The goal of this article is to present all eyecare practitioners with a comprehensive approach to collaborative refractive surgery management. When evaluating a possible candidate for refractive surgery, one of the first things to understand is the patient’s goals.

Why do they prefer to avoid wearing spectacles? Would they consider refractive surgery? Are they looking for distance or near vision? Are they seeking spectacle independence for recreation or for work?

Considerations include profession, age, recreation, lifestyle, and medical history. Systemic disease plays a role, as conditions like diabetes may affect wound healing. Family history is important, especially for those with family history of corneal disease. Ocular history and prior surgery are considerations, as are medications, especially those associated with dry eye or ocular surface disease.

Setting expectations is important. Explain the various stages of ocular development, such as presbyopia and likely eventual cataract formation, and inform the patient that the surgery will not prevent future ocular disease. Emphasize the importance of continued eye care after the procedure to monitor ocular health.

Patients seeking distance vision correction approaching presbyopia should be made aware of the impending changes, especially for myopic patients for whom near-point tasks have never been a problem. With surgical correction, this will change. Inform the patient that there are options to minimize the need for spectacles, but they may not eliminate them for all tasks.

The initial evaluation should be a comprehensive examination, collecting baseline information, and assessing ocular health. Special emphasis should be placed on the refraction, pupil examination—especially mesopic diameter—and slit lamp examination with emphasis on signs of ocular surface disease and detailed examination of the cornea and lens. Dilated fundus examination is important, with careful attention paid to the macula.

Ancillary testing should include topography and tomography, if available. These scans will certainly be performed at the consultation or preoperative visits. Still, the co-managing physician’s ability to follow the patient’s cornea over time requires one of these devices.

This examination will not determine the procedure that the patient will ultimately undergo, so a general discussion of cornea and lens-based vision correction is appropriate. Try to avoid discussing particular procedures or intraocular lens (IOL) options at this point. Rather, inform the patient that multiple factors will be examined and the correct procedure and options will be chosen.

CONTACT LENSES AND REFRACTIVE SURGERY

Patients who have worn contact lenses may exhibit corneal changes that should be allowed to resolve before referral for refractive surgery. It is paramount to ensure the cornea and ocular surface have resumed their normal physiology. Serial corneal topography, corneal optical coherence tomography (OCT) to evaluate epithelial changes, refractions, k readings, slit lamp examinations with vital dyes, and retinoscopy can all be used to assess corneal regularity before referral.

For patients who fail in contact lenses and still seek to avoid spectacles, refractive surgery might provide an opportunity to deliver significant benefits. This is especially true for patients who engage in risky contact lens habits, are unsuccessful with application and removal, or have dropped out of contact lens wear. In a consumer review of contact lens wear habits, the vast majority of patients wear contact lenses to be free of spectacles, and approximately 25% reported either occasionally, usually, or always sleeping in lenses.¹

Contact lens wear carries an increased risk for complications, and microbial keratitis risk is the highest with overnight wear.² Of new contact lens wearers, approximately 26% discontinue contact lens wear in the first year.³ For patients who have dropped out of contact lenses, the leading cause for discontinuing is discomfort during lens wear. For CL dropouts refitted into contact lenses, by one month, 23% have dropped out again, and by six months, 45%; only 18% report that they were likely to continue lens wear.⁴ Refractive surgery can be a solution for these patients.

Price surveyed 1,800 patients over three years, comparing those who wore contact lenses at baseline and underwent laser-assisted in situ keratomileusis (LASIK), those who wore spectacles at baseline and underwent LASIK, and those who continued to wear contact lenses.⁵ Most contact lens users were successful lens wearers for five or more years, whereas in the spectacles group, many had dropped out of contact lens wear due to dryness and discomfort with lens wear. At the three-year mark, those reporting “strong satisfaction with their current vision correction method” decreased from 63% at baseline to 54% in the contact lens group. In comparison, the former spectacles and contact lens wearers were 77% and 88%, respectively.

Interestingly, both LASIK groups reported significantly fewer issues with night driving and nighttime visual disturbances. Notably, the proportion who had dry eye symptoms one, two, or three years after LASIK was not significantly increased compared to continued contact lens wear.

DRY EYE DISEASE AND REFRACTIVE SURGERY

Evaluation and treatment of dry eye and ocular surface disease (OSD) before refractive surgery are important. These conditions directly affect an eye’s optical quality and create measurement error sources and thus impact surgical outcomes. The literature has shown that OSD is present and asymptomatic in many patients who have cataracts; it reduces the accuracy of preoperative refractive measurements and reduces postoperative visual quality, quantity, and performance.^6-8

The Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) teaches triage, diagnosis, and treatment strategies.⁹ Any of the principles in this document can apply to the refractive surgery workup. The most applicable is the evaluation of homeostasis markers such as tear break-up time equal to or less than 10 seconds, vital dye staining with fluorescein and lissamine green, with relevant findings being 5 or more corneal punctate, 9 or more conjunctival punctate, and lid margin staining greater than 2mm in length or 25% in width. Its dry eye subtypes classification and staged treatment approach are also extremely helpful in guiding pharmaceutical and procedural intervention.

These simple tests allow you to find and treat before surgical referral, expediting the surgical process and improving surgical outcomes. However, this must be balanced with the patient’s needs. For example, considering a patient with cataracts affecting the activities of daily living, such as the ability to drive, delaying treatment for the mild ocular surface disease is not prudent. Meanwhile, for a patient seeking spectacle freedom, delaying surgery to optimize the ocular surface is indicated (Figure 1).

REFRACTIVE SURGERY OPTIONS

The preoperative evaluation allows the most appropriate refractive procedure to be chosen by using a multitude of diagnostic devices and clinical examination. It is critical to understand the interpretation and nuances of the data from each device. For a more in-depth review of the preoperative workup and relevant diagnostics, please refer to the unabridged online version of this article.

Refractive surgery procedures can be broadly broken into two categories: cornea-based and lens-based. Cornea-based procedures can remove, add, or modify tissue properties. Lens-based procedures can add a lens in the eye (i.e., phakic procedures) or replace the crystalline lens (i.e., pseudophakic procedures). A refractive lens exchange (RLE) procedure is the same as a cataract procedure; however, a cataract procedure removes crystalline lens pathology, while an RLE replaces a clear crystalline lens for refractive purposes.

CORNEAL-BASED OPTIONS, CURRENT AND UNDER INVESTIGATION

Subtractive Photorefractive keratectomy (PRK) was first introduced in the 1980s.¹² The procedure uses the excimer laser, which ablates tissue from the corneal surface. The laser works by use of argon gas and high voltage to create ultraviolet energy, which is directed at the cornea in a series of spots that disrupt the bonds in the cornea to remove tissue without causing collateral damage to surrounding tissue. These qualities allow for meticulous, micron-level reshaping of the corneal surface and, thus, refractive error correction.¹³

In LASIK, a corneal lamellar flap is created to preserve the epithelium and reflected. Next, an excimer laser photoablation is applied to the exposed corneal stromal bed, and the flap is then placed back into its original position.

Historically these flaps were mechanically created with a microkeratome blade system. However, continued advancement in ophthalmic lasers brought the femtosecond laser. This laser works in the infrared spectrum. Its pulses create molecular level tissue disruption at ultrafast speed to create targeted intrastromal plasma formation resulting in cavitation bubble formation to create precise tissue dissections. The femtosecond laser causes nearly no damage to surrounding corneal tissue due to its speed and ultra-high precision. Thus, modern LASIK uses both lasers.

LASIK has become the most popular corneal refractive surgery due to its proven track record of safety, rapid visual recovery, and low risk for corneal haze. Many studies have compared postoperative outcomes of LASIK and PRK, primarily focusing on VA, induction of higher-order aberrations, postoperative complications, and patient satisfaction or subjective quality of vision.^14,15 LASIK and PRK may cause a temporary increase in dry eye symptoms and severity, vision fluctuations, and foreign body sensation over baseline in the early postoperative period, with PRK causing greater visual fluctuations compared to LASIK. However, visual quality and symptoms tend to return to their baseline preoperative levels by the one-year postoperative mark in both procedures.¹⁵

Excimer lasers have evolved to create optimized and customized ablation profiles to improve the quality of vision. The original was wavefront-optimized ablation profiles utilizing more peripheral spots to produce larger and smoother optic zones, reducing undesired aberrations.

Next came diagnostic device-guided ablations; first were wavefront aberrometry-guided treatments, followed by topography-guided treatments.^16,17 The most recent addition outside the U.S. is using a combination device containing a tomography, biometer, and aberrometry to create ray-traced customized ablations.¹⁵ This novel technology has the potential advantage of more accurately addressing the normalization of an irregular cornea compared to traditional anterior corneal surface or wavefront data alone.¹⁵

Furthermore, this novel technology may ablate less stromal tissue than pure anterior surface topography-guided ablation as the anterior corneal surface that compensates for the posterior corneal irregularity will not be ablated.¹⁸ The preliminary findings are promising, but more cases and longer follow-ups may be needed to validate this technology.

The most recent subtractive corneal procedure is small incision lenticular extraction (SMILE). This technique uses the femtosecond laser only to cut an intrastromal lens-shaped wafer of tissue (lenticule), which is removed from the intrastromal space through a small corneal incision.¹⁹ There are no flaps and no surface ablation. The potential advantage of the SMILE technique is that it avoids potential flap complications and less corneal nerve disruption than the LASIK procedure.

Studies have demonstrated effective, safe, and stable treatment using the SMILE technique for the treatment of myopia and myopic astigmatism at five years,²⁰ and show similar results and safety profile as LASIK with induction of fewer HOAs with SMILE.^21-23 SMILE studies have reported less disruption of corneal nervous innervations resulting in fewer dry eye symptoms.^24,25 It’s important not to view these procedures as competitive technologies, each has its place in the refractive surgery toolbox.

Biomechanic Other procedures are being developed to create corneal-shaped changes without removing corneal tissue. For instance, the U.S. Food and Drug Administration (FDA) approved conductive keratoplasty (CK) for the treatment of hyperopia.²⁶ This procedure uses a radiofrequency energy-charged ultrathin probe to create controlled collagen shrinkage. This is a thermal and biomechanical procedure in which the energy creates a precise temperature. At 65º Celsius, collagen can retract but retain its natural configuration. In the procedure, the probe is inserted into the peripheral cornea at eight evenly spaced locations, energy is applied, and collagen retraction follows, creating a steepening of the central cornea. The treatment is seldom used now in favor of excimer laser-based correction.

Another biomechanical treatment is corneal cross-linking (CXL). The traditional application of this procedure is to increase the biomechanical strength of ectatic corneas. The procedure works by saturating a cornea with riboflavin, then exposing it to ultraviolet (UV) light. A photochemical reaction, with oxygen as a catalyst, occurs in the anterior stroma to increase bonding and, thus, corneal strength. This procedure could have refractive applications.

Photorefractive intrastromal cross-linking (PiXL) is being studied to reduce refractive error in patients by using a modified version of traditional corneal crosslinking. In PiXL, specific ultraviolet-A (UVA) patterns and intensities are applied to allow for localized strengthening and to flatten the cornea. Pilot studies have shown stable results for 12 months showing that this may be a safe and effective method for treating mild refractive error.^27,28

Refractive Index Another noninvasive method of correction is being studied, laser-induced refractive index change (LIRIC), which uses a femtosecond laser but extremely low-pulse energies.²⁹ This minimal energy does not create tissue cavitation; rather, it densifies collagen and reduces water content to change the cornea’s index of refraction rather than its shape.²⁹ Its noninvasive nature preserves the corneal and stromal nerves, thus theoretically avoiding optical regression caused by epithelial remodeling and rates of postoperative dry eyes.^29,30

Additive The concept of adding tissue to the cornea is nothing new; epikeratophakia was a technique studied in the 1980s where allograft corneal stromal tissue was added on top of a cornea after de-epithelialization to create a refractive correction.³¹ Today, additive procedures such as lenticule intrastromal keratoplasty (LIKE) are being studied, specifically for treating hyperopia. Despite the technological advances in corneal procedures, moderate-to-high hyperopia remains difficult to treat due to increased aberrations and treatment regression from epithelial remodeling.^32-35

The LIKE procedure starts with a femtosecond laser to create a flap or pocket. An allograft stroma tissue lenticule, refractively shaped by a femtosecond laser, is placed under the flap or in the pocket and centrally positioned on the optical axis.³⁶ Early study data using allogenic corneal inlay from a lenticule for presbyopia show good safety and efficacy.^37,38

Historically, corneal inlays for presbyopia have been explored with synthetic materials.³⁹ Although successful visual outcomes were achieved with the synthetic materials, they lacked biocompatibility and thus induced complications such as haze and stromal melts.³⁹ This biocompatibility issue can be overcome with allograft stroma; thus, corneal allograft inlay procedure is being studied.³⁸ These presbyopic lenticules are 2mm hyperprolate shapes that increase the depth of focus and are implanted under a flap. In this way, this addition can be added during a LASIK procedure.³⁷ It is possible that the procedures may emerge as large players in treating hyperopia and presbyopia in the future, and adoption may be quick as it does not require the purchase of new laser technologies.

LENS-BASED OPTIONS, CURRENT AND UNDER INVESTIGATION

Phakic Lens Implants For patients who have high myopia or thin corneas, intraocular refractive surgery with the implantable collamer lens (ICL) may be the best option, which can correct myopia and astigmatism while avoiding ablation to the cornea. Recently, a new version of the ICL with a central fenestration and larger optic was approved by the FDA.⁴⁰ In previous ICL iterations, the procedure required two steps: first, the formation of peripheral iridotomies (PIs), then the implantation of the ICL.

The newly approved version allows aqueous to flow through the lens, eliminating the need for PIs and streamlining the procedure. In the case of a refractive target miss or unexpected refractive changes occurring, the ICL can be exchanged or explanted, making the procedure reversible.⁴¹ Some studies have also shown that ICL implantation possesses better optical and visual quality in comparison to LASIK in patients with high myopia.^41,42 Outside of the U.S., options exist for the correction of hyperopia and even presbyopia, utilizing extended-depth-of-focus (EDOF) optics.^43,44

Pseudophakic Lens Implants There exists an extensive variety of IOLs. The refractive profile options include monofocal, toric, multifocal, trifocal, and EDOF.^45,46 Optics can be diffractive or non-diffractive in nature. Advancements include shape changes to reduce issues with negative dysphotopsia, material changes to include light filtering and reducing glistenings, and optimized eccentricity to improve optical quality. Generally, bifocals offer two distinct focal points at distance and near; trifocals offer three distinct focal points for distance, intermediate, and near; and EDOF profiles distance and intermediate. Different optical profiles and refractive targets can be mixed and matched to achieve desired visual outcomes, providing an increased range of vision. In cases where there is a refractive target miss, this can be addressed in those who are good candidates with a corneal refractive procedure, but it would be ideal to change the power of the IOL without further surgery. This is now possible.

The light-adjustable lens allows for post-implantation power adjustments.⁴⁷ It is made of a unique photoactive material that can be polymerized to change the refractive power. To do this, a UV-illumination device exposes the lens to the UV wavelength that triggers polymerization of the lens material and changes the refractive power. The next IOL innovation, which just received FDA approval, is small aperture optics (SAO).⁴⁸ This IOL has a pinhole aperture design, which creates EDOF and reduces aberration.^49,50 Both may be particularly beneficial to those who have irregular corneal astigmatism.

A similar but different concept to the one that adjusts to light is refractive index change. In studies, the same LIRIC laser discussed earlier for application to the cornea is being explored to change the refractive index of IOLs and, thus, the optical powers and profiles.⁵¹ To provide a visual simulation for patients undergoing RLE, LIRIC may also be applied to certain contact lenses to create an optical profile similar to what a patient may observe.⁵² Consider this as a visual test drive. The current U.S.-based refractive surgery options are given in Table 1.

REFRACTIVE MILESTONES AND REFRACTIVE MANAGEMENT OPTIONS FOR THE NORMAL CORNEA

The concept of refractive management is a collaboration between optometrists and ophthalmologists, to address the refractive needs and refractive pathologies of the patients. In this concept, there are four principal refractive milestones in a patient’s life and a myriad of options for correction to address a patient’s refractive needs (Table 2).

The first stage of refractive management is ocular development. This occurs during the first two decades of a patient’s life. Here, the important consideration for refractive management is the control of progressive myopia. It may be more appropriate to describe progressive myopia as progressive axial length elongation (PALE). The goal is to slow PALE and prevent high myopia and the associated comorbidities.

The next milestone is ocular maturity, which occurs in the late teens to early 20s. Multiple factors such as behavioral, genetic, and environmental influences affect the timing in each individual.⁵³ Ocular maturity brings the option for permanent vision correction procedures with LASIK, PRK, SMILE, and ICL. Procedures to aid in minimizing reliance on reading glasses include monovision, also known as blended vision, which can be achieved via corneal-based procedures, with LASIK, PRK, SMILE, and RLE. Additionally, options for extending focus can be diffractive or non-diffractive IOLs. There is also an emerging role for topical pharmaceuticals, currently with a transitory effect, and many new options are on the horizon, mostly focusing on small aperture optics.

The final refractive milestone is the development of cataracts. Consider this a pathology with a refractive impact. Cataract surgery removes the pathology and the IOL creates the refractive outcome. With all the advancements in cataract surgery, this should be considered a division of refractive surgery.

POSTOPERATIVE MEDICATIONS

The typical postoperative time course for corneal or intraocular refractive procedures is similar and uneventful. No matter the surgery, most patients will use an antibiotic for prophylaxis, a steroid for inflammation, and a non-steroidal anti-inflammatory for pain management. Oral analgesics are rarely needed in the acute postoperative period but can be helpful for patients in need.

Selection and dosage of medications are dependent on multiple factors, such as the amount of postoperative inflammation, allergies, and preservatives, and are subject to change based on healing. The duration of use is typically based on risk factors, such as a history of macular edema, and findings during an examination as shown in Table 3.

Patient compliance with medication is always a challenge and several options are used or have been approved to alleviate drop burden. Topical compounded combination medications can reduce the need for multiple drops per day. Intracanalicular drug delivery (such as dexamethasone ophthalmic insert 0.4 mg) and intracameral drug delivery (such as dexamethasone intraocular suspension 9%) can eliminate the need for patient compliance with steroids.^54,55

The next evolution may be drug-eluting contact lenses, as these have been studied for the management of postoperative pain.⁵⁶ Additionally, as most patients own some form of connected device, software has been used to improve compliance by sending reminders via text, tracking usage of medications, and surveys for subjected patient outcomes.⁵⁷

COMANAGEMENT, POSTOPERATIVE CARE, AND TYPICAL TIME COURSE

In general, the one-day and one-week postoperative examinations represent the acute healing phase and are assessing for grossly normal healing. After one month, the focus changes to the evaluation of the refractive outcome. The one-month visit is typically the first time a patient will be refracted postoperatively; the patient should be healed and achieve the anticipated level of visual acuity (VA). If a refractive miss is identified, a patient who underwent a corneal-based procedure should be reassured that the cornea may still be remodeling, and they should wait until three months of stability before having a touch-up. For those who have undergone an IOL-based procedure, send them back to the surgeon, and their issues can be addressed at the one-month postoperative visit (Table 4).

DAY 1

On day one, the patient will be patched or have a clear shield or goggles. There may be mild lid and adnexal swelling; this is normal. Patients typically report some soreness, tenderness, or scratchy sensations. For cataract patients, specifically those with a retrobulbar block, ophthalmoplegia can occur and the pupil may be pharmacologically dilated. Mandatory testing should include VA, slit lamp examination—with or without vital dye stain—and, for cataract patients, tonometry.

For a patient who has undergone a cornea-based procedure, those having undergone LASIK or SMILE should present with good VA, while those having undergone PRK will have variable vision. Slit lamp examination may show minor injection and or subconjunctival hemorrhages. For LASIK, the flap will be in place and for PRK, the cornea will have an epithelial defect with an overlying bandage contact lens in place.

For IOL-based procedures, VA after ICL or RLE should be good but may be variable after cataract extraction where the severity of the cataract may dictate the amount of postoperative inflammation and VA. At the slit lamp, the conjunctiva may show minor injection and subconjunctival hemorrhages, and the cornea may show signs of edema up to grade 2+. The anterior chamber should be formed with flare and cells less than or equal to grade 2+. The intraocular pressure (IOP) should be less than 25 mmHg.

WEEK 1

Occasionally a mild ptosis from the speculum will be present at week one. Patients should report improving vision, but fluctuations in vision are normal. Vital testing at this visit includes VA, slit lamp examination, and tonometry for intraocular procedures.

For corneal-based procedures, those who have corneal edema should have tonometry as well. At this visit, if the patient’s eye is white and quiet after a toric lens implant, is it appropriate to refract. If a misalignment of the lens axis is suspected, refer back to the surgeon, and have a low threshold for referral as this is a simple fix. For cornea-based procedures, vision should be nearing or at potential, slit lamp findings should show subconjunctival hemorrhages resolving, and the cornea should only show minor superficial punctate keratitis (SPK) or a healing line, otherwise be unremarkable.

For lens-based procedures, again, vision should be near or at potential, slit lamp findings should show subconjunctival hemorrhages resolving, and the cornea should be clear. The anterior chamber signs of inflammation should show signs of improvement, and IOP should be at preoperative levels or lower. A quick view of the macula is also indicated.

Typically, antibiotics and non-steroidal anti-inflammatory drugs (NSAIDS) are discontinued for corneal procedures; for intraocular procedures, the NSAID should be conitinued for an additional one to three weeks pending macular disease. Supportive therapy such as immunomodulators and preservative-free artificial tears should be continued or added.

MONTH 1

The expected time course continues with stabilization of vision and continued use of supportive therapies for the ocular surface. At this visit, it is typical to discontinue steroid and NSAID use. For corneal-based procedures, vision should be at potential and slit lamp findings unremarkable with a pristine cornea. Intraocular procedures should also have vision at potential, an unremarkable slit lamp examination, and tonometry at preoperative levels or lower.

A refraction may be performed as well as topography, which is important for corneal procedures, and other diagnostics as needed. A dilated examination is indicated in those undergoing intraocular procedures or those with high preoperative prescriptions. This visit is where refractive outcomes should be evaluated.

On occasion, a refractive miss will occur. At one month, the cornea is still remodeling in patients who have undergone corneal-based procedures, especially PRK. Reassure the patient and wait for the three-month postoperative examination to assess stability. If the refractive target has indeed been missed, refer back to the surgeon for evaluation and possible enhancement. For lens-based procedures, a refractive miss can be addressed at one month. For those who have postoperative dryness, continue supportive therapy. If patients were adequately counseled, they were aware of these preoperatively and should be reminded.

Complications are rare, although many educational courses focus on this aspect of refractive surgery. The overwhelming majority of cases are uneventful. However, there is a spectrum of conditions that have varying levels of severity and urgency. Some early issues that may arise are appropriate to be treated and managed by the co-manager, while anything moderate or worse should be managed by the surgeon. When in doubt, the patient should return to the surgeon for examination and management. It is of utmost importance that the comanaging practitioner and refractive surgeon, together as the patient’s care team, communicate frequently and effectively. This is summarized in Table 5.

CO-MANAGEMENT RELATIONSHIPS AND FINANCIAL CONSIDERATIONS

Appropriate co-management strategies are beneficial for both providers and patients. For out-of-pocket procedures, software exists to separate payments for the procedure and postoperative care, making payment division to the surgeon and co-managing doctor easy and efficient without blurring the lines of payment for the referral. Contracts between the comanager and surgeon are appropriate to define roles and responsibilities.

Consent forms for patients are also important as it reinforces the role of each provider and who to follow up with and contact in case of emergency. It is the job of both the surgeon and the referring doctor to remind the patient that ocular disease is not prevented by the procedure; and it is necessary, especially for those with high myopic correction, to continue to be followed for comprehensive examinations.

CONCLUSION

Advances in refractive surgery allow for nearly any refractive error to be corrected from ocular maturity onward. Consider the concept of refractive management as a comprehensive and collaborative approach with all the options. This is an exciting time for those seeking spectacle-free vision correction. This is particularly important in patients who fail in contact lenses and still seek to avoid spectacles, where collaborative care of the patient provides an opportunity to deliver significant patient benefit. CLS

REFERENCES

1. Vision Council. Consumer Barometer Report. 2019.
2. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115:1655-1662.
3. Sulley A, Young G, Hunt C. Factors in the success of new contact lens wearers. Cont Lens Anterior Eye. 2017 Feb;40:15-24.
4. Young G, Veys J, Pritchard N, Coleman S. A multi-centre study of lapsed contact lens wearers. Ophthalmic Physiol Opt. 2002 Nov;22:516-527.
5. Price MO, Price DA, Bucci FA Jr, Durrie DS, Bond WI, Price FW Jr. Three-Year Longitudinal Survey Comparing Visual Satisfaction with LASIK and Contact Lenses. Ophthalmology. 2016 Aug;123:1659-1666.
6. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018 Sep;44:1090-1096.
7. Brissette AR, Drinkwater OJ, Bohm KJ, Starr CE. The utility of a normal tear osmolarity test in patients presenting with dry eye disease like symptoms: A prospective analysis. Cont Lens Anterior Eye. 2019 Apr;42:185-189.
8. Trattler W, Goldberg D, Reilly C. Prospective health assessment of cataract patients’ ocular surface. Paper presented at World Cornea Congress, Boston. 2010 Apr 8.
9. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017 Jul;15:539-574.
10. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019 May;45:669-684.
11. Ruiz Hidalgo I, Rodrigues P, Rozema JJ, et al. Evaluation of a Machine-Learning Classifier for Keratoconus Detection Based on Scheimpflug Tomography. Cornea. 2016 Jun;35:827-832.
12. Somani SN, Moshirfar M, Patel BC. Photorefractive Keratectomy. In Stat-Pearls. 2022 Jun 21. Available at ncbi.nlm.nih.gov/books/NBK549887 . Accessed Sept. 28, 2022.
13. Pidro A, Biscevic A, Pjano MA, Mravicic I, Bejdic N, Bohac M. Excimer Lasers in Refractive Surgery. Acta Inform Med. 2019 Dec;27:278-283.
14. Lee MD, Manche EE. Quality of vision after wavefront-guided laser in situ keratomileusis or photorefractive keratectomy: Contralateral eye evaluation. J Cataract Refract Surg. 2017 Jan;43:54-59.
15. Murakami Y, Manche EE. Prospective, randomized comparison of self-reported postoperative dry eye and visual fluctuation in LASIK and photorefractive keratectomy. Ophthalmology. 2012 Nov;119:2220-2224.
16. He L, Liu A, Manche EE. Wavefront-Guided Versus Wavefront-Optimized Laser in Situ Keratomileusis for Patients with Myopia: A Prospective Randomized Contralateral Eye Study. Am J Ophthalmol. 2014 Jun;157:1170-1178.
17. Kanellopoulos AJ. Comparison of Sequential vs Same-Day Simultaneous Collagen Cross-Linking and Topography-Guided PRK for Treatment of Keratoconus. J Refract Surg. 2009 Aug;25:S812-S818.
18. Kanellopoulos AJ. Keratoconus Management With Customized Photorefractive Keratectomy by Artificial Intelligence Ray-Tracing Optimization Combined With Higher Fluence Corneal Crosslinking: The Ray-Tracing Athens Protocol. Cornea. 2021 Sep;40:1181-1187,
19. Sekundo W, Kunert KS, Blum M. Small incision corneal refractive surgery using the small incision lenticule extraction (SMILE) procedure for the correction of myopia and myopic astigmatism: results of a 6 month prospective study. Br J Ophthalmol. 2011 Feb;95:335-339.
20. Blum M, Täubig K, Gruhn C, Sekundo W, Kunert KS. Five-year results of Small Incision Lenticule Extraction (ReLEx SMILE). Br J Ophthalmol. 2016 Jan;100:1192-1195.
21. Ganesh S, Gupta R. Comparison of Visual and Refractive Outcomes Following Femtosecond Laser-Assisted LASIK With SMILE in Patients With Myopia or Myopic Astigmatism. J Refract Surg. 2014 Aug;30:590-596.
22. Yang W, Liu S, Li M, Shen Y, Zhou X. Visual Outcomes after Small Incision Lenticule Extraction and Femtosecond Laser-Assisted LASIK for High Myopia. Ophthalmic Res. 2020 Jul;63:427-433.
23. Ang M, Ho H, Fenwick E, et al. Vision-related quality of life and visual outcomes after small-incision lenticule extraction and laser in situ keratomileusis. J Cataract Refract Surg. 2015;41:2136-2144.
24. Wang D, Liu M, Chen Y, et al. Differences in the corneal biomechanical changes after SMILE and LASIK. J Refract Surg. 2014 Sep;30:702-707.
25. Xu Y, Yang Y. Dry eye after small incision lenticule extraction and LASIK for myopia. J Refract Surg. 2014 Mar;30:186-190.
26. McDonald MB, Hersh PS, Manche EE, Maloney RK, Davidorf J, Sabry M; Conductive Keratoplasty United States Investigators Group. Conductive keratoplasty for the correction of low to moderate hyperopia: U.S. Clinical trial 1-year results on 355 eyes. Ophthalmology. 2002 Nov;109:1978-1989.
27. Stodulka P, Halasova Z, Slovak M, Sramka M, Liska K, Polisensky J. Photorefractive intrastromal crosslinking for correction of hyperopia: 12-month results. J Cataract Refract Surg. 2020 Mar;46:434-440.
28. Fredriksson A, Näslund S, Behndig A. A prospective evaluation of photorefractive intrastromal cross-linking for the treatment of low-grade myopia. Acta Ophthalmol. 2020 Mar;98:201-206.
29. Zheleznyak L, Butler SC, Cox IG, et al. First-in-human laser-induced refractive index change (LIRIC) treatment of the cornea. Invest Ophthalmol Vis Sci. 2019 Jul;60:5079.
30. Wozniak KT, Butler SC, He X, Ellis JD, Knox WH, Huxlin KR. Temporal evolution of the biological response to laser-induced refractive index change (LIRIC) in rabbit corneas. Exp Eye Res. 2021 Jun;207:108579.
31. Werblin TP, Kaufman HE, Friedlander MH, Sehon KL, McDonald MB, Granet NS. A prospective study of the use of hyperopic epikeratophakia grafts for the correction of aphakia in adults. Ophthalmology. 1981 Nov;88:1137-40.
32. Llorente L, Barbero S, Merayo J, Marcos S. Total and corneal optical aberrations induced by laser in situ keratomileusis for hyperopia. J Refract Surg. 2004 May-Jun;20:203-216.
33. Oliver KM, O’Brart DP, Stephenson CG, et al. Anterior corneal optical aberrations induced by photorefractive keratectomy for hyperopia. J Refract Surg. 2001 Jul-Aug;17:406-413.
34. Plaza-Puche AB, Yebana P, Arba-Mosquera S, Alió JL. Three-Year Follow-up of Hyperopic LASIK Using a 500-Hz Excimer Laser System. J Refract Surg. 2015 Oct;31:674-682.
35. Moshirfar M, Desautels JD, Walker BD, Murri MS, Birdsong OC, Hoopes PC. Mechanisms of Optical Regression Following Corneal Laser Refractive Surgery: Epithelial and Stromal Responses. Med Hypothesis, Discov Innov Ophthalmol. 2018 Spring;7:1-9.
36. Moshirfar M, Shah TJ, Masud M, et al. A Modified Small-Incision Lenticule Intrastromal Keratoplasty (sLIKE) for the Correction of High Hyperopia: A Description of a New Surgical Technique and Comparison to Lenticule Intrastromal Keratoplasty (LIKE). Med Hypothesis, Discov Innov Ophthalmol. 2018 Summer;7:48-56.
37. Jacob S, Kumar DA, Agarwal A, Agarwal A, Aravind R, Saijimol AI. Preliminary Evidence of Successful Near Vision Enhancement With a New Technique: PrEsbyopic Allogenic Refractive Lenticule (PEARL) Corneal Inlay Using a SMILE Lenticule. J Refract Surg. 2017 Jan;33:224–229.
38. Kiliç A, Tabakci BN, Özbek M, Muller D, Mrochen M. Excimer Laser Shaped Allograft Corneal Inlays for Presbyopia: Initial Clinical Results of a Pilot Study. Clin Exp Ophthalmol. 2019 Sep;10:1000820.
39. Moshirfar M, Henrie MK, Payne CJ, Ply BK, Ronquillo YC, Linn SH, Hoopes PC. Review of Presbyopia Treatment with Corneal Inlays and New Developments. Clin Ophthalmol. 2022 Aug 24;16:2781-2795.
40. FDA. EVO/EVO+ VISIAN Implantable Collamer Lens – P030016/S035. 2022 Apr 18. Available at fda.gov/medical-devices/recently-approved-devices/evoevo-visian-implantable-collamer-lens-p030016s035 . Accessed Oct. 5, 2022.
41. Jiang Z, Wang H, Luo DQ, Chen J. Optical and visual quality comparison of implantable collamer lens and femtosecond laser assisted laser in situ keratomileusis for high myopia correction. Int J Ophthalmol. 2021;14:737-743.
42. Liu HT, Zhou Z, Luo WQ, et al. Comparison of optical quality after implantable collamer lens implantation and wavefront-guided laser in situ keratomileusis. Int J Ophthalmol. 2018 Apr;11:656-661.
43. Alshamrani AA, Alharbi SS. Phakic intraocular lens implantation for the correction of hyperopia. J Cataract Refract Surg. 2019 Oct;45(10):1503-1511.
44. Packer M, Alfonso JF, Aramberri J, Elies D, Fernandez J, Mertens E. Performance and Safety of the Extended Depth of Focus Implantable Collamer® Lens (EDOF ICL) in Phakic Subjects with Presbyopia. Clin Ophthalmol. 2020 Sep 18;14:2717-2730.
45. Bellucci R. Multifocal intraocular lenses. Curr Opin Ophthalmol. 2005 Feb;16:33-37.
46. Shen Z, Lin Y, Zhu Y, Liu X, Yan J, Yao K. Clinical comparison of patient outcomes following implantation of trifocal or bifocal intraocular lenses: a systematic review and meta-analysis. Sci Rep. 2017 Mar;7:1-9.
47. Schojai M, Schultz T, Schulze K, Hengerer FH, Burkhard DH. Long-term follow-up and clinical evaluation of the light-adjustable intraocular lens implanted after cataract removal: 7-year results. J Cataract Refract Surg. 2020 Jan;46:8-13.
48. AcuFocus Inc. AcuFocus Announces FDA Approval for the IC-8© Aptherea™ Intraocular Lens and Only Small Aperture for Cataract Surgery. 2022 Jul 25. [Press release] Available at businesswire.com/news/home/20220725005273/en/AcuFocus-Announces-FDA-Approval-for-the-IC-8%C2%AE-Apthera%E2%84%A2-Intraocular-Lens-the-First-and-Only-Small-Aperture-Lens-for-Cataract-Surgery . Accessed Sep. 30, 2022.
49. Breyer DRH, Kaymak H, Ax T, Kretz FTA, Auffarth GU, Hagen PR. Multifocal Intraocular Lenses and Extended Depth of Focus Intraocular Lenses. Asia-Pacific J Ophthalmol (Phila). 2017 Jul;6:339-349.
50. Dick HB, Piovella M, Vukich J, Vilupuru S, Lin L. Prospective multicenter trial of a small-aperture intraocular lens in cataract surgery. J Cataract Refract Surg. 2017 Jul;43:956-968.
51. Bacharis C Tsilikas G, Sianoudis I, Makropoulou M, Zoulinakis G, Serafetinides AA. LASER-Induced Refractive Index Modification of Intraocular Lenses. e-JST. 2018;13:89-96.
52. Butler SC, Leeson C, Huxlin KR, et al. Next generation diffractive multifocal contact lenses for presbyopia correction using LIRIC. Invest Ophthalmol Vis Sci. 2019 Jul;60:3723.
53. The COMET Group. Myopia Stabilization and Associated Factors Among Participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013 Dec;54:7871-7884.
54. Yellepeddi VK, Sheshala R, McMillan H, Gujral C, Jones D, Singh TRR. Punctal plug: a medical device to treat dry eye syndrome and for sustained drug delivery to the eye. Drug Discov Today. 2015 Jul;20:884-889.
55. Donnenfeld E, Holland E. Dexamethasone Intracameral Drug-Delivery Suspension for Inflammation Associated with Cataract Surgery: A Randomized, Placebo-Controlled, Phase III Trial. Ophthalmology. 2018 Jun;125:799-806.
56. Alvarez-Lorenzo C, Anguiano-Igea S, Varela-García A, Vivero-Lopez M, Concheiro A. Bioinspired hydrogels for drug-eluting contact lenses. Acta Biomater. 2019 Jan;84:49-62.
57. Jaya MKA, Endarti D, Kartika IGAA, Veryanti PR, Swastini DA. The Role Of Medication Reminder Technology As An Enhancement Of Patients Compliance. Int J Pharm Res. 2020 May;12:418-427.