.50 D and
postoperatively −0.40 D at 1 month. Pseudophakic patients
with bioptics had a mean preoperative spherical equiva-
lent refraction of −2.61 D and postoperatively +0.90 at 1
month. The most frequent complication was keratitis sicca,
occurring in approximately 10% of patients.145,146
Aphakia
Lenticular procedures for the management of aphakia
involve the placement of intraocular lenses. Planning sec-
ondary intraocular lens placement depends on the status of
the lens capsule and angle structures along with the pres-
ence or absence of glaucoma. In the setting of an intact
lens capsule, an IOL may be placed within the capsular
bag. If anterior capsular support is adequate but poste-
rior capsular support is inadequate, sulcus fixation of the
lens is preferred. In the absence of adequate anterior or
posterior capsular support, anterior chamber lens place-
ment, iris-suture fixation and scleral-suture fixation are
options.
Presbyopia
At present, there is no single widely accepted lenticular
or scleral procedure for the treatment of presbyopia. As
described earlier, monovision procedures achieve distance
and near vision correction by creating a different refrac-
tive error in each eye, resulting in some sacrifice in bin-
ocularity. This option has been applied in patients who
undergo keratorefractive procedures or bilateral intraocu-
lar lens placement in the setting of cataract surgery. The
techniques described later aim at providing good distance
and near vision in the same eye through the use of mul-
tifocal or accommodating lenses or through the restora-
tion of accommodative function. Next, we summarize
three lenticular and two scleral methods that have been
investigated.
Multifocal Intraocular Lenses
Multifocal IOLs can provide distance and near vision in
patients who undergo cataract surgery. These lenses rely on
either diffractive optics or zones of different refractive power
to create their multifocal effect. Diffractive IOLs use light
diffraction at an interference grid to produce two different
focal points. In refractive IOLs, superimposed images are
created on the retina by the different zones of the lens. If a
distance object is being viewed, its image will be focused
clearly on the retina while areas of the lens for near viewing
produce a defocused retinal image. Multifocal PIOLs have
also been implanted for presbyopia.147
15
Common disadvantages of multifocal IOLs include
glare, halos, and loss of contrast sensitivity or image
quality.148,149 It is also important to accurately target emme-
tropia in these patients because residual refractive error can
adversely affect near vision. Patients with multifocal IOLs
have reported increased range of vision and decreased
dependence on spectacles.150 Multifocal IOLs offer the
optical advantage of a two- to threefold increase in the
depth of field at the expense of a 50% reduction in retinal
image contrast.151,152 However, several large studies, includ-
ing comparisons with monofocal IOLs, have found good
quality of vision outcomes. A 2016 Cochrane review com-
paring monofocal and multifocal IOL implants after cata-
ract extraction concluded that both groups had similar
distance visual acuity outcomes but those with multifocal
implants achieved better near vision and were less depen-
dent on spectacles. There was some evidence that contrast
sensitivity may be lower in people receiving multifocal
IOLs. In the Array prospective nonrandomized series
reported by Steinert et al., 81% of bilateral multifocal IOL
patients could read without glasses compared with 53% to
58% of unilateral cases.153
Accommodating and
Pseudo-Accommodating Lenses
Accommodative IOLs attempt to provide clear near and
distance vision by taking advantage of residual contraction
of the ciliary body. Still under investigation, these lenses are
placed in the capsular bag and provide near vision by
moving the optic forward with accommodative effort.
Single optic designs have a movable lens with flexible
haptics. With ciliary body contraction, the lens optic moves
forward to provide accommodation. Double-lens designs
contain two optics placed in the capsular bag. Accommoda-
tive effort causes the more posterior optic to move forward,
providing greater clarity of vision at near. There are a variety
of other lenses in the development pipeline that employ
different models of accommodation, including fluid-filled
haptics that actuate a central lens curvature change with
ciliary body contraction, which may provide a greater degree
of accommodative range. Lens models with increased
number and area of haptic coverage may allow improved
coupling with the ciliary body force.
The only FDA-approved accommodating monofocal
IOL is the Crystalens (Bausch & Lomb), a single-piece,
hinged lens. FDA clinical trials with 2-year data demon-
strated that 91.9% of eyes achieved an uncorrected distance
acuity of 20/40 or better and 95.3% achieved an uncor-
rected near acuity of J3 or better. The percentage of patients
with uncorrected distance acuity of 20/20 or better or J1 or
better at 2 years was 58.4% and 48.8%, respectively.154 A
2014 Cochrane review of accommodating IOLs concluded
that while patients with accommodative IOLs saw improve-
ment in near vision at 6 and 12 months after implantation
relative to those with monofocal IOLs, the improvement
was small and reduced with time. Some studies have
16 se c t i o n I Introduction

A B

C D
• Fig. 1.14Phaco-Ersatz for restoration of accommodation. (A) The anterior chamber is entered through
clear cornea, a capsulorhexis of approximately 1 mm diameter is made, and the lens is removed through
this opening. (B) The empty, intact capsule remains. (C) A polymer is injected into the capsular bag.
(D) A new, flexible lens is the end result.

demonstrated decreased distance vision beyond 12 months

after surgery.155
Phaco-Ersatz
Phaco-Ersatz is a method in which accommodation is
restored by replacing the contents of the crystalline lens with
a soft polymer gel. A small capsulorhexis is made in the
anterior capsule of the lens, allowing the lens material to be
removed. The capsule is then filled with a polymer gel. The
amount of accommodative power is determined by the refrac-
tive index of the gel material or the amount of filling of the
capsular bag (Fig. 1.14). In nonhuman primates, up to 4 D
of accommodation has been created with this method.156

Scleral Relaxation and Scleral
The Helmholtz model of accommodation suggests that as
the ciliary muscle contracts, tension on the lens zonules
is reduced, allowing the lens shape to change and accom-
modation to occur.157 Presbyopia may occur because of a
decrease in elasticity of the lens zonules and sclerosis of the
lens with age. An alternative model of accommodation has
been proposed by Schachar.158 The Schachar model suggests
that ciliary body contraction increases tension on the equa-
torial zonules while decreasing tension on the anterior and
posterior zonules. This process causes an increase in the lens
diameter, thinning the periphery and thickening the center,
resulting in accommodation. Presbyopia, in this model, is
the result of lens growth and crowding. Increased size of
the lens with age results in a decreased ability of the lens
to expand into the posterior chamber with accommodative
effort. In addition, increased lens size decreases the distance
between the lens equator and the ciliary muscle, reducing
the effective pull of the ciliary muscle with accommodation.
Scleral relaxation and scleral expansion are surgical
methods that rely on the concepts of the Schachar model
in order to restore accommodation.159 Scleral relaxation
• Fig. 1.15Scleral expansion for treatment of presbyopia. Conjunctival
peritomies are performed in the 4 oblique quadrants. Scleral belt loops
are made in the oblique quadrants and individual polymethylmethac-
rylate segments are inserted.
techniques attempt to increase accommodation by increas-
ing the space between the lens equator and the ciliary body.
Anterior ciliary sclerotomy is a procedure that has been
suggested in which eight equally spaced radial incisions are
placed through the conjunctiva and sclera overlying the
ciliary body. Early results have shown an increase in accom-
modative amplitude of up to 2.2 D; however, this effect
regresses with healing of the sclerotomies. A modified tech-
nique has been used in which sclerotomies are performed
with placement of silicone scleral expansion plugs. Four
polymethylmethacrylate (PMMA) segments are placed
under scleral pockets or belt loops in the oblique quadrants,
just posterior to the limbus (Fig. 1.15) to reorient tension
on the posterior zonules and improve the efficiency of the
ciliary body in reshaping the lens This technique can
increase accommodation from between 1 D to 10 D and
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plainly visible as they crawl along the resounding beach at a mile’s
distance. Happily, though hungry for prey, they will not be satisfied.
Swimming would be of no use, but an “Icelandic water-horse”
seldom blunders or makes a false step. But another danger lies in
the masses of ice swept down by the whirling waves, many of which
are sufficiently large to topple over horse and rider.
How the horses are able to stand against such a stream is every
traveller’s wonder; nor would they do so unless they were inured to
the enterprise from their very youth. The Icelanders who live in the
interior keep horses known for their qualities in fording difficult rivers,
and never venture to cross a dangerous stream unless mounted on
an experienced “water-horse.”
The action of the Icelandic horses in crossing a swift river is very
peculiar. They lean all their weight against the current, so as to
oppose it as much as possible, and move onwards with a
characteristic side-step. This motion is not agreeable. It feels as if
your horse were marking time, like soldiers at drill, without gaining
ground, and as the progress made is really very slow, the shore from
which you started seems to recede from you, while that to which you
are bound does not seem to draw nearer.
In the mid-stream the roar of the waters is frequently so great that
the travellers cannot make their voices audible to one another. There
is the swirl of the torrent, the seething of the spray, the crunching of
the floating ice, the roll of stones and boulders against the bottom,—
and all these sounds combine in one confused chaotic din. Up to this
point, a diagonal line, rather down stream, is cautiously followed; but
when the middle is reached, the horses’ heads are turned slightly
towards the current, and after much effort and many risks the
opposite bank is reached in safety.
Lord Dufferin says, with much truth, that the traveller in Iceland is
constantly reminded of the East. From the earliest ages the
Icelanders have been a people dwelling in tents. In the days of the
ancient Althing, the legislators, during the entire session, lay
encamped in movable booths around the place of council. There is
something patriarchal in their domestic polity, and the very migration
of their ancestors from Norway was a protest against the
antagonistic principle of feudalism. No Arab could be prouder of his
high-mettled steed than the Icelander of his little stalwart, sure-
footed pony: no Oriental could pay greater attention to the duties of
hospitality; while the solemn salutation exchanged between two
companies of travellers, as they pass each other in what is
universally called “the desert,” is not unworthy of the stately courtesy
of the gravest of Arabian sheikhs.
It is difficult to imagine anything more multifarious than the cargo
which these caravans import into the inland districts: deal boards,
rope, kegs of brandy, sacks of rye or wheaten flour, salt, soap, sugar,
snuff, tobacco, coffee; everything, in truth, which is necessary for
domestic consumption during the dreary winter season. In exchange
for these commodities the Icelanders give raw wool, knitted
stockings, mittens, cured cod, fish-oil, whale-blubber, fox-skins,
eider-down, feathers, and Iceland moss. The exports of the island in
wool amount to upwards of 1,200,000 lbs. of wool yearly, and
500,000 pairs of stockings and mittens.
 ICELANDERS FISHING FOR NARWHAL.
Iceland offers abundant sport to the enthusiast in fishing. The
streams are well supplied with salmon; while the neighbouring seas
abound in seals, torsk, and herrings. The narwhal-fishery is also
carried on, and has its strange and exciting features. The implement
used is simply a three-pronged harpoon, like a trident, with which the
fisherman strikes at the fish as they rise to the surface; and his
dexterity and coolness are so great that he seldom misses his aim.
Numerous works, in English, have been written upon Iceland and
the Icelanders; the most trustworthy are those by Dr. Henderson,
Professor Forbes, Holland, Chambers, and Lord Dufferin. The King
of Denmark visited Iceland in 1874.
 CHAPTER VII.
THE ESKIMOS.

he land of the Eskimos is of very wide extent. From Greenland

and Labrador they range over all the coasts of Arctic America
to the extreme north-eastern point of Asia. Several of the
Eskimo tribes are independent; others acknowledge the rule of Great
Britain, Denmark, Russia, and more recently of the United States.
The whaler meets with them on the shores of Baffin Bay, and in the
icy sea beyond Behring Straits; the explorer has tracked them as far
as Smith Sound, the highway to the North Pole; and while they
descend as low as the latitude of Vienna, they rove as far north as
the 81st and 82nd parallels. They are the aborigines of the deserts of
ice and snow, the ancient masters of the Arctic wilderness, and all
Polar America is their long-acknowledged domain. To a certain
extent they are nomadic in their habits; compelled to migrate by the
conditions of the climate in which they live, and forced to seek their
scanty sustenance in a new locality when they have exhausted the
capabilities of any chosen habitat. As Mr. Markham tells us, traces of
former inhabitants are found throughout the gloomiest wastes of the
Arctic regions, in sterile and silent tracts where now only solitude
prevails. These wilds, it is known, have been uninhabited for
centuries; yet they are covered with memorials of wanderers or of
sojourners of a bygone age. Here and there, in Greenland, in
Boothia, on the American coast, where life is possible, the
descendants of former nomads are still to be found.
Arctic discovery, as yet, has stopped short at about 82° on the
west coast, and 76° on the east, of Greenland. These two points are
about six hundred miles apart. There have been inhabitants at both
points, though they are separated by an uninhabitable interval from
the settlements further south; we may conclude, then, that the terra
incognita further north is also or has been inhabited. In 1818 it was
discovered that a small tribe of Eskimos inhabited the bleak west
coast of Greenland between 76° and 79° N. They could not
penetrate to the south on account of the glaciers of Melville Bay;
they could not penetrate to the north, because all progress in that
direction is forbidden by the great Humboldt glacier; while the huge
interior glacier of the Sernik-sook pent them in upon the narrow belt
of the sea-coast. These so-called “Arctic Highlanders” number about
one hundred and forty souls, and throughout the winter their
precarious livelihood depends on the fish they catch in the open
pools and water-ways. Under similar conditions, it is probable that
Eskimo tribes may be existing still further north; or if, as geographers
suppose, an open sea really surrounds the Pole, and a warmer
atmosphere prevails, the conditions of their existence will necessarily
be more favourable.

Before we come to speak of the characteristics of the Eskimos,

we must briefly notice the Danish settlements in Greenland, which
are gradually attracting no inconsiderable number of them within the
bounds of civilization. These are dotted along the coast, like so many
centres of light and life; but the most important, from a commercial
point of view, are Upernavik, Jacobshav’n, and Godhav’n.
Upernavik is the chief town of a district which extends from the
70th to the 74th degree of north latitude, and enjoys the distinction of
being the most northerly civilized region in the world. Its northern
boundary represents the furthest advance of civilization in its long
warfare against the Arctic climate.
 UPERNAVIK, GREENLAND.
The town of Upernavik is situated on the summit of a mossy hill
which slopes to the head of a small but sheltered harbour. It contains
a government-house, plastered with pitch and tar; a shop or two;
lodging-houses for the Danish officials; some timber huts, inhabited
by Danes; and a number of huts of stone and turf, intermingled with
seal-skin tents, which accommodate the natives. Its principal
evidences of civilization are its neat little church and parsonage.
The inhabitants are chiefly occupied in fishing and hunting, and in
the manufacture of suitable clothing for the protection of the human
frame against the winter cold. Reindeer, seal, and dog skins are
deftly converted into hoods, jackets, trousers, and boots. The last-
named are triumphs of ingenuity. They are made of seal-skin, which
has been tanned by alternate freezing and thawing; are sewed with
sinew, and “crimped” and fitted to the foot with equal taste and skill.
Dr. Hayes informs us that the Greenland women, not exempt from
the love of finery characteristic of their sex, trim their own boots in a
perfectly bewitching manner, and adopt the gayest of colours. Red
boots, or white, trimmed with red, he says, seemed most generally
worn, though there was no more limit to the variety than to the
capriciousness of the fancy which suggested it. And it would be
difficult to imagine a more grotesque spectacle than is presented by
the crowd of red, and yellow, and white, and purple, and blue-legged
women who crowd the beach whenever a strange ship enters the
harbour.
The population of Upernavik numbers now about two hundred
and fifty souls; comprising some forty or fifty Danes, a larger number
of half-breeds, the remainder being native Greenlanders,—that is,
Eskimos.

DISKO ISLAND, GREENLAND.

In describing one Danish settlement we describe all, for they
present exactly the same characteristics, the difference between
them being only a question of population.
 GODHAV’N, DISKO ISLAND, GREENLAND.
Jacobshav’n and Godhav’n are situated on the island of Disko,
which is separated from the west coast of Greenland by Weygat
Strait, and has been described as one of the most remarkable
localities in the Arctic World. The tradition runs that it was translated
from a southern region to its present position by a potent sorcerer;
and an enormous hole in the rock is pointed out as the gully through
which he passed his rope. It is a lofty island, and its coast is belted
round by high trap cliffs, of the most imposing aspect. Near its south-
west extremity, in lat. 69° S., a low rugged spur or tongue of granite
projects into the sea for about a mile and a half,—a peninsula at low
water, and an island at high water,—and forms the snug little recess
of Godhav’n, or Good Harbour. To the north of the bay, in face of
rocky cliffs, which rise perpendicularly from the sea to a height of
2000 feet, lies the town of the same name, which our English
whalers know as Lievely, probably a corruption of the adjective lively;
for the tiny colony is the metropolis of Northern Greenland; and since
the beginning of the present century has been the favourite
rendezvous of the fishing fleets and expeditions of discovery.
 Further to the north lies Jacobshav’n, which possesses a
celebrity of its own as one of the most ancient of the Moravian
mission-stations in the north of Greenland. Besides a church, it
boasts of a college for the education and training of natives who
desire to be of service to their fellow-countrymen in the capacity of
catechists or teachers. So great has been the industry, and so well
deserved is the influence of the missionaries, that it is difficult now to
find an Eskimo woman in this part of Greenland who cannot read
and write. Prior to the Danish colonisation of Greenland, the
language of the natives was exclusively oral. Only through the
medium of speech could they represent their simplest ideas; and the
picture-writing of the North American Indians was beyond their skill.
But the missionaries have raised the Eskimo tongue into the rank of
written languages. At Godthaab a printing-press is in full operation,
and has already produced some very interesting historical narratives
and Eskimo traditions.

DANISH SETTLEMENT OF JACOBSHAV’N, GREENLAND.

As is the case with all the Greenland colonies, Jacobshav’n owes
its prosperity to the seal-fishing. Moreover, the Greenland, or “right”
whale, in its annual migrations southward, enters the neighbouring
waters during the month of September, and furnishes employment to
the fishing population.
 In the neighbourhood of Jacobshav’n an enormous glacier, one of
the offshoots of the great central mer de glace of Greenland, finds its
way to the sea. Yet the temperature is said to be milder than at
Godhav’n.

The following remarks apply, of course, to those Eskimos who

still lead a nomadic life, and have profited little or nothing by the
Christian civilization of the Danish settlements and Moravian
missions.
Among themselves the Eskimos are known as Inuits, or “men;”
the seamen of the Hudson Bay ships have long been accustomed to
call them Seymos or Suckemos—names derived from the cries of
Seymo or Teymo with which they hail the arrival of the traders; while
the old Norsemen designated them, in allusion to their discordant
shouts, or by way of expressing their infinite contempt, Skraelingers,
“screamers” or “wretches.”
The European feels impelled to pity the hard fate which
condemns them to inhabit one of the dreariest and most inhospitable
regions of the globe, where only a few mosses and lichens, or plants
scarcely higher in the scale of creation, can maintain a struggling
existence; where land animals and birds are few in number; and
where human life would be impossible but for the provision which the
ocean waters so abundantly supply. As they live in a great degree
upon fish and the cetaceans, they dwell almost always near the
coast, and never penetrate inland to any considerable distance.
In the east the Eskimos, for several centuries, have been
subjected to the civilizing influences of the English and the Dutch; in
the west, they have long been under the iron rule of the Muscovite.
In the north and the centre their intercourse with Europeans has
always been casual and inconsiderable. It will therefore be
understood that the different branches of this wide-spread race must
necessarily exhibit some diversity of character, and that the same
description of manners and mode of life will not in all points apply
with equal accuracy to the savage and heathen Eskimos of the
extreme northern shores and islands, the Greek Catholic Aleüts, the
faithful servants of the Hudson Bay Company, and the disciples of
the Moravian Brethren in Labrador or Greenland. Yet the differences
are by no means important, and it may be doubted whether any
other race, living under such peculiar conditions, and extending over
so vast an area, can show so few and such inconsiderable specific
varieties. When one thinks of an Eskimo, one naturally calls up a
certain image to one’s mind: that of a man of moderate stature or
under medium size, with a broad flat face, narrow tapering forehead,
and narrow or more or less oblique eyes; and this image or type will
be found to be realized throughout the length and breadth of Eskimo
America. The Eskimo, generally speaking, would seem to have
sprung from a Mongol stock; at all events, he can claim no kinship
with the Red Indians. Happily for Europeans, if inferior to the latter in
physical qualities, he is superior in generosity and amiability of
disposition.
The Eskimos are sometimes spoken of as if they were dwarfs or
Lilliputians, but such is not the case. They are shorter than the
average Frenchman or Englishman, but individuals measuring from
five feet ten inches to six feet have been found in Camden Bay. Dr.
Kane speaks of Eskimos in Smith Strait who were fully a foot taller
than himself. It is true of the females, however, that they are
comparatively little.
The Eskimos are a stalwart, broad-shouldered race, considerably
stronger than any other of the races of North America. In both sexes
the hands and feet are small and well-shaped. Their muscles are
strongly developed, owing to constant exercise in hunting the seal
and the walrus. They are also powerful wrestlers, and on no unequal
terms could compete with the athletic celebrities of Devon and
Cornwall. Their physiognomy, notwithstanding its lack of beauty, is
far from displeasing; its expression is cheerful and good-tempered,
and the long winter night does not seem to sadden their spirits or
oppress their energies. The females are well made, and though not
handsome, are scarcely to be stigmatized as ugly. Their teeth are
very white and regular; and their complexion is warm, clear, and
good. It is true that it cannot be seen to advantage, owing to the
layers of dirt by which it is obscured; but it is not much darker than a
dark brunette, and as for the dirt—well, perhaps, it is preferable to
cosmetics!
Even in the Arctic World, woman seems conscious of the
influence of her charms, and man seems willing to recognize it. They
plait their black and glossy hair—these Eskimo beauties!—with much
care and taste; and they tattoo their forehead, cheeks, and chin with
a few curved lines, which produce a not altogether unpleasant effect.
From Behring Straits eastward, as far as the river Mackenzie, the
males pierce the lower lip near each angle of the mouth, in order to
suspend to it ornaments of blue or green quartz, or of ivory, shaped
like buttons. Some insert a small ivory quill or dentalium shell in the
cartilage of the nose. They decorate themselves, moreover, with
strings of glass beads; or when and where these cannot be obtained,
with strings of the teeth of the musk-ox, wolf, or fox; hanging them to
the tail of the jacket, or twining them round the waist like a girdle.
The influence of climate upon dress is a subject which we
commend to the notice of art-critics and æsthetic philosophers.
Within the Arctic Circle the problem to be solved is, how to obtain the
greatest amount of protection for the person, without rendering the
costume too heavy or cumbrous; and the Eskimos have succeeded
in solving it satisfactorily. They can defy the rigour of the Arctic
winter, its extreme cold, its severest gales, and pursue their
avocations in the open air even in the dreariness of the early winter
twilight, so cleverly adapted is their garb to the conditions under
which they live. Their boots, made of seal-skin, and lined with the
downy skins of birds, are thoroughly waterproof; their gloves are
large, but defend the hands from frost-bite: they wear two pair of
breeches, made of reindeer or seal-skin, of which the under pair has
the close, warm, stimulating hair close to the flesh; and two jackets,
of which the upper one is provided with a large hood, completely
enveloping the head and face, all but the eyes. The women are
similarly attired, except that their outer jacket is a little longer, and
the hood, in which they carry their children, considerably larger; and
that, in summer, they substitute for the skin-jacket a water-tight shirt,
or kamleika, made of the entrails of the seal or walrus. They sew
their boots so tightly as to render them impervious to moisture, and
so neatly that they may almost be included in the category of works
of art. In Labrador the women carry their infants in their boots, which
have a long pointed flap in front for the purpose.
In a preceding chapter we have spoken incidentally of the Eskimo
huts. These, like the Eskimo dress, are admirably adapted to the
circumstances of the country and the nature of the climate. The
materials used are either frozen snow, earth, stones, or drift-wood.
The snow-hut is a dome-shaped edifice, constructed in the following
manner:—
First, the builders trace a circle on the smooth level surface of the
snow, and the snow gathered within the area thus defined is cut into
slabs, and used for building the walls, leaving the ice underneath to
serve as the flooring.
The crevices between the slabs, and any accidental fissures, are
closed up by throwing a few shovelfuls of loose snow over the
building. Two men are generally engaged in the work; and when the
dome is completed, the one within cuts a low door, through which he
creeps. As the walls are not more than three or four inches thick,
they admit a soft subdued light into the interior, but a window of
transparent ice is generally added. Not only the hut, but the furniture
inside it, is made of snow; snow seats, snow tables, snow couches—
the latter rendered comfortable by coverings of skins. To exclude the
cold outer air, the entrance is protected by an antechamber and a
porch; and for the purposes of intercommunication, covered
passages are carried from one hut to another.
 BUILDING AN ESKIMO HUT.

The rapidity with which these snow-huts are raised is quite

surprising, and certainly affords a vivid illustration of the old saying
that “practice brings perfection.” Captain M’Clintock for a few nails
hired four Eskimos to erect a hut for his ship’s crew; and though it
was twenty-four feet in circumference, and five and a half feet in
height, it was erected in a single day.
Much ingenuity is frequently displayed in their construction.
Dr. Scoresby, in 1824, found some deserted huts on the east
coast of Greenland, which showed no little constructive skill on the
part of their builders.
A horizontal tunnel, about fifteen feet in length, and so low that a
person entering it was compelled to crawl on his hands and knees,
opened with one end to the south, while the other end terminated in
the interior of the hut. This rose but slightly above the surface of the
earth, and being generally overgrown with moss or grass, could
scarcely be distinguished from the neighbouring soil. It resembled,
indeed, a large ant-hill, or the work of a mammoth mole! In some
cases the floor of the tunnel was on a level with that of the hut; but
more frequently it slanted downwards and upwards, so that the
colder, and consequently heavier, atmospheric air was still more
completely prevented from mixing too quickly with the warmer air
within. The other arrangements exhibited the same ingenuity in
providing against the inconveniences of a rigorous climate.
From the huts of the Eskimos we pass to their boats.

THE ESKIMO KAYAK.

The kayak or baidar is as good in its way as the light and swift
canoe of the Polynesian islanders. It consists of a narrow, long, and
light wooden framework, covered water-tight with seal-skin, with a
central aperture for the body of the rower. Sometimes the frame is
made of seal or walrus bone. The Eskimo takes his seat in his
buoyant craft, with legs outstretched, and binds a sack—which is
made from the intestines of the whale, or the skins of young seals—
so tightly round his waist, that even in a rolling sea the boat remains
water-tight. Dexterously and rapidly using his paddle, with his spear
or harpoon before him, and preserving his equilibrium with
marvellous steadiness, he darts over the waves like an arrow; and
even if upset, speedily rights himself and his buoyant skiff. The
oomiak, or woman’s boat, consists in like manner of a framework
covered with seal-skins; but it is large enough to accommodate ten
or twelve people, with benches for the women who row or paddle.
The mast supports a triangular sail, made of the entrails of seals,
and easily distended by the wind.
It has been observed that a similar degree of inventive and
executive skill is displayed by the Eskimos in their spears and
harpoons, their fishing and hunting implements. Their oars are
tastefully inlaid with walrus teeth; they have several kinds of spears
or darts, according to the character of the animal they intend to hunt;
and their bows, with strings of seal-gut, are so strong and elastic as
to drive a six-foot arrow a really considerable distance. The
harpoons and spears used in killing whales or seals have long shafts
of wood or bone, and the barbed point is so constructed that, when
lodged in the body of an animal, it remains imbedded, while the shaft
attached to it by a string is loosened from the socket, and acts as a
buoy. Seal-skins filled with air, like bladders, are also employed as
buoys for the whale-spears, being stripped from the animal with such
address that all the natural apertures are easily made air-tight.
Fish-hooks, knives, and spear or harpoon heads, the Eskimos
make of the horns and bones of the deer. In constructing their
sledges, and roofing their huts, they have recourse to the ribs of the
whale, when drift-wood is not available. Strips of seal-skin hide are a
capital substitute for cordage, and cords for nets and bow-strings are
manipulated from the sinews of musk-oxen and deer.
 THE ESKIMO OOMIAK.
A strange and deadly antagonism prevails between the Eskimos
and the Red Indians. On the part of the latter it would seem to
originate in jealousy, for the Eskimos are superior in skill, social
habits, general intelligence, personal courage, and strength; on the
part of the former, in the necessity for self-defence and the
provocations they have received from a sanguinary enemy.
Hence, the Indians inhabiting the borders of the Polar World seek
every opportunity of surprising and massacring the inoffensive
Eskimos. Hearne relates that, in the course of his expedition to the
Coppermine River, the Indians who accompanied him obtained
information that a party of Eskimos had raised their summer huts
near the river-mouth. In spite of his generous efforts, they resolved
on destroying the peaceful settlement. Stealthily they made their
approach, and when the midnight sun touched the horizon, they
swooped down, with a frightful yell, on their unfortunate victims, not
one of whom escaped. With that love of torture which seems
inherent in the Red Indian, they did their utmost to intensify and
prolong the agonies of the sufferers; and one aged woman had both
her eyes torn out before she received her death-blow. The scene
where this cruel slaughter took place is known to this day as the
“Bloody Falls.”

Dr. Kane supplies some interesting particulars of a party of

Eskimos with whom he became acquainted during his memorable
expedition. The intimacy began under unfavourable circumstances,
for three of the party had been detected in a scandalous theft, had
attempted to carry off their plunder, were pursued, overtaken, and
punished. Soon afterwards, Metek, the head man or chief, arrived on
the scene, and a treaty of peace was concluded.
On the part of the Inuit, or Eskimos, it ran as follows:—
“We promise that we will not steal. We promise we will bring you
fresh meat. We promise we will sell or lend you dogs. We will keep
you company whenever you want us, and show you where to find
the game.”
On the part of the Kablunah, or white men, it ran as follows:—
“We promise that we will not visit you with death or sorcery, nor
do you any hurt or mischief whatsoever. We will shoot for you on our
hunts. You shall be made welcome aboard ship. We will give you
presents of needles, pins, two kinds of knife, a hoop, three bits of
hard wood, some fat, an awl, and some sewing-thread; and we will
trade with you of these and everything else you want for walrus and
seal meat of the first quality.”
The treaty, says Dr. Kane, was not solemnized by an oath; but it
was never broken.
The Eskimo settlement at Anatoak, lat. 73° N, on the shore of
Smith Strait, near Cape Inglefield, seems to merit description.
 The hut or igloë was a single rude elliptical apartment, built not
unskilfully of stone, the outside lined with sods. At its further end, a
rude platform, also of stone, was raised about a foot above the
entering floor. The roof was irregularly curved. It was composed of
flat stones, remarkably large and heavy, arranged so as to overlap
each other, but apparently without any intelligent application of the
principle of the arch. The height of this cave-like abode barely
permitted one to sit upright. Its length was eight feet, its breadth
seven feet, and an expansion of the tunnelled entrance made an
appendage of perhaps two feet more.
The true winter-entrance is called the tossut. It is a walled tunnel,
ten feet long, and so narrow that a man can hardly crawl along it. It
opens outside below the level of the igloë, into which it leads by a
gradual ascent.
Thus the reader will see that the hut at Anatoak was constructed
on the same principles as the huts discovered by Dr. Scoresby.
Time had done its work, says Dr. Kane, on the igloë of Anatoak,
as among the palatial structures of more southern deserts. The
entire front of the dome had fallen in, closing up the tossut, or tunnel,
and forcing visitors and residents to enter at the solitary window
above it. The breach was wide enough to admit a sledge-team; but
the Eskimos showed no anxiety to close it up. Their clothes
saturated with the freezing water of the floes, these men of iron
gathered round a fire of hissing and flaring whale’s blubber, and
steamed away in apparent comfort. The only departure from their
usual routine was suggested probably by the open roof and the
bleakness of the night; and therefore they refrained from stripping
themselves naked before coming into the hut, and hanging up their
dripping vestments to dry, like a votive offering to the god of the sea.
Their kitchen implements were remarkable for simplicity. “A rude
saucer-shaped cup of seal-skin, to gather and hold water in, was the
solitary utensil that could be dignified as table-furniture. A flat stone,
a fixture of the hut, supported by other stones just above the
shoulder-blade of a walrus,—the stone slightly inclined, the cavity of
the bone large enough to hold a moss-wick and some blubber; a