UNIVERSITY OF GONDAR

COLLEGE OF MEDICINE AND HEALTH

SCIENCEs
School of medicine
Departement of optometry
 
Article review
PREPARED BY :- KALKIDAN BERHANE
 Introduction
• Refractive surgery refers to any procedure that corrects or minimizes
refractive errors.

• It aims to reduce dependence on contact lenses or spectacles for use in

routine daily activities.

• A wide variety of surgical techniques are available, and all require an

appropriate preoperative evaluation to determine the best technique and
ensure the optimal outcome for each patient individually
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 Refractive surgical procedures can be categorized broadly as corneal or intraocular

Keratorefractive (corneal) procedures . Intraocular refractive procedures

• Incisional, • Phakic intraocular lens (PIOL) implantation

and cataract surgery or
• Laser ablation,
• Refractive lens exchange (RLE) with
• Lamellar implantation,
implantation of a monofocal, toric,
• Corneal collagen shrinkage, and
multifocal, accommodative, or extended
• Corneal crosslinking techniques depth of focus intraocular lens

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Cont …

• From those procedures laser refractive surgery is recognized as an extremely

effective and safe procedure for low to moderate levels of refractive error.

• With more than 99.5% achieving spectacle independence

• The US FDA run Patient-Reported Outcomes with LASIK, on average, 95%

of patients satisfaction was reported

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•Was the first to devise refractive surgery procedure in 1948.
•He called the procedure “keratomileusius” which means “carving the cornea”

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• Today, refractive surgery has evolved beyond the stereotypical ‘laser eye
surgery’.

• Developments in
 Femtosecond laser technology
 corneal biomechanics to corneal topography instruments (pre-op
evaluation )

• Leads the procedure to extera higer level

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Preoperative evaluation for refractive surgery

• Corneal topography and wavefront analysis, these investigations have

been routinely used in preoperative evaluation

• Types of corneal topography

• Placido-based curvature topographic systems
• Scheimpflug corneal tomography

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At the present …..

• Preoperative assessments now allow for customized laser ablations to further

achieve better visual quality.

• Developments in preoperative and intraoperative OCT imaging may also

improve surgical planning and accuracy of incisions or placement of implants

• Also innovative technologes of Wavefront aberrometers and lens densitometry

increase the qualiity of the procedure

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Beyond 2020…

• The future development of pre op assesment is assosiated with machin

learning and deep learning.

• Thise techniaues tought to be greater in meaurement of parameters like

corneal curvature, cornea thicness corneal power error and so on.

• Several studies have reported on the sensitivity and the specificity of

keratoconus detection using machine learning

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• Not only in diagnostic technologey, thire is also development in ablation
technology from Conventional excimer laser ablation to wavefront-
guided ablation, Wavefront-optimized lasers and Topography-
guided ablations, which plays a great role in minimizing HOA's.

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TYPES OF REFRACTIVE
SURGERIES AND THERE
EVOLUTION
Keratorefractive surgery

• Keratorefractive essentially involves treating refractive errors by reshaping the

cornea

• The history of thise surgery starts with surface abliation techniques

• PRK
• LASEK

• In both procedures the cornea epithelium will be removed

• Can correct low to moderate degrees of spherical errors and up to 3D

Asstigmatism 14
Complications

• Cornea takes time to heal

• Following the ephitelial removal patient might complain discomfort

and pain

• Moreover, scarring and haze can occur from the healing response in
the Bowman’s layer and anterior corneal stroma

• Dry eye may last 3-6 month in some conditions may be to 1yr
In recent time removing the epithelium also done by using eximer
leser and called transepithelial PRK.
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Laser in situ keratomileusis (LASIK)

• A procedure which combines keratomileusis with excimer

laser stromal ablation,

• It is currently the most frequently performed keratorefractive

procedure because of its safety, efficacy, quick recovery of
vision, and minimal patient discomfort

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• This procedure can correct

• Myopia = up to 6D

• Hyperopia = up to 4D

• Asstigmatism = up to 5D

• A carefull corneal assesment must be done

• For patient with thin cornea , it is better to do other surface

ablation procedure inorder to avoid complications

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Procedure

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• Previously corneal flaps were created using an oscillating microkeratome.

• Significant flap complications such as buttonhole, free cap, and irregular cuts
were major disadvantages

• Thise complications are highly reduced after the addition of femtosecond

lasers

• Using femtosecond lasers also improve Flap thickness reproducibility and

increease RST

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A review of LASIK outcomes…

• Reported by Sandoval et al. in 2016

• They found UDVA was 20/40 or better in 99.5% of eyes,

• Spherical equivalent refraction was within ±1 diopter (D) of target in 98.6% of

eyes,

• Loss of 2 or more lines of corrected distance visual acuity (CDVA) was0.61%.

• Subjectively, patients were very satisfied

• Only 1.2% of patients reporting to be dissatisfied with the procedure

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Complications

• Dry eye

• Flap displacement

• Diffuse lamellar keratitis (DLK)

• Epithelial ingrowth

• Rarely, corneal ectasia

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Advances in excimer laser and wavefront-guided treatments

• The introduction of flying spot lasers and a Gaussian beam profile

• Laser frequency has been increasing

• Increasing in optical zone diameter

• Use of aberrometry measurements

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Beyond 2020: keratorefractive surgery for presbyopia correction

• By making the patient mono vision with keratorefractive surgery

• By creating a multifocal cornea

• Suggested selection criteria include

• low hyperopia (up to +3 D)or myopia (up to −4 D), low astigmatism,

• a maximum requirement of +2 near vision add and

• photopic pupillometry of less than 3.5 mm

• Laser blended vision (LBV)

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Small incision lenticule extraction (SMILE)

• SMILE has been developed resently following the introduction of fematosecond

leaser thechnology

• Using a femtosecond laser to delineate a refractive lenticule within the stroma

connected to the surface by a small incision

• Appropriate procedure for patients who are involved in contact sports or high-risk
professions.

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• The SMILE procedure is approved for treatment of stable refractive error of

• Myopia with or without astigmatism from –1.00 D to –10.00 D sphere

• –0.75 D to –3 D cylinder

• But patients with corneal ectatic diseases and susceptibility to postoperative

ectasia needs to be excluded

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Procedure

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Advantages of SMILE over LASIK

• Because of the minimally invasive pocket incision in SMILE It has

• Faster dry eye symptom recovery

• Better spherical aberration control

• Another advantage is because it leave anterior stroma un cut it preserv the

stronger anterior stromal lamellae

Randleman et al. and Scarcelli et al.

Petsche et al.
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Complications

• trace haze (8.0%),

• central abrasion (0.3%), and minor interface infiltrates (0.3%).
• epithelial dryness on postoperative day 1 (5.0%)
• Topographic irregular astigmatism (1.0% )
• resulting in reduced 3-month best-corrected visual acuity
• Ghost images.
• Lenticule remnant in the interface.
• Postoperative ectasia has also been reported.

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Beyond 2020: stromal lenticule implantation

• The lenticule extract from SMILE could be potentially used for treatment of hyperopia,
presbyapia, and corneal ectatic conditions

• syntetic inlays within the stromal lenticule may have a greater advantage in
biocompatablity when it compared to other intracorneal inlays

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• After traied in vivo results suggest biocompatibility, safety and long-term

transparency

• But it has got a limitation of unpredictability of the refractive outcome

• encouraging results are being reported for advanced keratoconus, where a

precise refractive outcome is not the target, but refractive stability may delay
the need for corneal transplantation

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Intracorneal implants

• Keratophakia described in 1964 as a lamellar refractive surgery procedure

• Due to its scaring and unpridictable refractive results it has got abunded.

• But it gives a way for the development of synthetic intracorneal implants

(“inlays”).

• Early corneal inlays (made of polymethyl-methacrylate- PMMA)

• Newly developed inlays are called intracorneal ring segments (ICRS)

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• ICRS are a biocompatible syntetic material that are implanted deep to the
stroma and modiffay the cornea curvature

• ICRS is important in therapeutic approach for the visual rehabilitation of

keratoconic eyes

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Types of inlays

• corneal reshaping inlays :- to reshape of the anterior corneal curvature,

leaving a multifocal cornea

• refractive inlays :- where there is a modification on the refractive index of

the cornea with a bifocal optic

• Small aperture :- inlay which improves the depth of focus

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Complications

• Frequent problems of centration,

• biological intolerance, and optical performance,

• late complications such as cornealstromal opacities,

• late hyperopic shift

• Inadequate visual performance

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Beyond 2020: future of intracorneal implants and corneal inlays

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Phakic IOL implantation

• The first phakic IOLs (PIOLs) were angle-supported and placed in the
anterior chamber in 1953

• Tow decades later , Prof. Worst developed the ‘irisclaw’ lens made from
PMMA, reducing complications such as glaucoma
• Then in 1983 Dr. Fyodorov, who’s designed was adapted to develop
the (ICL)

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cont,…

• PIOL found to have higer advantage over keratorefraction in terms of

vision and patient satsfaction

• Also avoids the risk of corneal ectasia

• It keeps lens retained and keep natural accomodation

• Less posterior chamber segment complications

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• PIOLs come in two varieties: anterior chamber PIOLS and posterior
chamber PIOLs

• . Anterior chamber can be further divided into angle-supported IOLs and

iris-claw IOLs but only the iris-claw is still available

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 Beyond 2020: presbyopia-correcting PIOLs

• The next future for PIOL is correcting presbyopia.

• The new phakic contact lens is a hydrophilic acrylic trifocal diffractive lens

• The lens also can correct myopia and hyperopia

• its in clinical trial

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Refractive lens exchange

• Extraction of the clear lens and insert iol with power

• Indicated for patients where corneal laser surgery is not possible, or cannot
achieve the desired refractive outcome

• It’s a procedure with lot of serious complications

• Nonetheless, with the advances in surgical technology leading t o

• better refractive outcomes,
• fast visual recovery and
• reduction in postoperative complications 42
Beyond 2020: accommodative IOL implants

• AIOLs) attempt to imitate the mechanism of natural accommodation

• They may be placed either in the sulcus or inside the capsular bag

• A dual-optic lens design essentially consists of two separate optics: a high-

powered ‘plus’ anterior optic of fixed dioptric power and a ‘minus’
posterior optic, coupled by spring haptics

• ,

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• Lumina AIOL acrylic hydrophilic polymer AIOL

• It consists of two mobile optical elements, which is implanted in the

ciliary sulcus.

• The anterior element provides 5 D of correction, while the posterior

provides 10–25 D of correction

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Summary

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Thank you

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