What is the most appropriate refractive surgery technique to operate on sight

In this article in which you will find the guidelines that most European countries, including UK, have defined (or follow) to operate the view and define which is the most appropriate refractive surgery technique based on visual error, the age of the patient, the grade to be corrected, the state of the cornea, ….

At the end of the article you will find a link to the source, where you can also check which are the guidelines defined in other European countries: France, Italy, Germany, …

Guidelines and cost of refractive surgery

UK does not have defined guidelines to operate the view

Although UK does not have defined guidelines for refractive surgery, there is a general consensus that surgeons follow regarding the preoperative examination, indications and follow-up according to the technique chosen to operate on the patient.

In the public health service, eye surgery is free but with limitations

It is important to bear in mind that in UK patients are covered by public and private health services. The public health system, which is universal and free, is responsible for approximately three-quarters of cataract surgeries made in UK.

Standard public coverage does not include premium IOLs or excimer lasers. Private ophthalmic centers have access to the leading technology in refractive surgery, such as lasers (excimer and femtosecond) and premium IOLs, and offer a wider range of treatments than public centers.

Refractive surgery techniques and types of intraocular lenses most used

Current trends in refractive surgery for eye operation show an increase in the use of surface ablation techniques, particularly advanced surface ablation and PRK; an increase in phakic IOL implantation, which represents 4% to 5% of all refractive surgery procedures performed in young patients; and an increased use of femtosecond lasers to create thin LASIK flaps.

Refractive lens exchange (RLE) is becoming the technique of choice in patients over 50 years of age. This may be due to the safety of surgical technique, more accurate biometrics, and the development of premium IOLs.

400,000 lenses implanted per year

More information: Operation with intraocular lenses

In UK, the implantation of premium lenses represents approximately 10% to 12% of the 400,000 lenses implanted per year; of them, from those 40,000 to 48,000 premium lenses, 70% to 80% are multifocal, and 20% to 30% are toric IOLs (data on file with Alcon Laboratories, Inc., Fort Worth, TX, and Abbott Medical Optics, Inc., Santa Ana, CA). The percentage of premium IOLs is much higher if we consider only patients treated in the private setting.

Before eye surgery

The preoperative regimen for patients scheduled for refractive surgery requires a complete ophthalmic evaluation after discontinuation of contact lens wear for at least 1 to 2 weeks.

Evaluation includes subjective refraction under cycloplegia, slit lamp examination with emphasis on ocular surface and tear film quality, mesopic and scotopic pupillary diameter, IOP, fundus examination and topography, and corneal pachymetry.

In some cases, corneal hysteresis is also highly recommended. In UK, the increasing use of personalized laser surgery with aspheric ablations has made the pupillary diameter less relevant, as long as it exceeds 7.5 mm in scotopic conditions.

Examining the tear film and ocular surface has become more important, as it helps surgeons decide if the patient is a candidate for corneal refractive surgery.

Refractive surgery techniques according to age and refractive error

Indications for surgical techniques vary according to the age of the patient. In UK, refractive surgery is not approved in children, except in cases that cannot be managed with standard treatments such as high amblyopic anisometropia.

In order to have vision surgery, people must be at least 18 years old to undergo corneal refractive surgery or phakic IOL implantation; however, surgeons generally prefer patients to be at least 20 years old.

The corneal refractive surgery it is the gold standard for all patients under 45 years of age who meet the accepted diopter range. In older patients, the surgery of choice is RLE. Some exceptions can be made in terms of age limits. For example, RLE can be offered to younger tall hyperopes (40-42 years) and later (± 50 years) in tall myopics.

The techniques of excimer laser they are considered the gold standard for myopic refractive errors down to -7.00 D and are widely used in this country, with approximately 180,000 procedures performed per year (data on file with Alcon Laboratories, Inc. and Abbott Medical Optics Inc.).

The surface ablation procedures have recently become more popular among Spanish surgeons, and now account for almost a third of excimer laser procedures, mainly in patients with myopia up to -4.00 D. mitomycin C It is widely used, mainly in deep ablations, compound myopic astigmatism treatments and enhancements.

For patients with myopic errors greater than -7.00 D, the first option is usually the implantation of a phakic IOL. Phakic IOL implantation requires a preoperative endothelial cell count of more than 2,000 cells / mm2 and an anterior chamber depth greater than 2.8 mm from the endothelium to the lens. In this country, 80% of phakic IOLs are posterior chamber models and 20% are anterior chamber models.

In patients with hyperopia up to 4.00 D, my first option is Lasik
using an optical ablation zone of more than 6.5 mm. When the hyperopic defect is greater than 4.00 D, the implantation of a phakic IOL or, if there is presbyopia, a Multifocal IOL.

The main surgical options to control astigmatism in young patients include ablation with excimer laser or toric phakic IOL implantation in those who are not candidates for LASIK.

For older, presbyopic patients, Toric pseudophakic IOL they are the preferred approach. Incisional astigmatic surgery, such as limbal relaxing incisions, has practically been abandoned by surgeons in UK; It is used only in patients undergoing cataract surgery with monofocal IOLs.

The intracameral cefuroxime is the intraoperative treatment used for the prophylaxis of infections in all intraocular refractive procedures (either cataract surgery, phakic IOL implantation or ERR).

Postoperative after eye surgery

Topical antibiotics are prescribed postoperatively for 1 week and topical steroids for 2 to 4 weeks.

For LASIK, I prescribe a combination of antibiotics and steroid drops three times a day for the first week and artificial tears five times a day for at least 2 months.

If you need more information, do not forget to consult the link that you will find below.

Source: Current European Guidelines for Refractive Surgery

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