Refractive Surgery

The latest treatment option for myopia, hyperopia, and astigmatism is laser refractive surgery with the excimer laser. Photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) use the excimer laser to remove corneal tissue to flatten the cornea or make it steeper. In the PRK procedure, the laser cuts through the surface cornea. Myopia of -1.00 to -10.00 diopters can be successfully corrected with PRK. This procedure does not involve a corneal flap, unlike LASIK, and has good visual recovery response. However, it is more painful than LASIK. The LASIK procedure is performed under a corneal flap. A 6-mm zone is cut with a microkeratome and the laser treatment directed to the exposed stromal tissue. LASIK is the preferred procedure for more than 6 to 8 diopters of myopia; its benefits are greater accuracy with the laser, reduced postoperative complications, quicker recovery of vision, and predictable healing. Some studies have suggested that LASIK has a slightly higher retreatment rate.

Hyperopia and astigmatism can now also be corrected with laser refractive surgery. The LASIK procedure is the preferred treatment for these conditions; PRK and LASIK are widely available. In the past several years, refractive surgery for myopia, hyperopia, and astigmatism has been considered instead of contact lenses or glasses. Recently, conductive keratoplasty has been advanced for treating presbyopia. However, there may be a compromise in balancing distance and near-vision postoperatively. Potential surgical complications include infections, epithelial ingrowth, halos, and loss of contrast sensitivity. In a patient with moderate cataracts, cataract surgery is more advisable than refractive surgery, because the patient will often have only a few years of vision correction before needing cataract surgery.

Decisions regarding refractive surgery procedures should be based on surgeon expertise, patient refraction, and available equipment. The patient should be informed about the possible options. For patients who are not candidates for laser refractive surgery, other surgical methods can correct refractive error. For example, implantable collamer lenses (ICLs) are particularly useful for high myopic patients, are generally well tolerated, and have a lower incidence of postoperative symptoms (e.g., halos).

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