Mayo Clin Proc, August 2001, Vol 76Refractive Surgery823
Mayo Clin Proc. 2001;76:823-829823
© 2001 Mayo Foundation for Medical Education and Research
Making Sense of Refractive Surgery in 2001:
Why, When, for Whom, and by Whom?
MARK J. MANNIS, MD; WILLIAM A. SEGAL, MD; AND JASON K. DARLINGTON, MS
From the Department of Ophthalmology, University of California
Individual reprints of this article are not available. Address corre-
spondence to Mark J. Mannis, MD, Department of Ophthalmology,
UC Davis Medical Center, 4860 Y St, Suite 2400, Sacramento, CA
ALK = automated lamellar keratoplasty; D = diopter; DLK =
diffuse lamellar keratitis; ICR = intracorneal ring; LASIK =
laser in situ karatomileusis; PRK = photorefractive keratec-
tomy; RK = radial keratotomy
ties of the eye have led to development of what is now
considered by many a bona fide surgical subspecialty in the
field of ophthalmology. The repertoire of procedures for
the correction of refractive errors, including myopia,
hyperopia, astigmatism, and presbyopia, has been varied,
innovative, and daring, if not always predictable, effective,
or lasting. The evolution of refractive surgery as a subspe-
cialty has been fueled by consumer/patient enthusiasm, a
spirited response by the ophthalmic profession, an enormous
investment by the technical industry, and a relatively high
overall degree of patient satisfaction. It is difficult for any
physician to determine with certainty which procedures are
the safest and most efficacious for his or her patients because
of the inconsistencies in scientific documentation of surgical
outcomes in the ophthalmic literature and the heavy dose of
entrepreneurism that has accompanied refractive surgery
since its introduction to the Western Hemisphere in the late
ver the past 25 years, surgical procedures designed
specifically to alter the focusing or refractive proper-
Surgical alteration of the focusing or refractive properties
of the eye has been performed on millions of patients. An
array of procedures to correct myopia, hyperopia, astig-
matism, and presbyopia have been introduced over the
past 25 years with varying degrees of success. Improved
technology has increased patient and physician satisfac-
tion and enthusiasm. Currently available surgical proce-
dures can be categorized as incisional, surface-altering,
lamellar, and intraocular. The choice of procedure de-
pends on individual patient indications and contraindica-
tions based on results of ocular examinations, eg, corneal
pachymetry to measure corneal thickness, keratometry to
measure the corneal curvature, basal tear secretory rate,
and dark-adapted pupil size. The postoperative uncor-
rected visual acuity depends, in large part, on the quality
of the preoperative evaluation and refraction. Before
scheduling a patient for surgery, the ophthalmologist must
ensure that the patient understands the potential risks of
the procedure and has realistic expectations for the post-
operative level and quality of uncorrected visual acuity.
Postoperative complications include corneal flap displace-
ment, undercorrection and overcorrection, and epithelial
ingrowth under the corneal flap and inflammatory kerati-
tis. Postoperative dry eye, infection, and inflammation are
usually treated medically. Ongoing technological innova-
tions to customize the surgical approach to an individual
patient’s eye continue to improve outcomes.
Mayo Clin Proc. 2001;76:823-829
1970s. In the space allotted for an article of this type, it is not
possible to discuss every aspect of refractive surgery. This
article concentrates on the procedures used most commonly
and attempts to provide some practical guidelines for deter-
mining the appropriateness, safety, and efficacy of the most
commonly used refractive surgical procedures. Refractive
surgery offers the appropriately selected patient gratifying
visual results. A good result is predicated on a careful assess-
ment of the patient’s needs, a realistic evaluation of the
outcomes to be expected, and skilled management before,
during, and after the surgical encounter.
Let us first clarify briefly the nature of the problems pre-
sented by the common refractive errors, including myopia,
hyperopia, astigmatism, and presbyopia. Understanding
the basic concept of refractive error enhances understand-
ing of which types of refractive error may be correctable
and by which procedures.
Myopia (nearsightedness) is prevalent in roughly 25%
of white persons and 13% of African American persons.1
Myopia is a refractive error resulting in displacement of
images in front of the retina. It may result either from the
eye being too long (axial myopia) or from the cornea and
lens being too powerful (refractive myopia). As a result, the
primary functional impairment is blurring of distance vi-
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, August 2001, Vol 76Refractive Surgery829
zations recommend that this practice be limited to situa-
tions in which there is limited access to regular ophthalmo-
Refractive surgery has yielded good results in millions of
patients and has brought a new and technologically excit-
ing field of interest to ophthalmology. As with any new
technology, referring physicians need to be cognizant of
the effective applications of these procedures, the suitabil-
ity of surgical candidates, and the associated risks and
alternatives. The ophthalmologist practicing refractive sur-
gery is the appropriate resource for this information and
can assist the primary care physician in counseling the
patient. In the carefully selected patient and with good
patient education, LASIK and other refractive surgical pro-
cedures can provide safe, effective, and gratifying vision
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For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.