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First published 2004

ISBN 0 7506 5560 7

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Note
Medical knowledge is constantly changing. As new information becomes available, changes in
treatment, procedures, equipment and the use of drugs become necessary. The
author/contributors and the publishers have taken great care to ensure that the information
given in this text is accurate and up to date. However, readers are strongly advised to confirm
that the information, especially with regard to drug usage, complies with the latest legislation
and standards of practice.

Printed in Spain by Grafos SA, Arte sobre papel.


Recent years have seen an exponential
growth in the field of refractive surgery. In
1996, the US Federal Drug Administration’s
approval of certain excimer lasers to correct
myopia lead to a rapid increase in the uptake
of excimer laser procedures. Further
approvals have been granted for other laser
manufacturers, and for the correction of
astigmatism and hyperopia. Popularity
increases as patients hear about the suc-
cessful outcomes for friends and relatives.
Famous people who undergo this surgery
are a further boost, and laser clinics are
quick to state the names of famous patients
who have undergone treatment. Techniques
have improved, better lasers and other equip-
ment are available and there seems to be an
unlimited supply of patients willing to
undertake surgical alternatives to wearing
spectacles or contact lenses. Practitioners,
both optometrists and ophthalmologists,
seem to be split over refractive surgery. Some
advocate its usefulness as a viable alterna-
tive, whereas others feel it is nothing more
than cosmetic surgery for refractive error. It
may be oversimplifying the issue to call
refractive surgery a cosmetic procedure, as
patients often state that their disability
requires the use of optical aids, almost like
using an aid to assist hearing. However, it
would be correct to say that refractive sur-
Preface
gery is an elective procedure, as the patient
chooses to undergo surgical intervention on
an otherwise healthy eye, and the surgeon
agrees to operate on an eye that is without
pathology.
In the UK refractive surgery is offered
on a private basis only. There have been
attempts to treat higher refractive errors
on the NHS, but these schemes tend to be
regional and not the norm. Patients who
decide to undergo refractive surgery
either book in to a refractive surgery clin-
ic or go to see a consultant ophthalmol-
ogist who offers treatment privately.
Surgeons who offer refractive surgery do
not need to be consultant ophthalmolo-
gists accredited with the Royal College of
Ophthalmologists, although many are.
However, they must have suitable quali-
fications, such as Member or Fellow or
the Royal College of Ophthalmologists
(MRCOphth or FRCOphth), Fellow of the
Royal College of Surgeons (FRCS) or be list-
ed on the European Specialist Register. Most
laser manufacturers ensure that doctors
who use their lasers have attended the rel-
evant training courses to use that particu-
lar apparatus. In the UK the most common
types of refractive surgery currently
employed are photorefractive keratectomy
(PRK) and laser in-situ keratomileusis
(LASIK), although PRK is being replaced by
laser epithelial keratectomy (LASEK). Both
of these use the same currently widespread
excimer laser technology. Other techniques
are available, but to a lesser degree.
This book examines various aspects
that may be relevant to those interested in
learning more about the current status of
refractive surgery, with particular atten-
tion paid to patient selection, available sur-
gical techniques and the evaluation of
patients pre-operatively and post-opera-
tively (details of some specialist instru-
mentation are also outlined). Clinicians
with a degree of knowledge in refractive
surgery may be interested in the chapters
that discuss wound healing after refractive
surgery and case reports from surgeons.
Of general interest, the book also discuss-
es legal issues and future trends in this fast-
changing area.
Notes for the CD-ROM
The large size of the videos means that the
loading of video clips 4 and 5, in particu-
lar, may take 1–2 minutes on some com-
puters, and users of Mac OS9 may see a
white screen while the videos are loading.
When the videos finish loading, the screen
will change and the Play, Pause, and other
buttons will appear
Shehzad A Naroo
 Contributors
Alejandro Cerviño
DOO (EC)

W Neil Charman
DSc, PhD

Paul MH Cherry
MBBS, LRCP, FRCS(Ed), FRCS, FRCSC, FRCOphth

Catharine Chisholm
PhD, MCOptom

Sandip Doshi
PhD, MCOptom

Stephen J Doyle
BSc(Hons), MRCOphth

Balasubraminiam Ilango
FRCS(Ed), MRCOphth

Mohammad Laiquzzaman
MBBS, PhD

Shehzad A Naroo
MSc, PhD, MCOptom, FIACLE

Sunil Shah
FRCS(Ed), FRCOphth

Baldev K Ubhi
BSc(Hons)
 1
Patient selection and
pre-operative assessment
For many patients who want to find out
more about refractive surgery the first port
of call is often the local ophthalmic prac-
tice, while others call dedicated clinic
phone lines or browse the Internet.
Prospective patient interest can be classed
into two categories: those who make casu-
al enquiries to see if they are suitable and
those who have decided that this is defi-
nitely something they will opt for. The first
group may progress to become part of the
second group when they feel they are more
informed. The latter group can sometimes
be difficult to dissuade from surgery if they
are found to be unsuitable. Those patients
who make casual enquiries often seek gen-
eral advice only and can usually be
referred to websites or professional bod-
ies that produce this type of information.
Whereas for patients who have decided to
opt for refractive surgery, it is usually advis-
able to make a specific appointment to dis-
cuss the surgical options and perform the
relevant tests (or else refer the patient to
a colleague who is able to do this).
Some patients may suspect that
optometrists have their own agenda and
advise against refractive surgery because
they want to protect their own livelihood.
Furthermore, many optometrists may feel
that their knowledge about the current
state of affairs is not adequate and thus
choose not to become involved at all and
advise patients not to proceed with this
option. A proactive approach towards
refractive surgery by optometrists is
advised by some refractive surgery clinics,
and more recently the number of
optometrists who have become involved in
co-management schemes with refractive
surgery providers has increased (discussed
in Chapter 7). However, a careful balance
needs to be struck by optometrists in rou-
Shehzad A Naroo
tine practice to ensure they are best able to
serve their patient’s needs.1 Optometrists
are in a unique primary care position in
eye health from which they can offer an
unbiased opinion.
Various studies have shown the aver-
age age of prospective patients to be the
mid-to-late thirties with an almost equal
ratio of male to female patients.2,3 The
author recently completed a study (not yet
published) that shows the average patient
age to be creeping up to around 40 years,
and there seems to a shift towards more
female patients. Since refractive surgery
usually involves an initial financial out-
lay comparable to that for contact lens-
es, which in the UK are often paid by
monthly bank debits, most studies seem
to show a prevalence of patients from
higher socio-economic groups. This may
partly explain the age groups of refractive
surgery patients too. Figure 1.1 shows the
breakdown of the occupational groups of
new patients who presenting for refrac-
tive surgery.
Unemployed
Student 5%
Retired 3%
6%
Unskilled
12%
Semi-skilled
9%
Clerical
31%
Figure 1.1
Breakdown of the occupational groups of new patients who present for refractive surgery3
Most studies highlight that many
patients who present for refractive surgery
are former contact lens users.4,5 Often the
reasons why people want contact lenses
are similar to the motivation for patients
to have refractive surgery, so it is not sur-
prising that there are some similarities in
the types of patients who present for both
types of refractive correction. Both groups
of patients often say that they want the
freedom from spectacles or they want to
achieve a cosmetic look that spectacles do
not allow, or perhaps the reasons are relat-
ed to certain activities (work or sports,
etc.). Patients who cease contact lens use
in favour of refractive surgery often com-
plain of the inconvenience of contact lens-
es and/or complications with contact
lenses, which is a primary motivation for
their decision. Often, many of the less seri-
ous complications with contact lenses that
patients complain of could be minimized
with improved contact lens management,
which requires the appropriate input from
their contact lens practitioners.
Professional
19%
Management
15%
2 ■ Refractive surgery: a guide to assessment and management
Also, some patients choose refractive
surgery as a primary alternative to spec-
tacles and present for surgery even though
they have not tried contact lenses. This
may result, in part, from the way that laser
refractive surgery is marketed. In many
cases it would be useful for the patient to
try contact lenses first. Laser refractive sur-
gery clinics advertise on the radio, news-
papers and television. There seems to be
an interesting shift in the way that adver-
tisers have portrayed refractive surgery
over the years. In the early days the con-
venience of refractive surgery was used to
herald it as being a ‘quick’, ‘painless’ and
‘safe’ treatment that only took a few sec-
onds or minutes to complete and the
patient would return to work shortly after-
wards. The next wave of advertising
seemed to use people that patients could
relate to, either celebrities who would
advocate a certain clinic or ‘real’ people
that were respected in the community,
such as firemen, nurses and even priests.
The most recent advertising trend seems
to focus on the technology that a particu-
lar centre uses, although in the UK this
approach has come under the scrutiny of
the Advertising Standards Association.
Patients who opted for refractive surgery
gave the main factors shown in Figure 1.2
as those that influenced their decision to
cease contact lens use; the values relate to
the percentage of patients who offered the
particular reason as an influential factor.3
Patients who are former contact lens
wearers are advised to remove their contact
lenses prior to their pre-operative refractive
surgery consultation. The time period for
lens removal depends on the type and
modality of lens worn. Typically, soft lens-
es are removed for 7–14 days prior to the
appointment and gas permeable lenses for
Costs
21%
Overwear
17%
Intolerance to solutions
Intolerance to lenses
7%
Figure 1.2
Main factors that influenced the decision to cease contact lens use and opt for refractive surgery
(values relate to the percentage of patients who offered the particular reason as an influential
factor)3
10–21 days. Users who wear hard poly-
methylmethacrylate (PMMA) lenses may
find that they have to leave their lenses out
for a few months, especially if they are long-
term wearers, to ensure that any corneal
distortion is eliminated.
Patients are often asked to produce
past refraction details, for up to the previ-
ous 3 years, to show that they have some
level of stability. A patient with a large
recent change in refraction would prob-
ably be advised to wait until two or three
consecutive prescriptions were similar. If
patients undergo refractive surgery and
then find that a year later their prescrip-
tions naturally became worse, they will
often be dissatisfied with the outcome. It
has been suggested that refractive surgery
may aid visual development in children
with squints that are purely accommoda-
tive. This type of service would not typi-
cally be offered by most commercial
refractive surgery clinics and currently it
is not widely available in hospital refrac-
tive clinics either. Patients under the age
of 21 years who present for refractive sur-
gery are often advised to wait until they
reach 21, or until their prescription has
stabilized.6 Although there is no upper
age limit for refractive surgery, it may be
unwise to perform a corneal procedure on
late presbyopic patients with lens sclero-
sis, as they may be better suited to clear
lens extraction with an accurately calcu-
lated intraocular lens implant.
Patients with only one ‘seeing’ eye are
considered a contraindication to refractive
surgery, as infection in the good eye would
seriously compromise the patient’s visual
function, although the risk of sight-threat-
ening infection is extremely rare after
refractive surgery.7,8 Also, in photorefrac-
tive keratectomy (PRK) surgery the two
Red eye
14%
Dry eye
18%
Professional advice
5%
Advice from friends
1%
17%
eyes are operated on over an interval of
around 3 months, and the operated eye
does not achieve its final prescription for a
few weeks and often is quite blurred dur-
ing the first week after surgery. So patients
who are amblyopic in the non-treated eye
may experience some degree of visual dis-
ability while the first treated eye reached
its final prescription.9,10
Conical corneas, such as keratoconus or
keratoglobus, are considered as contraindi-
cations to refractive surgery. Both of these
conditions have associated thinning at the
apex of the conical cornea, which may lead
to ectasia after corneal refractive surgery.
However, a corneal topography pattern that
appears to indicate keratoconus without any
other clinical sign of the disease may not
necessarily be a contraindication.11,12 An
irregular corneal surface, possibly caused by
other types of disease or dystrophy such as
Fuchs’ endothelial dystrophy, is also consid-
ered a reason not to proceed with refractive
surgery. However, many corneal surgeons
use an excimer laser to perform a pho-
totherapeutic keratectomy (PTK) on patients
with conditions such as recurrent corneal
erosions or band keratopathy. In this an even
layer of stromal tissue is removed to smooth
off the irregularities at the anterior stroma,
with a wide ablation diameter, without alter-
ing the overall corneal curvature and refrac-
tion greatly.
Patients with known, current viral
infections are not suitable for treatment
while they have an active disease process.
Patients undergoing drug therapy or treat-
ment that may affect their corneal healing
should consider refractive surgery only
when they have completed their other
therapy. Glaucomatous patients may be
thought unsuitable for PRK, as they might
require the use of corticosteroid drops
post-operatively.13–15 Patients with a fam-
ily history of glaucoma should be made
aware that after corneal surgery the meas-
urement of intraocular pressure (IOP) can
be affected.16–19 Similarly, pregnancy is
considered a contraindication to refractive
surgery as there may be subtle changes in
refraction during gestation, and also many
patients may be wary if drug treatment is
indicated after refractive surgery.
Inappropriately motivated patients
should not be encouraged to have refractive
surgery as they may have unrealistic expec-
tations that cannot be met. Motivation for
treatment should be assessed carefully pre-
operatively, and patients should not feel
coerced into proceeding. This can be espe-
cially difficult, as most refractive surgery
takes place in a very commercial environ-
ment in which competition, pricing and
advertising is often fierce. Nonetheless, it

should be remembered that an unhappy
patient is more likely to tell his or her
friends about the experience than a happy
patient. It would almost be a false econo-
my to treat patients who were unsure
about going ahead. Many refractive sur-
gery clinics allow a cooling off period for
potential patients between the time of their
initial consultation and the actual surgery
so that they do not feel pressurized. This
tends to be the norm for laser in situ ker-
atomileusis (LASIK) surgery, but opinions
vary on this for surface-based laser treat-
ments like PRK and laser epithelial ker-
atomileusis (LASEK; see Chapters 3 and
4 for details of the types of surgery).
Patients who are unable to comprehend
the rationale of treatment should not be
treated, unless for therapeutic reasons.
This includes anyone who is unable to give
informed consent, such as minors or men-
tally disadvantaged individuals.
When assessed subjectively, it appears
as though the majority of patients are sat-
isfied with the outcome of refractive sur-
gery.20, 21 The complications of refractive
surgery are mentioned in patient literature
and detailed in ophthalmic literature.
Patients with realistic expectations are
more likely to be successful candidates.22
Often it is asked why patients are will-
ing to undergo refractive surgery knowing
the potential risks associated with it and
not knowing if there will be any long-term
effects that are yet to be uncovered.23
Studies to carry out recognized psycho-
metric personality tests on a group of
refractive surgery patients and compare
them to a control group, or maybe com-
pare them to patients who present for
other types of elective or cosmetic surgery
are currently underway.24,25 Is there an
underlying trait in some refractive surgery
patients that leads them on a compulsive
drive for perfection?26
Practitioner’s who evaluate prospective
patients for refractive surgery should first
assess that the patient is suitably motivat-
ed towards undergoing surgery, as high-
lighted above. It is usually advisable that
the patient be armed with some informa-
tion before attending for consultation. The
actual pre-operative assessment routine
may differ slightly from clinic to clinic, but
the essence of the examination is the
same. The individual tests that are usual-
ly performed are mentioned below,
although this list is not conclusive and
some tests can be omitted depending on
the type of refractive surgery that the
patient is to undergo. Most of these tests,
unless indicated, do not require equipment
additional to that currently available in the
routine ophthalmic practice.
Patient selection and pre-operative assessment
Visual acuity
It is important to know the patient’s visu-
al acuity (VA) before refractive surgery, as
it can be used as a guide to post-operative
success, and also to detect amblyopia. Loss
of best-corrected visual acuity (BCVA) can
occur after excimer laser refractive sur-
gery and can result from one or more of
the complications of the procedure men-
tioned here. Independent loss of BCVA
may be attributed to the alteration that
occurs in the magnification from the
patient’s spectacle lenses. In the case of
a moderate hyperope, the patient does not
receive the extra magnification, after
refractive surgery, in their VA that they
previously had as a result of their hyper-
opic spectacles. Conversely, in refractive
surgery for moderate myopia the patient
does not have the reducing effect of their
spectacle lenses after surgery. This means
that the patient shows an improvement in
the BCVA or, in the presence of other post-
operative problems, the patient does not
show a reduction in BCVA.27,28 Most cli-
nicians use Snellen acuity, although bet-
ter analyzes could be made if Bailey–Lovie
charts were used. Often the figures quot-
ed suggest that patients lose or gain lines
of BCVA based on Snellen acuity. This may
hold true for a Snellen chart, but it is not
as accurate as quoting Bailey–Lovie
charts (Figure 1.3) in which the lines of
letters have equal numbers of letters and
an equal rate of change exists between
each line of letters.29,30
Figure 1.3
High-contrast (90 per cent) distance
Bailey–Lovie chart
■ 3
Full refraction
It is vitally important that an accurate pre-
scription is measured for all prospective
patients. A patient whose prescription is
too minus will end up with a result that is
overcorrected and thus will become hyper-
opic. A patient with an undetected latent
hyperopia will also end up with a result
that is hyperopic. This is especially impor-
tant in presbyopes and pre-presbyopes, as
a small hyperopic result will be more detri-
mental to them than a small myopic result.
Cycloplegic refraction is often useful to
eliminate any concerns of latent hyperopia
or an over-minus of the refraction. It is not
unreasonable to assume that some of the
hypocorrections and hypercorrections
that occur after refractive surgery result
from an incorrect pre-operative refraction.
The author routinely performs cycloplegia
on all potential patients to avoid any
refractive surprises.
Pupil diameter
Early excimer laser refractive surgery used
smaller diameter ablations of up to
3–4mm, so that the depth of the ablation
keratectomy was kept to a minimum. The
downside of this was noted in some
patients with larger pupils, who found, at
night especially, that their pupil would
dilate to beyond the treatment zone.31 The
result of this was a ghosting around bright
objects and lights.32,33 This is very similar
to the ghosting that a patient may experi-
ence from a decentred corneal contact
lens, where the optic zone diameter cross-
es over the pupil margin. Nowadays, this
is less of a problem as most excimer laser
refractive surgery uses larger diameter
ablations,34 but it still may be an issue in
cases for which a small diameter ablation
is used (possibly because the patient has
a relatively thin cornea; see Corneal
pachymetry below). Usually, a central stro-
mal area is ablated with the full refractive
correction and a blended zone is ablated
around it, similar to the optic zone and car-
rier portion of a contact lens. This allows
the depth of the ablation keratectomy to
be kept to a minimum.35,36 However,
there remains the problem that this cre-
ates substantial spherical aberration in the
outer zones of the dilated pupil, so that
some degradation of the retinal images
occurs.37–39 Pupil diameters are meas-
ured either with a ruler under normal
lighting conditions or, preferably, using a
pupillometer such as the Colvard unit
(Oasis Technologies, California, USA) or
Keeler pupillometer (Keeler Ltd, Windsor,
4 ■ Refractive surgery: a guide to assessment and management
Berkshire, UK) or similar. One clinic in the
UK exclusively uses a computerized pupil-
lometer device to measure pupil diameter
under different lighting levels.
Corneal topography
Most routine optometric practices use a
keratometer to assess central corneal cur-
vature for contact-lens fitting. In the pre-
assessment of patients for refractive
surgery a keratometer is inadequate since
it takes measurements from the central
3–4mm of the anterior cornea only.40
Excimer laser refractive surgery involves
removal of corneal tissue by ablation over
a wide area. In myopic refractive surgery
this tissue is removed from the central
corneal area (up to about 7mm), and in
hyperopic surgery the tissue is removed
from the mid-peripheral cornea (up to
about 9mm). The net result of the sur-
gery means there is a change in the ante-
rior corneal profile. It is important to
measure the full anterior corneal shape
before refractive surgery, to check for any
contraindications, such as corneal con-
ditions or dystrophies, and corneal irreg-
ularities. All refractive surgery clinics use
a corneal topography unit to measure
the whole corneal shape to obtain base-
line data for the cornea, but also a very
flat cornea may prove to be more difficult
in flap creation with a microker-
atome.31,41,42 Contact lens users who
present for refractive surgery are advised
to remove their lenses for a period of time
before surgery to eliminate warpage
Figure 1.4
Eyesys 2000 topography unit, which uses a large Placido disk and is able
to give information about the radius of curvature on the anterior corneal
surface
induced by contact lenses. For a patient in
whom warpage is observed, the topogra-
phy measurements are repeated on sub-
sequent visits until no further changes are
seen in the topography maps; only then is
the patient considered suitable for surgery.
Most corneal topography units use
Placido disc technology (Figure 1.4), which
allows measurements of the anterior sur-
face only. The change in the anterior cur-
vature is dependent upon the amount of
initial refractive error.43–47 Recent devel-
opments in corneal biometry include slit
scan topography machines, which use
light slits across the cornea to take a three-
dimensional image.48 Until very recently,
the Orbscan corneal topography system
(Figure 1.5), developed by Orbtek, Salt Lake
City, Utah (Bausch and Lomb, Rochester,
New York, USA), was the only commer-
cially available machine able to assess the
posterior corneal shape, but a recent unit
by Oculus (Giessen, Germany) uses a rotat-
ing Scheimplug camera to take similar
measurements. A map is produced by
these newer devices that may be more rep-
resentative of the true corneal shape, with
attention given to the posterior surface
topography and corneal thickness. This
allows a better evaluation of anterior
corneal and posterior surface astigmatism,
and of residual lenticular astigmatism.
More information on corneal topography
is presented in Chapter 2.
Recent literature shows that there can
be an associated change in the posterior
corneal curvature, too, which is also relat-
ed to the amount of treatment.49–51 In the
LASIK procedure the microkeratome cuts
Figure 1.5
Original Orbscan corneal analysis unit, which uses scanning slit
technology. The Orbscan allows the posterior corneal surface curvature
and corneal pachymetry to be viewed. Note the acquisition head does not
use Placido technology, but contains two scanning slit lights. (Courtesy of
Bausch and Lomb)
approximately one-quarter to one-third
into the depth of the cornea to create a
flap. Although there are no reported inci-
dences of corneal ectasia after LASIK,
there is concern over what happens to the
posterior corneal curvature after this pro-
cedure, especially in high refractive cor-
rections. It is not unreasonable to assume
that an alteration in posterior corneal cur-
vature occurs in LASIK also.52,53
Slit-lamp examination
Detailed slit-lamp biomicroscopy exami-
nation is important prior to refractive sur-
gery. Contraindications to refractive
surgery should be identified, and include
anterior corneal scars and opacities, clin-
ical signs of conditions such as kerato-
conus (e.g., Vogt’s striae and Fleischer’s
ring) and lenticular changes.54 A patient
with nuclear sclerosis may be deemed
unsuitable for excimer laser surgery, but
may benefit from clear lens extraction with
an appropriately calculated intraocular
lens.55 Previous contact-lens complica-
tions, such as neovascularization, do not
usually contraindicate refractive surgery.
Corneal pachymetry
As mentioned above, PRK and LASIK
involve the removal of small areas of
corneal tissue by ablation with an
excimer laser, which results in an alter-
ation of the overall corneal curvature. If
a patient has a very thin cornea, then
 Patient selection and pre-operative assessment ■ 5

cutting a flap with a microkeratome may

not leave sufficient cornea under the flap Ablation depth depends on correction and diameter
to sustain corneal strength. Most sur- 200

Theoretical ablation depth (␮m)

geons like to leave a bed of at least
250–300μm under the ablated stroma
left untouched. Pachymetry is also
important for cases in which repeated
PRK is warranted for similar reasons.
Conditions that lead to areas of corneal
thinning, such as keratoconus or pellu-
cid margin degeneration, may also be
detected by carefully positioned pachym-
etry measurements. Corneal thickness is
usually measured with an ultrasonic
pachymeter using an appropriate anaes-
thetic, since it is a contact device. The
amount of tissue removed during laser
refractive procedures depends on the
level of ametropia to be corrected and
the diameter of the laser ablation. The
relationship between diameter and depth
of ablation was investigated by
Munnerlyn et al., 56 and many clinicians
still use their formula to estimate the
amount of treatment (Figure 1.6).
Fundus examination
To identify abnormal ocular conditions of
the fundus, patients should undergo full
ophthalmoscopic examination. Some cli-
nicians warrant dilated fundus exami-
nation with an indirect ophthalmoscope,
such as a Volk lens, in addition to direct
ophthalmoscopy. Many patients who
elect to undergo refractive surgery are
high myopes. In the case of high myopia
the likelihood of spontaneous retinal
detachment is about 1 per cent. 57,58
After laser refractive surgery the retina is
unchanged and the retina is as likely to
detach spontaneously as before surgery.
However, very often the patient’s lifestyle
may change, especially if this was one of
the primary motivations for having
refractive surgery, and the patient may
partake in activities and sports that before
were hindered by the use of spectacles.
Retinal detachment after laser refractive
surgery has been reported and patients
should be warned about the risks, in the
same way as high myopes would be
warned routinely. Authors have quoted
incidences of retinal problems after
LASIK of between 0.06 and 0.25 per cent
of eyes, and of about 0.08 per cent after
PRK.59–62 The low incidence of retinal
problems after refractive surgery may
reflect careful pre-operative assessment
of patients to assess potential risks. Some
clinics apply prophylactic treatment to
patients deemed at risk of later retinal
detachment problems.63,64
175
150
125
100
75
50
25
1 2
Figure 1.6
Amount of ametropia on the horizontal axis and the estimated laser ablation depth on the
vertical axis for different ablation diameters. (Courtesy of Stefan Pieger)
Intraocular pressure
measurement
Active glaucoma is a contraindication to
refractive surgery, although most refrac-
tive surgery clinics do not assess visual
fields on all potential patients, unless war-
ranted. IOP is of interest to refractive sur-
geons as there have been suggestions in
the literature of instances of altered IOP
readings after PRK. It is thought that the
thinner cornea still has the same mechan-
ical forces acting on it and that regular
tonometers do not make an allowance for
thinner corneas.65–71 Hence, a lower
tonometer force may be required to
applanate the cornea by the required
amount, and so the IOP reading is falsely
low. Attempts have been made by some
workers to quantify the change in IOP
readings with the amount of ablation
received by the cornea.16,17,19,72–79 The
altered IOP reading is of particular impor-
tance if a patient who has undergone
refractive surgery develops glaucoma in
future years. For this reason other con-
tributing factors towards glaucoma should
be noted, such as positive family history,
refractive error, age, race and anterior
chamber depth.
Muscle balance
Although not essential, it can be useful to
check the muscle-balance status of
patients. A post-surgical problem, which
may only be theoretical, since it has not
been described in the literature, is the
4.0mm
4.5mm
5.0mm
5.5mm
6.0mm
7.0mm
3 4 5 6 7 8 9 10 11 12 13 14 15
Spherical refractive error (D)
breakdown of binocularity. A patient who
is a moderate-to-high myope has a base-in
prismatic effect when performing near
tasks with spectacles on. After refractive
surgery the patient loses this additional
base-in prism and may develop a fixation
disparity. This is likely to be more prob-
lematic in pre-presbyopic patients, who
may find the need for a reading add if their
base-in prism for near is removed from
their habitual state. Furthermore, in early
and pre-presbyopes a change in accom-
modative demand when moving from
spectacles to refractive surgery (or contact
lenses) can occur and may be problemat-
ic for the myopic patient. As hyperopia
increases, the demand on ocular accom-
modation increases. Hence, as the specta-
cle refraction is moved towards the ocular
Figure 1.7
Pelli–Robson CSF chart
6 ■ Refractive surgery: a guide to assessment and management
plane the hyperope benefits from the lower
demand on accommodative effort, where-
as the myopic patient places a higher
demand on the accommodative effort.80
Contrast sensitivity function
Reduced contrast sensitivity function (CSF)
has been described after refractive surgery,
and hence its measurement with a suitable
test, such as a Pelli–Robson chart (Figure
1.7), is useful.81 In PRK patients this may
be the result of corneal haze. Haze is
thought to be an immune response of the
stroma and forms precisely at the level of the
site of laser ablation (i.e., the epithelial–stro-
mal interface). To combat haze, some sur-
geons use corticosteroids prophylactically
with all patients, some use them only if haze
is beginning to appear and others prefer to
use them with patients who are deemed to
be more likely to develop haze, such as
patients with higher refractive errors.14,15
It has been suggested that newly synthesized
cells cause haze, and an aggregation of ker-
atocytes may play a part in the aetiology of
References
1 Conway R (1994). PRK counselling in the
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2 Orr D, Sidiki SS and McGhee CNJ (1998).
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5 Whittaker G (1996). Are contact lens-
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haze. The new stromal tissue deposited is not
laid in a regular pattern, which leads to a
reticular pattern of fibres. Studies have
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Supplementary tests
Altered tear secretion has been reported
after LASIK,88,89 and it is useful to assess
tear-film quality and measure tear break-
up time. Appropriate instruments, such as
the Keeler Tearscope (Keeler Ltd, Windsor,
Berkshire, UK) could be useful in identify-
ing patients with potentially low tear vol-
umes or break-up times. This may be
important for patients who undergo PRK,
for whom an incidence of recurrent ero-
sions of about 3 per cent is quoted.90–92
Many patients find ocular lubricants use-
ful for a period of time after corneal laser
refractive surgery (corneal wound healing
after these types of surgery is discussed in
Chapter 3). There have been reports in the
literature of changes in corneal sensation
after PRK and LASIK, although most
authors suggest the corneal sensation is
usually at its pre-operative level within a
year, or sooner.93–95 However, it is not
common to take aesthesiometry meas-
urements before refractive surgery using
devices such as the Cochet–Bonnet aes-
thesiometer mounted on a slit lamp.
intraocular pressure after excimer laser
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after excimer laser photorefractive
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29 Moniz N, Fernandes T, Narayanan KK and
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39 Maeda N, Klyce SD, Smolek MK and
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40 Bennett AG and Rabbetts RB (1989).
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Patient selection and pre-operative assessment
42 Schallhorn SC, Reid JL, Kaupp SE, et al.
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44 Maldonado A and Onnis R (1998). Results of
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45 Maguen E, Salz JJ, Nesburn AB, et al.
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46 Lindstrom RL, Lineberger EJ, Hardten DR,
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47 Salz JJ, Maguen E, Nesburn AB, et al.
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48 Dave T (1998). Current developments in
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51 Naroo SA and Charman WN (2000).
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52 Wang Z, Chen J and Yang B (1999).
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53 Maloney RK (1999). Discussion of article
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54 Lawless M, Coster DJ, Phillips AJ and
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55 Colin J and Robinet A (1997). Clear
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59 Arevelo JF, Ramirez E, Suarez E, et al.
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61 Ruiz-Moreno JM, Artola A and Alio JL
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62 Ruiz-Moreno JM, Perez-Santonja JJ and
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 2
Corneal topography and its role
in refractive surgery
Shehzad A Naroo and Alejandro Cervino
The cornea plays a fundamental role in
both the structural integrity and the
refractive state of the eye. Thus, both the
determination and representation of its
shape are important for refractive and sur-
gical purposes, as well as in the diagnosis
and evolution of several pathologies that
express corneal shape alterations, such as
keratoconus, marginal degeneration and
other ectasias. The adult cornea is char-
acterized by its specific distributions of cur-
vature and thickness along the different
meridians, distributions that are essential
for the correct function of the cornea as
the most important and powerful refrac-
tive element of the human eye.
History
Early interest in corneal topography dates
back to Father Christopher Scheiner, who
in 1619 compared corneal images to mar-
bles. Using daylight he viewed the image
formed when daylight shone through the
cross-shaped glazing frame bars of his
windows onto corneas and compared the
images formed to those formed on marbles
of a known size. Senff introduced the first
concepts about human corneal topogra-
phy in 1846, reporting that the anterior
corneal surface flattens towards the lim-
bus and compared the anterior surface of
the cornea with a revolution ellipsoid.
Henry Goode (1847) described the first
keratoscope, which comprised a small
luminous square held near to the eye.
Helmholtz (1853) invented the ophthal-
mometer, and introduced the first dou-
bling image system to avoid the problems
caused by the continuous micro-move-
ments of the eye that existed until then.
This ophthalmometer was difficult to use,
but it served as a base for the development
of the keratometers. In 1880 Antonio
Placido introduced a flat disc with a series
of concentric black and white rings, with
the corneal reflections of the rings exam-
ined through a central aperture. It is illu-
minated from a light source above or
beside the patient’s head. The Placido disc,
as it became known, must be held normal
to the line of sight or it will give a false
impression of the toricity of the cornea.
Gullstrand (1896) was the first to photo-
graph the corneal image formed with the
Placido disc.1,2
Classification of corneal
topography
Since the early investigations of Javal and
Helmholtz, a basic model of corneal topog-
raphy has been established that uses the
ellipse as a first-order approximation to the
normal corneal profile. This classic model
of the corneal contour corresponds to a
surface with two zones, a central spheri-
cal zone of 4–5mm diameter and a periph-
eral zone that flattens towards the limbus.
The central zone is responsible for the
foveal image formation, and within this
area of the cornea the changes in curva-
ture are small, so often uniformity is
assumed. However, it has been demon-
strated by Bennett that this is not actually
correct,3 but rather each point on the
cornea is conical (as mentioned below).
The anatomic centre of the apical zone
rarely corresponds to the visual centre or
the geometric centre, although most
instruments assume this to be true. The
position of the apex is independent of the
geometric centre and is usually located
0.5mm on the temporal side with respect
to the geometric centre.4 Other classifica-
tions have also been developed, such as
that of Rowsey and co-workers who con-
sidered the quantity and symmetry of
peripheral flattening,5 and classified the
corneas into essentially four types:
• Type A: paracentral zone is symmetri-
cal (nasal–temporal difference less
than 0.2mm), peripheral zone is sym-
metrical and the difference in flatten-
ing between the paracentral and
peripheral zones is less than 0.2mm.
• Type B: paracentral zone is symmet-
rical, as is the peripheral zone, but the
difference in flattening between both
zones is more than 0.2mm.
• Type C: paracentral zone has a trace
asymmetry (about 0.2mm), the
peripheral zone is symmetrical and the
difference in flattening between them
is less than 0.2mm.
• Type D: paracentral zone has a
nasal–temporal asymmetry and the
peripheral zone is symmetrical, but the
difference in flattening between the
paracentral and peripheral zones is
greater than 0.2mm.
The classification of the cornea into
anatomic zones is considered inappropri-
ate by several authors, because the cornea
is a smooth surface, the curvature of
which is submitted constantly to subtle
changes,3,6,7 which suggests that at any
individual point the cornea is conical and
represented by Equation (2.1)
y2 = 2ro – px2 (2.1)
where p is the shape factor of the cornea
(see below) and ro is the central radius of
curvature of the cornea.
However, in the central 3–4mm the
changes are small, as mentioned above,
and hence some level of uniformity is often
assumed. The anterior peripheral cornea
10 ■ Refractive surgery: a guide to assessment and management
flattens with respect to the central curva-
ture, a pattern mimicked by the posterior
corneal curvature. The rate of flattening
may be different along different meridians.
The corneal asphericity is described in
mathematical terms as being a prolate
shape or a flattening ellipse. This shape of
the cornea partially compensates the
spherical aberration of the eye and
improves the quality of the retinal image.
The technical requirements for a cor-
rect and reliable measurement of corneal
topography were established by Bibby:8
• The units used to describe the corneal
topography must not depend on the
method of obtaining the values.
• The instrument must measure the
total area of interest.
• All the information must be acquired
simultaneously.
• The technique employed must be pre-
cise and reproducible.
Following these requirements, his work
suggested mean values for the corneal
shape of 0.85 ± 0.18 in 2100 eyes and,
later, of 0.79 ± 0.15 in 32,000 eyes.
In the 20th century, the growth of the
field of contact lenses, and later of refrac-
tive surgery, led to an increased interest in
corneal topography. This, along with the
parallel development of the computer
technologies, resulted in great advances in
corneal topographical analysis. Various
workers have helped to develop better
designs of photokeratoscopic systems and
better graphic presentation and analysis
of the data. Colour-coded topography
maps were introduced by Klyce and later
developed further by Maguire.9,10
Corneal shape
Evaluation of the corneal shape is of great
importance in the monitoring and follow-
up of corneal pathologies, contact lens fit-
ting and refractive surgery, and in the
evaluation of sequential temporal changes
induced by contact lens wear, refractive
surgery or orthokeratology. However, the
description of the cornea may not be the
same for a contact lens fit as for refractive
surgery purposes, for example. Mandell
described the cornea in three ways,
according to the viewpoint required:11
• From a qualitative point of view, sever-
al corneal zones are considered: the
central, paracentral, peripheral and
limbal. Also, a division into optic and
peripheral zones can be made for prac-
tical purposes, in which the central
optic zone, with an almost constant
curvature, is surrounded by a periph-
eral zone with a radius that progres-
Table 2.1 Corneal descriptors and their mathematical relations
Mathematical description Shape factor (p)
Hyperbola shape p<0
Parabola shape p=0
Prolate shape 0<p<1
(flattening ellipse)
Circle p=1
Oblate shape p>1
(steepening ellipse)
sively increases. Near the apex the
degree of change in the radius of cur-
vature is very low, but it increases
quickly towards the periphery. To
establish the size of the central zone a
1D change criterion is usually accept-
ed or, in other words, the area of the
corneal surface at which the dioptric
powers differ by less than 1D. In most
cases this is a 4mm diameter central
portion of the cornea.
• From a mathematical point of view, a
simple mathematical expression is
used to define the cornea as an ellipse
or polynomial expression. In most
normal corneas, the central zone is
more curved than the peripheral zone,
which means it has the form of a sec-
tion of a prolate ellipse (with a positive
shape factor and an asphericity in the
range 0 to 1). There are studies that
draw the conclusion that the different
refractive groups have similar corneal
eccentricity values, but different val-
ues for the apical radius.12
• The third way to describe the corneal
surface, as Mandell reports,11 is point
by point, which consists simply of a col-
lection of values for the corneal radius
of curvature or power found at differ-
ent positions on the cornea. If all the
adjacent numbers with the same value
are connected in a contour map, the
result obtained is transformed into an
easily comprehensible pattern that
gives a global image of the particular
corneal shape.
A series of descriptors of the corneal shape
has been defined to unify the different cri-
teria of the range of normal corneal
shapes. Also, some investigators have
defined a number of corneal indexes to
give a better understanding of corneal
topography and its variations. The com-
monly used descriptors of corneal shape
Asphericity (Q) Corneal example
Q<0 Normal corneal
shape
Q=0
Q>0 Post-myopic laser
surgery or post-
radial keratotomy
are eccentricity (e), shape factor (p) and
asphericity (Q). These indices are related
by simple mathematical equations:
p = 1 – e2 (2.2)
Q = –e2 (2.3)
and
Q=p–1 (2.4)
Table 2.1 shows corneal descriptors and
their mathematical relations.
Some of the information collected by
corneal topography is used to describe the
corneal shape in easy-to-understand
terms, which can both aid interpretation
of the data and decipher the colour maps.
A few examples of these are given below,
although many corneal topography units
have their own individual indices.
Corneal uniformity index or surface
regularity index
The corneal uniformity index (CUI) or sur-
face regularity index (SRI) represents the
smoothness of the surface, a relation of the
change in local corneal radius of curvature
or corneal power over a determined area.
It is evaluated from the frequency distri-
bution of powers along the different merid-
ians. This index is sometimes used to give a
value to the visual acuity (VA), based on
the assumption that the cornea is the only
limiting factor in the patient’s VA; this is
called the predicted corneal acuity (PCA).
Simulated keratometry readings
Simulated keratometry (SimK) readings
are calculated using the steepest meridian
from the central area along every meridi-
an (SimK1), and the power and axis of the
meridian orthogonal to the steepest
(SimK2). These readings are useful substi-
tutes of traditional keratometric meas-
urements and have been reported as useful
in the calculation of intraocular lens
power.13 They are often taken as the steep-
est and flattest profiles, although if they

are calculated perpendicular to each other
this may not be exactly correct.
Elevation is a relative measurement of
corneal topography, and is described as the
elevation difference with respect to a plane
or to a flatter or steeper surface. Elevation
may also be taken in relation to a reference
sphere, which may be a floating sphere (i.e.,
related only to that cornea) or a fixed sphere
(used to calculate the elevation of all corneas
with that machine). Usually a floating
sphere is used, and its radius of curvature is
the mean radii for that cornea; all other data
points are related to this reference sphere,
which is termed the best-fit sphere (BFS).
Figure 2.1 shows a Holliday diagnostic
summary (HDS) from the EyeSys 2000
machine.
Corneal topography
measurement methods
Currently, numerous evaluation methods
for corneal topography exist, some more
precise than the others, but basically all are
developments of the same fundamental
theme. The idea is to make a three-dimen-
sional reconstruction of the corneal sur-
face, but difficulties arise when trying to
represent a three-dimensional shape using
a two-dimensional image. To do this some
assumptions and simplifications are made:
Figure 2.1
Holliday diagnostic summary (HDS) from the EyeSys 2000 machine. The box underneath the
four maps shows some corneal parameters for this cornea measured over 3mm, except for the
asphericity value (Q), which is measured over an area of 4.5mm. Note that the steepest and
flattest refractive profiles (column 1) are not the same axes as the SimK axes (column 2)
Corneal topography and its role in refractive surgery
• The working distance from the object
point to the image is constant.
• The instrument axis is perpendicular
to the corneal surface.
• The light from the object is reflected in
the same meridian onto the plane on
which the image is created (i.e., it is
assumed that no circular inclination
of the corneal surface occurs).
• The position of the image on the plane
is unique for a determined surface.
• The image point is on a non-curved
plane.
• The refractive index of the cornea is
the same for all individuals and
remains constant in a particular
patient.
Image capture in corneal topography can
be divided into two basic types:
• Reflection techniques: the cornea
works as a curved mirror and the
reflected image is viewed directly or
captured and analyzed. Examples of
this technique are keratometry, ker-
atoscopy and videokeratoscopy.
• Projection techniques: in this group of
techniques, the cornea acts as a pro-
jection screen. An example of this is
rasterstereography, which is used suc-
cessfully in other areas of medicine
such as spinal curvature measure-
ment.
Another technique is that of interferometry.
■ 11
Using the cornea as a reflector system
Nearly all optometry practices have a ker-
atometer. The main function of the ker-
atometer is to measure the radius of
curvature of the central portion of the
front surface of the cornea.14 This result
is usually obtained indirectly by measur-
ing the angular size of the reflected image,
formed by the cornea, of an object of
known angular size; this is the first
Purkinje image.6 In most instruments, this
is an object with a linear size that is fixed
or measurable at a predetermined distance
from the image plane. Since it would be dif-
ficult to read off the reflected image height
from the cornea, because of involuntary
eye movements, the principle of doubling
is used in keratometers. The image size is
measured by lateral displacement of a dou-
bled image (doubling may be achieved
using a series of lenses, mirrors or, more
commonly, prisms). In most keratometers,
doubling takes place in one meridian only,
along the line that joins the mires. Such
an instrument must be rotated about its
axis to align it with each of the principal
meridians of the cornea in turn, and is
therefore known as a two-position ker-
atometer, such as a Javal–Schiötz type.
A one-position keratometer (such as
the Bausch and Lomb type, see Figures 2.2
and 2.3) is an instrument in which vari-
able doubling of mutually perpendicular
pairs of mires is produced by two doubling
devices in the corresponding meridians.
The instrument is rotated about its axis to
align the mires with both principal merid-
ians of the cornea, and the images in each
can then be brought into contact without
further rotation.6
The primary use of the keratometer in
contact lens practice is to measure the cen-
tral radius of the cornea to determine the
back optic zone radius of a contact lens
Figure 2.2
Bausch and Lomb style keratometer
12 ■ Refractive surgery: a guide to assessment and management
a b
Figure 2.3
Reflection of the mires from a Bausch and Lomb style keratometer. (a) The mires incorrectly
aligned. (b) The mires correctly aligned when the keratometry readings are taken
that will produce the best fit. It is also used
to check the radii of a corneal lens and to
assess the fit of soft contact lenses.
Changes in central corneal shape can also
be detected with the keratometer, both
quantitatively and qualitatively (by assess-
ing the regularity of the mires), and in this
capacity it is often used by clinicians to
assist in the diagnosis of keratoconus.14
Keratometry has a number of inherent
problems. The one-position keratometer
described above assumes that the two prin-
cipal meridians of the cornea are perpendi-
cular. All keratometers measure corneal
radius with pencils of light reflected by small
areas, each situated not less than 1mm and
up to about 1.7mm from the centre. The ker-
atometer does not allow for decentration of
the corneal apex or for corneal asphericity.
The main source of error is focusing. If the
mire images formed by the object are not
focused accurately in the intended primary
image plane, the radius measurement will
be incorrect, since the object–image sepa-
ration is then incorrect, and the unfocused
mire images have a different separation from
the sharply focused ones.15 These blurred
images may not appear to be so if compen-
sated for by the observer’s accommodation
and his or her own uncorrected ametropia
(especially astigmatism). Also, local distor-
tion of the cornea in the region of the reflec-
tion area causes a corresponding distortion
of the mire and renders focusing of the
instrument uncertain.6,16
Adaptations of keratometers have been
used to assess the peripheral corneal
shape. New keratometers have been
designed and modifications made to older
designs. A modified Bausch and Lomb ker-
atometer with the mire separation reduced
from 64mm to 26mm and a series of off-
axis fixation points was able to take meas-
urements of the corneal periphery.11
Bennett describes a keratometer based on
the Drysdale effect and used to measure
the central and peripheral cornea.3
Videophotokeratoscopy
Modern corneal topography devices are an
accumulation of techniques learned from
the historical methods of keratoscopy and
photokeratoscopy, described above. High-
resolution video cameras record the reflec-
tion of the Placido disc mires from the
patient’s cornea. Once the patient is aligned
in front of the videophotokeratoscope, with
the chin on the rest, the images are cap-
tured. The system is aligned when the
tracking lights of the two superimposed
laser beams reflected by the cornea are
placed in the centre of the cross-hair tar-
get located in a box displayed on the mon-
itor screen. The reflected image of the mires
is recorded on a close-circuit video camera
and analyzed by computer software to yield
a representation of the corneal contour.
Examples of different machines
The machines mentioned here are just a few
of the many types of topography units cur-
rently available. This is not intended to be
an exhaustive list, but merely a representa-
tion of the variety of designs around. The
two most widely used computer-assisted
videophotokeratography systems are the
EyeSys Corneal Analysis System (by EyeSys
Technologies) and the Topographic
Modelling System (TMS, by Tomey instru-
ments), and these represent the two
extremes of design. The EyeSys machines
have a Placido disc and a longer working
distance than their Tomey rivals, which
have a Placido cone. A larger working dis-
tance makes the instrument less sensitive
to small displacements of the eye, but has
the disadvantage that the instrument is less
compact. The cone systems use a shortened
working distance, and the size of the cone
means they are able to move closer to the
eye, which allows a larger corneal coverage.
The TMS-1 uses a 25-ring Placido cone,
with a total of 6400 data points, and utilizes
a short working distance of approximately
70mm. The EyeSys-1 uses 16 rings, each
giving rise to 360 data points, a total of
5760 data points. The latest EyeSys topog-
raphy unit, EyeSys-2000, uses 18 rings, but
maintains a longer working distance. It still
collects data from 360 points along each
ring, to give a total of 6480 data points. The
TMS-2, like its predecessor, uses a Placido
cone, but increases the number of rings to
34, while maintaining 256 data points per
ring over a maximum corneal diameter of
11.5mm. The latest offering from Tomey, the
TMS-3, boasts an impressive automated
image-capture system. It has 31 rings with
256 data points per ring, to give a total of
7936 data points. The automated image
capture of the TMS-3 leads to a small sacri-
fice in corneal coverage, and offers up to a
maximum diameter of 9.5mm.17,18
As corneal topography has become less
of a research tool and more clinically wide-
spread, the number of models available has
increased. All use either the Placido cone
system, as in the TMS units, or the Placido
disc system, as in the EyeSys units. Most use
a working distance that is between the two
extremes of these two units. Haag-Streit and
Oculus both offer the same unit, but pack-
aged slightly differently. This machine has
22 rings on a Placido disc and offers 10,000
data points, which is currently the most of
any topography unit; this device also has a
very accurate collimating measurement for
more accurate SimK readings. While a
greater number of sampling points, in prin-
ciple, allows the topography to be assessed
in more detail, the validity of the device’s
data depends on the algorithms used and, as
yet, few comparative studies have been made
on the performance of different units.
Topcon offer a novel system, the KR-
7000P, which is a combined autorefrac-
tor–autokeratometer–topographer. As well
as providing automated refraction and
central corneal curvature readings along
the two principal meridians, it gives the
topography over a corneal diameter of
7mm, but it only offers 2600 data points
in total. This unit can be used as a stand-
alone machine with a built-in printer or
can be linked to a desktop computer.
Once a patient is aligned on the topog-
raphy machine and the cornea is in focus
the actual image capture (automated or
manual) is very quick, typically 33 mil-
liseconds, as with the TMS-3 unit. Each
data collection point measures the curva-
ture at that reflected point on the cornea
and all the data points are represented on
a colour map display.
Presenting topography data
Two scales are commonly used to display
topographic features; the absolute (also
called standard scale) and the normalized

(also called the relative scale or autoscale).
The absolute scale generates a colour-coded
map with 1.0D increments on a pre-set
scale, usually between 37D and 51D, and
thus allows comparison of different
corneas and different machines. The nor-
malized scale uses smaller increments to
span the range of dioptric powers of an
individual cornea, and thus the same
colour may not represent the same numer-
ical value on different corneal pictures. The
normalized scale is created by assigning the
red range of colours to the steepest curva-
ture of the cornea being examined, and the
blue range of colours to the flattest curva-
ture. The remaining colours are divided
into equal step sizes and assigned their par-
ticular ranges (Figures 2.4 and 2.5).
The normalized scale is intended to ren-
der similar contours similar in appearance,
irrespective of their absolute radius of cur-
vature. Hence, the normalized scale, being
more specific to an individual, is more sen-
sitive in detecting subtle topographic
changes in the anterior corneal surface.
With both scales, steep areas are depicted
by so-called ‘hot colours’ (i.e., reds and
browns) and flatter areas are represented
by ‘cold colours’ (i.e., blues and greens).
The keratometric data display gives
details of the steepest and flattest corneal
curvature in the central 3mm, 5mm and
7mm (the central data may be represented
on the colour map). The profile map shows
the corneal curvature in dioptric powers
over the corneal surface by calculating the
profile along the steepest and flattest merid-
ians from the central 3mm zone.19 Most
software algorithms assume that the
corneal contour changes smoothly and
hence ‘average’ the curvature over an area
of a few square millimetres. Unfortunately,
little information is available on this effect,
which may be of importance in relation to
ablation geometry in laser refractive sur-
gery. Each local area of the cornea is gen-
erally a toric surface, rather than a
sphericalone, and hence possesses both
spherical and cylindrical power.
Sagittal and tangential data
In corneal topography, the light from the
topographer mires is directed onto the
cornea. Off-axis light, when reflected from
a curved surface, gives rise to two focal
points. One represents the radius of cur-
vature normal to the reflected mires,
known as the sagittal (or axial) reflection.
The other focal point represents the radius
of curvature that contains the reflected
mires, the tangential image.
Sagittal and tangential data can be
represented as different types of topog-
raphy maps, and for the same cornea
Corneal topography and its role in refractive surgery
Figure 2.4
Absolute (or standardized) scale of a
corneal topography map. The scale is preset
by the machine manufacturer. (Note the
large range of the dioptric scale)
a Figure 2.6
b show clearly how sagittal
they may look different (Figure 2.6),
although the main features of the map
remain the same.
Using the cornea as projector
system
The cornea was first used as a projector
system to determine the corneal topogra-
phy by Bonnett and Cochet (1962).20 It
consists of the projection of a diffraction
grid onto the corneal surface and the pat-
tern produced by the grid is a function of
the corneal topography. However, the
cornea must first be made opaque to allow
the grid pattern to be detected. Initially, tal-
cum powder (in conjunction with topical
anaesthesia) was used for this purpose, but
more recently sodium fluorescein has been
used. Accuracy of the measurements
taken depends on the magnification used
on the slit lamp and the way that the
image is viewed or captured.7
■ 13
Figure 2.5
Normalized (or relative) scale of the same
cornea as in Figure 2.4. In the map the
dioptric scale has a much smaller range,
which enables differences in the radius of
curvature to be detected more easily
Corneal topography maps
of a patients’ eyes taken
with the Orbscan
topography unit. The map
on the left in both (a) and
(b) represents sagittal
data and that on the right
represents tangential
data. Both (a) and (b)
and tangential data can
look very different for the
same eye, but the main
emphasis remains the
same
Similar technology is adopted in the
Orbscan topography unit (Orbtek Inc., Salt
Lake City, Utah). The Orbscan takes 40 slit
sections of the cornea during two scans,
each scan lasting 0.7 seconds. Each slit
section is similar to an optical section
viewed through a slit lamp. Similar to
Placido-based topography, the patient rests
on a chin rest and the instrument is
aligned using an XYZ manipulator base
(see Figures 1.5 and 10.1). The image cap-
ture takes a total of 1.4 seconds and any
eye movements render the image void.
The corneal curvature results are usu-
ally presented in the form of a contour
map that shows height deviations from the
best-fitting spheres, but a variety of other
numerical descriptions can also be
obtained. It has been shown that the
measurement of anterior surface curva-
ture, as assessed using calibrated stan-
dards, has a high accuracy and that the
14 ■ Refractive surgery: a guide to assessment and management
thickness measurement on human
corneas has a high reproducibility.21,22
The default topography map that the
Orbscan produces, the quad map, consists
of four pictures (Figure 2.7). The quad map
has maps of the anterior corneal height, the
Figure 2.8
Surgical options, ‘birds-eye’ view of a
normal cornea (note the central steepening
of the cornea)
Figure 2.9
Surgical options, view of cornea that has
undergone myopic PRK, with the associated
central corneal flattening
Figure 2.10
Surgical options, view of an eye after radial
keratotomy. (Courtesy of Orbtek)
Figure 2.7
The quad map consists of
maps of the anterior
corneal height, the
posterior corneal height,
the keratometric data and
the pachymetry, but
these maps can be altered
to suit the user’s
preferences (see text)
posterior corneal height, the keratometric
data and the pachymetry, but these maps can
be altered to suit the user’s preferences.
Height maps indicate the relative height
above or below a mean of the radii of cur-
vature of the surface (anterior or posterior).
The mean radius of curvature of the corneal
surface, the BFS, is subtracted from all other
radii of curvature points of the surface. Thus,
the height maps do not indicate the curva-
ture of the cornea at a particular point, but
rather the relative height with regard to the
BFS (similar to an Ordnance survey map, in
which heights are shown with respect to sea
level). The height maps use ‘hot’ colours to
indicate areas that are higher than the BFS,
and ‘cold’ colours to indicate areas that are
lower than the BFS. The keratometric map
shows the radius of curvature data of the
cornea at any point. In the quad map, it is
viewed as an overall value for the anterior
and posterior corneal surfaces, but these sur-
faces can be viewed individually. The final
map in the quad selection is a pachymetry
map that shows the thickness of the entire
area of cornea assessed.
Another option that the Orbscan allows
is called ‘surgical options’. This view pro-
duces a three-dimensional schematic image
of the examined eye. It can be adjusted to
produce a view of the anterior or posterior
cornea, or both simultaneously. The ante-
rior lens can also be imaged using this
option, although lens curvature data are not
available directly. This type of three-dimen-
sional schematic view is available on other
types of topography systems too, but is usu-
ally calculated from radius of curvature
data, whereas the Orbscan uses elevation
data. Figure 2.8 shows a ‘birds-eye’ view of
a normal cornea (note the central steepen-
ing of the cornea). Figure 2.9 shows a cornea
that has undergone myopic photorefractive
keratectomy (PRK), with the associated cen-
tral corneal flattening. Figure 2.10 shows an
eye after refractive keratectomy.
A new device recently available from
the Birmingham Optical Group is the
Oculus Pentacam system (Oculus,
Giessen, Germany). This is discussed
again in Chapter 10, as currently no pub-
lished studies have used it. Essentially, it
is a rotating Scheimplug camera and is
able to image up to the fourth Purkinje
image in a patient with a dilated pupil; oth-
erwise, it is able to at least obtain data from
three surfaces, like the Orbscan. The image
creation and caption system is different to
that of the Orbscan, so it remains to be seen
how the two systems compare. The
Pentacam is a table-mounted device and,
similar to standard topography units, it uses
an XYZ manipulator base with the patient
lined up in front of the instrument with his
or her chin upon a chin rest (Figure 2.11).
The data are collected in around 2 seconds
and approximately 25,000 data points are
taken. The data can be represented as ele-
vation data or radius of curvature data.
Figure 2.11
The Oculus Pentacam
system is a table-
mounted device that
uses an XYZ
manipulator base with
the patient lined up in
front of the instrument
and his or her chin
upon a chin rest
 Corneal topography and its role in refractive surgery ■ 15

Corneal topography in
refractive surgery
Irregular and regular astigmatism can be
observed using topography after cataract
surgery and post-penetrating keratoplas-
ty, which allows the surgeon to assess sta-
bility. For cases in which there is a lot of
post-surgical astigmatism, corneal topog-
raphy maps can be used to indicate poten-
tial areas of suture removal (Figure 2.12).
Corneal topography is a vital tool in
refractive surgery. Pre-operative assessment
checks for any contraindicated corneal con-
ditions and dystrophies. Contact lens users
who present for refractive surgery are
advised to remove their lenses for a period of
time before surgery to eliminate warpage
induced by the contact lens. Warpage
appears as an irregular topography picture
with distortion that does not have a regu-
lar pattern. For a patient in whom warpage
is observed, the topography is repeated on
subsequent visits until no further changes
are seen in the topography maps and only
then is the patient considered suitable for
surgery. Figure 2.13 shows a patient with
corneal warpage in the right eye, but a rela-
tively normal left eye.
Post-operative assessment is essential
to check astigmatic results, stability and
irregular healing. Different techniques of
refractive surgery show characteristic post-
operative changes. For example, myopic
excimer laser surgery shows central flat-
tening, whereas after hyperopic surgery a
mid-peripheral flattening is seen. Post-ker-
atotomy, steepening of the areas of surgical
incision and an accompanying flattening of
other areas of the cornea are seen.
Topography pictures taken at different
visits allow the clinician to observe the
healing changes that occur to an eye over
a period of time post-surgery (Figure 2.14).
During aftercare appointments topogra-
phy is often conducted to pick up abnor-
malities such as central islands, which can
be identified clearly. Decentred zone abla-
tions can also be identified with corneal
topography. Areas of surface scarring,
such as complications of corneal flaps, ero-
sions and sutures, are also detectable.
Limitations of corneal
topography
The quality of the anterior reflective sur-
face of the cornea and inaccuracies in
numerical assumptions can limit the use-
fulness of topography. Images are restrict-
ed nasally and superiorly because the
recording mechanisms are eclipsed by the

Figure 2.12
A patient’s right eye after penetrating keratoplasty. The map labelled A
was taken 1 week after surgery. Her corrected VA was 6/18, as there
was some irregular astigmatism present. The surgeon removed one
suture to try and make the astigmatism more regular. Picture B was
taken a few minutes later, and gives corrected VA of 6/9 (Refraction:
+6.00/–3.00 × 100). The main map shows the difference map obtained
by subtracting map B from map A

Figure 2.13
Patient with corneal warpage in the right eye, but a relatively normal left
eye

Figure 2.14
A cornea before and after photorefractive keratectomy. The initial
refraction was –3.25/–0.25 × 175 and the 12 weeks post-surgical
refraction was +1.00/–0.50 × 10. Picture A is the post-surgical map
and picture B is the pre-surgical map. The larger picture is the difference
between the two. The pre-surgical map has been subtracted from the post-
surgical picture to demonstrate the area of cornea removed by ablation. It
can be seen that a central area of approximately 5mm has been flattened
(the actual laser setting for the ablation diameter was a 5.5mm optic
zone and a total ablation zone of 6.5mm)
16 ■ Refractive surgery: a guide to assessment and management
nose, brow and upper eyelid. Superficial
corneal scars and similar abnormalities
confuse the topographies, especially if they
are central. The patient’s ability to main-
tain fixation is vital.
Corneal topography and
aberrometry
Currently, practically aberrometry is
becoming a very popular technique in
refractive surgery. It is used to create better
ablation profiles and also to assess post-
operative patients, especially those with
complications. In fact, pre-operative wave-
front aberrometry examination should help
the surgeon decide whether a traditional
refractive surgery procedure would solve the
visual problems of the patient, or if a cus-
tomized ablation is indicated. Some aber-
References
1 Shah S and Naroo SA (1998). Corneal
topography. Continued Medical Education.
J Ophthalmol. 2, 16–19.
2 Corbett MC, Rosen ES and O’Brart D
(1999). Corneal Topogrography.Principles
and Applications, Ch 1, p. 3–11 (London:
British Medical Journal Books).
3 Bennett AG (1964). A new keratometer
and its application to corneal topography.
Br J Physiol Opt. 21, 234–235.
4 Edmund C (1987). Determination of the
corneal thickness profile by optical
pachometry. Acta Ophthalmol. 65,
147–152.
5 Rowsey JJ (1984). Corneal topography. In
Contact Lenses: The CLAO Guide to Basic
Science and Clinical Practice, Ed. Dabezies
OH Jr, Ch 4. (Orlando: Grune and
Stratton).
6 Bennett AG and Rabbetts RB (1989).
Measurements of ocular dimensions. In
Clinical Visual Optics, Second Edition, p.
457–483, Eds Bennett AG and Rabbetts
RB (London: Butterworths).
7 Dave T (1998). Current developments in
measurements of corneal topography.
Contact Lens Anterior Eye 21, S13–S30.
8 Bibby MM (1976). The Wesley–Jenssen
System 2000 photokeratoscope. Contact
Lens Forum 1, 37–45.
rometers are able to separate aberrations of
the cornea from those of the whole eye,
whereas other devices only give the whole-
eye aberrations. The custom ablation tech-
niques allow a method of correcting the
whole eye’s aberrations on the corneal sur-
face. In a similar way, traditional refractive
surgery would correct a patient’s full ocu-
lar refraction on the cornea, even though
some components of the prescription may
be elsewhere, such as the crystalline lens.
Most corneal topography devices now
have software that enable radius of curva-
ture data to be interpreted to express the
corneal high-order aberrations, often in
terms of Zernike polynomials or Fourier
analysis. Some newer topography devices
now take aberrometry measurements in
addition to corneal curvature data. The
Nidek OPD device (Figure 2.15) has a Placido
disc and, in addition to that, uses a skiascopy
9 Klyce SD (1984). High resolution
graphic presentation and analysis of
keratoscopy. Invest Ophthalmol Vis Sci.
25, 1426–1435.
10 Maguire LJ, Singer Dem and Klyce SD
(1987). Graphic presentation of
computer-analyzed keratoscope
photographs. Arch Ophthalmol. 105,
223–230.
11 Mandell RB (1962). Methods to measure
the peripheral corneal curvature. Part 3:
Ophthalmometry. J Am Optom Assoc. 33,
889–892.
12 Sheridan M and Douthwaite WA (1989).
Corneal asphericity and refractive error.
Ophthalmic Physiol Opt. 9, 235–238.
13 Ilango B, Shah S and Clark IH (2001). A
review of biometry techniques. Eye News
8, 24–28.
14 Sheridan M (1989). Keratometry and slit
lamp biomicroscopy. In Contact Lenses,
Third Edition, p. 243–259. Eds Phillips A
and Stone J (London: Butterworths).
15 Applegate RA and Howland HC (1995).
Non-invasive measurement of corneal
topography. IEEE Eng Med Biol Mag. 14,
30–42.
16 Douthwaite WA and Evardson WT (2000).
Corneal topography by keratometry. Br J
Ophthalmol. 84, 842–847.
technique to measure ocular high-order
aberrations. The combination of both tech-
niques means that corneal aberrations can
be separated from whole-eye aberrations.
Figure 2.15
The Nidek OPD
17 Douthwaite WA, Hough T, Edwards K and
Notay H (1999). The EyeSys
videokeratoscopic assessment of apical
radius and p-value in the normal human
cornea. Ophthalmic Physiol Opt. 19,
467–474.
18 Hilmantel G, Blunt RJ, Garrett BP,
Howland HC and Applegate RA (1999).
Accuracy of Tomey topographic modelling
system in measuring surface elevations of
asymmetric objects. Optom Vis Sci. 76,
108–114.
19 Roberts C (1998). A practical guide to the
interpretation of corneal topography.
Contact Lens Spectrum 13, 25–33.
20 Bonnet R and Cochet P (1962). New
method of topographical ophthalmometry
– its theoretical and clinical applications.
Am J Optom Arch Am Acad Optom. 39,
227–251.
21 Lattimore MR Jr, Kaupp S, Schallhorn SS
and Lewis IV RB (1999). Orbscan
pachymetry: Implications of a repeated
measures and diurnal variation analysis.
Ophthalmology 106, 977–981.
22 Yaylali V, Kaufman SC and Thompson HW
(1997). Corneal thickness measurements
with the Orbscan topography system and
ultrasonic pachymetry. J Cataract Refract
Surg. 23, 1345–1350.
 3
Corneal anatomy, physiology and
response to wounding
The mainstay of current laser refractive
surgery centres on manipulation of the
properties of the cornea to achieve the
desired optical affect. As a result it is essen-
tial that the clinician has a strong under-
standing of the intricate architecture and
physiological properties of the organ.
Moreover, a firm understanding of the
basic science of the cornea allows the cli-
nician to plan treatments that result in a
minimal disruption to its structure, and
hence achieve a preferred visual outcome.
The cornea occupies approximately 7
per cent of the outer coat of the eye. It is
a highly organized five-layered structure
(Figure 3.1) that consists of:
Figure 3.1
Transverse section cornea
Sandip Doshi
• The epithelium;
• Bowman’s layer;
• The stroma;
• Descemet’s layer; and
• The endothelium.
With a standard slit-lamp biomicroscope and
appropriate magnification and observation
techniques only the epithelium, stroma and
endothelium are visible. Each corneal layer
is discussed separately in this chapter.
Corneal epithelium
The corneal epithelium is the outermost
layer (Figure 3.2) and is an anatomical
continuation of the conjunctival epithe-
lium. It is thinnest centrally, where it is typ-
ically around 50–60μm in thickness, and
thickens to around 70–80μm in the
periphery. Thus, the central corneal
epithelium constitutes approximately 10
per cent of the total corneal thickness.
The cornea is the major refractive com-
ponent of the eye. The epithelium is arguably
the most important layer for this property.
The reported refractive index of the epithe-
lium varies for different researchers, but
commonly is stated to range from 1.375 to
1.543. A uniform regularity and trans-
parency of the epithelium is essential if the
cornea is to be a perfect optical surface.
Being the outermost layer of the
cornea, the epithelium functions as a bar-
rier to protect the deeper layers from var-
ious insults. It also provides a barrier
against fluids from the tear film. As any
refractive surgeon knows, the epithelium
is remarkably tough and resilient to sig-
nificant trauma, but when damage does
occur the epithelium has an excellent
recovery rate (see the section on corneal
wound healing later).
Epithelium microanatomy
The normal human corneal epithelium
can be described as a non-keratinized,
stratified, squamous epithelium. Typically,
the corneal epithelium is five to six cell lay-
ers thick. Three distinct cell types can be
identified in the epithelium: basal, wing (or
umbrella) and squamous cells.
Figure 3.2
Corneal epithelium and
Bowman’s layer
18 ■ Refractive surgery: a guide to assessment and management
Basal cells are the innermost cells of the
epithelium and form a monolayer of large,
columnar cells. They are relatively uniform
in size and are typically 15–20μm in
height. Basal cells produce the basement
membrane of the corneal epithelium. The
organization of the basement membrane
allows the epithelium to attach to the
remaining layers of the cornea.
Superior (and so more external) to the
basal cell layer is the wing cell layer. This
consists of two or three layers of cells char-
acterized by a flattened dome-shaped
appearance. The wing cell layer tends to
be 20–25μm in height. Wing cells are
thought to be more mature than basal
cells. At the outermost aspect of the
epithelium is the squamous cell layer. This
superficial layer consists of one or two cell
layers. Typically, this layer tends to be
about 10–15μm. These cells are the most
mature of the epithelium and complete
their lifespan by sloughing off into the tear
film.
Epithelium ultrastructure
Resident cells of the corneal epithelium
Basal cells are large, columnar cells with
a slightly apically displaced nucleus that
is spherical or slightly oval and contains
dispersed chromatin. The cytoplasm con-
tains many intermediate filaments (most-
ly grouped into bundles known as
tonofilaments), free ribosomes, sparse
mitochondria, little granular endoplasmic
reticulum, glycogen granules and occa-
sionally Golgi complexes.
Basal cells are attached to the basement
membrane via a series of hemidesmo-
somes. Normally, the latter are so numer-
ous that they occupy at least one-third of
the area of the membrane. Interestingly,
these bonds are readily broken and
reformed – a feature that proves to be vital
as part of the wound-healing process.1
Hemidesmosomes are macula junctions
that are continuous with basal cell tonofil-
aments and consist of local thickenings of
the plasma membrane (lamina densa)
opposite a thickened zone of basement
membrane. A lighter interval between the
two thickened membranes (lamina lucida)
contains numerous fine, connecting fila-
ments, which in turn are attached poste-
riorly to fine, branched collagen fibrils,
called attachment (or anchoring) plaques,
that anchor the basal lamina and epithe-
lium to Bowman’s layer.
Anchorage of the epithelium to the
basal lamina occurs via a large number of
unevenly distributed hemidesmosomes.
This results in a strong adhesion of the
epithelium to the underlying surface. The
attachment of the basement membrane is
very stubborn and normally a blunt trau-
ma does not remove it. However, in some
varieties of refractive surgery, such as pho-
torefractive keratectomy (PRK), the
removal of the epithelium and the base-
ment membrane (and Bowman’s layer)
allows the anterior stroma to become
involved in the healing process, which can
lead to scarring. Moreover, the presence of
a normal basal lamina is essential for re-
epithelialization.
Basal epithelial cells continue to lay
down the basement membrane through-
out life and, therefore, there is an
increase in its thickness with age.
Bergmanson suggested that this might
be a reason for a weakening with age of
the attachment between the corneal
stroma and epithelium.2
Away from the innermost aspect, basal
cell borders are characterized by shallow
interlocking ridges that cover most of their
surfaces, with little or no space between
cells. These ridges are least frequent in
apposed membranes of basal cells.
Adjacent cells are joined by numerous
desmosomes. This results in the epitheli-
um being able to withstand a considerable
amount of abuse. A relatively small num-
ber of gap junctions are also seen through-
out the basal layer.
The wing cell layer is characterized by
dome-shaped cells with central round
nuclei. These cells flatten as they move
anteriorly away from the basal layer. The
number of cell layers varies from two to
three in the central cornea, but may
increase to four or five in the periphery.
Cells of this layer are derived from the basal
layer and represent more mature cells. Cell
organelles are more sparse than in the
basal layer, which suggests metabolic
activity in this layer is slower than that in
the basal layer. This is of some relevance
when the corneal epithelium is examined
in relation to stem cell theory (see later).
Like all cells of the corneal epithelium,
wing cells are tightly packed and there is
very little intracellular space. Cells attach
to their neighbours via numerous mem-
brane interdigitations and desmosomes.
As cells continue to mature through
the wing cell layer they become flatter and
ultimately move more superficially to the
squamous cell layer. This layer is charac-
terized by the presence of long, thin, flat-
tened cells that display an intensely
stained, elongated nuclei. Squamous cells
contain the fewest organelles of the epithe-
lium, which indicates that they possess the
lowest metabolic activity. Cells are joined
to their neighbours via membrane inter-
digitations and desmosomes and gap junc-
tions on the inner and lateral aspects. Gap
junctions contribute to intercellular adhe-
sions and are probably communicating
junctions that permit ionic exchange.
Additionally, the surface cells display tight
junctions (zonula occludentes) on their
most superficial surface. Unlike the other
junctions, these girdle the cells and form
the closest of contacts without achieving
complete fusion. This limits permeability
and permits access to the intracellular
space from the tear film or, in reverse,
through discrete pores only.3
Unlike surface cells of the skin, those
of the normal corneal epithelium are
non-keratinized and retain some
organelles, which indicates that even at
this late stage of maturation their meta-
bolic processes are still functioning. This
is particularly relevant as part of the nor-
mal wound-healing process. Squamous
cells display numerous microvilli (and
rarely microplicae). In humans, these can
be quite substantial, reaching up to
0.75μm in height. Pedler suggested that
as cells slough from the surface, desmo-
somes must split to achieve detachment,
and cytoplasmic extrusions at these
points may be responsible for microvilli
development.4 Microplicae represent
fusion of adjacent microvilli. The number
of microvilli on a cell surface is a good indi-
cator of its age – the greater the number of
microvilli on a cell surface, the older it is.
Microvilli provide an increased surface
area for the attachment of a fine glyco-
protein layer, the glycocalyx. This layer
provides anchorage for the pre-ocular tear
film. Damage to microvilli during the flap-
making process in laser in situ ker-
atomileusis (LASIK) and the resultant lack
of anchorage for the tear film components
is thought to be one of the reasons for dry
eye after the procedure.
Non-native cells of the corneal
epithelium
A non-native cell in any epithelia can be
described as one that does not form any
junctional complexes with its neighbours.
In humans, the normal corneal epitheli-
um has a complement of non-native cells
present at any time. Langerhans’ cells are
found in the basal layer of the corneal
epithelium. These dendritic, polymorphous
cells are thought to play an important role
in the ocular surface immune response.5
Although they perform a similar function
to their counterparts in skin, ocular
Langerhans’ cells are known to vary in
that they lack the thymocyte antigen
(T6).6 More recently, Doshi suggested that
ocular Langerhans’ cells might also vary
morphologically from those in the skin, in

that they lack the Birbeck granules char-
acteristic in skin.7 It is normal to see occa-
sional lone lymphocytes and macrophages
within a normal corneal epithelium, but
it appears that their presence is of no clin-
ical consequence. When present, these
cells tend to be confined to the peripheral
cornea.
Corneal epithelium stem cell theory
The concept of corneal epithelial stem cells
is now firmly established. Among many
other classifications, this theory describes
cells in relation to their proliferative capac-
ity and their state of maturation. The
cornea is unique in that its progenitor cell,
the stem cell, is located away from the
organ itself and is found in the basal layer
of the limbal conjunctival epithelium.8,9
Stem cells are immature and slow to mul-
tiply under normal conditions. Division of
a stem cell produces two offspring, one that
is a replica of itself and a second, transient
amplifying cell (TAC). The TAC is respon-
sible, by relatively rapid division, for
increasing cell volumes.
The sequestration of corneal epithe-
lial stem cells to the limbus requires their
offspring to migrate centripetally to
reach the cornea. Evidence of this cen-
tripetal flow is seen in individuals with
pigmented conjunctivae, who sometimes
display pigment slide into the peripheral
cornea.10 Further support for this obser-
vation was given by Thoft et al.,11 who
suggested that corneal epithelial stem
cells are located predominantly in the ver-
tical meridian. Additionally, they sug-
gested that the entire basal layer of the
corneal epithelium represents TACs that
had migrated centripetally from the lim-
bus. Lauweryns et al. corroborated this
observation and suggested that, conse-
quently, centripetal movement of epithe-
lial cells was limited to the vertical
meridian.12
Stem cell theory and the subsequent
centripetal migration that must exist for
this theory to hold true are the focal points
of corneal wound healing (see later).
Bowman’s layer
Bowman’s layer lies beneath the epithelial
basement membrane and separates the
epithelium from the stroma (Figure 3.2). It
is acellular and uniform in thickness,
which typically measures around 12μm.
Its thickness remains constant in a healthy
cornea. Bowman’s layer is present
throughout the cornea and terminates at
the periphery, which marks the beginning
of the limbus.
Corneal anatomy, physiology and response to wounding
Normally, epithelial damage occurs
readily without the involvement of
Bowman’s layer. This provides evidence of
its relative toughness. However, if damage
does occur to Bowman’s layer, fibrous scar
tissue is laid down and results in an opac-
ity, which tends to reduce in density with
time. Bowman’s layer does not regenerate,
and significant damage or surgical
removal of this layer, such as in PRK,
results in a permanent loss. However, in
such cases the anterior stroma becomes
more compact and loses its cellularity to
form a pseudo Bowman’s layer.
Bowman’s ultrastructure
Electron microscopy reveals a fine, ran-
domly orientated mesh of collagen fibrils.
These fibrils are finer than those of the
stroma. Bowman’s layer modifies anteri-
orly, where the anchoring filaments of the
basement membrane insert. Over the
whole of its area, Bowman’s layer is pen-
etrated by fine unmyelinated nerve fibres
that pass from the stroma to the epitheli-
um. To maintain transparency, the nerve
fibres loose their Schwann cell sheaths as
they leave the stroma.
Corneal stroma
The stroma constitutes 90 per cent of the
corneal thickness and gives the cornea its
strength. Despite its apparent acellularity,
the stroma is far from being passive.
Stromal cells are important in the pro-
duction and maintenance of corneal
transparency. This property is further
aided by the regularity of this layer and the
absence of blood vessels within it.
Stromal microanatomy
The stroma consists of around 200 lay-
ers of lamellae of collagen fibrils. The
fibres, which are buried in a matrix of pro-
teoglycans, have a periodicity that is char-
acteristic of collagen. The adult human
cornea lacks elastic fibres.13 Collagen fib-
rils are of a regular size at any given depth
of the cornea, and typically measure
34nm in humans.14
Cells occupy 2–10 per cent of the
corneal volume. Keratocytes, nerve fibres
and occasionally cells of a vascular origin
lie between the lamellae. Keratocytes pre-
dominate and are responsible for secreting
the proteoglycan matrix and procollagen.
Blood-borne cells are relatively small in
number. During inflammation, polymor-
phonuclear leukocytes (PMNs) produce
localized opacities called infiltrates, which
may contribute to the induction of stro-
mal oedema.15 Interestingly, keratocytes
■ 19
also have phagocytic capabilities and con-
gregate towards sites of inflammation.
Stromal ultrastructure
The majority of the stromal lamellae have
a similar thickness (1.5–2.5μm) and lie
parallel to each other, except in the ante-
rior third of the stroma where some of the
lamellae run obliquely. Fibrils within a
lamina are parallel, but the fibrillar orien-
tation in adjacent lamellae is angled, and
tends to be arranged orthogonally.16 A
bias of lamellar orientation has been
claimed, but the direction is not agreed as
the result differs according to the tech-
nique used.
Lamellae widths are difficult to meas-
ure; most are up to 250μm, but some
appear to be in excess of 1mm.
Although discreteness of adjacent
lamellae prevails, at least in the posteri-
or two-thirds of the stroma, occasional-
ly slightly oblique branches connect one
lamella to another. This arrangement
explains the ease with which the stroma
may be split parallel to the surface, as in
the preparation of flaps for LASIK or
lamellar grafts.
At the corneoscleral margin, the stro-
mal lamellar undulate, branch and inter-
weave. The fibrils of single lamellae remain
parallel to each other, but their diameters
increase significantly, up to tenfold.
The matrix of the stroma is composed
largely of glycosaminoglycans (GAGs)
covalently bound to protein, which con-
stitutes proteoglycans. The two major
types are keratan sulphate and chon-
droitin sulphate with a filamentous struc-
ture demonstrated by Hirsch et al.17 It is
the filaments that attach through their
core proteins to collagen fibrils, bridging
the spaces between them. Details of this
bottle organization are unclear, but Scott
proposed a model that may explain the
manner in which the matrix influences the
regular separation of collagen fibrils.18
During oedema that results from a com-
promised endothelium, GAGs are lost from
the cornea.19
Keratocytes are positioned in the inter-
face between adjacent lamellae. In a single
interface, keratocyte cell bodies are spaced
well apart across the cornea, but their thin,
lengthy processes are so extensive that they
may come into contact with processes from
neighbouring cells, which gives the appear-
ance of a fine, wide-mesh network. This is
repeated at each lamellar interface. The
nuclei of these cells are flat, oval and
embedded in a sparse perikaryon. More
than one nucleus may often be present. In
a normal eye there is little or no prolifera-
tive activity among keratocytes.20
20 ■ Refractive surgery: a guide to assessment and management

Descemet’s layer Figure 3.3

Corneal endothelium,
Descemet’s layer (or membrane) is the Descemet’s membrane
basement membrane of the corneal and posterior stroma
endothelium and can be found in embryos
as early as 8 weeks gestation (Figure 3.3).
There is a two-part formation and struc-
ture to this layer: the anterior striated or
banded portion is formed in utero and the
non-banded section is laid down after
birth. Descemet’s layer is around 5μm
thick at the first post-natal year and
increases by approximately 1.3μm each
decade.21 Stromal thickness, by compari-
son, remains unchanged.

Descemet’s ultrastructure
Under the light microscope, Descemet’s
layer appears void of any cells and lacks
internal structure. However, the anterior
part of this membrane displays a fine, reg-
ular organization under the electron
microscope. In tangential section it has a
two-dimensional lace network appearance
with a repeating hexagonal unit in which
seven dense nodes mark the angles; fine
filaments of equal length connect these.
The networks are stacked in depth regis-
ter, as revealed by transverse sections. Dark
bands are discernible perpendicular to the
plane of the cornea and consist of dark
granules, which are the nodes of the tan-
gential section network.16 In contrast, the
posterior part of this layer has the same
fine, granular appearance in whichever
plane it is sectioned and shows no sign of
patterned organization.
The biochemical composition of
Descemet’s layer is not understood well in
humans. In other species it has been
found to consist primarily of type IV col-
lagen.22 There is evidence for the presence
of types I, II and V collagens in non-
human models.23–25
Corneal endothelium
mosaic is not always regular because of
the variation in cell size or as a result of
polymegathism. This increases with age
and is exaggerated by some forms of con-
tact lens wear.
Endothelial ultrastructure
Svedbergh and Bill reported that most pri-
mate endothelial cells averaged 20–25μm
in diameter.26 Therefore, with a corneal
surface of approximately 100mm2 to
cover, there are about 400,000 endothe-
lial cells in the typical cornea.
Endothelial cells are well stocked with
organelles, especially mitochondria. Cells
also display a prominent endoplasmic
reticulum. Both indicate an extensive
metabolic activity. Near the posterior bor-
der of this layer, the intercellular space is
reduced to form a tight junction of width
about 10nm that restricts movement in
and out of the cornea between adjacent
endothelial cells.
Endothelial replication,
regeneration and healing after
wounding
The importance of the corneal endothelium
in the maintenance of stromal deturges-
cence and clarity means a considerable
amount of literature has been published on
the response of this organ to wounding.
Spontaneous mitosis and migration
occur in young rabbit endothelium after
trauma. This is followed by mitotic activi-
ty to replenish the normal cellular densi-
ty. Early specular microscopic studies
suggested that there was no mitotic activ-
ity in human endothelium, and wound
healing was accomplished by the spread-
ing, enlargement and finally contact inhi-
bition of adjacent endothelial cells. Over
time an equilibration of endothelial cell
size across a large area was seen to occur,
even when the initial wound was limited
to a small central area.
Treffers challenged this view on find-
ing that tritated thymidine was incorpo-
rated both in vitro and in vivo in humans,27
which indicated that the corneal endothe-
lium does have a proliferative capacity.
Some cells typical of those seen in the M-
phase of mitosis were observed by specu-
lar microscopy28, which corroborated the
Treffer’s study27.
Human corneal endothelial cells grown
in culture have responded favourably to
the administration of epidermal and
fibroblast growth factors.29 In fetal tissue,
endothelial cells are seen to respond to

The corneal endothelium is a monolayer

of hexagonal cells that lines the inside of
the cornea. These cells assume a hexago- Figure 3.4
nal array that varies with age, trauma and Tangential section of the
disease. This layer plays a pivotal role in corneal endothelium
the maintenance of corneal clarity
because its function is to maintain stromal
deturgescence (Figure 3.4).

Endothelial microanatomy
Seen in tangential section, cell borders are
ill-defined because of the oblique cell inter-
faces and the interdigitation of the broad
processes of adjacent cells. Cell nuclei are
often oval or kidney-bean shaped and the
cytoplasm appears grainy. The endothelial

similar agents.30 Cytofluorometric tech-
niques have indicated that most human
endothelium may be stable in the post-
mitotic G1 phase.31
Whether human corneal endothelial
cells actually undergo mitosis and assist in
wound healing or in the repair of natural
endothelial cell loss remains unclear, with
strong arguments for and against.
Specular microscopic studies strongly sug-
gest that if mitosis does occur, it does not
appear to result in the formation of
endothelial cells of normal size. It is likely
that the response to endothelial wounding
(e.g., after surgery) is an initial lag phase
followed by migration and enlargement of
endothelial cells that surround the defect
until these cells re-establish contact with
one another. At this stage, intercellular
junctions are reformed and the eventual
establishment of endothelial function by
thinning of the overlying corneal stroma
is observed.
Corneal innervation
The cornea is served by 70–80 small sen-
sory nerves that issue from ciliary nerves
which branch from the ophthalmic divi-
sion of the trigeminal nerve. They enter
the sclera from the uvea at the level of the
ciliary body and pass anteriorly to enter
the cornea radially and predominantly in
the middle layers of the cornea. Other
nerves from the same source enter the
cornea more superficially. They enter the
conjunctival epithelium from the subep-
ithelial tissue at the limbus and pass direct-
ly into the corneal epithelium at basal
level.32 A minority of the nerve fibres that
enter the cornea possess a myelin sheath,
but this is lost at the limbus or within 1mm
of entering the cornea. Rarely, myelin per-
sists a little further. The perineurium and
the fibres and cells of the endoneurium
also terminate at the limbus. Only the
nerve fibre bundles advance into the
cornea. Each bundle consists of several
axons enclosed by a Schwann cell sheath.
Initially, the fibre bundles of each nerve
are grouped together. These separate and
spread, overlapping and running together
with branches of neighbouring nerves to
produce the plexiform arrangements seen
in full thickness preparations of the
cornea. The plexus is particularly dense
beneath Bowman’s layer.
Axons separate and some divide at
intervals and form fine terminal branch-
es, some of which may lose their Schwann
cell covering; these terminal axons follow
a lengthy course between the stromal fib-
rils. They possess numerous small, bead-
Corneal anatomy, physiology and response to wounding
like varicosities, with a final, often larger,
one that marks the end of the axon.
Fibres from a single nerve bundle at the
limbus may be distributed to as much as
two-thirds the area of the cornea.
Consequently, there is considerable over-
lap of nerve fibres from different bundles.
This arrangement explains why sensitivi-
ty persists in all areas of the cornea sub-
sequent to large surgical incisions, and is
also the reason why the cornea localizes
stimuli poorly.
The epithelium receives a prolific sup-
ply of terminal fibres that pass perpendic-
ularly from the anterior stromal plexus
and penetrate Bowman’s layer. The small
nerve fibre bundles lose their Schwann cell
covering before they enter the epithelium,
where the fine, naked axons disperse and
turn sharply to lie nearly parallel to
Bowman’s layer. Varicosities similar to
those in the stroma occur in the epitheli-
um. Such axons may run a course up to
2mm long, and the fine beaded branches
that issue from them are directed through
successive layers of the epithelium to
almost the surface of the cornea.
Matsuda observed two types of epithe-
lial nerve terminal beads in rabbits and
humans.33 One contained mitochondria
and the other contained mitochondria and
vesicles. He suggested that beads without
vesicles serve a sensory function, while
those with vesicles were probably motor.
There is no reliable evidence of parasym-
pathetic fibres in the cornea. There is, how-
ever, a strong body of evidence for some
sympathetic innervation to the cornea.
Variety in their chemistry suggests that
sensory fibres may consist of functionally
distinct subgroups; some contain the neu-
ropeptide substance P, and others of
unknown chemical identity do not.
Calcitonin gene-related protein (CGRP) also
exists within nerves. It is thought to coexist
with substance P in the same terminal.34
Corneal sensitivity
It is generally undisputed that the sensitivi-
ty of the normal cornea is unsurpassed by
any other organ of the body. Aesthesiometry
has furnished the clinician with essential
data relating to the sensitivity of the corneal
surface. From such data it is now accepted
that the sensitivity of the cornea varies from
a maximum apically to a minimum at the
periphery, with a further considerable drop
in sensitivity at the limbal conjunctiva.
Sensitivity varies with age. In a study
of patients between 10 and 90 years of age
Boberg-Ans found peak sensitivity to be up
to three times greater in the younger indi-
■ 21
viduals than that in the eldest.35 Most sen-
sitivity reduction occurs between the ages
of 50 and 70 years.36,37
Sensitivity variations between the two
eyes are normally minimal. Millodot and
Lamont found significant reduction
(almost half) in a sample of pre-menstru-
al and menstrual women,38 which indi-
cates the possibility of a variation, albeit
for a limited time, between the sexes.
The cornea displays a diurnal variation
in sensitivity, with about a third greater
sensitivity as the day progresses from
morning to evening.39 However, perhaps
the most striking variation displayed is that
between individuals with different iris
colour. Blue-eyed individuals have a
greater sensitivity than those with dark-
brown irides. Non-white people with dark-
brown irides have less sensitive corneas
than Caucasians with a similar iris colour.
Generally, non-white people have four-
times less sensitive corneas than blue-eyed
individuals and half as sensitive corneas
as those of brown-eyed Caucasians.40
A normal nervous supply is essential to
maintain regular corneal function.
Without this several key features of the
cornea are diminished or absent. Epithelial
cell migration diminishes and epithelial
cell turnover is hampered. It is widely
accepted that both LASIK and PRK cause
corneal hypoaesthesia, but there seems to
be disagreement in the literature as to
which procedure has a more profound and
longer effect. The variety in results may
reflect differences within surgical tech-
niques. Moreover, variation in clinical
techniques and corneal location in aes-
thesiometric results cannot be excluded.
Yang et al. reported that corneal sensi-
tivity was more reduced in PRK than in
LASIK in the early stages post-proce-
dure.41 In eyes that had undergone PRK,
they found it took 6 months to recover
baseline (pre-operative) levels. By contrast,
eyes that had undergone LASIK recovered
to baseline levels within 1 month.
The majority of the literature, howev-
er, seems to corroborate the findings of
Perez-Santonja et al.42 They found that
corneal sensitivity was reduced for the first
3 months after LASIK and only recovered
to pre-operative levels after 6 months. In
PRK, corneal sensitivity recovered its pre-
operative values within 1 month, except
at the central cornea, which took 3
months. In comparing both groups, they
found that corneal sensitivity was more
depressed after LASIK than after PRK dur-
ing the first 3 months. No differences were
found between the groups at 6 months.
Matsui et al. reported recovery in corneal
sensitivity as early as 1 week after PRK,
22 ■ Refractive surgery: a guide to assessment and management
with recovery to pre-operative values with-
in 3 months.43 In agreement with the
results of Perez-Santonja et al.,42 they
found LASIK had a more profound effect
on corneal sensitivity, with recovery begin-
ning around 3 months post-procedure.
However, over the short duration of this
study (3 months) these workers found that
sensitivity after LASIK failed to reached
baseline levels.43
In vivo confocal microscopy has provid-
ed excellent information about the regen-
eration of corneal nerves after laser
refractive surgery. Kauffmann et al. com-
pared the regeneration of corneal nerves
after PRK and LASIK.44 In PRK, recovery
of subepithelial re-innervation started from
the margin of the ablated zone towards the
centre of the cornea. At 8 weeks post-oper-
atively, rarefied subepithelial nerve fibres
were visible at the edges, and after 3
months single non-branched nerve fibres
were present at the centre of the ablation
zone. By 6–8 months after PRK, subep-
ithelial nerve regeneration seemed to be
complete; however, abnormal branching
and thin accessory nerve fibres were pres-
ent without exception.
After LASIK, corneal nerve-fibre regen-
eration followed the same course as
described for PRK, except that the regen-
erated subepithelial nerve fibres were bare-
ly visible in the central cornea after 6
months. Further changes in nerve struc-
ture were visible for up to 12 months post-
operatively. These observations correlate
well with clinical data obtained on the
return of corneal sensitivity.
Corneal transparency
If each corneal layer has the same refractive
index, then the transparency of the cornea
is explained easily. However, this is not the
case. The refractive index of the epithelium
is quoted to range from 1.375 to 1.543,45
while that of the stroma is typically around
1.55 in the dry state. It is probably fair to say
that the exact reasons for corneal trans-
parency are still poorly understood.
Maurice has offered an explanation of
the transparency of the stroma.46,47 His
theory embraces light of all incidences and
explains how transparency is lost in vari-
ous circumstances. According to Maurice,
six neighbouring fibrils surround each col-
lagen fibril in a regular, hexagonal array
or lattice. The fibrils are arranged so
because they act as a series of diffraction
gratings that permit transmission through
the liquid ground substance, which has a
lower refractive index of 1.34. As the fib-
rils in adjacent regions of the stroma have
very regular diameters and spacing, a
duplication of the diffraction grating exists
in any plane.
Spacing between adjacent fibrils is
approximately one-tenth the wavelength of
visible light.48 Normally, this spacing is
quite regular. The incident light that
impinges on the collagen fibrils either pass-
es through or reflects off the fibril, such that
light scatter cancels by destructive interfer-
ence. As a result, the matrix can transmit
visible light with an efficacy of 90–98 per
cent. Supporting this hexagonal theory is
that the collagen fibrils of the sclera have a
larger diameter and are spaced more irreg-
ularly than those in the cornea.
When the cornea is oedematous its trans-
parency is reduced. This may be explained
in terms of the lattice theory in that the
excessive fluid disturbs the regularity of the
fibrillar spacing, so the efficacy of the fibrils
as grating elements is lost. Alternatively,
transparency loss with oedema may be
explained by the formation of spaces with-
in stroma. A similar explanation can be
applied when loss of stromal transparency
occurs as an adverse response to surgery.
Corneal wound healing
In the context of laser refractive surgery,
corneal wound healing is best described in
terms of epithelial and stromal healing.
Neither is exclusive and now a strong body
of evidence indicates that there is interac-
tion between these organs as part of the
normal wound-healing process. This is
thought to occur via a number of chemo-
tactic factors. Endothelial wound healing
is a less important feature in the context of
laser refractive surgery, but is discussed
briefly here.
Epithelial wound healing
The pattern of epithelial wound healing is
generally size dependent. Small, central
wounds tend to recover more slowly than
larger more peripheral ones. The rate of
corneal wound healing is also dependent
on the presence or absence of the epithe-
lial basement membrane. When present,
re-epithelialization takes a shorter period
of time, typically 2–3 days, but when
absent the same process can take longer,
normally 5–7 days.49 Epithelial wound
healing is described in four distinct stages:
the latent phase, cell migration, cell pro-
liferation and adhesion.
Latent phase
Extensive reorganization occurs at both
cellular and subcellular levels as a result
of wounding. Initially, PMNs from the tear
layer and limbus appear in the basal layer
at the edge of the wound to remove dead
cells and debris. After this, cells at the lead-
ing edge of the undamaged epithelium lose
their surface microvilli and subsequent-
ly flatten and separate. These flattened
cells develop surface ruffles and filopodia
at their free edges.50 Concurrently,
hemidesmosomes are broken between
basal cells and the basal lamina, which
allows the cells to slide. The ruffles and
long, fine filopodia extend to form attach-
ments to the basal lamina, which gives the
impression of a capacity to draw cells for-
wards into the area of the defect.
Cell migration
Between 4 and 6 hours after wounding,
epithelial cells migrate across the wound-
ed area. This migration results, initially,
in a monolayer of cells that plug the
wound. Consequently, this accounts for
the disappearance of symptoms 4–6
hours post-wounding. As a result of
numerous chemical changes in the basal
lamina, the formation of hemidesmo-
somes is suspended. Consequently, sliding
cells are supported by actin filaments,
located in the filopodia, which act as a
cytoskeleton.
Cell migration occurs in a centripetal
manner and as a continuous sheet. It is
rare for cells to migrate independently.
Individual cells generally maintain the
same position within a sheet. Sheet migra-
tion occurs from several directions, which
meet at a junction as the wound closes.
Cell proliferation
After cell coverage of the wound with a
monolayer of epithelial cells, the corneal
epithelium undergoes stratification. This
is facilitated by mitosis of the corneal
epithelial stem cells located in the basal
layer of the limbal conjunctiva. In the nor-
mal ocular surface, stem cells are relative-
ly quiescent and rarely undergo mitosis.
However, in response to wounding these
cells readily divide.
Division of a stem cell produces two off-
spring, one a stem cell and the other a TAC.
The newly produced TACs migrate cen-
tripetally from the basal layer of the lim-
bus, where they are generated originally,
to the basal layer of the cornea. It is prin-
cipally the rapid division of a TAC that
results in stratification of the corneal
epithelium. As these cells mature and
become more differentiated they move
away from the basal lamina to become
post-mitotic cells (PMCs). Near the corneal
surface, PMCs become fully differentiated
into terminally differentiated cells that are
eventually sloughed off into the tear film.

Adhesion
The final stage of epithelial healing involves
reconstruction of the normal epithelium
adhesion structures to Bowman’s layer.
Intraepithelial attachments also form
and can take up to 8 weeks to become
complete. Prior to this the attachments
are relatively weak. The speed of
hemidesmosomal attachment to the
basement membrane is dependent on
whether the latter is intact. A more rapid
regeneration occurs when the basal lam-
ina is undisturbed.
Stromal wound healing
As epithelial wound healing begins, stro-
mal keratocytes disappear. This is a rapid
process and can begin as soon as 30 min-
utes after wounding. Within 15 hours of
the initial injury almost 40% of the ante-
rior stroma is void of keratocytes.51
Reduction of keratocyte numbers occurs
by apoptosis. Helena et al. suggested that
in refractive surgery this was because these
cells became redundant.52 A benefit of
apoptosis is that minimal damage occurs
to the surrounding tissue, as a conse-
quence of which corneal clarity is pre-
served. Another advantage of apoptosis is
that a potential vehicle for infection is
closed down.
As time passes stromal keratocytes
undergo migration and proliferation to
regenerate a normal stroma. Stromal ker-
atocytes migrate from the posterior stroma
to the surface and expand the cell numbers
by undergoing mitosis. Keratocyte repro-
duction begins after the wound has been
covered by new epithelial cells and, typi-
cally, reaches a peak 3–6 days later. The
newly generated keratocytes synthesize col-
lagens, glycoproteins and proteoglycans
(Figure 3.5). After corneal injury, this effect
is intense for the first 3 months and tapers
off at 6–15 months.
Corneal anatomy, physiology and response to wounding
Endothelial wound healing
Any significant decrease in endothelial cell
density or a change to the cell mosaic
results in corneal decompensation.
Additionally, it is well established that
human corneal endothelium has a low
capacity for regeneration. Both of these
observations have stimulated research into
the effect of laser refractive surgery on this
layer of the cornea. It appears that the
majority of work has found no significant
change in either property in PRK or
LASIK. Stulting et al. noticed, however, an
increase in central cell density and a cor-
relating decrease in the periphery.53 This
was attributed to recovery of the central
area through a migration of some of the
cell mass from the periphery after discon-
tinuation of contact lens wear.
Confocal microscopy after
refractive surgery
The advent of in vivo confocal microscopy
has furnished the clinician with a way to
improve imaging of the living cornea.
This facility has been used to study the
cornea at the cellular level, to describe
normal morphology, keratitis and other
corneal pathologies, and lately the effects
of refractive surgery. Moreover, confocal
microscopy has furnished the clinician
with highly accurate morphometric data.
In normal human corneas, Patel et al.
demonstrated that the full thickness den-
sity of corneal keratocytes was 20,522 ±
2981 cells/mm3.54 This study investigat-
ed 70 subjects who did not wear contact
lenses and had normal corneas, with ages
that ranged from 12 to 80 years. These
workers found that keratocyte density was
highest in the anterior 10% of the stroma
and that density decreased with age at a
rate of 0.45% per year. Using a continu-
Figure 3.5
Corneal fibroblasts
(keratocytes) viewed
topographically
■ 23
ous through-focus method (CTFM), they
found that the normal central corneal
thickness was 563.0 ± 31.1μm and the
central epithelial thickness was 48.6 ±
5.1μm.
Erie et al. investigated the affect of
LASIK on epithelial and stromal thick-
ness.55 They found a similar epithelial
thickness (46 ± 5μm) to Patel et al. (48.6
± 5.1μm) before treatment.54,55 After sur-
gery, epithelial thickness had increased
22% by 1 month. Thereafter, epithelial
thickness did not change, but remained
thicker at 12 months after LASIK (54 ±
8μm) than before. Post-operative epithe-
lial hyperplasia has also been linked to
refractive regression after myopic LASIK.56
Spadea et al. demonstrated that epithelial
thickness increased as early as 1 week after
LASIK, reached maximum thickness
between 1 and 3 months, and then
remained stable for up to 1 year.57
An increase in epithelial thickness has
also been demonstrated after myopic PRK
treatments.58,59 However, unlike in
LASIK, the epithelium continues to thick-
en for up to 1 year after surgery. Normally,
LASIK does not disrupt the corneal epithe-
lium or Bowman’s layer and, consequent-
ly, it should affect anterior corneal
homeostasis less than PRK. Erie et al. sug-
gested, however, that although preserva-
tion of the anterior corneal layers does not
prevent thickening, it does seem to allow
the earlier establishment of a stable epithe-
lium compared with that in PRK.55
The cause of epithelial remodelling
after LASIK is unclear. Epithelial hyper-
plasia is noted frequently in corneal dis-
eases associated with stromal loss as the
epithelium attempts to fill and restore a
smooth corneal surface. Dierick and
Missotten suggested a tension model in
which the epithelium attempts to restore
the original curvature of the cornea.60
Reinstein et al. used high-frequency ultra-
sound to demonstrate that the epithelium
varies in thickness after LASIK and
appears to possess the ability to remodel
itself to compensate for underlying stro-
mal surface anomalies.61 The origin of
this property is thought to be the semi-
rigid concave tarsus of the upper eyelid,
which polishes and remodels the epithelial
surface during blinks.
Erie et al. found no significant change
in the thickness of the total stroma, flap
stroma or base stroma between 1 and 12
months after LASIK.55 However, rather
than being relatively quiescent, as this
observation would suggest, Vesaluoma et
al. demonstrated marked cellular activity
near the ablation zone.62 They found acti-
vated keratocytes near the interface. The
24 ■ Refractive surgery: a guide to assessment and management
initial response to LASIK is the creation of
a thin keratocyte-free zone on both sides
of the lamellar cut. Apoptosis is thought
to be the mechanism that underlies the dis-
appearance of keratocytes.
Activated keratocytes have been indi-
cated as part of the healing process after
PRK,63 and have been implicated in the
stromal thickening shown to occur after
this procedure.64 The duration of activat-
ed keratocytes in LASIK was shown to
diminish after 1–2 weeks by Vesaluoma’s
group,62 whereas it typically peaks 3
weeks to 4 months after PRK.65
Keratocyte activation after PRK is
thought to be caused by an epithelial–stro-
mal interaction mediated by the release of
cytokines during epithelial removal.
However, as the epithelium and Bowman’s
layer are left intact on LASIK, it is possible
that keratocyte activation and subsequent
stromal regeneration are less than that
observed in PRK, which may in part
explain the lack of stromal thickening
found after LASIK. Studies in rabbits have
shown that the wound-healing process
occurs only in the periphery of the corneal
flap and in relative proximity to the epithe-
lium,66 which further supports the theo-
ry that epithelial–stromal interaction
mediates keratocyte activation.
A surprising and novel finding after
LASIK is the apparent loss of cells in the
most anterior keratocyte layers, beginning
at 6 months after surgery.62 The exact rea-
son for this is poorly understood. It is now
thought that there is a direct innervation
of keratocytes by stromal nerve fibres.67
During LASIK, most of the stromal nerve
trunks are cut – only those at the hinge are
spared. Consequently, most of the kerato-
cytes in the flap zone probably lose their
neural input. Lack of communication with
the sensory nerves may be the reason for
the loss of the anterior-most keratocytes.
However, it is important to remember that
inconsistencies in this theory exist.
Keratocyte loss is not observed until after
6 months, and innervation in LASIK is on
the whole restored after 6 months.
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30 Hyldahl L (1986). Control of proliferation
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31 Ikebe H, Takamatsu T, Itol M and Fujita S
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40 Millodot M (1975). Do blue-eyed people
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41 Yang B, Chen J and Wang Z (1998).
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42 Perez-Santonja JJ, Sakla HF, Cardona C,
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sensitivity after photorefractive
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43 Matsui H, Kumano Y, Zushi I, Yamada T,
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44 Kauffmann T, Bodanowitz S, Hesse L and
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■ 25
45 Clark BAJ and Carney LG (1971).
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49 Dayhaw-Barker P (1995). Corneal wound
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53 Stulting RD, Thompson KP, Waring GO
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55 Erie JC, Patel SV, McLaren JW, et al. (2002).
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56 Lohmann CP and Güell JL (1998).
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57 Spadea L, Fasciana R, Necozione S and
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58 Gartry DS, Kerr-Muir MG and Marshall J
(1992). Excimer laser photokeratectomy.
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59 Gauthier CA, Epstein D and Holden BA
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60 Dierick HG and Missotten L (1992). Is
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61 Reinstein DZ, Silverman RH, Sutton HFS
and Coleman DJ (1999). Very high
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complications of lamellar refractive
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surgery. Ophthalmology 106, 474–482.
62 Vesaluoma M, Perez-Santonja J, Petroll
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1447–1452.
26 ■ Refractive surgery: a guide to assessment and management
63 Del Pero RA, Gigstad JE and Roberts AD
(1990). A refractive and histopathologic
study of excimer laser keratectomy in
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64 Møller-Pedersen T, Cavanagh HD, Petroll
WM and Jester JV (2000). Stromal healing
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65 Frueh BE, Cadez R and Böhnke M (1998).
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66 Perez-Santonja JJ, Linna TU, Trevo KM,
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67 Müller L, Pels L and Vrensen GFJM (1996).
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68 Böhnke M, Thaer A and Schipper I (1998).
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corneas. Br J Ophthalmol. 82, 1393–1400.
 4
Surgical procedures
Sunil Shah, Mohammad Laiquzzaman and Stephen J Doyle
Although the idea that the ocular power of
the human eye could be changed to correct
ametropia has been around since ancient
times, the modern concepts of refractive
surgery were devised in Europe during the
early part of 19th century and developed to
its modern status in Japan and Russia.1–3
These concepts were based on the idea that
modification of the corneal curvature
could alter the refractive power of the eye
and thereby help millions of people to be
able to see without any visual aids. Radial
keratometry (RK) has played a critical role
in the development of refractive surgery.
RK opened the window to the surgical cor-
rection of common refractive disorders.
However, the relative safety and efficacy of
excimer laser refractive surgery has brought
this new field into the realm of everyday
practice and made refractive surgery accept-
able to the general public as well as to the
ophthalmic profession. As about one-quar-
ter of the world’s population have refractive
errors,4 the potential population for treat-
ment is huge.
History
In the late 19th century, Lans showed exper-
imentally that non-perforating radial inci-
sions caused central corneal flattening
accompanied by peripheral steepening.5
Greater central flattening was noted with
deeper incisions. In the 1930s, Sato of Japan
noted corneal flattening in several patients
with keratoconus after spontaneous rup-
tures in Descemet’s membranes.6 Based on
this concept, Sato performed RK in patients
with keratoconus and successfully induced
central corneal flattening.7 Enhanced flat-
tening was achieved in the late 1940s by
adding anterior radial incisions.7 Sato’s tech-
nique was modified by several Soviet oph-
thalmologists during the 1970s. They placed
radial incisions in the anterior peripheral
cornea only. Multifactorial formulas that
incorporated patient and surgical variables
were devised by Fyodorov to improve pre-
dictability.8,9 Millions of Americans under-
went this procedure in the subsequent years.
However, the procedure did not become pop-
ular in the UK or in many parts of Europe,
which may, in part, be because in Europe
excimer lasers were approved for refractive
surgery many years before the Food and
Drugs Administration (FDA) in the USA gave
similar approval.
In 1983, Trokel et al. discovered a new
form of tissue–laser interaction. 10,11
Srinivasan, an engineer, was studying the
far ultraviolet (193nm), argon fluoride
(ARF) excimer laser for computer-chip
photo-etching applications, when Trokel,
an ophthalmologist, observed that corneal
tissue could also be removed discretely and
precisely with minimal damage to the
adjacent corneal tissue. Trokel recognized
the potential of the excimer laser to offer
a new sculpting approach to corneal sur-
gery.
Photoablation occurs because the
cornea has an extremely high absorption
coefficient at 193nm, such that the 193nm
photon has sufficient energy to break direct-
ly carbon–carbon and carbon–nitrogen
bonds that form the peptide backbone of the
corneal collagen molecule. Consequently,
excimer laser radiation ruptures the colla-
gen polymer into small fragments and a dis-
crete volume of corneal tissue is removed
with each pulse of the laser.12,13 The depth
of the ablation per pulse is dependent on the
radiant exposure, typically within the range
0.1–0.5μm per pulse at a radiant exposure
of 50–250mJ/cm2.14,15
Table 4.1 Currently available
refractive procedures
Refractive keratotomy
Arcuate or astigmatic keratotomy
(AK)
Photorefractive keratectomy (PRK)
Laser epithelial keratectomy (LASEK)
Laser in situ keratomileusis (LASIK)
Intracorneal ring segment (ICRS)
Corneal inlay lenses (CIL)
Phakic intraocular lenses (phakic IOL)
Clear lens extraction (CLE)
Presbyopic surgery
During the early years, it was suggest-
ed that the excimer laser could be used as
a ‘laser scalpel’ for corneal surgery in pro-
cedures such as RK.16 However, the
excimer laser is a poor replacement for a
cutting scalpel, because the laser removes
tissue rather than incising it.17
The more promising application of the
excimer laser is to re-shape the corneal cur-
vature and thereby alter its refractive
power.18 This new technique was termed
photorefractive keratectomy (PRK) by
Marshall et al. and Liu et al.18,19 McDonald
et al. treated the first sighted human eye
in 1989.20 The currently available refrac-
tive procedures are listed in Table 4.1.
Decision making for
appropriate surgical
procedures
About 25% of the adult Caucasian popu-
lation are myopic and 90% of these are
–6D or less. As a rough guide, most low
myopes (less than –6D) achieve within
0.5D of the goal and most higher myopes
28 ■ Refractive surgery: a guide to assessment and management
(–6 to –10D) achieve within 1D. Although
surgery is less accurate for the higher
myopes, the patients are often even more
pleased, as they are effectively blind with-
out glasses or contact lenses.
The end results of PRK and laser in situ
keratomileusis (LASIK) are the same in
low prescription ranges.21 It is expected
that the results from laser epithelial kera-
tectomy (LASEK) will be similar. LASIK
‘gets there’ faster and with less patient dis-
comfort than PRK or LASEK, whereas
PRK and LASEK are essentially safer.
Which procedure to choose depends on
each patient’s attitude to risk versus con-
venience. Neither procedure should be
used for myopia greater than about –10 D,
as the optical zones carved on the cornea
are too small for low light vision. One even-
tually simply runs out of cornea! If the
cornea is thicker than average, more treat-
ment is possible and, correspondingly, if it
is thinner then less is viable. LASIK is bet-
ter for the high myopes because of the
speed of visual recovery and predictabili-
ty. There is an ‘overlap’ area between –2 to
–3D for which the pros and cons are about
even. LASEK is a recent modification of
PRK and can be the treatment of choice
for patients with high myopia and a thin
steep cornea, and in patients for whom
LASIK is contraindicated.22
Excimer laser technology
The term excimer comes from ‘excited
dimer’ – a mixture of two inert gases that
bind together to produce an unstable
diatomic gas halide. The gases involved
are from the halogen and noble gas
groups. Krypton fluoride (KrF) lasers use
an ultraviolet wavelength of 248nm and
ArF lasers use an ultraviolet wavelength
>+4.5 +4.5 to +1 +1 to –2
CLE LASIK LASEK
Figure 4.1
Author’s treatment plan for an individual patient
of 193nm. Ultraviolet light is strongly
absorbed by most biomaterials. At 193nm
the laser-head photon energy is around
6.4 electron volts (eV), sufficient to break
the corneal intermolecular bonds, which
are about 3.6eV, without causing any
thermal effects. The remaining energy is
used to expel particles from the surface at
supersonic speeds, but with no significant
heating of the adjacent tissues. At wave-
lengths greater than 200nm, the thermal
effects become more marked locally.
Investigations of a range of excimer lasers
have shown the ArF laser to produce the
smoothest ablations of the corneal tissue,
with minimal collateral damage from ther-
mal diffusion. However, even at 248nm,
the photons still cannot penetrate more
than a few microns.23,24
Treatment plan
Figure 4.1 gives a proposed plan for sur-
gery favoured by the authors.
Individual surgical procedures
Refractive keratectomy and PRK are not
discussed separately as the authors feel
these are essentially outdated procedures.
PRK versus LASEK versus LASIK
Shah et al. carried out a prospective, non-
randomized, comparative, paired-eye trial
that comprised 72 eyes of 36 patients,
using a Nidek EC-5000 excimer laser.25
The eyes were divided into two groups. The
first eye of each patient was treated with
20% ethanol debridement and the second
eye with an epithelial flap, which was
replaced after treatment. After a mean fol-
low up of 62.6 weeks, the final mean
–2 to –3 –3 to –6
LASEK LASIK LASIK
LASEK +
mitomycin 0.02%
spherical equivalent (MSE) was +0.07 ±
0.61D in the debridement group and –0.24
± 0.43D in the epithelial flap group. There
was no statistically significant difference
between the two groups in the post-oper-
ative MSE. The best-corrected visual acu-
ity (BCVA) was better in the epithelial flap
group at all visits, a difference that was sta-
tistically significant (p < 0.05). The corneal
haze was less in the epithelial flap group,
and again the difference was statistically
significant (p < 0.05). In another study,
Anderson et al. also found better and quick-
er post-operative results, and most patients
achieved a better correction for myopia and
myopic astigmatism than achieved with
LASIK, quicker epithelial healing and no or
fewer complaints of pain.26 Serrati con-
cluded that LASEK may prove superior to
LASIK.27 Shahinian reported no serious or
vision-threatening complications with
LASEK,22 for a wider range of patients and
with the elimination of stromal flap com-
plications.
LASEK
Indications, absolute contraindications
and relative contraindications for LASEK
are given in Table 4.2.
Overview
LASEK is a relatively new technique that
combines particular advantages of LASIK
and of PRK, and is slowly gaining popular-
ity. The technique is safe, the epithelial heal-
ing is faster with reduced stromal haze, and
it has quicker post-operative recovery and
minimum post-operative pain compared
with PRK.22,25–29 The main rationale
behind LASEK is to keep the corneal epithe-
lium alive to prevent biochemical changes
in the cornea, which can lead to haze for-
mation. It is inherently safer than LASIK and
so patients are attracted to this treatment.
>–6
Thick cornea, Thin cornea
consider unsuitable for LASIK
for LASIK
Phakic IOL CLE
>35 years >35 years

Surgical procedure
The cornea is anaesthetized by topical
anaesthetics. Usually, the non-operated eye
is covered with an eye pad. The patient is
made to lie on a couch and asked to focus on
a flashing light. A lid speculum is inserted in
the eye to be treated. A LASEK 8.0mm
corneal trephine is used to create an epithe-
lial incision. The circular blade is designed
to perform a 270° incision with a blunt sec-
tion at the 12 o’clock position for a hinge. A
9mm corneal ring is applied, which acts as
a cup and is filled with 18% ethanol and left
for 30 seconds. This 9mm corneal ring
allows a 7.5mm treatment zone to be
achieved, as the epithelium at the edges is
still adherent. A flap can be raised in most
eyes 20–25 seconds after the application of
ethanol, but in some patients the epithelium
is more adherent and needs more time. The
ethanol is soaked up with a mercel sponge
and the cornea washed with a topical non-
steroidal anti-inflammatory agent applied
(diclofenac). An epithelial flap is fashioned
by lifting (not debriding and not damaging
the stromal bed) the edge of the loosened
epithelium with a sharp beaver blade. The
flap can be created horizontally or vertical-
ly, or the epithelium is cut in the centre and
a flap is created in all four directions. Once
the epithelial flap has been created, the
Table 4.2 Indications, absolute
contraindications and relative
contraindications for LASEK
Indications
Age 21 years and above
Stable refraction
Adequate central corneal thickness
Myopia –3.00D to –6.00D
Hyperopia up to +4.00D
Astigmatism up to 4.00D
Absolute contraindications
Keratoconus
Herpes virus infection of the cornea
Deep corneal dystrophy
Grossly amblyopic eye
Corneal melt
Unstable refraction
Relative contraindications
Significant cataract
Certain occupations (pilots, computer
programmers and heavy goods
vehicle drivers, because contrast
sensitivity and glare can be a
handicap among these groups of
patients)
Patients with obsessive personality
corneal stroma is bare and laser is applied
without delay, before the stroma dehydrates,
as this might lead to overcorrection. The
patient must be warned that the ablation
usually produces a burning smell.
After laser ablation the flap is replaced
onto the cornea. A contact lens is then
placed on the eye and removed after 4
days. This results in less pain and quicker
visual recovery than for standard PRK.
This procedure is especially beneficial for
patients with small palpebral apertures,
deep-set eyes, extremely flat or steep
corneas, thin corneas or high myopia, as
well as for patients who may not qualify
for refractive surgery.28
Post-operative care
Post-operative care includes topical
antibiotics for 1 week. The patients are
told to avoid swimming, contact sports,
dust and smoke for about a month. Reviews
of the patients are usually after 1 week, 6
weeks and 6 months. The vision gradually
improves over a few days to a few weeks (at
most) depending on the size of the ablation.
Complications of LASEK
As LASEK and PRK are essentially same
procedures, the potential complications
are the same.26 However, in the authors’
experience since using this technique, the
incidence of complications is very low. The
authors have not seen haze that affects
visual acuity. The complications after
LASEK can be classified into two broad
groups:
• Refractive; and
• Miscellaneous.
These are summarized in Table 4.3.
Table 4.3 Complications after
LASEK
Intra-operative
Intra-operative loss of epithelial flap25
Refractive
Early:
• Induced irregular astigmatism
• Primary undercorrection
• Primary overcorrection
Late:
• Regression
• Undercorrection
• Overcorrection
• Miscellaneous
• Decentred ablation
• Glare
• Haloes
• Ptosis
• Infectious keratitis
Surgical procedures ■ 29
LASIK
Overview
LASIK was first performed by Pallikaris et
al. in 1990,30 and is a combination of
excimer laser with lamellar corneal surgery
for the correction of refractive errors. LASIK
is mainly carried out to correct myopia, but
it is also used to correct astigmatism and
hyperopia. Most refractive surgery in the
USA is now LASIK. To achieve the desired
refractive power the corneal thickness and
shape are altered. The excimer laser is used
to ablate the corneal stromal tissue to
achieve the desired refractive change.30,31
Indications, absolute contraindications
and relative contraindications for LASIK
are given in Table 4.4.
Surgical procedure
The patient lies on a couch with the
excimer laser delivery system above the
patient’s head. The cornea of the eye to be
operated is anaesthetized with topical
anaesthetic drops.
A lid speculum is inserted after instill-
ing topical anaesthesia. The patient is
asked to fixate on the laser bream and the
cornea is marked with gentian violet to
help realign the flap. A suction ring is
applied to the limbus and the pressure
increased to more than 65mmHg to
Table 4.4 Indications, absolute
contraindications and relative
contraindications for LASIK
Indications
Stable refraction (no change over a
period of 2 years)
Age ≥21 years
Adequate central corneal thickness
Myopia ≤–10.00D
Hyperopia ≤+4.00 to 5.00D
Astigmatism ≤6D
Absolute contraindications
Keratoconus
Central corneal thickness <410μm
Unstable refraction
Deep corneal dystrophy
Previous corneal melt (or systemic
conditions predisposing to corneal
melt)
History of herpetic keratitis
Amblyopia
Relative contraindications
Cataract
Selected occupations (e.g., commercial
pilots)
Obsessive personality
30 ■ Refractive surgery: a guide to assessment and management
ensure a regular cut. This is confirmed
using an applanation tonometer. The
patient may feel a transient loss of vision
because of increased intraocular pressure.
An automated microkeratome is fitted on
the track and activated to pass across the
cornea to create stromal flap. The vacuum
is released and the epithelial flap is reflect-
ed back to expose the stromal bed. The
hinge of the flap is made, either nasally or
at the 12 o’clock position. Pachymetry is
repeated to ensure adequate residual tis-
sue, and excimer laser ablation is carried
out on the corneal stroma. The patients
are warned that they might experience a
pungent smell during laser ablation. The
ablation usually takes less than 90 sec-
onds. The flap is washed with balanced salt
solution and replaced. Centration is
checked and the edges are smoothed
down. After checking the adhesion, the
speculum is removed. Topical antibiotics
and topical corticosteroid are prescribed
for 1 week.
Post-operative care
The patient is directed to avoid swimming,
dust or smoke and any contact sport for
about 1 month after the surgery. A clear
eye shield is worn during sleep for 2 weeks
to avoid trauma while sleeping. The patient
is examined after 1 day, 1 week, 1 month,
3 months, 6 months and 1 year.
Complications
Complications of LASIK can be divided
into two broad groups, intra-operative and
post-operative, which can be further sub-
divided as early and late.
Flap related complications
The intra-operative flap complications
include incomplete or free (completely cut)
flap, lost flap, decentred flap, irregular flap
and flap stria.32 However, Jacobs and
Taravella, in a study on 84,711 eyes, con-
clude that overall flap complications are
very low (0.3%).33
Late complications are epithelial
ingrowth (epithelium within the stromal
interface, one of the most common caus-
es of reduced visual acuity),32 wrinkles or
striae, interface infection and flap disloca-
tions.34,35
Refractive complications
These include under- or overcorrection,
regression, decentred ablation and induced
irregular astigmatism caused by folds or
microstriae of flaps.32 This is often difficult
to correct and results in decrease in visual
acuity and/or quality of vision. Other com-
plications are given in Table 4.5.
Clinical outcomes
LASEK
Predictability
Claringbold conducted a study in 222 eyes
with myopia that ranged from –1.25 to
–11.25D and astigmatism up to 2.25D.29
Of these, 84 eyes had a 1 year follow-up,
of which 82.0% had an uncorrected visu-
al acuity (UCVA) of 20/20 or better and
100% had an UCVA of 20/25 or better.
In another study, 343 eyes with refrac-
tive errors that ranged from –1.00 to
–14.00D and astigmatism up to +4.75D
were followed up for 6 months. Of these
patients, 98% had unaided visual acuity
of 20/40 or better.26 Shahinian reported,
in a study of 146 eyes with myopia that
ranged from –1.00 to –14.38D, that the
UCVA was 20/40 or better in 96% of the
eyes after a 12 month follow-up.22
Stability
O’Bart, in a study on 105 eyes, reported
that refractive stability was rapid with a
mean refractive change between 1 week
and 6 months post-operatively of
±0.34D.37 Claringbold reported that all
eyes achieved ±0.75D of the intended cor-
rection and more than 96% of the eyes
were within ±0.5D after 12 months.29
Loss of uncorrected visual acuity
In a study of 222 eyes with myopia that
ranged from –1.25 to –11.5D, UCVA was
20/40 or better after 4 days in more than
80% and 20/20 or better in 75% after 2
weeks.29
Loss of best-corrected visual acuity
Claringbold in a study on 222 eyes report-
ed no loss of BCVA.29
Table 4.5 Non-refractive
complications after LASIK
Central islands36
Interface debris32
Haze
Glare and haloes34
Infectious keratitis (rare)32,34
Diffuse interstitial keratitis (sands of
Sahara)32
Dry eye34
Endothelial cell loss34
Night-vision problems36
Reduction in corneal sensitivity34
Posterior ectasia29
LASIK for myopia
Predictability
Pop and Payette reported a study of 107
LASIK-treated myopic eyes with refractive
error that ranged from –1.00D to
–9.00D.21 Of these eyes, 70% (77 eyes)
were evaluated 12 months post-opera-
tively, of which 100% had UCVA of 20/40
or better and 83% achieved UCVA of
20/20 or better. In another study of 290
highly myopic eyes (range from –9.00 to
–22.00D), the UCVA was 20/40 or better
in 73.3% after 1 month.38
Stability
In 131 eyes with high myopia (range from
–9.00 to –22.00D), overall most scores
were stable or improved between early and
late follow-ups. In 88% of the eyes, UCVA
was stable or improved after 1 month and
in 95% of the eyes BCVA was stable or
improved after 1 month.38
Loss of best-corrected visual acuity
Pop and Payette reported that after 1
month of surgery 90% of the eyes were
within ±1.00D and 64% of the eyes were
within ±0.5D of BCVA.21 After 12
months, 99% were within ±1.00D and
78% were within ±0.5D. No eye lost two
Snellen lines of BCVA.
LASIK for hyperopia
Predictability
LASIK can be used reasonably successful-
ly to treat low hyperopia. Cobo-Soriano et
al. conducted a study of 376 hyperopic
eyes (range from +1.00D to +8.50D), for
which a mean post-operative refraction of
+0.46 ± 0.8D was achieved after a follow
up of 8.2 months.39 In eyes with an error
of ≤+4.00D, the final UCVA was 20/40 in
96%, and 88% in patients with >+4.00D.
In another study on 54 hyperopic eyes
(range +1.00D to +6.00D), Lian et al.
reported that predictability was good after
12 months: 83% eyes were within +1.00D
and 66% achieved +0.5D.40
Loss of uncorrected visual acuity
Lian et al. also reported that 92.6% of the
eyes had UCVA of 20/40 or better and
63% had 20/20 or better.40 One eye lost
two lines of BCVA and two eyes gained two
or more lines.
LASIK versus LASEK
This topic is covered in more detail in
Chapter 8, but here it is sufficient to say
that in some prescription groups the end
results of LASIK and LASIK are the simi-
lar. Claringbold suggests that LASEK
appears to be safe and more effective than

LASIK in that complications related to the
stromal flap are eliminated and it can be
performed in patients for whom LASIK
may be contraindicated (e.g., deep-set eyes,
thin corneas, etc.).29 However, LASEK has
some disadvantages with respect to LASIK:
• Patients experience varying degrees of
pain during the first 2 days after sur-
gery;
• Recovery of vision is slower, as vision
is somewhat blurred for the first week
after LASEK surgery; and
• Patients may have mild recurrent
epithelial erosion and so require post-
operative corticosteroid for a longer
period than required after LASIK.
Intracorneal ring segments
Overview
Intracorneal ring segments (ICRS) is a pro-
cedure based on the assumption that the
refractive error can be corrected by flat-
tening the cornea using tissue added to the
outer two-thirds of cornea. This extra tis-
sue in the peripheral cornea distends the
cornea, which in turn flattens the central
cornea.41
This technique is used to correct low
myopia and astigmatism. In this procedure
half-ring segments of Perspex are insert-
ed into channels created in the corneal
stroma, which results in a flattening of
cornea. The advantage is that the central
cornea is not involved and the ring is posi-
tioned outside the pupillary margin. This
process is easily reversible and the corneal
shape remains intact.
The indications for ICRS are low grade
myopia <4.5D and keratoconus.
Surgical procedure
The operation is carried out under sterile
conditions. The geometrical centre of the
cornea is marked and intra-operative
ultrasonic pachymetry carried out at the
sight of incision. The diamond blade is set
at 70% of the measured corneal thickness
to create a single radial incision that is less
than 2.0mm at the steepest meridian. A
stromal pocket is dissected on both sides of
the incision using a modified spatula. The
intrastromal dissection is created to the full
depth of the incision. Either a suction
device is used to dissect a stromal plane to
create semicircular lamellar pockets or this
can be carried out manually.42 After
removal of the suction device, two intra-
corneal rings of different thicknesses are
inserted into each semicircular channel.
Selection of the rings is based on the
refractive error. Finally, the radial incision
is sutured with nylon sutures. Post-opera-
tive antibiotics and hydrocortisone are
given to minimize the risk of keratitis. The
advantages and disadvantages are given
in Table 4.6, but the procedure is not pop-
ular among UK surgeons,
Holmium laser thermokeratoplasty
and diode thermokeratoplasty
Holmium laser thermokeratoplasty (LTK)
and diode thermokeratoplasty (DTK) are
used to correct hypermetropia. In both of
these procedures an infra-red laser is used
to coagulate the cornea. Spots are
arranged in a ring 6–9mm from the cen-
tre of cornea, and as the scar tissue forms
the central cornea steepens. Charpentier
et al. reported that the stability of refrac-
tive outcome is poor.44
Phakic intraocular lenses
Overview
The word ‘phakic’ is derived from the Greek
phakos, which means lens. Phakic intraoc-
ular lenses (PIOLs) are artificial lenses
placed inside the eye to correct refractive
error such as myopia and hyperopia. For
years, intraocular lenses (IOLs) have been
used during cataract surgery after removal
of the natural crystalline lens. More recent-
ly, IOLs were designed to be placed in the eye
to correct refractive error without removal
of the natural lens. Additional IOLs are used
to treat refractive errors. This surgical pro-
cedure is generally carried out to treat high
refractive errors for which corneal surgery
cannot be performed. In this technique,
lenses made of polymethylmethacrylate or
colorate (which is a soft lens made of col-
lagen, water and polymers) are placed inside
the eye. The lens is wedged between the pos-
terior surface of the cornea and the ante-
rior surface of the iris, or is attached to the
Table 4.6 Advantages and
disadvantages of intracorneal ring
segments
Advantages
Corneal shape is not disturbed
Centre of the cornea is not touched
Process is reversible
Surgical procedure is safe
Adjustment can be performed using
thinner or thicker rings41
Useful in keratoconus eyes
Predictability of surgical outcome is
good44
Disadvantage
Can only be used in low myopia (e.g.,
<4.50D)
Surgical procedures ■ 31
anterior surface of the iris by a clip, or is
placed in the space between the posterior
surface of the iris and the anterior surface
of the natural lens of the eye.
The indications are:
• Myopia >–5.00D;45
• Hyperopia >+5.00 to +15.00D;45
• Thin corneas;
• Previous refractive keratotomy sur-
gery.
Surgical procedures
Anterior chamber lens implantation
The surgery is carried out under sterile
conditions to avoid intraocular infection.
The pupil is dilated with mydriatics and
anaesthesia, either topically or with
peribulbar anaesthetics. A temporal
corneal incision of about 3–3.5mm is
made with the diamond blade. Sodium
hyaluronate is injected into the anterior
chamber to deepen it. The lens is implant-
ed into the anterior chamber, the haptic
ends are placed under the iris with a spat-
ula and the lens is centred. Peripheral iri-
dectomy is performed to avoid blockage
by the peripheral haptic. The viscoelastic
material is removed by either irrigation
or aspiration with balanced solution. Post-
operative antibiotic and corticosteroid
drops are given for 5–7 days.
Posterior chamber lens implantation
The pupil is dilated with mydriatics and the
eye to be treated is anaesthetized with
peribulbar anaesthetics. A temporal or
nasal corneal incision of about 3–3.5mm
is made with the diamond blade. The sili-
cone IOL is implanted in front of the nat-
ural crystalline lens, under the protection
of a viscoelastic substance. No suture is
necessary. A peripheral iridectomy is per-
formed, either intra-operatively or by laser
after surgery. At the end of the surgical
procedure, gentamicin and corticosteroid
are given topically or both topically and
subconjunctivally.
The advantages and disadvantages of
PIOL procedures are given in Table 4.7.
Surgical outcome, anterior chamber
lens implant
Loss of best-corrected visual acuity
Hoyos et al. reported for anterior chamber
lens implantation a mean BCVA in myopic
eyes of 20/35 and in hyperopic eyes of
20/23 after 1 year in a study on 31 eyes
(17 myopic and 14 hyperopic, myopia
ranged from –11.8 to –26.00D and hyper-
opia from +5.25 to +11.00D).45 In
myopic eyes, no eye lost lines of acuity, and
in hyperopic eyes one eye gained one line
of BCVA and one eye lost one line.
32 ■ Refractive surgery: a guide to assessment and management
Table 4.7 Advantages and
complications of phakic
intraocular lenses
Advantages
Preservation of accommodation
Compatibility with proved cataract and
phakic IOL implantation procedures
Correction of higher levels of myopic
and hyperopic refractive errors
Reversibility46–48
Complications
Post-surgical astigmatism
Secondary glaucoma (major
complication of the anterior
chamber lens)
Chronic intraocular inflammation
Pigment dispersion
Uveitis
Endothelial cell damage
Cataract formation
Endophthalmitis
Glare and poor-quality vision at night
with a wider pupil
Predictability
After 1 year follow-up, the MSE of refrac-
tion was –0.22 ± 0.87D in myopic eyes,
with 87% within the desired refraction of
±1.00D; in hyperopic eyes the MSE was
+0.38 ± 0.82D, with 79% within the
desired refraction of ±1.00D.45
Surgical outcome, posterior chamber
lens implant
Loss of best-corrected visual acuity
Brauweiler et al. evaluated 18 eyes with
high myopia (pre-operative MSE –14.58 ±
3.04D).49 BCVA remained unchanged in
one eye or improved by two lines or better,
and three eyes lost one line of BCVA.
Predictability
After 2 years follow-up the MSE was –1.33
± 0.71D.
Clear lens extraction
Overview
Various treatments for patients with high
refractive errors have been used in the past
(e.g., glass spectacles, contact lenses, etc.),
but the higher the refractive error the
higher the dissatisfaction with these tra-
ditional treatment methods. During the
past two decades refractive surgery has
made much progress and become popular.
More and more patients with refractive
error seek life without these traditional
methods of treatment (e.g., glass and con-
tact lenses), and refractive surgery results
are promising in terms of rapid recovery
and safety.29
The indications are:
• High myopia >6.00D; and
• Hyperopia.
Surgical procedure
This surgical procedure is similar to a
cataract operation, the only difference
being that the natural crystalline lens is
removed even though it is not opaque, and
an artificial lens is implanted. The IOL’s
strength is calculated such that when it
replaces the crystalline natural lens the
required refractive power is achieved.
The complications of clear lens extrac-
tion are given in Table 4.8.
Results
Loss of best-corrected visual acuity
Usitalo et al. reported that, for 38 eyes,
71.9% gained one or more lines and
40.6% gained two or more lines in their
study of highly myopic eyes (range from
–7.75D to –29.00D), and 6.2% lost one
line of BCVA after 1 year.50
Accuracy
In the same 38 eyes, the spherical equiv-
alent refraction was within ±1.00D in
81.6% and within ±0.5D in 71.1%, and
in eyes with myopia <–18.0D refraction of
within ±1.00D was achieved in 96.4%
and within ±0.5D in 85.7%.50
In another study by Pop et al. of 65 eyes
with hyperopia up to +12.25D, 1 month
after clear lens extraction the BCVA was
20/40 or better in 95% of eyes and 20/20
or better in 38.5%.51
Long-term safety
The short-term results are very promising,
and long-term safety is as for cataract sur-
gery.
Presbyopic surgery
Overview
Accommodation is the mechanism by
which the curvature of the anterior surface
of a crystalline lens increases, and it pro-
duces the optical power of the lens.52 In a
relaxed state the suspensory ligament,
which is attached to the lens and ciliary
muscle, is in tension and so stretches the lens
and keeps it flatter. However, during accom-
modation the ciliary muscle contracts,
which in turn reduces the tension of the sus-
pensory ligament and allows the anterior
surface of the lens to move towards the
cornea. The change in the curvature of lens
Table 4.8 Complications of clear
lens extraction
Post-surgical astigmatism
Chronic intraocular inflammation
Posterior capsular opacity
Endothelial cell damage
Uveitis
Endophthalmitis
Glare
occurs in the centre, and the peripheral part
flattens. With advancing age the lens mate-
rial reduces or loses its elasticity, which
results in a reduction or loss of forwards
movement of the lens and finally in loss of
accommodation. This condition is known as
presbyopia.
Surgery for presbyopia is in its infancy.
It can be either corneal, scleral or an IOL
implant using a multifocal or accom-
modative lens. The lens is implanted after
cataract surgery, on the assumption that
movement of the vitreous gel behind the
lens will create the desired refraction.53
Surgical procedure
Corneal surgery
A multifocal cornea is created under a
LASIK flap by steepening the cornea infe-
rior or by implanting a multifocal intra-
corneal inlay.
Scleral surgery
Scleral surgery can be carried out by sur-
gical incision or laser. The required result
is expected to be achieved by creating a
multifocal cornea.
Intraocular
An intraocular procedure was first
described in 1997, and is called presbyopic
lens exchange (PRELEX).53 IOLs are used
to restore accommodation at the time of
cataract surgery.52 Two types of lenses are
used mainly:
• Accommodative lenses are single-
power optic lenses. The theory is that
this will mimic the natural physiology
of the eye, whereby relaxation and
contraction of the ciliary muscle will
result in a change in the power of the
lens.
• Multifocal lenses comprise two main
types, refractive and defractive multi-
focal IOLs. Use of these lenses to treat
presbyopia has been approved by the
FDA.
The complications of presbyopic surgery
are given in Table 4.9.

Table 4.9 Complications of
presbyopic surgery
Dislocation of lens
Long-term refractive stability
Lens decentration
Fibrosis of the lens capsule that
resultsin loss of forwards movement
of the implanted lens
Glare
Haloes
Post-operative refractive errors
Surgically induced astigmatism
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 5
Post-operative follow-up of the
refractive surgery patient
Patients who have undergone any form of
refractive surgery procedure require careful
follow-up, particularly during the first year.
In some clinics the operating surgeon under-
takes all such examinations, but it is increas-
ing likely that optometrists will be called
upon to share the ever-increasing workload.
The optometrist may be involved merely in
refraction and topography measurements,
or may have to undertake the full examina-
tion, particularly in cases for which the sur-
geon is not on site. Opinions vary
considerably as to the point at which care of
a patient can be passed from the surgeon to
an optometrist, although 3 months appears
to be a common handover point to general
optometrists who do not specialize in post-
refractive surgery patient care. It is impor-
tant to clarify with whom the responsibility
for the patient lies – this will vary depending
on the co-management set up, which is dis-
cussed in Chapter 7. If time permitted, many
surgeons would prefer to see the patient right
up until the point of discharge to maintain
continuity of care and collect outcome data.
This allows surgeons to audit their own per-
formance and modify their techniques
accordingly. For this reason, it is important
that optometrists involved in the assessment
of refractive surgery patients provide feed-
back after each assessment, which should
include details such as residual refractive
error, uncorrected and best-correction
vision, slit-lamp findings, symptoms, etc. The
surgeon or a designated ophthalmological
colleague must be contactable at all times in
case problems are detected during a follow-
up examination. Referral to the Hospital Eye
Service should remain the last resort.
Once the refractive error and topogra-
phy have stabilized, the cornea is quiet and
any visual problems have been dealt with,
the patient can be discharged back to their
Catharine Chisholm
own optometrist with a letter that provides Initial post-operative period
details of the surgery and outcome.
Optometrists involved in refractive surgery The primary purpose of follow-up exami-
co-management are responsible for edu- nations during the early post-operative
cating the patients on the importance of period is to recognize and manage acute
regular eye examinations. Patients will still problems, such as infections, slipped
need reading glasses when they reach pres- corneal flaps, etc. Over the longer term,
byopia and the health of their eyes should examinations should include the investi-
be checked at least every 2 years, as for any gation of refractive and topographical sta-
other patient. Occasionally, non-presbyopic bility, address any visual problems and
patients require a small residual correction refer patients back for enhancements
for certain critical tasks, which again can where necessary. Table 5.1 summarizes
be provided by the optometrist. time scales for follow-up examinations.
Table 5.1 Suggested time scale for follow-up examinations
Follow-up time Personnel Primary purpose
Immediately Surgeon Check flap position and integrity
post-operative (LASIK and LASEK)
1 week Surgeon and Check flap (LASIK and LASEK);
optometrist check for epithelial closure (PRK)
1 month Surgeon and Look for epithelial ingrowth (LASIK)
optometrist Haze maximum after PRK
Assess initial refractive outcome
3 months Optometrist Full examination
(and surgeon?) Consider enhancement post-LASIK if
required and refraction stable
6 months Optometrist Full examination
(and surgeon?) Consider enhancement post-PRK if stable
12 months Optometrist Full examination
(and surgeon?) Discharge to general optometric practice if no
problems
Information letter to patient’s own optometrist
36 ■ Refractive surgery: a guide to assessment and management

Photorefractive keratectomy
Some degree of aqueous flare is present in
a large proportion of eyes during the first
24–48 hours.1 Patients can suffer quite
severe pain and photophobia caused by the
large epithelial wound and will need to use
systemic painkillers during the first 24
hours, in addition to topical medication
[antibiotics and non-steroidal anti-
inflammatory drugs (NSAIDs)]. Bandage
contact lenses can be fitted to manage
pain, but are rarely used after photore-
fractive keratectomy (PRK).
At 1 week
Re-epithelialization occurs within 4.6 ±
0.2 days of PRK (range 3–6 days).2
Epithelial cells from the margin of the
wound migrate and proliferate to form a
single layer of cells across the central
cornea. Once this stage has been complet-
ed, mitosis gradually increases the num-
ber of layers to form a stratified epithelium.
Functional vision returns upon re-epithe-
lialization, with 83% of low myopes (–1.00
to –5.99D) achieving an unaided vision of
6/12 by 1 week.3 The initial refraction
tends to be slightly hyperopic followed by
a gradual drift towards emmetropia or
myopia. Irregularities of both the refrac-
tion and topography are common at this
stage. A significant epithelial defect is vis-
ible without fluorescein staining, but if
this has to be used the eye should be irri-
gated thoroughly afterwards to remove
any remaining dye. Slow re-epithelializa-
tion tends to be associated with greater
haze and regression in the longer term. By
1 week, there should be no pain, although
mild grittiness may persist. If corticosteroids
have been prescribed and the epithelium is
intact, careful tonometry can be undertak-
en to detect steroid responders.
At 1 month
Subepithelial haze develops during the first
month, and reaches a peak in intensity
between 6 and 12 weeks.4,5 The formation
of haze is a process of tissue remodelling
that involves corneal basal epithelial cells,
Table 5.2 Grading of haze post-PRK7
Grade of haze Description
0 Clear
0.5 Haze barely detectable
1 Mild haze, refraction unaffected
1.5 Mild haze that affects refraction
2 Moderate haze, refraction difficult, high-contrast vision affected
3 Opacity prevents refraction, vision impaired, anterior chamber visible
4 Opacity impairs view of anterior chamber
5 Unable to see anterior chamber
activated keratocytes and the deposition of
type III collagen within the stroma.6 Haze
is visible because the cornea both reflects
and scatters light back towards the observ-
er. Haze should be graded as shown in
Table 5.2. Grade 0.5–1.5 haze is not
uncommon at 1 month and may be asso-
ciated with a reduction in low-contrast
acuity. Haze does not influence Snellen
acuity unless it reaches grade 2 or more,
but it can affect post-operative Orbscan
data corneal thickness measurements
should be interpreted with caution in the
presence of significant haze.8
At 3 months
There should be little if any stromal haze
by 3 months and best-corrected visual
acuity (BCVA) should have returned to
pre-operative levels. The refractive error
should have regressed from low hyperopia
to near emmetropia and some individuals
may even show signs of refractive and top-
ographical stability. If significant myopic
regression is going to occur, it is generally
evident by 3 months post-PRK.
At 6 months and beyond
Since PRK is now reserved for treatments
of –4.00D or less, refractive stability is gen-
erally achieved within 6 months of sur-
gery. Cellular activity ceases at around 3
months, but long-term healing processes
continue for up to 18 months post-opera-
tively. The time course of this activity cor-
relates with an initial reduction in visual
performance, associated with changes in
the number, size and density of the stro-
mal keratocytes.9,10 Stromal haze rarely
persists beyond 12 months.5,7
Refractive outcome
By 12 months, 87–99% of low and medium
myopes (<–6.00D) are within ±1D of
emmetropia. Enhancement procedures can
be performed to correct residual refractive
error, but predictability is not as good as for
the initial procedure. Diurnal variations that
result from PRK are clinically insignificant
and any shift tends to be in the hyperopic
direction, and therefore has little or no
impact on vision.11,12 The reduction in
atmospheric pressure and reduced oxygen
levels found at high altitude have been
shown to result in temporary, but significant,
peripheral corneal thickening in PRK sub-
jects. This does not appear to be associated
with any refractive shift.13
Complications specific to PRK
Persistent haze
Up to grade 1.5 haze (on a 0–4 scale) is
expected during the first 2–3 months post-
PRK, but more significant haze may devel-
op in those treated for higher refractive
errors and in those with darker irides.14
Intense and persistent haze may require
the use of topical corticosteroids. Research
into wound healing post-PRK suggests that
anti-transforming growth factor-B (TGF-
B) and mitomycin may help to prevent and
treat stromal haze in the future.15
Anisometropia
Most clinics and surgeons perform PRK on
patient’s eyes unilaterally. It is usual to
have an interval of a few months between
the PRK for each eye, during which time
some patients find the level of ani-
sometropia between the eyes uncomfort-
able. This is especially difficult immediately
prior the second operation, as the patient
will have to cease contact lens use in
preparation for the next operation.
Epithelium irregularity
PRK involves removal of the corneal
epithelium pre-operatively and subsequent
re-epithelialization of the cornea, and
some patients have reported recurrent
corneal erosions. This may be troublesome
for patients with seasonal ocular allergies
and many patients feel the need for occa-
sional ocular lubrication.
Laser in-situ keratomileusis
Immediately post-surgery
Immediately after laser in situ keratomileusis
(LASIK), a slit lamp should be used to check
the flap position and look for wrinkles, striae
(Figure 5.1) or significant interface debris that
may require the flap to be re-floated by the
surgeon.16 Failure to do so could result in a
compromised visual performance because of
significant corneal irregularity over the pupil.
No fluorescein staining should be visible,
other than a little around the flap margins,
but some degree of anterior chamber activ-
ity is relatively common.1,17 If fluorescein
reveals an epithelial defect (Figure 5.2), cor-
ticosteroids can be used to prevent or at least
limit interface inflammation. In the majori-
ty of cases, functional vision returns within
a few hours of surgery, with 80% achieving

Figure 5.1
Striae post-LASIK. (Courtesy of Michelle
Hanratty)
a level of vision within one line of their pre-
operative BCVA by 3 days after LASIK.18
Patients may experience grittiness, photo-
phobia and perhaps burning for the first 24
hours until the epithelium around the flap
margin has healed, but discomfort can gen-
erally be controlled using anti-inflammato-
ry drops (e.g., 0.5% diclofenac sodium,
extended release) rather than a bandage con-
tact lens19 Eye rubbing or squeezing can dis-
lodge or distort the flap during the early
post-operative period, so the patient is usu-
ally fitted with a transparent eye shield to
minimize the risk of this happening.
At 1 week
The epithelium should fully cover the flap
margin by 1 week post-LASIK. The mar-
gins can be quite difficult to detect at this
stage, as fibrosis has yet to take place.
Epithelial defects should be monitored
carefully, since they increase the risk of
epithelial ingrowth and diffuse lamellar
keratitis (DLK). Interface debris should also
be watched as it may lead to focal infil-
trates that require flap re-floatation.
Topographical irregularities and sub-clin-
ical flap oedema complicate objective and
subjective refraction and limit visual qual-
ity in the early post-operative period.
At 1 month
By this stage, the vision tends to be very
good. However, as the novelty of clear vision
without glasses begins to wear off, some
patients start to notice visual problems such
as reduced-quality night vision and haloes
around lights. The refractive error may have
stabilized in those treated for lower degrees
of myopia (<6.00DS), although regression
of approximately 15% of the pre-operative
error is not uncommon20 (e.g., –0.25D after
LASIK for –1.50D, and –1.50D after LASIK
for –10.00D), and is associated with an
increase in corneal thickness and central
corneal steepening.21 If epithelial ingrowth
is going to develop it tends to do so within
the first month. The clinician must then
Post-operative follow-up of the refractive surgery patient
Figure 5.2
Flap-edge defect post-LASIK. (Courtesy of
Michelle Hanratty)
decide whether the location and extent of
the ingrowth warrant intervention.
At 3 months
After LASIK, healing is limited to the region
around the lamellar interface and haze
occurs around the flap margin only. Histo-
logical investigations show a regular stro-
mal architecture, in contrast to the obvious
anterior stromal disorganization seen after
PRK.22 Most LASIK patients demonstrate
a stable refractive error by 3 months, with
the exception of those treated for very high
myopia.23,24 The possibility of an enhance-
ment procedure can be discussed if the
refractive outcome is poor, but few surgeons
consider an enhancement unless the resid-
ual error is greater than 1.00DS. LASIK
enhancements are usually performed
between 3 and 6 months after the first pro-
cedure. At this stage, the flap can still be lift-
ed after removal of the epithelium from
around the margin. Flaps in some patients
can be lifted more than 18 months post-sur-
gery.25 Late enhancements require a sec-
ond lamellar cut, which increases the risk
of complications.26 If an enhancement pro-
cedure is to be considered, both the refrac-
tion and corneal topography must be stable
and there must be sufficient residual
corneal thickness. As with the pre-opera-
tive examination, a cycloplegic refraction is
essential to minimize the risk of overcor-
rection. Any enhancement obviously
requires the follow-up period to begin again.
At 6 months and beyond
The percentage of eyes that achieve with-
in ±1.00D of emmetropia has been quot-
ed as 88–100% at 6 months post-LASIK
for corrections of –8.00D or less.27,28 To
correct low hypermetropia, hyperopic
LASIK has proved slightly more successful
than hyperopic PRK,29 but the stabiliza-
tion rate is approximately four times longer
than for myopic treatments.30 As with
PRK, there is no evidence of a diurnal vari-
ation in vision, although a temporary
■ 37
increase in myopia and an associated
reduction in vision have been reported at
high altitude after LASIK.31
Complications specific to LASIK
Complications can arise from either the flap
or, less commonly, the laser ablation.32 Flap
complications include those that occur at
the time of surgery (in approximately 0.3%
of cases), such as an incomplete or decen-
tred flap,33 and complications that present
after surgery, such as flap striae and epithe-
lial ingrowth.32,34 The vast majority of
complications manifest themselves within
6–8 weeks of LASIK surgery. Most can be
treated and have a minimal effect on the
final outcome after surgery, if managed
properly.35 Serious adverse complications
that lead to a significant permanent visu-
al loss, such as infections and corneal ecta-
sia, are very rare, but side effects such as
dry eyes, night-time starbursts and reduced
contrast sensitivity are relatively common
for the first few months.36 Surgeon expe-
rience is a key factor in the initial outcome.
Epithelial ingrowth
Epithelial ingrowth occurs when nests of
epithelial cells trapped beneath the flap
begin to proliferate (Figure 5.3). Ingrowth
presents as a milky deposit in the interface
(Figure 5.4) and is more common after
Figure 5.3
Nests of proliferating epithelial cells trapped
beneath the flap can result in epithelial
ingrowth. (Courtesy of Michelle Hanratty)
Figure 5.4
Ingrowth often presents as a milky deposit
in the interface. (Courtesy of Michelle
Hanratty)
38 ■ Refractive surgery: a guide to assessment and management
enhancement than after the initial proce-
dure. The extent should be measured since
growth less than 1.0mm from the flap mar-
gin is acceptable, as it is usually self-limiting.
Ingrowth greater than 1.0mm, invading the
visual axis or progressing rapidly requires
surgical management, particularly if the
flap margin is rolled or eroded, as it can lead
to significant irregularity and flap melt.
Although a small degree of ingrowth is com-
mon (approximately 15% of eyes), few cases
require management. Untreated ingrowth
can lead to corneal irregularity and glare,
and very occasionally to corneal melt.
Microstriae
Fine grey lines that are related to crinkles
in Bowman’s membrane are not uncom-
mon in those treated for moderate or high
myopia, as the flap does not fit the remod-
elled stromal bed. Such cases are difficult
to manage and are usually left alone unless
vision is compromised.
Interface debris
Some debris is seen in virtually all eyes post-
LASIK. Sources include dust from the
atmosphere, meibomian secretions (Figure
5.5), metallic deposits and oils from the
microkeratome blade and fibres (Figure 5.6).
Debris is usually inert and causes no prob-
lems, but it can be associated with stromal
infiltrates or DLK, in which case it requires
treatment with topical corticosteroids.
Figure 5.5
Post-LASIK interference debris. (Courtesy
of Michelle Hanratty)
Figure 5.6
Fibres trapped in the interface post-LASIK.
(Courtesy of Michelle Hanratty)
Diffuse lamellar keratitis (Sands of the
Sahara)
DLK is a sterile, diffuse inflammation at the
level of the interface that may be accom-
panied by anterior chamber activity
(Figure 5.7).37 It looks a little like post-PRK
haze, but is very obviously confined to the
interface. It is thought to be an immune
response to interface debris or perhaps bac-
terial toxins. The onset tends to occur
within a day or two of the LASIK proce-
dure, with symptoms such as pain and
photophobia, and additional signs of cil-
iary hyperaemia and lacrimation. Visual
quality may be reduced because of the
increase in forward light scatter, although
Snellen acuity is unaffected generally.
Referral back to the operating surgeon is
required for treatment with topical corti-
costeroids such as fluorometholone,
antibiotics and cycloplegics. The flap may
be lifted and irrigated in some cases.
A number of systems are used to grade
DLK, including one that divides cases into
one of four categories (Table 5.3). A clus-
ter is defined as a group of DLK cases that
occur in patients treated on the same day.
One study found that DLK occurred in
1.3% of eyes treated, with 58% and 42%
showing type I and type II, respectively.
Cases with central involvement (type II)
took significantly longer (12.1 days) to
resolve than cases with central sparing
(type I – 3.5 days). Not surprisingly, cen-
tral involvement carries a much higher
risk of a reduction in BCVA. The majority
of cases were sporadic rather than part of
Figure 5.7
DLK is a sterile, diffuse inflammation at the
level of the interface. (Courtesy of Michelle
Hanratty)
Table 5.3 Classification of DLK38
No central involvement
Sporadic case Type IA
Case part of a cluster Type IB
a cluster.38 DLK can also present many
months after LASIK in association with an
epithelial defect.39 White blood cells
migrate from the limbal blood vessels into
the interface, since it is the easiest path for
them to take. Central corneal sparing is
much more likely if the DLK is related to
an epithelial defect. There is also a report-
ed case of DLK that occurred 10 months
post-LASIK in association with acute iri-
tis,40 which suggests that DLK is a non-
specific corneal inflammatory response
rather than a condition caused by a par-
ticular agent. Appropriate management of
patients with DLK generally results in
complete resolution of the condition.
Corneal integrity
Concern has been raised as to the integri-
ty of the globe post-LASIK, since healing
does not appear to lead to the growth of
collagen fibres between the corneal flap
and the ablated stromal bed. The flap is
attached to the underlying cornea only at
its margins, by the corneal epithelium, and
therefore does not contribute significant-
ly to the strength of the cornea. However,
a study that examined the integrity of the
globe after a range of different refractive
surgery procedures concluded that,
although LASIK eyes required slightly less
energy to rupture than control eyes, the
difference was not significant.41 LASIK
eyes ruptured either at the flap margin or
at the edge of the limbus. Other studies
have also concluded that ocular integrity
is not compromised by LASIK.42,43 The
risk of the flap being dislodged is very low,
with one study on rabbit eyes showing no
flap damage even at 1 week post-LASIK,
when an airgun was fired at the edge of
the flap.44 This can be attributed to the
endothelial pump and the multiple layers
of corneal epithelium that cover the flap
margin. In a few isolated reports of flap
damage, this occurred with 2 months of
the procedure.45,46 However, one study
reported flap dislocation 6 months post-
LASIK after focal trauma from a tree
branch.47 This suggests that flap disloca-
tion can occur at any time if the trauma is
discrete and from such an angle that it
catches the edge of the flap. Patient’s who
report with flap dislocation should be
referred urgently to the operating surgeon
Central involvement
Type IIA
Type IIB

for irrigation and refloating of the flap, fol-
lowed by a course of topical antibiotics
and corticosteroids, since DLK and epithe-
lial ingrowth are common after such an
occurrence.
Keratectasia
Keratectasia is a rare condition in which
surgically induced corneal thinning leads
to protrusion of the corneal tissue, an
increase in myopia and irregular astig-
matism, and consequently to a reduction
in visual performance.48 Some cases
require a corneal graft to achieve func-
tional vision. This is a severe complication
that may not present for a year or more
post-surgery (mean of 1 ± 0.3 years).49,50
Most cases of keratectasia can be attrib-
uted to miscalculation of the remaining
corneal thickness. The general consensus
is that keratectasia can be avoided by
ensuring that the residual stromal bed
after creation of the flap is at least 250μm
in thickness. Unless the thickness of the
stromal bed is measured intra-operatively,
it is not always possible to ensure that ade-
quate thickness remains because of the
limited accuracy of microkeratomes,
(standard deviation of ±30μm).
Iatrogenic ectasia is most commonly
associated with the treatment of high
myopia (>–15.00DS),24,49,51 since a
deeper ablation is required and residual
corneal thickness calculations become
much more critical. A recent study of
2873 eyes reported ectasia in 0.66%.52
The authors noted that ectasia did not
occur in those treated for less than
–8.00DS or those with a residual corneal
bed thickness of 325μm or more.52
Studies have suggested that there maybe
more to ectasia than simply inadequate
residual corneal thickness. The anterior
100–120μm of the corneal stroma is
known to have a more tightly interwov-
en anterior lamellae than the underlying
stroma,53 which makes this part of the
stroma stronger and more resistant to
swelling than the deeper layers.
Differences between individuals in their
stromal structure may mean some
corneas are innately susceptible to devel-
oping ectasia. Examination of the bio-
mechanics of the cornea after severance
of anterior lamellae during the creation
of the flap and the reshaping of the
underlying stroma suggests that the
whole cornea, including the posterior
surface, bows forwards as a result of sur-
gery.54,55 This movement, which has also
been implicated in the refractive regres-
sion seen post-LASIK, suggests that the
anterior lamellae play an important
structural role.
Post-operative follow-up of the refractive surgery patient
Retinal complications
The risk of retinal detachment increases
with increasing myopia above –3.00D, and
highly myopic eyes (greater than –10D)
also have an increased risk of primary open
angle glaucoma, pigment dispersion syn-
drome, cataracts and myopic maculopa-
thy.56–59 In theory, creation of the corneal
flap could lead to retinal complications,
such as retinal tears or rhegmatogenous
retinal detachment, particularly in sus-
ceptible individuals. A large study of almost
30,000 eyes reported vitreopathologic con-
ditions in only 0.06% of eyes post-LASIK.60
Since the average onset was 13.9 months
post-surgery, these cases might have been
unrelated to the surgery and simply the
result of myopic retinal degeneration. This
highlights the importance both of a thor-
ough retinal examination with scleral
indentation (to allow the identification and
treatment of retinal lesions prior to sur-
gery) and of the education of all patients
in the importance of regular eye examina-
tions post-surgery.
Laser subepithelial keratectomy
Immediately post-surgery
After laser subepithelial keratectomy
(LASEK), the epithelial flap should be
examined to ensure that it is as smooth
as possible. A bandage contact lens is
often fitted over the flap to hold it in place.
Plano silicon hydrogel lenses (e.g., Ciba
Night and Day or Bausch and Lomb
Purevision), or medium water content,
non-ionic lenses (e.g., Bausch and Lomb
Soflens 66) are popular options. All top-
ical medication instilled into an eye that
has a bandage lens should be preserva-
tive free (e.g., Minims chloramphenicol).
Bandage lenses are associated with an
increased risk of infection and infiltrates
and therefore eyes fitted with a lens
should be monitored carefully. Lens
removal on day three or four should be
accompanied by copious irrigation to pre-
vent damage to the fragile epithelium. If
flap damage occurs at any point during
the procedure and the epithelial layer
cannot be saved, the patient should be
managed as if he or she had undergone a
PRK procedure.
At 1 week
The epithelium should be examined to
ensure that it is intact, but by 1 week the
flap should have been replaced by new
epithelial cells that migrate from the lim-
bus. There is a rapid recovery of vision fol-
lowing LASEK – in one recent study of 222
eyes (range from –1D to –11D), 98% of the
eyes achieved 6/12 unaided vision at the
2 week examination.61
■ 39
At 1 month
LASEK produces less haze than does
PRK,62,63 and therefore there is little to see
at 1 month. The cornea should be checked
for fluorescein staining.
At 3 months
For the treatment of low and medium
myopia (<–6.50DS), differences in unaid-
ed vision and refractive outcome between
LASEK and PRK are insignificant by 3
months post-surgery.63
Refractive outcome
Of 222 eyes, 63% achieved 6/6 unaided
vision at 1 year.61 The procedure appears
to be safe, since no eyes showed a reduc-
tion in BCVA despite the wide range of pre-
operative myopia.
Complications common to all forms
of excimer laser surgery
Undercorrection
Residual myopia is usually the result of an
inaccurate pre-operative refraction or an
insufficient period free of contact lenses
prior to surgery. Enhancement can be
considered once the refraction has stabi-
lized.
Overcorrection
An initial hyperopic result is to be expect-
ed after PRK, but if hyperopia greater than
1.00D with minimal haze formation is still
present 6 weeks post-surgery, the patient
may be an ‘under-healer’64 and require a
hyperopic enhancement. Hyperopic treat-
ments are not as successful as myopic pro-
cedures, with a relatively high risk of
regression, irregularity and a long stabi-
lization period.
Regression
Regression is the loss of refractive effect over
time and is more common following larger
refractive corrections, particularly after
PRK. A degree of regression is expected dur-
ing the first 6 weeks post-PRK and the first
3 weeks post-LASIK, and is associated with
stromal remodelling, thickening of the
epithelium and corneal biomechanics.21,65
Severe regression associated with intense
haze is very rare now that PRK is limited
to the treatment of low myopia. The risk of
regression is much higher in all people
exposed to high levels of ultraviolet radia-
tion (natural sunlight and sun beds), and in
females who take oral contraceptives.66
Dry eye
Grittiness and asthenopia associated with dry
eye are relatively common during the first 6
months post-excimer laser surgery. A num-
ber of possible causes include damage to the
40 ■ Refractive surgery: a guide to assessment and management
conjunctival goblet cells by the lid speculum
and impaired corneal sensitivity.67–69
Preservative-free ocular lubricants through-
out the day (e.g., carmellose) and an oint-
ment at night (e.g., liquid paraffin) normally
suffice. Punctal plugs can be useful in more
severe cases and lid hygiene to maximize
meibomian gland function is useful.
Intraocular pressure elevation
If corticosteroids are used to treat the
intense haze of DLK, for example, a small
proportion of patients will demonstrate a
significant rise in intraocular pressure
(IOP). Steroid responders require immedi-
ate referral for cessation of topical corti-
costeroids and possible beta-blocker
treatment. When assessing IOP post-sur-
gery, clinicians should note that all
excimer laser techniques lead to an artifi-
cially low IOP reading,70 by about
2mmHg, which is related to the reduced
thickness of the central cornea.
Stromal infiltrates
Infiltrates, both sterile and infectious, can
occur in the presence of a bandage con-
tact lens (post-PRK or -LASEK) or interface
debris (post-LASIK). Sterile infiltrates are
also associated with the use of non-
steroidal anti-inflammatory eye drops.71
These must be assumed to be infectious
until proved otherwise and the patient
referred back to the surgeon for topical
antibiotics (infectious) or topical corticos-
teroids (sterile).
Corneal infections
Cases of infectious keratitis are rare, but
both fungal and bacterial infections have
been reported in the early post-operative
period.72,73 These can take the form of a
corneal ulcer with epithelial staining,
infiltrates and stromal oedema, or be con-
fined to the interface (LASIK). Rapid refer-
ral is necessary to identify the cultures
and for intensive treatment, but a pene-
trating keratoplasty may be the only solu-
tion. Excimer laser procedures have also
been known to reactivate the herpes sim-
plex virus, of which the classic dendritic
pattern should be a warning. Those at risk
should have been screened out prior to
surgery.74,75
Visual outcome
Unaided vision
PRK
For low and medium degrees of myopia
(<–6.00D), 88–99% achieve 6/12 or bet-
ter (uncorrected vision), and 58–78%
achieve 6/6 or better by 12 months post-
PRK.76–79
LASIK
For eyes treated for –9.50D or less, the per-
centage of eyes that achieve 6/6 or better
has been quoted as 83%, with 6/12 vision
or better achieved by 86–100% at 6
months post-LASIK.27,28,80
LASEK
For a range of myopia up to –11.25D, an
unaided vision of 6/4.5 was achieved by
19% of eyes, 6/6 by 63% of eyes and 6/7.5
by 18% of eyes.61
Visual complications
Poor unaided vision is a common reason
for dissatisfaction post-surgery,81 particu-
larly if the patient’s expectations are unre-
alistic. However, these cases can be
managed with an enhancement proce-
dure, spectacles or contact lenses to cor-
rect the residual error. Corneal refractive
surgery procedures are designed to mini-
mize refractive error, but in modifying the
shape of the cornea, they also tend to alter
the optical quality of the eye. In the major-
ity of post-surgery patients, these changes
are clinically insignificant, and result in no
apparent loss of visual performance. One
indicator of the safety of a refractive sur-
gery procedure is the percentage of eyes
that lose two or more lines of BCVA.
Recent studies on myopes being treated for
<–6.00D suggest that 0–1.8% of eyes lose
two or more lines of BCVA after PRK, com-
pared to 0–1.2% post-LASIK.27,80 Further
work is needed to determine the corre-
sponding percentage for LASEK, but ini-
tial studies suggest that the level of risk is
similar.61 For all excimer laser procedures,
the percentage of eyes that exhibit a reduc-
tion in visual acuity increases with the
degree of pre-operative myopia. An unac-
ceptably high percentage of patients
(7.3%) treated for hypermetropia
>+4.00D were found to lose two or more
lines of best-corrected acuity,82,83 and
therefore the majority of surgeons do not
consider medium and high hypermetropes
for corneal refractive procedures.
High-contrast acuity provides limited
insight into visual quality in the real world,
and a loss of high-contrast visual acuity
tends to indicate a significant loss of visu-
al quality. Of the many patients who exhib-
it normal levels of high-contrast BCVA
post-surgery, a proportion complain of
poor visual performance, particularly
under low illumination. Also, a minority
of patients have compromised vision and
yet are unaware of it because they rarely
find themselves in visually demanding
environments.
Reasons for patients refusing treatment
to their second eye include glare, haloes
and poor-quality night vision.84 A study
of 690 patients who had undergone PRK
reported that 92% of patients were satis-
fied with the surgical outcome, with the
degree of satisfaction closely related to the
post-operative uncorrected vision in the
better eye. Approximately 30% of patients
reported some problems with their night
vision.81 The Refractive Status and Vision
Profile (RSVP) questionnaire has estab-
lished itself as a useful tool with which to
assess patient views on visual outcome.
The overall RSVP score has been shown to
correlate with changes in patient satisfac-
tion.85
The reduction in visual performance
that can occur post-refractive surgery has
been attributed to an increase in forwards
scattered light within the eye and
increased aberrations (optical imperfec-
tions). Active keratocytes and disorganized
collagen fibrils within the post-operative
cornea act as scatter sources, scattering
light both forwards (towards the retina)
and backwards (towards the observer –
e.g., stromal haze). The stray light is super-
imposed over the retinal image, which
reduces its contrast. A reduction in the
contrast of a high-contrast image, such as
a Snellen letter, has limited impact on the
ability of the eye to discriminate it – the let-
ter will still be visible, just slightly fainter.
Reducing the contrast of a low-contrast
image is likely to result in the image con-
trast falling below the threshold for dis-
crimination, that is the detail of the object
will no longer be visible. Scattered light
can cause disability glare (image degrada-
tion) in all individuals in the presence of a
significant glare source, such as car head-
lights, but those who have raised levels of
intraocular light scatter suffer reduced
vision, even when there is no bright glare
source, because light is scattered from one
part of the retinal image to another.
To date, most refractive procedures
have concentrated on correcting spheri-
cal and cylindrical refractive errors, which
constitute approximately 97% of all aber-
rations. The eye naturally possesses high-
er order aberrations, which are known to
increase with age.86 Axial aberrations are
known to be the most problematic in
terms of visual performance, particular-
ly spherical aberration and coma. Both
are highly dependent on pupil size and, on
average, there is between a five- and
seven-fold increase in total aberrations as
the pupil dilates from 3 to 7mm.87,88 The
problem for most patients is not that tra-
ditional excimer laser procedures cannot
correct these aberrations, but that both
PRK and LASIK actually induce a signif-
icant and permanent increase in the aber-

rations.89–93 An increase in total aberra-
tions of between 25 and 300 times has
been reported for a 7mm pupil.87,88 Coma
is associated with decentration of the
ablation zone in relation to the pupil cen-
tre and increases with increasing pre-
operative refractive error. The degree to
which the aberrations of the eye increase
varies considerably between individuals.
Previous studies reported a high inci-
dence of night-vision problems (such as
haloes, starbursts and poor-quality night
vision) after laser surgery.94–96 These
problems were associated with high levels
of stromal haze, which caused stray light,
and with treatment zones significantly
smaller than the average pupil, which led
to extreme aberrations. Nowadays, haze is
less common and much less severe
because high myopes are no longer treat-
ed with PRK. LASIK and LASEK cause lit-
tle or no haze in the majority of cases and
ablation zone diameters for all techniques
have increased from around 4 or 5mm up
to 6 or 6.5mm, which makes them larger
than or the same size as the average pupil
under low illumination.
PRK
Forward light scatter is known to
increase during the first 2 weeks post-
PRK, peaking at 3 months and return-
ing to normal levels comparable to those
of spectacle wearers and soft contact lens
wearers by 12 months. 97,98 However,
evidence suggests that the distribution of
light scatter around the retinal image is
permanently modified by PRK, with an
increase in the spread of stray light lead-
ing to a reduction in retinal image con-
trast. 99 PRK has also been shown to
induce higher order aberrations.88–100
Since both forwards scatter and aberra-
tions cause a reduction in the retinal
image contrast, low-contrast acuity and
contrast sensitivity are affected for the
first 3 months,101,102 with permanent
changes in a minority of cases that
exhibit large aberrations or persistent
scatter.103 High-contrast acuity is only
affected in severe cases. Studies indicate
that visual performance under dilated
pupil conditions (low illumination) may
be compromised for a year or more, par-
ticularly for low-contrast acuity
tasks.104,105
LASIK
Forward light scatter does not appear to
increase significantly following LASIK,99
unless the patient suffers from DLK.
Higher-order aberrations are known to
increase following LASIK,87,106 and spher-
Post-operative follow-up of the refractive surgery patient
ical aberration is thought to be greater after
LASIK than after PRK, since the ablation
zone is often smaller87 and creation of the
flap leads to an increase in aberrations
independently of the ablation profile.
Limited study has been made of the effects
of LASIK on visual performance, but there
are suggestions that problems are less com-
mon and less severe than those that result
from PRK. Some studies suggest that con-
trast sensitivity for high and medium spa-
tial frequencies is reduced for the first 3
months,107–109 although some spatial fre-
quencies do not appear to fully recover
before 6 months.110 There is evidence that
mesopic contrast sensitivity is reduced once
photopic sensitivity has returned to nor-
mal.105 Contrast discrimination thresholds
are persistently raised for many LASIK sub-
jects compared to untreated subjects, but
the ‘real-world’ significance of such find-
ings is difficult to predict.111
LASEK
Since LASEK is a relatively new develop-
ment, its impact on scattered light, aber-
rations and visual performance has yet to
be considered. However, the procedure is
very similar to that of PRK and therefore
the outcome is likely to be similar to PRK
and LASIK. Less forward light scatter
would be expected than is seen after PRK
because of the limited stromal haze, but
aberrations are likely to be similar.
Managing patients with visual
symptoms
Patients with visual problems should be
questioned carefully about their symp-
toms. There is a tendency to gloss over
problems that do not significantly impact
on high-contrast acuity or cannot be
attributed to slit-lamp or topography find-
ings. It is essential that practitioners incor-
porate suitable tests into their assessment
to obtain a full picture of any visual prob-
lems and hence select the correct man-
agement strategy. The percentage of
patients who suffer from a significant
reduction in visual performance may be as
high as 10–15%,85,111 but this is likely to
reduce in the future as wavefront tech-
nology improves and becomes more read-
ily available. Although such technology is
unlikely to live up to the initial expecta-
tions that it would create ‘super’ vision in
a high proportion of patients, it should
reduce levels of induced aberrations and
provide some hope for those who already
suffer from high levels of surgically
induced aberrations.
■ 41
Modification of standard
assessment techniques
Vision and visual acuity
measurement
Most optometrists and ophthalmologists
rely on the Snellen chart, but the benefits
of a logMAR chart are considerable if the
data are to be analyzed and/or pub-
lished.112 Bailey–Lovie logMAR charts, for
example, use equal numbers of letters per
line and have equal increments of change
of letter size between the lines. Further
information can be obtained from patients,
where necessary, by employing high- and
low-contrast logMAR charts, as outlined
below.
Refraction
Autorefractors often give a poor measure
of refractive error post-corneal surgery,
as a result of the significant changes in
corneal profile.113 Retinoscopy can also
prove difficult because of irregularity of
the reflex, particularly during the early
post-operative period or when the ablation
zone is decentred or very small compared
to the pupil. A 3–4mm ‘pinhole’ can be
helpful in such circumstances. The
retinoscopy reflex can also detect some
cases of corneal ectasia should it develop
at a later stage (swirling reflex). Subjective
refraction is also complicated by both any
irregularity and the multifocal nature of
the post-operative cornea. The increase in
spherical aberration associated with treat-
ment for myopia alters the equivalent
defocus by 0.25D or more for large pupils
(≥6mm) in 27% of eyes. The advantage
for the patients is that they tend to see bet-
ter than would be expected for their
apparent refractive error, and the onset of
presbyopia may be delayed. The disad-
vantage is a reduction in the quality of
vision and a shift towards myopia with
pupil dilation. As with contact lens
patients, do not assume that visual symp-
toms are necessarily associated with the
surgery.
Assessment of corneal profile
Keratometers are poorly suited to refrac-
tive surgery work because of the small
area of the cornea from which the curva-
ture is calculated, which does not enable
sufficient information regarding the regu-
larity of the cornea to be gathered. The
strange shape of the post-operative cornea
also means that the keratometry readings
are inaccurate and useless for contact lens
fitting or intraocular lens calculations.
It is essential that clinicians involved in
the management of refractive surgery
have access to topographic equipment and
42 ■ Refractive surgery: a guide to assessment and management
are able to understand and assess the plots
produced. On occasions the topography
plot is influenced by artefacts such as the
lids or a disrupted tear film, so it is worth
viewing the Placido disc image prior to
processing the image (not relevant for
Orbscan). The choice of scale is critical,
since treatment for myopia produces a gen-
eralized flattening of the central cornea
and the absolute scale tends to obscure
useful detail because of the large intervals.
Although a normalized plot may not allow
comparison with other eyes, it generally
better reveals the ablation zone margin
and irregularities of the scale that affect
vision. A good post-PRK or -LASEK plot
(myopia) shows a large central flattened
area with smooth contours if an axial
algorithm is employed. Tangential maps of
the same eye reveal a smaller flat zone sur-
rounded by a steep ring. Post-LASIK
topographies tend to be less regular with
discontinuous contours and localized
areas of flattening. Often, a crescent-
shaped region that relates to the flap mar-
gin is visible. The corneal profile becomes
smoother as the epithelium is modified
post-surgery. Some systems can give an
estimate of the potential acuity based on
the irregularity of the cornea after com-
pensation for any residual sphere or regu-
lar astigmatism, but they do not consider
whole eye aberrations.
Particular topographical features that
may signal problems include central islands,
decentred ablations and irregularities. A
central island is defined as a 2–4mm area
with 1.5–3.5D of corneal steepening asso-
ciated with undercorrection, more common
after treatment with a broad-beam laser.114
They tend to subside over the first year.115
Decentrations of the ablation in the region
of 0.5mm are very common and tend to
cause a slight reduction in visual quality,
related to an increase in higher order aber-
rations (coma), but rarely a reduction in
high-contrast acuity. Larger decentrations
can cause monocular diplopia, irregular
astigmatism and a loss of BCVA. Such cases
require retreatment, ideally using a laser
with a topographic or wavefront link.
Decentrations may be symptom free if the
pupil itself is slightly decentred.
Slit-lamp examination
A detailed examination of the anterior seg-
ment, including the anterior chamber, is
essential on every follow-up visit. By vary-
ing the magnification and the illumination
technique employed, complications can be
identified quickly. Retroillumination is par-
ticularly useful in revealing complications
such as flap microstriae, interface debris
and ectasia.
Assessment of visual quality
High-contrast acuity alone is inadequate
to assess the visual outcome of refractive
surgery and patient satisfaction correlates
poorly with visual acuity.116 Any residual
refractive error must be corrected when
assessing visual quality, as optical defocus
attenuates high spatial frequencies. All
tests of contrast vision have their limita-
tions and it is difficult to compare the
results of different tests, since they employ
different stimuli, measurement techniques
and, often, different light levels. The full
contrast-sensitivity function can be deter-
mined by finding the contrast at which an
eye can detect a series of sine wave grat-
ings of different spatial frequencies.
However, this is very time consuming and
is generally reserved for the field of
research. The Contrast Acuity Assessment
(CAA) test is a computer-based psy-
chophysical test that measures contrast
acuity over the central ±5° field and is
able to determine whether visual per-
formance falls within the normal range
under both photopic and mesopic condi-
tions. Thresholds for those with an increase
in forward light scatter and aberrations are
elevated.117
In practice, one simple method is to
compare high- and low-contrast acuity
measurements, but it is important that
both letter charts are logMAR rather than
Snellen, to allow accurate scoring and to
overcome other drawbacks of the Snellen
chart, such as the non-geometric letter size
progression between lines and the varia-
tion in the number of letters per line.118
Normal subjects show a difference of
approximately one line of letters between
high- and low-contrast acuity (10% con-
trast), but those who suffer from an
increase in forward light scatter and/or
aberrations will have reduced low-contrast
acuity, which results in a larger difference
between the two. The Pelli–Robson chart
is easy to use and shows good repeatabili-
ty if each letter is scored individually.119
The chart examines mid spatial frequen-
cies close to the peak of the contrast-sen-
sitivity curve, which are known to be
affected by refractive surgery.110 Normal
scores vary with age,120 and are around
1.84 for those between 20 and 40 years,
reducing to around 1.68 for those over 60
years.
An assessment of performance under
dim illumination can provide additional
information, particularly in those who
complain of night-vision problems.
Measurements of pupil diameter should
ideally be made using an infrared pupil-
lometer that allows assessments at very
low light levels.
Glare testing is an indirect way to assess
intraocular light scatter. Like contrast-sen-
sitivity testing, glare tests vary consider-
ably and result in a wide range of
outcomes. In general, they are not partic-
ularly useful since the increased retinal
illumination that results from the glare
source tends to cause pupil constriction
and hence an improvement in visual per-
formance.121 The City University Light
Scatter Program is a computer-based psy-
chophysical technique that can measure
forward light scatter directly.122 However,
it is rather time consuming and therefore
maybe not currently suitable for clinical
use.
Specific visual symptoms
Poor-quality vision
If a patient is symptomatic under daylight
conditions, he or she is also very likely to
experience problems at night. Poor con-
trast vision under photopic conditions
when the pupil is relatively small can often
indicate poor central optical quality with-
in the pupil area. This may relate to an
increase in aberrations or an irregularity
caused by flap striae, epithelial ingrowth,
and so on. Examination of the topography
plot may help identify the problem,
although such irregularities are often too
subtle to detect. Rigid contact lenses may
improve visual quality and, in future,
wavefront technology may allow induced
irregular aberrations to be corrected. The
cornea should also be examined for haze,
although the quantity of forward light
scatter cannot be directly predicted from
backscatter.123
Poor-quality night vision
Night vision in the normal population is
relatively poor compared to vision under
good illumination. Firstly, the dark-adapt-
ed retina relies on the rod receptors,
which have poor resolution compared to
cone receptors and are more sensitive to
scattered light within the eye. Secondly,
pupil dilation is associated with an
increase in aberrations. The peripheral
cornea is known to scatter more light
than the central cornea, so pupil dilation
also increases the stray light within the
eye.124 Thirdly, the contrast of an object
against its background tends to be much
lower at night and so any reduction in
image contrast as a result of scatter or
aberrations is more likely to render the
object invisible. Visual difficulties at night
may also relate to the presence of intense
glare sources, such as car headlights,
which further reduce contrast. If the abla-
tion zone is larger than the pupil, but well

centred, visual problems are likely to be
related to aberrations (including irregu-
larities) and scattered light within the
ablated area. A rigid contact lens may
help, as it provides a smooth refracting
surface. Ideally, an enhancement proce-
dure is needed to correct induced aberra-
tions, but wavefront technology is still in
its infancy and the ability to correct aber-
rations is not as advanced as the ability to
measure them; the healing response of
the eye adds further unpredictability. A
decentred zone gives rise to visual prob-
lems that relate to coma and, if severe, the
patient may complain of monocular
diplopia or polyopia.
Haloes
Individuals with particularly large pupils
under low illumination may suffer from an
extreme version of positive spherical aber-
ration. Peripheral light rays pass through
the untreated cornea and superimpose an
unfocussed image over the clear retinal
image to give the appearance of haloes
around lights at night.94,125 Haloes are
more common in eyes that have under-
gone small-diameter ablations, and in
patients with naturally large pupils
(6.5–7.0mm in diameter). Ablation diam-
eters of 6.0mm or more have significant-
ly reduced halo problems in the majority
of patients, although Roberts and
Koester126 suggested the use of even larg-
er diameter ablations for ‘at risk’ groups
(i.e., young patients with large pupils,
those with deep anterior chambers and
patients in occupations for which glare is
of serious concern). Some laser software
quotes the complete zone size, including
the transition zone, rather than the optic
zone size. Those with significant haloes
may benefit from a further excimer treat-
ment to increase the ablation zone, which
has been shown to reduce symptoms in
seven out of ten cases without any signif-
icant change in refraction.127 Topical
miotic drops, such as 0.25% or 0.5% pilo-
carpine, can provide temporary relief,
although pilocarpine can cause headaches
and blurred vision.128 Carbachol is an
alternative that has fewer side effects.
Patients can be comforted by the fact that
the pupil diameter does decrease with age.
Table 5.4 Selection of BOZR for first trial lens post-refractive surgery
Source of curvature information
Pre-operative K readings
(or from second untreated eye)
Post-operative K readings
Post-operative follow-up of the refractive surgery patient
Starburst effects
Starburst effects are related to forward
light scatter and high cellular activity post-
PRK. They tend to subside over time as
haze resolves. Many patients confuse star-
burst effects, haloes, glare and even pho-
tophobia. In such cases more details may
need to be obtained through subjective
questioning, as well as testing methods.
Contact lens fitting post-refractive
surgery
In some cases, the only solution to visual
problems may be to fit the patient with
contact lenses. However, it should be real-
ized by the contact lens clinician that
many patients opt for refractive surgery
because of the inconvenience perceived
with contact lens wear. It is, therefore,
advisable that negative commentary by
the contact lens clinician be avoided. Soft
contact lenses are suitable for those with
a simple under- or overcorrection associ-
ated with a regular cornea and, as long as
an ultrathin lens is chosen, there is no
need to use a specialist lens designed for
oblate corneas.129 Aspheric soft lenses
designed to minimize aberrations (e.g.,
Ultravision) can reduce symptoms in those
with severe night-vision complaints and
may provide a reasonable alternative to
miotics. Soft lenses should not be fitted
after radial keratotomy (RK) because of the
high risk that neovascularization will be
induced along the radial incisions.
Some post-surgery patients require a
contact lens to correct surgically induced
irregularities. In such cases a rigid lens
provides a smooth refracting surface, but
fitting is complicated by the change in
corneal profile from prolate to oblate,
which necessitates a reverse geometry lens
or, at least, a back surface aspheric.
Materials should be of mid-to-high Dk, but
the most important factor is good materi-
al stability. Trial lenses are essential to
determine lens power, back optic zone
radius (BOZR; Table 5.4) and back optic
zone diameter (BOZD).
When fitting a back surface aspheric
lens, the lens should be centrally posi-
tioned with a degree of clearance over the
flattened ablation zone, a 1–2mm ring of
light touch in the mid-periphery and an
First BOZR selected
0.1 to 0.2mm flatter than flattest K
0.2 to 0.3mm steeper than flattest K
■ 43
edge lift of approximately 0.3–0.6mm. The
central clearance results in a positive tear
lens that necessitates compensation of the
lens power. Reverse geometry lenses have
a second curve that is steeper than the
BOZR by 0.6–1.2mm, to achieve mid-
peripheral alignment without excessive
central pooling. Topography can be used
to improve fitting success, but careful
selection of the most informative plot is
essential.
Binocular vision problems
In a few susceptible individuals, surgical
reduction of the refractive error can affect
their binocular status. Spectacles for
myopia may effectively control an
exophoric deviation and, likewise, hyper-
metropic corrections can control esodevi-
ations. Changes in the accommodative
convergence:accommodation (AC:A) ratio
are adapted to easily by the majority of
patients, but a careful pre-operative assess-
ment is essential to identify those who
might suffer from binocular vision prob-
lems post-surgery; a prismatic correction
is difficult to incorporate in an effectively
emmetropic correction.
Non-tolerance of monovision
A number of patients opt for monovision
to delay their need for reading glasses once
they reach presbyopia. In general, mono-
vision is well tolerated, and only about 4%
of patients require an enhancement pro-
cedure to correct both eyes for distance in
cases of non-tolerance.130 The majority of
monovision patients achieve good binoc-
ular visual acuity and adapt quickly.
Binocular summation and a degree of
stereopsis (40–800 seconds of arc) remain
as long as the difference between the two
eyes is no more than about 1.50D.131
Non-tolerant patients may complain of
disorientation and blurred distance vision.
Those who suffer from motion sickness are
less likely to adapt to monovision, but this
should be revealed by the pre-operative
monovision contact lens trial. Non-toler-
ance is more common if the dominant eye
has been corrected for near vision rather
than for distance, although many individ-
uals can tolerate this situation given
time.132 Some patients report haloes
around lights at night as the brain
attempts to fuse the blurred retinal image
in the near eye with the clear image in the
eye corrected for distance. Patients must
be made aware that the advantages of a
monovision correction reduce as accom-
modative power reduces with age,
although a +1.50D addition should allow
functional vision for most basic day-to-day
tasks. Around 20% of patients benefit
44 ■ Refractive surgery: a guide to assessment and management
from a balancing spectacle overcorrection
for detailed tasks such as driving at night
or computer use.
Long-term implications of
refractive surgery
It is not uncommon to hear concerns
voiced about the possible long-term impli-
cations of PRK and LASIK, since routine
excimer laser surgery has only been avail-
able for around 15 years. However, it
should be stressed that eye care clinicians
who continue to inform their patients that
excimer laser surgery is still experimental
or in its infancy are not only misinformed,
but also passing on poor advice to their
patients. Commonly raised concerns about
long-term implications are outlined below.
Endothelial damage
The corneal endothelium does not appear
to be affected adversely, with no significant
alteration in central cell density,133
although an increase in the coefficient of
variation of cell area and a decrease in the
percentage of hexagonal cells was report-
ed in one study.134
Cancer risk
Examination of unscheduled DNA syn-
thesis, a measure of the tissue repair
mechanism, revealed no difference
between the effects of an excimer laser and
a diamond knife.135 Extensive animal
studies have failed to establish a link
between epithelial or connective tissue
neoplasms and excimer laser exposure.
Risk of cataract
Short-term changes in the aqueous
humour and prolonged biochemical
changes in rabbit crystalline lenses in the
form of free radicals have been detected
after photoablation. These changes are
thought to be the earliest signs of catarac-
togenic changes.136 However, no signifi-
cant elevation of malondialdehyde (MDA)
levels, a possible indicator of oxidative
effects, has been found after PRK on rab-
bits,137 and to date there has been no
increase in the incidence of cataract.
Clinical implications of refractive
surgery
The increase in aberrations as a result of sur-
gery can make refraction rather difficult to
perform, particularly if the patient has large
pupils. A large 3–4mm pinhole can prove
useful during retinoscopy. When the aber-
rations are large, it is difficult to find a defi-
nite end point for the subjective refraction.
The change in corneal thickness after
corneal refractive surgery has implications
for the measurement of IOP. A thinner
cornea causes underestimation of the IOP,
since the resistance of the cornea to inden-
tation is altered. The average surgical
refractive correction reduces the central
corneal thickness (CCT) by 10–15% (20%
in a few high myopes), which leads to a
1–2mmHg decrease in measured pressure.
Examination of a wide range of studies led
Doughty to conclude that 2mmHg should
be added to IOP measurements for each
10% reduction in CCT.70
Modification of the corneal profile also
has implications for the calculation of a
suitable intraocular lens power if the
patient should undergo cataract surgery in
the future. Ideally, surgical records should
include a note of the patient’s pre-opera-
tive keratometry readings, since post-oper-
ative keratometry readings misrepresent
the power of the cornea,138 with the pos-
sibility of a significant refractive error post-
cataract surgery.
Radial keratotomy
Clinicians are unlikely to encounter new
patients who have undergone RK, as the
technique is now obsolete. However, prob-
lems can develop many years after inci-
sional surgery and clinicians should be
aware of the these and how to manage
them.
Refractive stability
The long-term stability of the refractive
result has been questioned following the
detection of a drift towards hyperopia in
up to one-third of patients after 4 years.139
The 10 year follow-up of the Prospective
Evaluation of Radial Keratotomy (PERK)
study revealed an alarming 43% of eyes
with a hyperopic shift greater than 1.00D
from the refractive result at 6 months post-
RK.139,140 In theory, patients who exhib-
it a hyperopic shift could be referred to a
surgeon for hyperopic excimer laser treat-
ment – both PRK and LASIK procedures
have been undertaken successfully after
unsuccessful RK.141 However, hyperopic
refractive errors, unless large, are usually
tolerated well by younger patients and,
since hyperopic treatments are less pre-
dictable than myopic corrections, a retreat-
ment is probably best avoided. Exposure to
high-altitude conditions has also been
shown to cause a significant hyperopic
shift (up to +1.50 ± 1.01D by day three)
in those who have undergone RK, but the
effect is reversible13
A relatively common complication of RK
is a diurnal fluctuation in refractive error
and hence visual acuity, associated with a
structurally weakened cornea.142–145 The
PERK study encountered an increase in
myopia greater than –0.50D in 30% of
eyes116 A study of firefighter applicants
who had undergone RK found a myopic
shift between morning and afternoon of
–0.41 ± 0.33D compared to +0.06 ±
0.42D in the control group. The refractive
change caused three out of 10 subjects to
fail the unaided vision standard in the
afternoon, despite passing in the morn-
ing.146 Unfortunately, patients who suffer
from a significant diurnal variation have
few options. Spectacles can be provided to
correct the refractive error at its most
myopic, but this is generally a poor com-
promise. Patients who cannot tolerate the
fluctuations in vision have few options
other than a corneal graft.
Ocular integrity
Corneal perforation is a serious, but very
rare, complication of RK.147 The conti-
nuity of collagen fibrils is not restored
after RK, and so the tensile strength of
the cornea is reduced. A reduction in
ocular integrity is not surprising, con-
sidering that micro-perforations of the
cornea have been shown to occur in
about 18% of eyes at the time of surgery;
these induce significant alterations in the
blood–aqueous barrier for the first week
post-RK.1 The formation of an epithelial
plug in an otherwise fully healed RK inci-
sion concentrates stress at the incision
site, which may predispose the cornea to
rupture. The variability in strength meas-
urements between post-RK corneas indi-
cates that the increase in rupture
susceptibility is hard to predict, since it is
dependent on the size of any epithelial
plug and the strength of the wound col-
lagen.148 One study reported three cases
of corneal rupture more than 10 years
after RK; these resulted from an assault,
a sports injury and ‘daily living’.149
Another study considered 28 eyes that
had ruptured some years after RK and
attributed seven cases to an assault, four
to sports injuries, five to car crashes and
12 to ‘daily living’.150 Wound leakage
that resulted from blunt trauma has been
reported 8 years after RK,151 and incision
rupture has occurred during routine
cataract surgery more than 11 years after
RK.152 Following suturing of the wound,
BCVA can return to normal levels, but a
corneal graft may be the only answer for
some patients. Clinicians are unlikely to
encounter such unfortunate individuals

at the acute stage, but might see them
some time after the incident if they expe-
rience problems associated with an irreg-
ular cornea.
Corneal infection that involves the inci-
sions has been reported many years after
surgery. Such patients are likely to be in
some discomfort and are more likely to
present to casualty. Clinicians should look
out for infiltrates, oedema and fluorescein
staining (rather than pooling) of incisions.
The need for routine yearly or two-yearly
eye examinations should be stressed to
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146–149.

Case reports
Sunil Shah, Stephen J Doyle and Paul Cherry
In this chapter we look at various inter-
esting and complicated patient outcomes
from refractive surgery. We begin, howev-
er, with a brief guide to the video clips on
the CD that accompanies this book.
Videos on CD
Video 1 – Orbscan
Video 1 (courtesy of Bausch and Lomb)
shows the two scanning slits of the
Orbscan anterior segment analysis unit in
operation. In real time each scan takes 0.7
seconds. The scans are also combined with
Placido information.
Video 2 – Superior flap
Video 2 (courtesy of Bausch and Lomb)
shows the Bausch and Lomb Hansatome
microkeratome cutting a corneal flap in a
laser in-situ keratomileusis (LASIK) proce-
dure. This is a two-piece microkeratome and
the cutting device can be seen being placed
onto the base plate. Note that the flap is
hinged superiorly (seen from the surgeon’s
6
persepctive), which some surgeons argue is
better for the healing of the cornea,
although others suggest that a nasal hinge
leads to less corneal nerve disturbance.
Video 3 – Amadeus
Video 3 (courtesy of AMO) shows the
Amadeus one-piece microkeratome by
Advanced Medical Optics (AMO). Note
that the corneal flap is hinged nasally and
that the flap thickness in this particular
case is slightly thicker than that in Video 2.
Video 4 – Laser subepithelial
keratectomy
Video 4 starts with the alcohol well in place
filled with a low percentage ethanol solution.
This is absorbed with a Merocel surgical
spear. The cornea is washed and dried and
the surgeon (Sunil Shah) then breaks the
epithelium. The epithelium is moved away
from the central area and the excimer laser
beam is applied to Bowman’s membrane to
create the new corneal profile, in accordance
with the refractive error. The epithelium is
replaced. Note that the epithelium does not
lift in one thick slice, but rather a thin sheet
is kept intact and removed and subsequent-
ly repositioned. The thickness of the epithe-
lium is around 50μm, as opposed to a LASIK
flap of around 160μm.
Video 5 – WAVE CL system
Video 5 (courtesy of Northern Lenses)
shows the Keratron SCOUT topography
unit, from Carlton Ophthalmic. This
portable device can be handheld, table
mounted or slit-lamp mounted. The sys-
tem is based on a Placido cone and able to
use its radius of curvature data from the
anterior cornea to design a gas permeable
contact lens for that particular cornea. The
data are used by Northern Lenses in their
WAVE system contact lenses. This system
is particularly useful when a corneal lens
is required for an irregular corneal profile.
Flap transaction
• Corneal consultant, Sunil Shah;
• Urgent patient referral to hospital
corneal consultant;
• 0/–1.5 refraction in affected eye, –2D
in other eye;
• Age 55 years, male.
The patient had planned to have surgery
on the left eye (LE) only, but on the day of
surgery (when he saw the surgeon at the
50 ■ Refractive surgery: a guide to assessment and management
high-street clinic for the first time), he was
persuaded to have surgery on the right eye
(RE) also. What persuaded the patient to
have surgery in the RE also is unclear, as
he stated that he could read reasonably
well with the RE and his personal thinking
previously had been that he could always
have the RE treated at a later date.
The Hansatome was apparently normal
(nothing unusual with the K-readings,
corneal topography or corneal examina-
tion), as no abnormality was noted by the
surgeon or scrub nurse. The pressure read-
ings were good. The LE was not treated.
When the microkeratome was removed
and the flap lifted, there was a horizontal
transaction of the flap (superior hinge
with half of the flap attached), a 9 o’clock
to 3 o’clock cut through the flap, with that
portion being a free flap.
Figure 6.1
Superior portion of flap in situ, with an
epithelial and stromal deficit inferiorly
Figure 6.2
Patient in Figure 6.1 at 3 month review: stable, no haze, BCVA back to 6/5
The inferior free-flap portion could not
be found on the eye or on the microker-
atome. Examination of the blade was
unremarkable. No abnormality could be
found in the microkeratome set up.
The patient was seen urgently by the
ophthalmological consultant at the hospital
that evening. Obviously extremely anxious,
he had been speaking to his solicitor in the
car while being transferred from the clinic.
Examination confirmed the superior por-
tion of the flap in situ, with an epithelial and
stromal deficit inferiorly (Figure 6.1). Options
were discussed with patient and conserva-
tive management suggested for the time
being. He was started on guttae hyaluronic
acid 0.18% hourly, ocular liquid paraffin six
times daily, and both chloramphenicol and
dexamethasone four times daily.
The patient was reviewed at 1 day, 1
week, 1 month and 3 months post-incident:
• 1 day review: no significant change,
with little epithelial healing.
• 1 week review: full epithelial healing,
and the epithelium looked quite
healthy. There was a clear stromal
deficit. Retinoscopy confirmed a mild
myopic astigmatism in the superior
portion and high hyperopia in the
lower portion.
• 1 month review: epithelium had filled
in the stromal deficit completely, with
refraction now stable across whole
cornea at pre-surgery levels.
• 3 month review: stable, no haze and
best-corrected visual acuity (BCVA)
back to 6/5 (Figure 6.2).
Epithelial remodelling
following laser subepithelial
keratectomy that caused an
increase in prescription
A patient persuaded the surgeon (Sunil
Shah) to perform laser subepithelial kera-
tectomy (LASEK) on her. She was very
eager to have surgery as a number of her
family members had previously undergone
successful refractive surgery by the same
surgeon. Initially, surgery was refused as
the prescription was very mild (0/–1.5D ×
115 and 0/–1.5D × 80) with an unaided
visual acuity (VA) of 6/12 in each eye,
improving to 6/9 binocularly unaided.
The prospective patient was adamant
that she wanted refractive surgery and
clearly stated that she was aware that she
may gain little benefit from laser refractive
surgery, but she wanted to take the
chance. She was particularly aware that
there was very little risk from LASEK for
this sort of prescription and agreed that
LASIK was an unnecessary risk in her
case.
Surgery was uneventful using the but-
terfly LASEK technique. Recovery was
unremarkable in that the epithelial heal-
ing occurred within 3 days. A review
appointment was given for 1 week. She
telephoned a few days later and said she
felt that her uncorrected visual acuity
(UCVA) was worse than it had been before
surgery and she had returned to wearing
her glasses.
At the 2 week review, her refraction was
–1/–1 × 90 and –0.75/–1.25 × 65. This
refraction was maintained over the next 3
months (subjective and objective), which
was presumed to result from epithelial
hyperplasia, and it played a significant role
as the original prescription was so small.
Bilateral flap infection
masquerading as diffuse
lamellar keratitis
The patient underwent routine uncompli-
cated LASIK in a full ophthalmic operat-
ing theatre (not just a clean laser room).
The surgery (Sunil Shah) was uncompli-
cated, in the middle of a laser list and all
the other patients were uncomplicated.
Review at 1 day was unremarkable, with
UCVA 6/9 in each eye.
An urgent review was carried out at 4
days, as the patient was worried. UCVA was
6/60 RE and 6/24 LE. The appearance was
of grade 1 diffuse lamellar keratitis (DLK)
with some small focal opacities in the RE
only. The patient was asked to continue top-
ical chloramphenicol four times daily, and

to increase the prednisolone acetate 1%
from four times a day to hourly in each eye.
On review 1 day later (at 5 days), the
DLK had substantially resolved, but one
focal abnormality in the RE was
unchanged and the LE had multiple tiny
focal abnormalities that appeared to be set-
tling. UCVA had not improved and the
treatment was continued. The eyes
remained white throughout.
On review 2 days later (at 7 days), the
UCVA was unchanged. The RE focal abnor-
mality was larger in size and had slightly
fluffy edges, the LE focal abnormalities
were unchanged and there was no further
evidence of DLK. A diagnosis of bilateral
flap infection was made. Treatment was
changed to prednisolone acetate 1% four
times daily, chloramphenicol once an hour
and ofloxacin once an hour.
On review 1 day later (at 8 days), there was
no deterioration, but no improvement, in the
LE; in the RE, the size was unchanged, but
there were satellite lesions around the origi-
nal lesion. A decision was made to collect
samples from the RE with a flap washout and
a corneal scrape. The LE was felt safe to leave.
The RE flap was lifted and a corneal scrape
performed. The opacity was not impressive in
terms of infection: it felt like a string of mucus.
There was no corneal melt around the opac-
ity. A washout was then performed.
Urgent microscopy revealed a staphy-
lococcus as the probable organism. The
treatment was felt to be adequate and
therefore continued. Culture of the organ-
ism confirmed Staphylococcus aureus, sen-
sitive to both chloramphenicol and
ofloxacin. It is worth noting that a typical
DLK is probably an infection and an indi-
cation for an early flap lift.
Slow resolution followed and left some
minor stromal scarring.
Refraction improved from –1.5/–2 × 90
RE and –1.25/–0.5 × 110 at 2 weeks to
0.75/–0.5 × 90 and –0.75/–0.25 × 100 at
3 months. BCVA was initially 6/20 in the RE,
which improved to 6/7.5 at 3 months, but
it remained at 6/5 in the LE throughout.
Flap melt after treatment for
epithelial ingrowth
The patient was referred from a ‘high-
street clinic’ to local corneal consultant
(Sunil Shah). Apparently an uncompli-
cated LASIK originally, but recurrent
epithelial ingrowth had been treated twice
already. Further recurrence occurred with
poor BCVA.
Examination revealed 30% epithelial
ingrowth that encroached on the visual
axis. Pre-operative refraction was –3DS,
Corneal anatomy, physiology and response to wounding
and the refraction on presentation to the
corneal consultant was +3/–2 × 85. The
other eye was UCVA 6/5, but for the
ingrowth eye BCVA was 6/15.
At surgery, the flap was lifted very eas-
ily. A notch in the flap found in an area of
ingrowth was assumed to be the cause of
the ingrowth.
Flap and base were cleaned and treat-
ed gently with absolute ethanol and then
copious irrigation. It was decided not to
suture the flap at this stage as, despite the
notch, the flap was sitting nicely and the
extent of the original treatment was
unclear because the original treating doc-
tor was no longer in the country and
records were sketchy.
Recovery was unremarkable. UCVA
improved to 6/12 and BCVA to 6/6, with
+0.75/+0.75 × 180.
Over the next 6 months, the peripheral
flap melted in an area of previous epithe-
lial ingrowth. The central flap was not
affected visibly, but the subjective cylinder
increased to 1.75D and the BCVA dropped
to 6/9. The flap melt remained stable.
Therefore, a rigid contact lens was tried,
which improved the BCVA to 6/5–. A cus-
tom-fit contact lens was ordered, based on
the topography, which gave an excellent fit
and visual outcome.
LASEK in one eye with LASIK
in the other eye because of
unilateral von Hippel–Lindau
lesion
This case is an example of both LASEK and
LASIK used to give the same end result for
each eye. The patient’s RE had a unilater-
al von Hippel–Lindau lesion (i.e., an
angiomatous lesion), which was at risk of
bleeding and had been treated with laser
previously by a medical retina surgeon in
an attempt to stabilize it.
The patient was –5D in each eye, and
the risks and benefits were discussed
with the surgeon (Sunil Shah). LASIK
was too risky in the RE as increased
intraocular pressure from the suction
ring may cause the angiomatous lesion
to bleed. The recommendation was to
have LASEK in the RE and LASIK in the
LE simultaneously.
The surgery was uncomplicated:
• 1 day post-operatively, UCVA 6/12 and
6/5.
• 1 week post-operatively, UCVA 6/6 and
6/5, refraction +0.5DS RE, 0 LE.
• 1 month post-operatively, UCVA 6/5
and 6/5, refraction plano both eyes.
The patient’s comments were that 3 days
of discomfort were well worth it, there
■ 51
was no significant pain and with visual
recovery within 1 week she had no par-
ticular problem.
When asked whether she preferred
LASIK or LASEK, she said she was petri-
fied by the cut of LASIK and so, if she had
to do it again, she would probably consid-
er bilateral LASEK.
Keratectasia case
The patient was a 24-year-old male:
• RE: –6.25/–2.25 × 15, best-corrected
spectacle visual acuity (BCSVA) 6/7.5;
• LE: –12.25/–2.0 × 15, BCSVA 6/10;
• Pupils were 6mm diameter;
• Pachymetry: RE 540 and LE 508.
LE LASIK was undertaken by the surgeon
(Doyle) with the aim of only –3.25
because of the depth problems (the patient
was happy with this outcome as then he
could wear normal best-form glasses even
if the RE was not good enough unaided).
The optical zone (OZ) was 5.5mm and the
treatment zone (TZ) was 7mm plus an
elliptical cylinder to save depth (Nidek EC
5000). The flap was 130μm (Moria ‘one’).
The predicted ablation depth was 130μm
and the predicted bed was 248μm. Intra-
operative pachymetry was not carried out
in this case, in either eye.
After 2 weeks RE LASIK was under-
taken, with 6mm OZ, 7.25mm TZ and a
predicted ablation depth of 131μm (Nidek
EC 5000). The flap was 160μm (Moria
‘one’), with a predicted bed of 249μm.
Post-operative pachymetry at 1 month
was 400μm in both eyes, at 6 months it
was RE 375μm and LE 400μm and at 1
year it was RE 385μm and LE 412μm.
Refraction at 2 months post-operative-
ly was:
• RE +1/–1 × 180 (VA 6/12 unaided
and 6/7.5 with glasses);
• LE –2/–1.5 × 30 (VA 6/15 unaided
and 6/10 with glasses).
At 30 weeks refraction was:
• RE –1/–0.75 × 140 (VA 6/12 unaided
and 6/7.5 with glasses);
• LE –3/–0.75 × 15 (VA 6/60 unaided
and 6/10 with glasses).
He developed keratectasia in the RE, and
serial topography showed that it started over
the area of an old small scar. This scar was
caused by a thorn when a child (thickness
over this area post-operatively was about
475μm). Whether the scar was a relevant
factor in this case is not known. What made
the surgeon discount this initially was that
surgeons carry out LASIK after penetrating
keratoplasty, with a full-thickness 360° scar
and the patients appear to have no prob-
lems. The initial topography was entirely
52 ■ Refractive surgery: a guide to assessment and management
regular and the patient had worn glasses
from the age of 4 years.
It appears that the depth of the ablation
and/or the flap was more than expected in
the RE. The surgeon would have expected
a greater likelihood of such a problem in
the LE because of the initial thinness.
The patient was referred to the local
University contact lens clinic for a gas per-
meable contact lens fitting, which was
accomplished with great skill, although
not without difficulty.
Late flap lift post-LASIK
The patient was first examined by the sur-
geon (Cherry) on 29 April 1997. He was
a high myope who successfully wore dis-
posable soft contact lenses that had last
been used 2 weeks prior to the examina-
tion. Presenting glasses prescription was
RE –9.00, LE –8.00. Cycloplegic refraction
was RE –8.50, –0.50 × 180, 6/7–, and LE
–8.00, 6/6–. Keratometry was recorded as
RE 43.87, 44.12 × 86, and LE 43.62,
44.00 × 98. He elected for a monovision
LASIK treatment because he was a current
successful wearer of monovision contact
lenses. His LE was dominant.
Treatment day was scheduled for 16
May 1997 at The Toronto Laser Sight
Centre. EyeSys topography was performed
prior to the procedure and showed no
abnormalities. Central pachymetry was RE
584, LE 580. Bilateral, simultaneous
LASIK was undertaken, using the VISX
20/20 excimer laser (software version
4.02c) and the ACS keratome, which pro-
duced 8.5mm flaps with nasal hinges. Two
treatments were undertaken in each eye,
in accordance with multi-zone technolo-
gy. Details were as follows (corneal plane):
• RE –2.31, –0.52 × 180, zone size an
ellipse 6.00mm × 5.4mm, ablation
36μm;
• RE –3.00, zone size of 6.00mm, abla-
tion 45μm;
• LE –3.43, zone size of 6.00mm, abla-
tion 52μm;
• LE –3.50, zone size of 6.00mm, abla-
tion 53μm;
• The flaps were 160μm in thickness, so
stromal beds of 343μm in the RE and
315μm in the LE remained.
Follow-up was uneventful. However, on 22
September 1997, the patient expressed
some dissatisfaction in that the reading
distance was too close with his RE. At that
time, manifest refraction was RE –3.75,
6/7– and LE plano, 6/7–. He elected to
have his RE retreated, which was accom-
plished by relifting the flap on 3 October
1997 at The Toronto Laser Sight Centre.
Topography prior to retreatment showed
central treatments with no complications.
Pre-enhancement pachymetry was RE
541μm, somewhat thicker than the pre-
dicted thickness of 343 + 160 = 503μm.
The laser used was the Chiron Keracor
116. Treatment for the RE, was –1.58,
zone size of 6.00mm and ablation 27μm
to leave a theoretical stromal bed of
316μm in the RE.
He was extremely happy after the re-
treatment, and did not quite complete his
scheduled follow-up visits, having last
attended for follow-up on 17 January
1998, when the uncorrected distance
vision was RE 6/60, LE 6/9+. Manifest
refraction was RE –1.50, –0.50 × 180,
and he was delighted with the reading dis-
tance that this remaining myopia pro-
duced.
His opinion about monovision slowly
changed, however. When he finally came
back for a further examination on 27
November 2001, he was still happy with
both his reading and distance vision, but
was considering having the RE enhanced
for distance in Arizona, where he was
planning to go to escape the Canadian
winter! At that time, cycloplegic refraction
was LE +1.50, –0.50 × 90, 6/7 but, despite
this overcorrection, he had no problems
with distance vision.
He returned for re-examination on 28
November 2002, having not had any sur-
gery in Arizona. Uncorrected distance
vision was LE 6/12–. He was still happy
with both his distance and reading vision,
but now expressed a definite wish to rid
himself of monovision and, further, to
have the procedure done in Toronto.
Keratometry was RE 39.37, 39.25 × 98.
Cycloplegic refraction was RE –1.50, 6/7–.
RE enhancement was performed at the
Sacor On-Site Laser, Toronto, on 3
January 2003, 5 years and 3 months after
the previous enhancement. Pre-operative
topography again showed no abnormali-
ties. Pachymetry was RE 528μm com-
pared with the theoretical corneal
thickness of 316 + 160 = 476μm. The
right scotopic pupil measured 5.5mm.
The flap was lifted at the operating micro-
scope using a Sinskey hook. The correct
site of the flap edge in the temporal,
peripheral cornea was first identified by
gentle pressure on the cornea. Flap lifting
was completed with a blunt spatula. It
was noted that the flap lifted very easily;
it certainly did not give the impression
that it had last been lifted 5 years and 3
months previously. The excimer laser used
to do the treatment was the Laser Sight
LSX with an Accutrack eye tracker. The
treatment at the corneal plane was RE
–1.47, zone size of 6.00mm with a 1mm
blend zone outside the optical zone, abla-
tion of 24μm to leave a theoretical stro-
mal bed of RE 316 – 24 = 292μm. A
bandage soft contact lens did not have to
be used post-operatively because the flap
junction had not been disrupted unduly.
The initial result of this second RE
enhancement on 10 January 2003 was
uncorrected RE vision of 6/7– with a
plano refraction. There was a small, hori-
zontal microstria just below the pupil mar-
gin at slit-lamp examination; this was
asymptomatic. The patient is currently lost
to follow-up because he has escaped the
Canadian winter again!
 7
Co-management issues
Shehzad A Naroo, Baldev K Ubhi and W Neil Charman
Introduction
It is clear that the development of refractive
surgery offers both a challenge and an
opportunity to ophthalmic practice. Many
patients, having been examined by an
optometrist, express an interest in the pos-
sibilities of refractive surgery and require
advice on what it involves and its likely suc-
cess rate. Such patients, if they opt for sur-
gery, represent lost short-term dispensing
revenue. Thus, maybe optometrists should
explore possible formal links with their local
refractive surgery centres, so that not only
are they better informed of the facilities
these offer, but also some integration of the
examination and advice offered in the prac-
tice can occur with the work of the centre.
It may be sensible to make available to
patients in the practice written information
on the pros and cons of refractive surgery.
A second, growing and possibly more
significant class of patients are those who
arrive at the practice and already have had
refractive surgery at some earlier date. It is
important that the optometrist be alert to
this possibility, since it may, for example,
affect the results of tonometry and be the
cause of dry eye and other problems (as
detailed in Chapter 5). Even though many
of these patients may consider that their
surgery was successful, they may still need
a spectacle or other form of correction, for
example to raise their acuity to the stan-
dard required for driving, or to correct
presbyopia. There is little information on
the long-term enthusiasm of patients for
‘enhancement’ procedures to correct the
slow drifts in refraction that occur through-
out adult life in all eyes,1 but it seems unlike-
ly that the majority of patients will wish to
(or be able to) rely exclusively on their sur-
gical correction. Many may be resentful
that having “thrown away their glasses and
contact lenses”, they now need an addi-
tional optical aid. It is, then, important that
the optometrist be able not only to recog-
nize the possible symptoms of post-surgical
patients, but also to respond sympatheti-
cally to any psychological difficulties that
they may be experiencing. Undoubtedly, as
the first generation of refractive surgery
patients age, new problems may emerge,
and probably the primary care optometrist
is best placed to detect these and alert the
general ophthalmic community.
Patients who discuss their desire to
undergo refractive surgery procedures with
their own optometrist often report com-
ments from their optometrist such as “laser
surgery is still experimental” or “the results
are not stable”. This often leads to patients
losing faith in their optometrist and possi-
bly seeking primary eye care from another
optometrist for themselves and, perhaps,
for their family. Usually, the optometrists
who dismiss refractive surgery with such
blasé comments are those who are ill-
informed about current techniques. At the
very least, optometrists should be aware of
the type of surgery that is available in their
local vicinity and should inform themselves
of the results being achieved, especially
now that refractive surgery has established
a firm foothold as an alternative to optical
aids. Those optometrists with more of an
interest might want to consider a ‘shared-
care’ scheme with a local refractive surgeon
or refractive surgery centre, although it
would be wise first to establish with whom
the responsibility for the patient ultimate-
ly lies. In this type of scheme the role of the
optometrist could also involve counselling
the potential patient, although ultimately
the treating surgeon will decide on the
patient’s suitability for surgery.
As newer techniques and instruments
are developed and complication rates are
minimized, refractive surgery is expected to
grow further. The need for all eye-care pro-
fessionals to be well equipped in their
knowledge of refractive surgery is becom-
ing increasingly important, as they are the
source of professional guidance for patients
who wish to undergo refractive surgery.
Optometrists and co-
management in refractive
surgery
Recent market research from a Mintel
report on Optical Goods & Eyecare suggests
that in the UK approximately 75,000 pro-
cedures were carried out in 2001 on
around 41,000 consumers and that this fig-
ure probably doubled in 2002.2,3 The ques-
tion arises, what is the appropriate level of
involvement that an optometrist should
have with refractive surgery?
Certain optical companies are now able
to provide some refractive surgery proce-
dures and to use their existing network of
practices to recruit potential patients, as well
as for the pre- and post-operative assessment
of patients. Certainly, for these latter tasks
an optometrist is qualified appropriately.4
Many independent practices enter
agreements with external laser eye clinics,
under which the patients are seen initially
at the optometric practice and are then
referred to the laser eye clinic for surgery,
with some of the post-operative assessment
carried out at the initial optometric prac-
tice. Some of these agreements involve the
laser eye clinic making a payment to the
referring optometrist, in return for the
optometrist making the initial assessment
and providing some of the post-operative
54 ■ Refractive surgery: a guide to assessment and management
aftercare. This can be a delicate issue, as the
optometrist should not feel that the pay-
ment is a ‘referral fee’. However, this fee is
often more than the optometrist would
charge his or her own routine patients for
a regular eye examination. Of course, it
could be argued that during a pre-opera-
tive consultation for refractive surgery the
optometrist performs additional tests (such
as pachymetry, pupillometry and corneal
topography). It could be further argued
that a typical regular eye examination fee
is actually less than the realistic fee calcu-
lated on the chair time for that appoint-
ment, and that the fee is subsidized by the
sale of optical appliances, which would not
be the case in a pre- or post-operative
refractive surgery appointment.
For example, let us say that a co-man-
agement fee of £250 is paid to an
optometrist for referring a patient to a
laser eye clinic. For this fee the optometrist
is expected to perform a pre-operative con-
sultation and post-operative assessments
at 1 week, 1 month, 3 months and 1 year.
This fee may be hard to justify if a routine
eye examination with that optometrist is
charged at £20; the excessive fee may be
seen as an inducement for referral.
Furthermore, the optometrist should not feel
any obligation or limitation to restrict him-
or herself to being able to advise patients to
go to one particular laser eye clinic.
Currently, the General Optical Council
(GOC) is examining the issue of co-man-
agement fees, and recently it made a pro-
posal to ban optometrists and opticians from
receiving co-management fees or induce-
ments.5,6 The GOC published a statement
on the professional conduct of optometrists
regarding photorefractive keratectomy
(PRK) in 1995, although currently there are
no other regulations on the more recent
techniques, such as laser in situ ker-
atomileusis (LASIK) and laser subepithelial
keratectomy (LASEK). The statement
advised that no optometrist should accept
any fee or other inducement for referring a
patient to a particular clinic. Nor should any
agreement be made whereby the optometrist
is restricted to referring a patient to a par-
ticular clinic. In addition, any work done
prior to a referral must be paid by the patient
to the optometrist and not by the clinic.
However, any work carried out after treat-
ment can be paid by a clinic on the patient’s
behalf and with the patient’s consent to
avoid any risk of bias or unethical behaviour.
Refractive surgery is considered a pri-
vate treatment and currently is not pro-
vided under the NHS. The necessary
interaction between general practitioners
(GPs), optometrists and refractive surgeons
and/or ophthalmologists is somewhat dif-
ferent to that which exists in the provision
of general ophthalmic services (GOS). The
sharing of care for a patient is often termed
‘co-management’, whereby the patient is
co-managed between the ophthalmologist
at the clinics and/or hospitals and the
optometrist. Post-surgery, the ophthal-
mologist refers only non-complicated cases
back to the optometrist involved, and com-
plicated cases remain under the care of the
surgeon until he or she feels that they are
ready to return back into the optometrist’s
care. However, although the management
may be passed on to the optometrist under
the co-management scheme, the ultimate
duty of care remains with the surgeon.7
The Royal College of Ophthalmologists
does not have specific guidelines for the
involvement of optometrists in the co-
management of LASIK patients, although
general guidelines on co-management
schemes were issued in 1996, in conjunc-
tion with the Royal College of General
Practitioners and College of Optometrists.
These general guidelines advise that every
scheme should be set out in a locally
agreed formal protocol that should speci-
fy overall clinical responsibility at any one
time. However, it has been claimed by
some optometric authorities in refractive
surgery that the reluctance of some clin-
ics to have an ophthalmologist on site full
time has meant that optometrists are
being forced to make clinical decisions
that lie outside the scope of their respon-
sibility. An example is the ‘prescribing’ of
topical ocular therapeutic agents, includ-
ing topical corticosteroids, as a result of
the surgeon’s absence, which is not only
against the advise from the College of
Ophthalmologists, but also against the
Opticians Act 1989.8
Training
Many laser clinics provide training to prac-
titioners who sign up for a co-management
agreement with that clinic. The level of
training varies from clinic to clinic; some
offer only a few hours, which may largely
consist of a visit to the laser clinic, where-
as other clinics insist on regular attendance
for training. There are also many other
courses in the management of refractive
surgery patients, some offered by the clin-
ics themselves and others by universities or
learned societies, such as the British Society
for Refractive Surgery (BSRS). Much of the
continued education and training (CET)
available is approved by the Directorate for
Optometric Continued Education and
Training (DOCET). However, there is no
requirement for those who elect to be
involved in co-management schemes to
undergo any CET.
Professional relationships and
responsibilities
It is worth taking a step back and looking
at the traditional relationships between
optometrist, GP and ophthalmologist
under the GOS system. A patient seen by
an optometrist and deemed to have a
pathology or abnormality that requires
medical intervention or observation is
referred, under the GOS terms and condi-
tions, via the GP to the ophthalmologist to
be seen under the Hospital Eye Service
(HES). The urgency of the referral is sug-
gested by the optometrist and the GP, but
ultimately the ophthalmologist decides on
how soon the patient is seen. The situation
is slightly different if the patient’s problem
is considered to be an emergency. In such
a case the optometrist and/or the GP may
arrange for an immediate appointment
with the ophthalmologist if this is deemed
to be in the patient’s best interest. When
the patient is sent by the optometrist
directly to be seen by an ophthalmologist,
the GP is notified. Let us also consider the
role of these three clinicians.
The GP’s role
A GP is described as a physician who does
not have a sub-speciality, but who has a
medical practice in which he or she inves-
tigates and treats illnesses. Complex prob-
lems or acute illnesses, however, are
referred for secondary care at the hospital
and, in terms of ophthalmological care, to
the HES. The GP may also refer a patient
with visual symptoms to the optometrist.
GPs are independent contractors of the
NHS, who are able to mix private practice
with NHS contracted work. Some GPs
work under the general medical services
(GMS) contract and others are employed
under the personal medical services (PMS)
scheme, which enable the GPs to have con-
tracts negotiated locally with commis-
sioning health bodies, such as primary
care trusts (PCTs). Patients generally are
referred to secondary care under the NHS,
whereby the GP refers a patient for further
specialized investigation in terms of the
management of a particular illness. The
GP delegates the responsibility for that par-
ticular condition to the consultant at the
hospital. However, if the condition is
resolved and the patient discharged, the
GP then continues to manage or monitor
his or her patient as normal under the
NHS, or privately. Thus, the responsibility
for the patient in terms of that particular

condition is delegated to a consultant and
team at the hospital, until discharged. At
present under the NHS, the GP would nor-
mally only refer a patient to an optometrist
if he or she believes the problem is refrac-
tive, although optometrists possess a range
of sophisticated equipment (e.g., a slit-
lamp or visual field testing equipment) that
is not available at most GPs and enables
optometrists to detect eye disorders and
diseases. However, once a patient is
referred to an optometrist for visual cor-
rection, only the responsibility of under-
taking a sight test is delegated to the
optometrists; the responsibility for medical
care, such as treating blepharitis and con-
junctivitis, still lies with the GP.
The ophthalmologist’s role
The ophthalmologist is both a physician
and a surgeon for conditions that occur in
and around the eye and the visual path-
ways. Most ophthalmologists tend to work
in the secondary-care environment, for
example in the eye department of hospitals,
and they may also hold out-patient depart-
ments at peripheral clinics. The surgical
work of the general ophthalmologist may
include cataract extraction, squint and
glaucoma surgery, and retinal, oculoplas-
tic and nasolacrimal surgery. Many con-
sultant ophthalmologists also have an area
of particular interest and expertise, such as
glaucoma, paediatrics, retinal disorders,
etc., for which they may hold special clin-
ics. For cases in which an ophthalmologist
holds a specific sub-speciality, it is not
uncommon for ophthalmologist colleagues
to make tertiary referrals.
Consultant ophthalmologists are
responsible for all the patients in their
care, and for supervising and training jun-
ior doctors. However, when a referral is
sent to the ophthalmologist, the consult-
ant or registrar decides upon the urgency
of appointment, and consequently the
responsibility for the patient is only taken if
the ophthalmologist decides to monitor or
treat the condition. It is, then, possible that
the patient may be sent back to the GP, in
which case the GP is responsible for moni-
toring the patient until secondary care is
available. In contrast, the patient is not nor-
mally referred back to the optometrist for
monitoring, unless the optometrist is
involved in a co-management and/or a
shared care scheme with the hospital.
The optometrist’s role
Optometrists are graduates who have
undertaken a 3- or 4-year university-based
undergraduate degree course at an accred-
ited optometry school followed by a period
of at least 1 year supervised practice before
taking professional qualification exami-
nations. Successful completion of these
examinations, set by the College of
Optometrists (a public benefit body for the
improvement and conservation of human
vision), leads to registration with the GOC.
The GOC licences optometrists to practice
in the UK under the provisions of the
Opticians Act 1989 and regulates the
practice of optometrists in the UK who
work privately or under the NHS. Once
qualified, optometrists are able to perform
a sight test, which includes the detection
of injury, disease or abnormality in the
eye, and a refraction, which enables them
to dispense spectacles, prescribe and fit
contact lenses and prescribe low-vision
aids. Optometrists work mainly in the pri-
mary care sector and are independent
contractors. They provide NHS examina-
tions by initially registering with the PCT
responsible for the location in which they
intend to offer the service. This seals a
contract with that PCT, under which the
optometrists agrees to abide by the ‘terms
of service’ for the provision of NHS serv-
ices (GOS) under the 1986 regulation
Statutory Instrument (SI) 1986/975. Free
NHS eye examinations are available to cer-
tain groups of qualifying patients, such as
minors (under 16 years of age), senior cit-
izens (over 60 years of age), students in full
time education, patients with low income,
diabetic patients, glaucomatous patients
and those above the age of 40 years with
direct relatives who suffer from glaucoma.
If during a routine eye examination an
optometrist detects an injury or disease, he
or she is obliged to manage the patient
under certain referral criteria set by the
NHS. The GOS Amendment (No. 2)
Regulations 1989 SI 1989/1175 requires
that a patient who is diagnosed with dia-
betes or glaucoma be referred to the
patient’s GP. This must also be done if a
satisfactory standard of vision is unlikely
to be achieved with corrective lenses. In
England and Wales this procedure is car-
ried out via the GOS 18 Referral Form,
which is the standard form for an NHS
referral.
Under the Opticians Act 1989, the GOC
is given the power under sections 31(5) and
5(A) to make rules on referral that apply to
all practising optometrists, be it under the
NHS or private. Thus, the ‘Rules relating to
Injury or Disease of the Eye, 1999’ are the
present regulation, and are set by the GOC.
Therefore, under these regulations a patient
who presents to an optometrist with an
injury or disease must be referred to the
patient’s GP, unless that patient is acting on
the advice or instructions of his or her GP or
if the patient is suffering from a condition
Co-management issues ■ 55
that requires immediate attention, in which
case the optometrist should refer the patient
directly to the local HES, although the GP
would be informed. If the professional judge-
ment of the optometrist deems that no refer-
ral to the GP is necessary, he or she may (at
his or her own discretion) decide to monitor
the patient and not refer on that occasion. It
is considered that, under SI 1999/3267, the
optometrist transfers the authority for deal-
ing with the patient to the GP upon referral.
This includes the dispensing of optical appli-
ances until the patient is released back to the
care of the optometrist or the optometrist
receives instruction from the GP or oph-
thalmologist to dispense the optical aid.
General optometry co-
management schemes
Recognition of the basic skills and train-
ing received by optometrists has led to
the establishment of various co-man-
agement schemes. These schemes deal
with pathological abnormalities of the eye,
such as cataract, diabetes, glaucoma and
low-vision aids. These are managed differ-
ently to refractive surgery co-management,
as they are set up to improve the quality of
referrals to secondary care. They are under-
taken in accordance with a protocol agreed
with hospital ophthalmologists and GPs, in
accordance with the 1996 general guide-
lines on co-management schemes from the
College of Ophthalmologists. This agreed
protocol usually involves a number of hours
per year training for the optometrist with
the ophthalmologist in a lecture and clini-
cal training format. Failure to comply with
this required training can lead to the
removal of the optometrist from the
scheme. Furthermore, the optometrist
undertakes responsibility for the part of the
service that is provided by him or her.
Additionally, the co-management schemes
provide for patients for whom a confirma-
tory diagnosis has been made in the sec-
ondary care sector, and the schemes are
outside the GOS. Payments to practitioners
are made from hospital and community
health services funds, although where
refraction is required as part of the agreed
protocol, a NHS sight test fee is claimed by
eligible patients. This is very different to the
situation that exists in the co-management
of refractive surgery patients.
As mentioned above, the co-manage-
ment schemes that exist in refractive sur-
gery do not have guidelines in terms of
training required, payment methods or
apportioning of responsibility. Optometrists
involved in these schemes see the respon-
sibility for the patients as remaining with
56 ■ Refractive surgery: a guide to assessment and management
the treating surgeon, which is what the clin-
ics advocate. This may lead to certain prob-
lems if the co-managing optometrist is
appointed by the clinic and does not have
any dealings with the treating surgeon. If a
problem arises, the treating surgeon may
argue that they did not approve the
optometrist involved in the scheme. Thus,
surgeons will need to feel comfortable with
the recruitment process that the clinic uses
to recruit co-management partners.
Insurance and legal issues of
responsibility
Surgeons involved in refractive surgery will
have their own medical defence indemnity
insurance cover. Some defence organizations
are reviewing whom they offer cover to
because of the proliferation of litigation
cases among refractive surgery patients. The
Royal College of Ophthalmologists recently
updated its advice to patients on refractive
surgery, and is currently also considering its
guidelines to surgeons. It is felt that the Royal
College of Ophthalmologists will suggest that
only surgeons who have been providing
refractive surgery for a certain number of
years or those who are accredited ophthal-
mologists should provide refractive surgery.
Optometrists in routine practice usu-
ally have indemnity insurance to protect
them against any potential litigation from
patients. It is a requirement of the College
of Optometrists that its practising mem-
bers or fellows have indemnity cover to at
least a pre-set level. Many optometrists in
the UK are members of the Association
of Optometrists (AOP), which provides its
members with some advice when enter-
ing co-management schemes, published
in their fortnightly journal Optometry
Today.9 The AOP’s advice to its members
says that they should obtain a written
contract that sets out the terms of
engagement. The AOP professional
indemnity insurance will cover them for
References
1 Saunders H (1981). Age-dependence of
human refractive errors. Ophthalmic
Physiol Opt. 1, 159–174.
2 Ewbank A (2001). The current status of
laser refractive surgery in the UK.
Optician 222, 24–27.
3 Ewbank A (2002). Trends in laser refractive
surgery in the UK. Optician 224, 20–24.
work that they may normally undertake
as optometrists, but not for work that
they do not normally perform (such as
prescribing medication or performing
surgical techniques). The AOP advises
good record keeping and suggests that
members do not advise patients on sur-
gery, but rather inform them of what the
surgery can offer, highlighting any pros
and cons. Importantly, the AOP also sug-
gests that if a member is involved in a co-
management scheme then the patient
must be given details of the agreement
that exists with a refractive surgery clin-
ic. The AOP suggests that taking this
course of action will mean that profes-
sional indemnity for the patient remains
with the treating surgeon and that, if
required, the clinic will be able to produce
satisfactory documentation to demon-
strate this professional indemnity to the
optometrist.
Sources of further information
There are various sources for information
on refractive surgery to which clinicians
may wish to refer. Many of the professional
bodies have their statements on their web-
sites. Below is a list of some useful organ-
izations and their respective web links.
Governing bodies
• General Medical Council (GMC) – all
practising medical practitioners in the
UK must be registered with the GMC.
www.gmc-uk.org
• General Optical Council (GOC) – all
practising optometrists in the UK must
be registered with the GOC.
www.optical.org
Professional bodies
• Royal College of Ophthalmologists –
produces the refereed journal British
Journal of Ophthalmology.
www.rcophth.ac.uk
4 Hanratty M (2003). Optometric co-
management of Lasik: Part 1 – Preoperative
assessment. Optician 225, 26–29.
5 Hunter I (2003). Frictionless fees. Optom
Today 43, 3.
6 Optometry Today (2003). GOC seeks ban
on referral fees. Optom Today 43, 4.
7 Doshi S (2001). Co-management
schemes. Optician 222, 34–35.
• College of Optometrists – produces the
refereed journal Ophthalmic and
Physiological Optics.
www.college-optometrists.org
Professional societies
• United Kingdom and Ireland Society of
Cataract and Refractive Surgery
(UKISCRS)
www.ukiscrs.org.uk
• British Society for Refractive Surgery
(BSRS)
www.bsrs.co.uk
• European Society of Cataract and
Refractive Surgeons (ESCRS) – jointly
produce the refereed Journal of Cataract
and Refractive Surgery
www.escrs.org
• American Society of Cataract and
Refractive Surgery (ASCRS) – jointly
produce the refereed Journal of Cataract
and Refractive Surgery
www.ascrs.org
• International Society of Refractive
Surgery (ISRS) – produce the refereed
Journal of Refractive Surgery and have
just become part of the American
Academy of Ophthalmology (AAO),
who produce the refereed journal
Ophthalmology
www.isrs.org
Other publications
• Cataract and Refractive Surgery Today
www.crstoday.com
• Refractive Eye News – the supplement
of Eye News
ren@pinpoint-scotland.com
• Ocular Surgery News
www.osnsupersite.com
• Eurotimes
www.escrs.org/eurotimes
• EyeWorld
www.eyeworld.org
• Optometry Today – journal of the AOP
www.optometry.co.uk
• Optician
www.optometryonline.net
8 Doshi S (2002). Co-management in
refractive surgery: a honey trap? Optician
224, 28–29.
9 Association of Optometrists (2001).
Optometric services in refractive surgery:
Advice for AOP members. Optom Today
41, 19.
 8
Surface laser treatments:
an alternative to LASIK?
Stephen J Doyle, Sunil Shah and Balasubraminiam Ilango
In this chapter laser in situ keratomileusis
(LASIK) surgery is detailed further and
the arguments as to its supremacy over
photorefractive keratectomy (PRK) and
laser epithelial keratomileusis (LASEK) are
considered. There may be some slight
overlap with previous chapters, but the
authors feel that this is appropriate here.
LASIK is often perceived by patients as
being the most up-to-date technique, part-
ly because some clinics and surgeons only
offer this type of laser surgery. However,
an increasing number of surgeons advo-
cate a glorified version of PRK (i.e.,
LASEK) as a more suitable option for some
prescription ranges.
Approximately one-quarter of the
world’s population need visual aids to cor-
rect their refractive errors. In the UK,
about 6.6% of the population are myopic.1
The discovery that argon fluoride (ArF)
excimer laser is able to alter the corneal
curvature has transformed some of these
people’s lives. The key refractive elements
of the eye are the cornea, lens and axial
length. Of these three factors the cornea
is the most easily accessible for modifica-
tion. In laser refractive surgery the aim is
to correct the patient’s ametropia by alter-
ing the corneal profile and changing the
overall power of the eye. To correct myopia
the excimer laser is used to remove corneal
tissue in the central area to produce an
overall flattening of the cornea shape. In
hyperopic patients, corneal tissue is
removed in the mid-peripheral area of the
cornea to produce a net steepening of the
corneal shape. One essential difference
between LASIK and PRK (or LASEK) is
where in the cornea the laser is applied. In
PRK and LASEK the excimer laser is
applied under the corneal epithelium, at
the Bowman’s membrane level, whereas
in LASIK the excimer laser is applied
underneath Bowman’s membrane, in the
stroma. PRK and LASEK are often termed
as being surface laser treatments.
Taboada et al.2 reported the use of
excimer laser on rabbit corneas in 1981.
Trokel and Srinivasan,3 in 1983, showed
the world that the 193nm excimer laser
could be used to remove corneal tissues
very precisely. Marshall et al.,4 during
1984, looked at the structural changes in
ablated rabbit and monkey corneas, using
scanning and transmission electron
microscopy. In 1985, Theo Seiler per-
formed the first phototherapeutic kerate-
ctomy procedure in Germany5. McDonald
et al.6 performed the first PRK procedure
in the USA on a myopic person in 1988.
During the same year, Gartry and Kerr-
Muir performed their first PRK on a sight-
ed person’s cornea at the St Thomas’
Hospital, London.
The development of LASIK
The concept of keratomileusis was intro-
duced by Pureskin in 1966.7 In the 1970s,
Jose Barraquer3 improved this idea when
he removed a thin corneal wafer, reshaped
it using a cryolathe and reinserted it onto
the cornea. Subsequently, in 1982, an auto-
mated device called a microkeratome was
used to cut a thin cap of the corneal tissue.
A second pass was then made to remove tis-
sue to flatten the cornea by a predetermined
amount, calculated using Barraquer’s ‘Law
of Thickness’ equation. The cap was then
replaced and allowed to heal, held in place
by the endothelial pump mechanism. This
technique was called an automated lamel-
lar keratectomy and was used to treat
myopic refractive errors up to 20D.7
The first of the present-day microker-
atomes was developed by Chiron and used
by Slade. The combination of a lamellar
incision and excimer laser ablation was
first named laser in situ keratomileusis by
Pallikaris in 1990.8 It employed the micro-
keratome to cut a plano-lamellar corneal
flap followed by excimer laser to the stro-
mal bed and flap replacement.
Excimer laser technology
Excimer laser is a term applied to a group
of lasers in which a molecule of inert gas,
such as krypton or argon, is forced to asso-
ciate with a molecule of halogen gas. The
term ‘excimer’ comes from ‘EXCited
dIMER’, which means a mixture of two
inert gases that bind together to produce
an unstable diatomic gas halide. In 1975
Velazco and Setser described properties of
inert gas halides that suggested they could
be used fore lasers in the ultraviolet
range.9 The high-energy photons pro-
duced by these lasers were found to be able
to destabilize valency bonds in the macro-
molecules and thus cause tissue destruc-
tion. This technique is known as
photoablation. The first working excimer
laser was produced in 1975.9
Krypton fluoride (KrF) lasers use an
ultraviolet wavelength of 248nm and ArF
lasers use an ultraviolet wavelength of
193nm. Ultraviolet light is strongly
absorbed by most biomaterials. At 193nm
the laser-head photon energy is around
6.4eV, sufficient to break the corneal
intramolecular bonds of about 3.6eV, but
not to cause any thermal effects. The
remaining energy is used to expel particles
from the surface at supersonic speeds, but
does not cause any significant heating of
58 ■ Refractive surgery: a guide to assessment and management
the adjacent tissues. At wavelengths
greater than 200nm the thermal effects
become more marked locally. However,
even at 248nm the photons still cannot
penetrate more than a few microns.10–13
Investigations of a range of excimer
lasers have shown the ArF laser to produce
the smoothest ablations of the corneal tis-
sue, with minimal collateral damage from
thermal diffusion. As an excimer laser, ArF
has the advantage that it provides an exact,
computer-controlled tissue removal, with a
linear relationship between energy densi-
ty and ablation depth. Dyer and Al-Dhair
first noted this property in 1990.3 The
major disadvantage of the excimer lasers
for refractive surgery is their expense. This
arises from the need for a sophisticated con-
tainment system for toxic gases, the daily
need to replace the gas fills and the require-
ment for high-quality optical components
to prevent irregular tissue removal that
results from inconsistent beam energy. For
these reasons, solid-state lasers are emerg-
ing in the market. However, the present-day
excimer lasers are still 193nm ArF lasers.
Laser equipment
A wide variety of laser hardware and soft-
ware is available. In broad terms, the types
of lasers can be divided into broad-beam,
scanning slit and flying spot lasers. Both
second- and third-generation lasers (scan-
ning slit and spot lasers) have the advan-
tage of a smaller beam, which minimizes
the effects of beam irregularities and
results in a smoother ablation profile.
Flying spot lasers have been in use in the
UK since the late 1990s. Their small beam
size makes them suitable for use in topo-
graphic feedback systems. Some systems
utilize a combination of technologies.
Each type of laser has its own advan-
tages and disadvantages. For example,
broad-beam lasers are limited as to the max-
imum ablation diameter and have a high
tendency to produce ‘central islands’ (which
have a refractive power different to the rest
of the ablation), but broad-beam lasers are
able to achieve the required ablation profile
quicker than are scanning lasers.
Software modifications have been made
frequently to adjust the algorithms to pro-
vide optimum results. Recent develop-
ments have allowed ablation assisted by
corneal topography to help customize the
laser treatment for individual patients. The
most recent developments are the wave-
front analyzer (works on a variety of opti-
cal principles), and it is now possible to
analyze higher order optical aberrations
with a degree of accuracy. In theory, wave-
front analysis linked into an excimer laser
would allow the correction of whole eye
aberrations with the possibility of ‘super-
vision’. However, as for much of refractive
surgery recently, media hype has far pre-
ceded clinical outcome data. In addition,
it is possible that wavefront-guided treat-
ments would need to be used either in ‘real
time’ or with PRK rather than LASIK
(because of the aberrations that LASIK
causes by cutting the flap itself).
LASIK versus PRK
It is clear that each of these techniques has
some advantages over the other. In the UK,
PRK has been by far the more popular
technique as it was developed earlier.
LASIK was developed to overcome some of
the problems encountered with PRK.
These include retaining Bowman’s layer
to give a low level of post-operative haze.
An intact corneal epithelium helps to
reduce the pain and the chances of surface
infection. LASIK patients also enjoy a fast
visual recovery. With healing after LASIK,
the apoptosis is limited to the lamellar
interface, and so less stromal wound heal-
ing, and usually the haze is limited to the
flap margin only.14
PRK is an inherently safer operative
procedure is needed as no cutting of the
corneal stroma is involved, and hence the
instrumentation is much simpler. The
complication rate for PRK rises in direct
proportion to the degree of treatment. The
complication rate for LASIK is relatively
constant, as the major complications are
related to cutting the flap. For each indi-
vidual surgeon, there is probably a point
at which the risks of PRK outweigh the
risks of LASIK. This point varies from sur-
geon to surgeon and also from patient to
patient, depending on other factors. In the
USA, consumer pressure has meant that
the vast majority of patients receive
LASIK.
The LASIK procedure requires suffi-
cient corneal thickness to ensure the abla-
tion does not approach within 250μm of
the endothelium. The risk of significant
endothelial damage is small – most stud-
ies quote a change in endothelial cell den-
sity similar to the physiological change
with age,15 even for high myopic correc-
tions. The risk of inducing a corneal ecta-
sia is small if a minimum of 30% of the
corneal thickness is left intact, and a thin-
ner flap is cut for thin corneas. A central
corneal thickness of <410μm usually con-
traindicates LASIK.16
A number of studies have shown that
the long-term results for low-to-moderate
myopia are identical for PRK and LASIK.
The difference is the short-term visual
recovery and the anisometropia (bilater-
al PRK does not tend to be performed
simultaneously).
LASIK is able to treat –1.00D to
–12.00D and +1.00D to +4.00D, depend-
ing on the corneal thickness. The range of
correction of refractive errors is from
–1.00D to –7.00D (maximum) and
+1.00D to +2.00D with the PRK tech-
nique. The crossover point between PRK
and LASIK for myopia is about –3D for
many surgeons.
The visual recovery is different between
the two techniques. For PRK the epitheli-
um takes up to 4 days to heal and then the
vision improves as the epithelium stabilizes
and the post-operative hyperopic shift set-
tles.
The modified version of PRK, known as
the epithelial flap,16 is slowly gaining pop-
ularity. In the epithelial flap procedure, the
epithelium is treated with 18% alcohol for
about 45 seconds and then an epithelial
flap is created (rather than the stromal flap
of LASIK). After laser ablation, the flap is
replaced. This results in less pain and
quicker visual recovery, and so attracts
patients to opt for the PRK treatment
because of the increased safety.
LASIK surgical procedure
The LASIK surgical procedure is usually
performed in a clean room, preferably an
operating theatre. Qualified nursing assis-
tance during LASIK surgery is mandato-
ry and is a prerequisite for local health
authority registration. The patient is made
to lie on a couch with the excimer laser
delivery system just above the position of
the head. The patient’s cornea is anaes-
thetized with local anaesthetic eye drops.
Very anxious patients can be given a mild
sedative about 30 minutes pre-operatively.
An eye speculum is inserted to expose
the cornea and to prevent the patient from
blinking during the treatment. The patient
fixates on the He–Ne laser beam and the
cornea is marked with gentian violet to
assist in realignment of the flap.
Various microkeratomes (manual and
automated) are available and the surgical
techniques differ between them. The
Hansatome has two pieces and employs
the following technique. A suction ring is
applied to the eye and the intraocular pres-
sure (IOP) is increased to >65mmHg to
ensure a regular cut. This can be con-
firmed using the Barraquer applanation
tonometer. The patient may experience a
transient loss of vision secondary to an

increase in the IOP in excess of the retinal
arterial perfusion pressure. The microker-
atome is placed onto the track and acti-
vated to pass across the cornea and back,
thus cutting the flap. Then the vacuum is
released and the corneal flap is reflected
back, to reveal the stromal bed. Some
microkeratomes (Nidek) are available as
one piece and do not need to be connected
together. The hinge of the corneal flap can
be made nasally, although cuts made with
the Hansatome are hinged at 12 o’clock.
The depth of the cut is usually no more
than one-third of the total corneal thick-
ness. The microkeratomes have 130 and
160μm blades. Most microkeratomes do
not always produce a flap of the exact
intended thickness and have a standard
deviation (SD) of about 30μm.18 However,
for many newer microkeratomes, such as
the Nidek MK2000, the SDs are signifi-
cantly less.
Ideally, pachymetry is repeated to ensure
that an adequate depth of corneal tissue
remains, and the excimer laser ablation is
carried out on the stromal bed. The patients
self-fixate throughout the laser ablation,
and the corneal centration should be main-
tained either manually or by the built-in eye
tracker mechanism. Patients must be
warned that they might experience a pun-
gent smell during the laser ablation, which
takes under 90 seconds in total.
The flap is washed thoroughly with bal-
anced salt solution to remove any debris.
The corneal flap is repositioned, centration
checked and the edges smoothed down.
The endothelial pump mechanism keeps it
in place. Adherence is verified and the
speculum removed. Some surgeons prefer
to apply a bandage contact lens over the
flap, and remove this after 24 hours. The
patients are sent home with an eye shield,
which prevents them from accidentally
rubbing their eyes and from direct trauma
to the eye. Flap position is rechecked at the
Table 8.1 Complications of LASIK
Period Flap related
Early Incomplete flap
Decentred flap
Irregular flap
Completely cut flap
Lost flap
Flap striae
Sands of Sahara (diffuse interstitial keratitis)
Late Epithelial ingrowth
Surface laser treatments: an alternative to LASIK?
slit lamp after a few minutes. Post-opera-
tive care for the LASIK patient is discussed
in Chapter 5.
Complications of LASIK
Complications after LASIK can be classi-
fied into three broad groups, summarized
in Table 8.1:
• Flap-related;
• Refractive;
• Miscellaneous.
The flap-related complications occur most-
ly because of mechanical problems, but
these are very rare with modern micro-
keratomes. Epithelial ingrowth results
from the entrapment of corneal epithelial
cells under the margin of the flap. Flap stri-
ae are caused by misalignment, slippage
or tenting of the flap during the early post-
operative period. Accidental eye rubbing
could also lead to this complication. Flap
striae can be reversed readily, if corrected
during the early post-operative period.
Total flap-related complications are quot-
ed as 2–5%, although serious flap compli-
cations are about 0.1%.
Diffuse interstitial keratitis is uncom-
mon and needs early aggressive therapy. It
is treated with topical corticosteroids and
possibly by lifting the flap and cleaning the
surface. Retinal haemorrhage is thought
to result from pre-existing pathology.19
Epithelial ingrowth, if sight threatening,
may need the flap to be lifted and the sur-
faces treated with absolute ethanol.
Results
Predictability
Of the patients with a pre-operative
myopia of –2.00 to –6.00D, 94.8%
achieve >6/12 unaided vision at 5.2
months post-LASIK. This percentage is
62.3% and 36.8% in the –6.00 to
–12.00D range and the –12.00 to
–20.00D range, respectively.16 Among the
–1 to –3D group, up to 36% of the patients
Refractive
Induced irregular astigmatism
Primary undercorrection
Primary overcorrection
Decentred ablation
Regression
Undercorrection
Overcorrection
■ 59
achieved 6/6 unaided vision in one
study.14 The predictability of achieving
6/12 or better is about 70–87% by 12
months, depending upon the initial level
of myopia.17 The results of PRK and
LASIK are very similar at 12 months post-
operatively.
Accuracy
The percentage of eyes that achieve a
residual refractive error within ±1.00D of
emmetropia at 12 months is between 68
and 86% for <–12.00D of treatment and
40–50% for >–12.00D of treatment.8
Stability
The refraction has been shown to stabilize
within 3–6 months after LASIK.20 Fiander
and Tayfour showed a refractive change of
±0.50D between 1 and 6 months in 90.4%
of high myopes and 81% of low myopes.21
This quick recovery has been attributed to
the limited stromal healing required after
LASIK.
Loss of best-corrected visual acuity
Most studies that involve low myopes
(<–6.00D) show no eyes losing more than
two lines of Snellen acuity. In the high
myopia group, 0–9.5% of patients lost two
or more lines of Snellen acuity after
LASIK. This remarkable result with LASIK
is because of the lack of haze and the lim-
ited stromal healing that is required.8
Contrast sensitivity
Spatial contrast sensitivity is reduced at
high and middle spatial frequencies at both
1 and 3 months post-operatively.22 In one
study, contrast sensitivity was studied in
14 eyes (–6.00 to –19.50D) after LASIK.
A reduction in contrast sensitivity was
detected at 1 month, after which a rapid
recovery was noticed, so that by the third
month no statistically significant reduc-
tion in sensitivity was seen at any spatial
Miscellaneous
Glare
Haloes
Ptosis
Infectious keratitis
Retinal haemorrhage19
Central retinal artery occlusion
Dry eye
Corneal anaesthesia
Retinal detachment19
Iatrogenic keratectasia
60 ■ Refractive surgery: a guide to assessment and management
frequency (Catherine Chisholm, personal
communication).
High myopia
The increase in IOP during surgery may
cause problems in large myopic eyes with
weak retinas. Arevalo et al. demonstrated
that 20 of 29,916 eyes exhibited vitreo-
retinal diseases after LASIK (14 retinal
detachment, four retinal tears and 2 mis-
cellaneous conditions),19 although this
may have been pre-existing.
LASIK for high myopia is possible, but
full correction is not always feasible since
about 250μm of the corneal thickness has
to be maintained to prevent corneal ecta-
sia. The greatest ablation that can be per-
formed depends on the laser and the
nomogram used.
Hyperopia
LASIK has been shown to produce slight-
ly better results in correcting low hyper-
opes than PRK. Condon showed that 80%
of the eyes achieved 6/12 or better. The
stabilization period was about four times
longer than that of myopia. About 7.3%
of the patients lost two or more lines of
best-corrected visual acuity (BCVA) in the
>+4.00D group.7
LASEK
Anyone who investigates refractive sur-
gery for themselves by reading advertise-
ments, looking on the internet, etc., would
be forgiven for thinking that LASIK is the
latest thing and that PRK is ‘old hat’. Some
providers in the UK do not offer any sur-
face laser, even in its latest form of LASEK.
They put forward LASIK as quicker, better
and very safe, but is this really true?
PRK was superseded by LASIK, partic-
ularly in the USA, for complex reasons.
The Food and Dug Administration (FDA)
made every manufacturer of excimer
lasers go through an initial accreditation
process for PRK, which meant that the first
American lasers on the market had a head
start. These were VISX and Summit, both
broad-beam lasers. One of the authors
used an early Summit laser and the qual-
ity of the ablations were not nearly as good
as those of today’s machines. The optical
zones were only 5mm, there was no blend
zone around the optic zone and the sur-
face was rough with visible rings from the
expanding diaphragm. Other laser manu-
facturers, such as Nidek and Technolas,
rapidly brought out their own machines
with flying spots, scanning slits, etc.,
which provided much smoother surfaces
on the cornea. For surface lasers in par-
ticular, ‘smoother is better’, as there is less
chance of haze developing. The standard
way to remove the epithelium at the time
was to scrape it off with a surgical blade.
This leaves a rougher surface than taking
it off with alcohol or a rotating brush and,
again, tends to lead to more haze. Hence,
many American surgeons were put off
PRK by the development of bad haze in
more patients than was comfortable. There
was also the issue of post-operative pain,
which can be quite severe and last for sev-
eral days. When LASIK was introduced it
offered a pain-free procedure, quick visu-
al recovery and no risk of haze. This is
because the corneal stroma is a relatively
quiescent tissue in comparison with the
very metabolically active epithelium. It is
the interaction between the healing
epithelium and the lasered stroma that
causes the deposition of glycoaminogly-
cans (GAGs) and collagen IV, which caus-
es the haze. Putting the laser ablation in
the middle of the stroma meant that this
was one complication, at least, that LASIK
did not have, although a raft of new ones
transpired rapidly, as mentioned above.
The public began to realize that there
was an operation that was almost com-
pletely painless, and that you could see the
next day, which gave what has been called
the ‘WOW factor’. For a high myope to
have clear vision the next day is a power-
ful selling point to encourage your friends
to have the same surgery. Even if the com-
plication rate was 5%, the noise from 95
very happy patients tends to drown out the
unhappy five. The American psyche is also
one that likes operations that are over
quickly, easily and let one ‘get on with your
life’. LASIK offered and still offers this. It is
the nearest thing to what one might call
‘stealth surgery’ – an operation that even
at one day post-operative is hard to detect,
even using a slit lamp.
In Europe, the surgeons could use
other lasers that were not yet available in
the USA. Also, perhaps being of a more
conservative nature, they tended to stick
with PRK as well as to learn LASIK and
begin to offer it to patients. Reports of the
complications of LASIK began to filter
across from America. This is not to say
that LASIK was not taken up in Europe.
LASIK is and remains a very successful
operation with a very low complication
rate. Quite a number of studies have com-
pared LASEK and PRK to LASIK, some-
times with LASIK in one eye and PRK or
LASEK in the other.23–25 All these articles
show that the final visual results are the
same for both techniques, which is not
surprising given that both operations use
the same laser, albeit in a slightly differ-
ent part of the cornea. One different fac-
tor with the introduction of wavefront
technology is the levels of higher order
aberrations after surgery. For these, sur-
face laser surgery seems to have the edge.
LASIK, having a mechanical element as
well as the laser, leads to an increase in the
‘root mean square (RMS)’ after surgery.
This is a random process caused by the
making and replacement of the flap in
LASIK.26
The ‘street cred’ of lasers is very high,
and the public perception is that any oper-
ation using a laser must be almost fool-
proof. However, in refractive surgery we
are operating on healthy patients and not
diseased ones. One might argue that a –10
myope is ‘sick’, but one cannot say that a
–2 myope is anything more than a physi-
ological variation or the body’s adaptation
to its environment. One of the most impor-
tant diktats of any doctor is ‘do no harm’.
If we operate on 100 cancer patients and
five die, this is perfectly acceptable as we
are trying to cure a sickness. Equally, in
doing cataract surgery, a patient who
develops macula oedema will have had
blurred vision before the surgery and may
feel at least no worse off than before hav-
ing the surgery. However, it is a disaster of
a different order for a low myope with 6/5
spectacle vision to be reduced to 6/18 best-
corrected vision by an elective refractive
operation. For an operation on such low
myopes, 5% with significant complications
is much too high. These are often young
healthy people and we do not want to leave
anyone with lifelong visual problems. In
the same way that refractive surgery is sold
as ‘something that you will appreciate
every waking moment for the rest of your
life’, problems such as monocular diplop-
ia, loss of contrast sensitivity, fuzziness of
objects, dry eyes, etc., can make patients
regret the surgery for the rest of their lives.
The popularity of the website www.sur-
gicaleyes.com is testament of this. At this
website refractive patients with problems
gather to compare notes and to look for
solutions. Hence, refractive surgery has a
different paradigm for the surgeon and he
or she should approach the refractive
patient in a different way to the elderly
cataract patient.23,27–29
PRK has improved much over the past
few years. As well as improved lasers,
epithelial management as in LASEK
(epithelial PRK, also called ‘PRK epiflap’
or ‘advanced surface ablation’) has meant
that haze is now much less of an issue.
There is a little confusion between differ-
ent authors as to the actual meaning of
the acronym LASEK, as some state it as
being ‘laser epithelial keratomileusis’ and

others say ‘laser sub-epithelial keratecto-
my’. It could be argued that the acronym
LASEK has been applied deliberately to link
it closer to LASIK and move it away from
PRK, since PRK is seen as ‘old hat’ and
LASIK as ‘new age’. LASEK is often quot-
ed as being ‘fancy PRK’ or a ‘halfway
house’ between LASIK and PRK. Probably
the former of these two quotes is nearer
the mark, as LASEK is a surface-based
laser procedure, like PRK, but involves
more delicate manipulation of the epithe-
lium. It maintains some of the safety fea-
tures of PRK combined with some of the
advantages of LASIK.30
Visual recovery is also quicker and pain
is somewhat less in LASEK than in
PRK.31,32 However, it is still the case that
LASIK is the procedure many patients pre-
fer because of the speed and pain-free
nature of the surgery. LASIK is perceived
and presented as a better surgical experi-
ence for patients. It is undoubtedly true that
many prospective patients are put off PRK
by the pain element and that many who
have had LASIK would not have had PRK.
Hence one might say that the ‘refractive
market’ has developed on the back of LASIK
rather than on PRK, especially in the USA.
Problems that come up are resolved with
new technology and with more experience.
For example, with the 5mm diameter opti-
cal zones in the early lasers there were some
night-vision problems. These have been
cured largely by using optical zones as large
as 7–9mm, along with blend zones going
out to 10–12mm. It has also been realized
that poor night vision is associated with
treating high myopes, mostly because of an
increased spherical aberration. Hence, the
initial enthusiasm for operating on myopes
of even –20D has been replaced with a
more realistic level of about –8 to –10D as
the upper end of treatment for corneal laser
surgery.
Similarly, when hyperopic treatment
became available, there was an initial
enthusiasm to treat young high hyperopes.
Patients flocked from the USA, where it
was not yet approved by the FDA, to just
over the border in Canada. Some surgeons
there found that they were operating on
very large numbers of hyperopes. There is
nothing like an unhappy patient sitting in
front of a surgeon threatening to sue him
or her unless the treatment parameters are
modified; the consequence meant that
these surgeons rapidly became more con-
servative. We now realize that we should
not steepen the cornea beyond 47–48D,
because beyond this the quality of vision
deteriorates markedly through the cre-
ation of a kind of iatrogenic kerato-
conus.33
Surface laser treatments: an alternative to LASIK?
However, this is the nature of progress
in medicine and we learn from experience.
Some patients, by their nature, are more
‘risk takers’ than others, which is fine as
long as we make clear to patients what the
risk factors in this surgery are in as much
detail as is necessary. Doctors always have
a prime duty to do the best they can for
their individual patient, even if that
patient is a fit –1.5D myope, and they
should not be swayed by how much money
can be made.
Commercial aspects
Excimer lasers are not inexpensive, with an
average price of about £300,000. They are
gas lasers and, as well as needing refills
every few weeks, they also need regular
servicing to clean the mirrors, check align-
ment of all the mechanical parts, and so on.
Some need new laser chambers every year,
which cost about £20,000. If they break
down complete chaos can result for a clin-
ic, as 20 patients may be waiting for laser
treatment on any given day. Hence, one has
to have emergency preparations to cover for
this event, as it will certainly happen.
The microkeratomes for LASIK cost
around £45,000 each and at least two
headsets are needed, at an extra £12,000.
The blades cost between £20 and £40
each and can be used for a maximum of
one patient. Finally, there are the costs of
marketing, staffing, billing and all the
other accoutrements of a modern busi-
ness. Optometrists will be aware of these
costs, as they are similar in type, if not in
degree, to those of any optometric prac-
tice. Hence, it is not surprising that com-
mercial groups have set up many of the
laser centres. Individual entrepreneurs,
existing optometric chains, groups of busi-
nessmen and health care groups have all
played their part. In the early-to-mid
1990s up to 40 different centres in the UK
provided PRK. However, a sharp downturn
occurred in the market and many of the-
ses centres ceased to operate.34,35
However, doctors used to dealing with
sick patients in the NHS, with perhaps a pri-
vate practice on the side, are not used to the
commercial world. Doctors used to be for-
bidden by the General Medical Council
(GMC) to advertise at all, and even now there
is a fine line between what is permitted and
what is not. However, there is nothing to stop
laser centres from advertising widely.
Different centres put forward what they
think is their best selling feature. This may
be price, or the qualities of a particular laser
system, or the backup of a large hospital,
which are all legitimate selling tactics.
■ 61
On selling features, it is interesting that
three of the authors’ consultant ophthal-
mologist peers have had LASIK, but chose
their surgeon by reputation and not by the
laser being used. It could be argued that
modern excimer lasers are of good quali-
ty and the quality of the individual sur-
geon is the most important factor.
Ophthalmologists or optometrists
employed by commercial laser centres
have to maintain their clinical freedom to
provide what they think is ethically the
best treatment for each particular patient.
This can lead to conflict with the business
side of the enterprise, the main purpose of
which is to make money for individuals or
shareholders. Businessmen can apply pres-
sure to treat unsuitable patients, and this
must be resisted by any optometrist and/or
ophthalmologist.
In surveys of patients who have had
refractive surgery, always about 5% are
‘disappointed’. Sometimes the reason for
this is clear to both doctor and patient, for
example bad haze in PRK or flap striae in
LASIK. However, in other cases it is not so
clear why the patient is unhappy. The doc-
tor or optometrist may think that a –8D
myope who has a post-operative refraction
of –0.75D should be happy and grateful.
However, the patient’s appreciation is just
that his or her uncorrected vision now is
not quite as good as it was with contact
lenses or glasses before surgery. Conversely,
and perhaps fortunately for the surgeons,
some patients are so pleased that their
uncorrected vision is better that they do not
notice they have lost some best-corrected
spectacle vision, for whatever surgical rea-
son. We think that they should be unhap-
py, but in fact they may be delighted.
Unilateral or bilateral
treatment?
One question that often arises in the
LASEK versus LASIK debate is whether to
perform the procedure unilaterally or bilat-
erally. It was common in PRK surgery to
separate the procedures for each eye by a
few months, to allow the first eye to stabi-
lize. LASEK has a quicker recovery period
than PRK, and if applied to only low pre-
scriptions this recovery time is very short.
As a result, some surgeons advocate bilat-
eral LASEK. In the case of LASIK, bilater-
al procedures have been the norm for a
while, so both eyes are treated while the
patient is still on the operating table.36,37
There is obviously much financial sense in
this for the various clinics or doctors, as it
increases the throughput of eyes treated
and hence the profits. However, what is
62 ■ Refractive surgery: a guide to assessment and management
best for the individual patient? The argu-
ments full into three groups: safety, accu-
racy and subjective.
Safety
Clearly, in a planned bilateral operation if
there is any intra-operative complication
in the first eye, treatment of the second
should be abandoned. In practice, the com-
plications are usually flap problems. The
authors also include any marked epithelial
loss or ‘slide’ caused by the passage of the
microkeratome, because the incidence of
the ‘sands of the Sahara’ syndrome is ten
times higher in such cases and does not
present until day 1 after the surgery if it
occurs. Such epithelial problems occur
more often in older patients. Any infection,
inflammation, flap wrinkles, etc., almost
always show up on day 1 post-operatively,
so waiting 2–7 days between eyes should
avoid a simultaneous bilateral problem.
LASIK and PRK are dependent on the
technology of the excimer laser machine,
which are gas lasers that are calibrated fre-
quently. They are complicated machines,
but are generally reliable and have many
safety features. However, if a technical
problem occurs and both eyes are treated,
it could affect both eyes adversely without
the surgeon being aware of it at the time of
surgery. The most likely fault is a simple
over- or undertreatment, which could be
corrected fairly easily in most cases. Worse
is when a beam irregularity occurs. Checks
are carried out on all the common
machines to pick this up, but there has
been a reported case in Canada of a mirror
problem in a machine that resulted in
irregular astigmatism in a group of bilat-
eral patients. These patients were correct-
ed with much angst, and it was realized
that the fault in the machine should have
been picked up before the surgery. However,
it is a salutary lesson!
Accuracy
As a general rule it is fair to say the more
extensive the treatment, the larger the
spread of results (accuracy issues are dealt
with in more detail below). If a patient falls
within the normal spread of dioptres, then
to treat both eyes at the same sitting does
not give any significant increase in accu-
racy than to operate on them apart, which
is the normal experience of most patients.
However, if an eye behaves oddly, at the
extremes of the statistical spread, operat-
ing on the eyes separately allows the sur-
geon to alter the laser settings for the
second eye. Scientific articles disagree as
to whether this really makes any differ-
ence, but the latest ones seem to indicate
about a 20% improvement in accuracy.
Hence, for a –7D correction with a stan-
dard deviation of 0.93D, this leads to a
mean improvement in accuracy of about
0.2D, which is small.
Subjective
Sometimes, especially in very high myopes,
full recovery of vision can take up to 2
weeks. Thus, if both eyes are lasered on the
same day, the patient may struggle to cope
for this period. Similarly, the patient may
find that the quality of vision after LASIK
in one eye is not to his or her liking. For
example, there may be night-vision prob-
lems, and so the patient may not want to
go ahead with the second eye. For these
and similar reasons patients may prefer
one eye to be operated on at a time.
However, unilateral treatment does lead to
a feeling of anisometropia, which for some
patients may be too uncomfortable to tol-
erate with a spectacle correction. This can,
of course, be overcome by contact lens use
in the non-treated eye, unless contact lens
intolerance was the reason behind the
patient’s initial option for surgery.
LASIK on both eyes on the same day is
more convenient, but is a slightly greater
risk than operating on separate days. It is
up to each patient to decide what he or she
wants to do, after consultation with the
individual surgeon. In most cases the risk is
the same whether both eyes are operated on
2 minutes apart or several hours apart on
the same day, and in some cases the risks
may not be reduced significantly by sepa-
rating treatment to each eye by a few days.
Photorefractive keratectomy
With PRK the situation is a little different.
The only real complication of PRK is haze,
which is not an immediate post-operative
complication, as most LASIK complica-
tions are. Haze is maximal at around 6
weeks post-operatively, although there are
cases of haze developing late at 6 months
or occasionally even later.38,39 Hence,
when PRK began, the eyes were operated
on separately, at least 3 months apart, to
reduce the risk of bilateral bad haze. The
risk of haze is greater with higher myopic
prescriptions and also with hyperopia,
because of the more extensive shape
changes made on the cornea with such
prescriptions. Also, the speed of recovery
of useful vision after PRK for high myopia
is slower than that for low myopia, as the
epithelium ‘models’ its new shape. Most
refraction occurs at the first air–fluid inter-
face of the cornea, which is disturbed
much more by PRK than by LASIK.
PRK has improved incrementally over
the years. Newer lasers leave a smoother
surface, and blend or transition zones also
make the shape changes more physiolog-
ical. The LASEK technique, in which alco-
hol is used to remove the epithelium,
which is replaced back on the cornea after
ablation, means that haze is now quite
rare and speed of recovery quicker. Hence,
surgeons began to do low myopes bilater-
ally (e.g., up to –3D). With more experi-
ence this has now increased to about –5D
and the debate today is whether to offer
bilateral LASEK to anyone who wishes it
in the same way, as with LASIK.
Also, if a patient developed bad haze,
there used to be no way to treat it, apart
from letting nature take its course. In fact,
most haze fades by itself if left long
enough, although this may take many
months in some cases. Attempts to remove
the haze mechanically or with the laser
worked initially, but it was soon found that
the problem returned, often worse than
before. However, now 0.02% mitomycin
on a sponge can be used, as described in
an earlier chapter, which seems to prevent
such haze recurrence successfully. Hence,
it may be said that even if bad haze devel-
ops bilaterally, there is now a method that
goes a long way to curing this problem and
allows the surgeon to undertake bilateral
PRK with more peace of mind. In very
high prescriptions, some surgeons use
mitomycin prophylactically to prevent any
haze from developing. Mitomycin has been
used for some years in enhanced tra-
beculectomies, especially in children. It is
known in these cases that late problems
can be caused by mitomycin, such as
corneal melt. There are hence worries that
similar problems may develop in the future
with its use in PRK. However, some clini-
cians have been using it for a few years and
say that they have had no such problems
as yet. They attribute this to the technique
of using mitomycin on a central sponge.
Relationship with the NHS
The existence of the NHS means that every-
one in the UK has free access to medical
care, which includes iatrogenic illness as
well as primary pathology. This has, over the
years, led to certain tensions between the
public and private medical sectors. For
example, private hospitals try to manage all
their own surgical complications. However,
on occasions they do not have the necessary
expertise or facilities, so patients have to be
transferred to a NHS facility. Sometimes the
private provider will pay the NHS for these
facilities and other times not. In the world
of ophthalmology some private cataract
services operate on large numbers of
patients to clear up waiting lists. Who

should manage and pay for any surgical
complications, such as yttrium–alumini-
um–garnet (YAG) capsulotomies for poste-
rior capsule fibrosis, when the original
surgeon may no longer be in the area? Who
should pay for more complicated problems
such as a dropped nucleus? Private clinics
often have their own set-ups to manage
these things, but there are undoubtedly
times when the NHS ophthalmic unit feels
unfairly used as, for example, when a pri-
vate patient presents unexpectedly in a hos-
pital casualty department.
Similarly, in the world of optometry,
contact lens patients develop complica-
tions, sometimes quite serious ones such
as corneal infections. These are almost
universally managed by the NHS, despite
being iatrogenic problems caused to
healthy people. It has been commented in
the past that contact lens practitioners
should shoulder some responsibility to
contact lens wearers who develop severe
adverse reactions that require medical
treatment. It is now accepted that these are
a normal part of the NHS ophthalmic
workload and there is no attempt to either
charge the referring optometrist or to be
angry with him or her.
In the world of refractive surgery simi-
lar problems can occur. Patients with severe
pain after excimer laser refractive surgery
may present at an ophthalmic casualty
unit. A LASIK patient may need a corneal
transplant because of keratectasia. Usually,
the larger providers of laser refractive sur-
gery have private financial arrangements
with individual ophthalmic surgeons to
cover such complications. Surgeons who
perform refractive surgery in an independ-
References
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2 Taboada J, Mikesell GW Jr and Reed RD
(1981). Response of the corneal
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3 Trokel SL and Srinivasan R (1983).
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4 Marshall JS, Trokel SL, Rothery S, and
Kreuger RR (1986). Photoablative
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Surface laser treatments: an alternative to LASIK?
ent capacity often manage their own com-
plications or may refer privately to a more
experienced colleague. However, in law
there is nothing to prevent a refractive
patient from being referred to the NHS for
a second opinion by his or her GP.
Generally, such problems are well man-
aged through mutual respect among pro-
fessionals, with a sense of proportion and
goodwill on both sides. In fact, with com-
mon sense, relationships between public
and private sectors can be managed to
everyone’s satisfaction, including that of
the most important individual, the patient.
Accuracy issues
At present there is no way to measure
what an excimer laser is doing ‘in real
time’ (i.e., while a cornea is under the
laser). Hence, if one person’s cornea is
more or less dense than the average, the
laser will take off more or less tissue with
each pulse. Surgical technique is particu-
larly important in this respect. The longer
the surgeon takes doing the surgery, the
more the cornea dries out and compacts,
which means that the laser tends to take
off more tissue and overtreat the patient.
Hence, it is very important for each sur-
geon to develop a standard technique. The
excimer laser does not penetrate water.
Some surgeons have a ‘dry’ technique, in
which the corneal surface is wiped a lot,
whereas others have a relatively ‘wet’ tech-
nique. Hence, each surgeon has to devel-
op his or her own personal algorithms.
Even using the same laser in the same clin-
ic, two surgeons may use slightly different
7 Brown AD and Craig JP (1997). Laser in-
situ keratomileusis (LASIK): A
contemporary overview. Eye News 4,
7–14.
8 Pallikaris IG and Siganos DS (1994).
LASIK and PRK for correction of high
myopia. J Refract Corneal Surg. 10,
489–510.
9 Naroo SA and Charman WN (2001).
Refractive surgery: Review and current
status. Optom Pract. 2, 1–17.
10 Setser DW, Piper LG and Velazco JE
(1974). Quenching rate constants for
the Ar(3P0), Ar(3P2) and Xe(3P2) states.
Radiat Res. 59, 441–443.
11 Dagenhardt AH (1976). Light
coagulation of the eye. Br J Physiol Opt.
31, 11–18.
12 Fitzsimmons TD, Fagerholm P,
Härfstrand A and Schenholm M (1992).
Hyaluronic acid in the rabbit cornea
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■ 63
laser settings. Although the room in which
a laser is situated is air-conditioned, the
geography can make a difference. Hence,
a laser in, for example, Calgary, which is at
high altitude and has very dry air, will tend
to overtreat more than a laser in Houston,
with a high humidity in the operating
room despite the best efforts of the air con-
ditioning.
Corneal healing also plays a part. The
epithelium in both PRK and LASIK may
hypertrophy and alter the result. In the
final analysis, refractive surgery is about
biological systems and not electro-
mechanical ones,
Attempts to try and measure laser abla-
tion during surgery are ongoing. The main
problem is that the smooth air–fluid inter-
face is highly disturbed by the act or sur-
gery. Topography machines of various
sorts are thus not useful. Research is
underway to try and establish real-time
measurements by using interference pat-
terns. Haag–Streit now supply a non-con-
tact optical coherence pachymeter, which
is claimed to measure corneal thickness to
an accuracy of 1 or 2μm with great speed.
Some laser manufacturers are testing
whether to fit this to their systems to estab-
lish a feedback loop. Corneal thickness can
be measured just before surgery and then
as the ablation proceeds. When the
required amount of tissue has been
removed, the laser is turned off.
We can be certain of one thing – that
refractive technology will advance and
improve with time. Professionals in the field
should keep up with these advances, try to
discern the reality from the hype, and so
offer the best solution to their patients.
13 Kerr-Muir MG, Trokel S, Marshall J and
Rothery S (1987). Ultrastructural
comparison of conventional surgical and
argon fluoride excimer laser
keratectomy. Am J Ophthalmol. 103,
448–453.
14 Wang Z, Chen J and Yang B (1997).
Comparison of LASIK and PRK to
correct myopia from –1.25 to –6.00D. J
Refract Surg. 13, 528–534.
15 Levy SG (2000). Refractive surgery, part
5 – LASIK. Optom Today 40, 33–39.
16 Guell B and Muller A (1996). LASIK for
myopia from –7 to –8 dioptres. J Refract
Surg. 12, 222–228.
17 Shah S, Sarhan AR, Doyle SJ, Pillai CT
and Dua HS (2001). Br J Ophthalmol. 85,
393–396.
18 Yildirim R, Aras C, Ozdamar A,
Bahcecioglu H and Ozcan S (2000).
Reproducibility of corneal flap thickness
in laser in situ keratomileusis using the
Hansatome microkeratome. J Cataract
Refract Surg. 26, 1729–1732.
64 ■ Refractive surgery: a guide to assessment and management
19 Arevalo JF, Ramirez E, Suarez E, et al.
(2000). Incidence of vitreoretinal
pathologic conditions within 24 months
after LASIK. Ophthalmology 107,
258–262.
20 Salah T, Waring GO III, el Maghraby A,
Moadel K and Grimm S (1996). Excimer
laser under a corneal flap for myopia –2 to
–20D. Am J Ophthalmol. 121, 143–155.
21 Fiander DC and Tayfour F (1995). LASIK
treatment in 124 myopic eyes. J Refract
Surg. 11, S234–S238.
22 Alanis L, Ramirez R, Suarez R et al.
(1996). Spatial contrast sensitivity in
pre- and post-operative LASIK for high
myopic patients. Invest Ophthalmol Vis
Sci. 37, S570.
23 Stephenson C (2002). Complications of
PRK, LASIK and LASEK: Diagnosis and
treatment. Refract Eye News 1, 6–11.
24 Scerrati E (2001). Laser in situ
keratomileusis versus laser epithelial
keratomileusis (LASIK vs. LASEK). J
Refract Surg. 17, S219–S221.
25 Lee JB, Song GJ, Lee JH, Seo KY, Lee YG
and Kim EK (2001). Comparison of laser
in situ keratomileusis and photorefractive
keratectomy for low to moderate myopia.
J Cataract Refract Surg. 27, 565–570.
26 Oshika T, Klyce SD, Applegate RA,
Howland HC and El Danasoury MA
(1999). Comparison of corneal wavefront
aberrations after photorefractive
keratectomy and laser in situ
keratomileusis. Am J Ophthalmol. 127, 1–7.
27 Ang RT, Dartt DA and Tsubota K (2001).
Dry eye after refractive surgery. Curr Opin
Ophthalmol. 12, 318–322.
28 Iskander NG, Peters T, Penno EA and
Gimbel HV (2001). Late traumatic flap
dislocation after laser in situ
keratomileusis. J Cataract Refract Surg.
27, 1111–1114.
29 Pushker N, Dada T, Sony P, Ray M, Agarwal
T and Vajpayee RB (2002). Microbial
keratitis after laser in situ keratomileusis. J
Refract Surg. 18, 280–286
30 Shah S, Sebai Serhan AR, Doyle SJ, Pillai
CT and Dua HS (2001). The epithelial
flap for photorefractive keratectomy. Br J
Ophthalmol. 85, 393–396.
31 Kornilovsky IM (2001). Clinical results
after subepithelial photorefractive
keratectomy (LASEK). J Refract Surg. 17,
S222–S223.
32 Azar DT, Ang RT, Lee JB, et al. (2001).
Laser subepithelial keratomileusis: An
electron microscopy and visual outcomes
of flap photorefractive keratectomy. Curr
Opin Ophthalmol. 12, 323–328.
33 Pallikaris IG, Kymionis G and
Astyrakakis NI (2001). Corneal ectasia
induced by laser in situ keratomileusis. J
Cataract Refract Surg. 27, 1796–1802.
34 Doshi S (2001). Co-management
schemes. Optician 222, 34–35.
35 Doshi S (2002). Co-management in
refractive surgery: A honey trap?
Optician 224, 28–29.
36 Gimbel HV, van Westernbrugge JA,
Anderson Penno EE, Ferensowicz M,
Feinerman GA and Chen R (1999).
Simultaneous bilateral laser in situ
keratomileusis: Safety and efficacy.
Ophthalmology 106, 1461–1468.
37 Pop M and Payette Y (2000). Results of
bilateral photorefractive keratectomy.
Ophthalmology 107, 472–479.
38 Caubet E (1993). Cause of subepithelial
corneal haze over 18 months after
photorefractive keratectomy for myopia.
Refract Corneal Surgery 9, S65–S70.
39 Lohmann CP, Gartry D, Kerr-Muir M,
Timberlake G, Fitzke F and Marshall J
(1991). ‘Haze’ in photorefractive
keratectomy: Its origins and consequences.
Laser Light Ophthalmol. 4, 15–34.
 9
Wavefront technology
As made clear in previous chapters,
excimer laser refractive surgery has now
reached a stage in its development at
which, in carefully selected patients, it
offers a realistic, routine alternative to ear-
lier methods used to correct refractive
error (spectacles and contact lenses), at a
comparable level of cost. Nevertheless, the
search continues for ways to improve visu-
al outcomes and further reduce the possi-
bility of post-operative complications.
In this chapter we discuss a relatively
new development, wavefront technology,
as applied to excimer laser surgery. It is
hoped that, as well as aiding the traditional
spherocylindrical correction of ametropia,
this will lead to reduced post-operative
optical aberrations and hence better opti-
cal outcomes. The question of how the
opportunities offered by the availability of
an effective refractive surgical option to
correct ametropic patients can best be
embraced by the existing ophthalmic pro-
fessions is also discussed.
Introduction
In the naturally emmetropic eye, the qual-
ity of vision achieved depends both on the
quality of the optical image on the retina
and on the neural properties of the retina
and subsequent visual pathways.
The quality of the in-focus foveal opti-
cal image depends upon the effects of dif-
fraction, optical aberration and light
scatter, at least the first two of which are
a function of pupil diameter. With very
small pupils (<2mm), the effects of dif-
fraction dominate, but with increases in
pupil diameter diffractive blur reduces and
the degradative effects of aberration
become progressively more important.
W Neil Charman
Although effects vary between individu-
als, the optimal optical performance is usu-
ally achieved with a pupil diameter of
about 3mm, which corresponds to that of
the natural pupil under bright photopic
conditions.1 A similar general pattern of
behaviour is found in ametropes correct-
ed by spectacles or contact lenses,
although it is modified slightly by effects
such as spectacle magnification and the
aberrations of the correcting lenses.
The early years of refractive surgery
using radial keratotomy (RK) were domi-
nated by the goal of achieving a tolerably
accurate refractive correction. However, it
was soon realized that, even when this was
achieved, the quality of vision was usual-
ly worse than that found in naturally
emmetropic eyes or in ametropic eyes cor-
rected with spectacles or contact lenses.
Measurements showed that the loss in
vision resulted from the much poorer qual-
ity of the ‘best-corrected’ retinal image,
which was degraded both by light scatter
at the corneal RK incisions and by the
much-increased levels of aberration asso-
ciated with the limited optical zone
achieved and the discontinuities produced
by the pattern of incisions.2
With the advent of methods based on
the use of excimer laser ablation it was
hoped that, since changes in surface cur-
vature were produced smoothly over a
broad area of corneal surface rather than
at a limited number of incisions, as in RK,
a much improved optical effect would be
produced. Again, early efforts with both
photorefractive keratectomy (PRK) and
laser in situ keratomileusis (LASIK) con-
centrated on producing a satisfactory sphe-
rocylindrical refractive correction, but the
final quality of vision was still often disap-
pointing, with a loss in photopic best-cor-
rected visual acuity. Performance under sco-
topic conditions, when the pupil was dilat-
ed, was frequently particularly poor, with
complaints of haloes and scatter from lights
during night driving.3 While the increased
scatter could be attributed to wound-heal-
ing problems, many of the optical problems
were again found to be derived from the
increased levels of aberration in the eye after
refractive surgery eye.4
These increases in aberration were
associated with a variety of factors. In
early PRK procedures using broad-beam
lasers, the ablated zone was often of small-
er diameter than the natural dilated pupil,
which gave a massively undercorrected
spherical aberration, while any temporal
or spatial beam inhomogeneity led to
unwanted changes in the ablation pattern.
Decentration of the ablation was a fur-
ther problem in some cases. Other prob-
lems identified included central islands,
probably caused by ablation plumes that
affected local ablation rates, and irregu-
lar ablations caused by changes in
corneal hydration. Wider ablation zones,
blending zones and other measures have
brought some improvement, but they
have not eliminated these problems.
Thus, one of the goals of more recent
developments in refractive surgery is to
find ways to reduce post-operative optical
aberration. It should, of course, always be
remembered that refractive surgery has a
negligible effect on the longitudinal chro-
matic aberration of the eye, which remains
essentially unchanged at about 2D across
the visible spectrum.
The monochromatic aberrations of any
optical system depend upon the shapes of
its surfaces, as well as other factors. In prin-
ciple, then, aberration might be reduced by
reshaping one or more surfaces. Early laser
66 ■ Refractive surgery: a guide to assessment and management

systems, which involved broad-beam lasers
and devices such as expanding diaphragms,
could only deliver ‘standard’ ablation pat-
terns. The advent of the new generation of
computer-controlled, spot-scanning laser
systems, able to ablate different regions of
the cornea selectively, rather than merely
to produce ‘standard’ ablation patterns, has
opened up the intriguing possibility of cor-
recting the axial monochromatic aberra-
tions of the eye by suitably reshaping the
corneal surface with an ablation ‘cus-
tomized’ for each individual. If monochro-
matic aberration correction can be
achieved, then visual acuity should match,
or perhaps surpass, that achieved in natu-
rally emmetropic eyes.5
This, then, is the promise of the new
generation of laser systems that combine
a device to measure the aberration and
refractive error of the individual eye, and
a spot-scanning or other form of laser that
can ablate the cornea selectively, not only
to correct the refractive error, but also to
minimize the eye’s monochromatic aber-
rations. Since the ocular aberrations, and
also the refractive error, are analyzed in
terms of the form of the corresponding
wavefront, rather than in terms of the clas-
sic Seidel aberrations (spherical aberra-
tion, coma, oblique astigmatism, distortion
and field curvature), this area is often
called wavefront technology.
In the next sections we discuss the con-
cept of wavefront aberration, current
methods of measuring it in the individual
eye and the limits to the overall quality of
vision that might be achievable under ideal
circumstances.
Wavefront aberration
Consider the case of a point source of
light placed at the first focal point of a
converging, positive lens. If the propaga-
tion of the light is viewed in terms of rays,
in the absence of aberration we can
envisage the rays as divergent from the
point to emerge from the lens as a paral-
lel bundle. Alternatively, if we think in
terms of Huygen’s wave theory, series of
concentric spherical wavefronts spread out
from the point source and, after refraction
by the lens, emerge as plane wavefronts. On
both sides of the lens surfaces the local
wavefronts are always perpendicular to the
local rays (Figure 9.1a).
Now consider the case of a similar, but
poorly designed and manufactured, lens
with aberration. The rays that emerge
from the lens are no longer parallel and the
associated wavefronts are no longer spher-
ical (Figure 9.1b).
Evidently, a point object at the first focal
point is a special case. In the more general
ideal case, when the object is not at the first
focal point and the image is not expected to
lie at infinity, rays diverge from the object
point to converge at a unique Gaussian
image point. In wave terms, spherical wave-
fronts diverge from the object point and the
lens reshapes these as a series of spherical
wavefronts, all centred at the image point
(Figure 9.1c). If there is an aberration, the
rays no longer intersect at the unique
image point and the imaging wavefronts
are no longer spherical (Figure 9.1d).
How can we quantify the aberration?
Evidently, we can approach this either in
terms of the characteristics of the emer-
gent rays or of the emergent wavefronts. In
principle, we can always derive one descrip-
tion from the other, since wavefronts and
rays are always locally perpendicular. For
example, we might specify the ray aberra-
tions in terms of the slope of each ray as it
leaves the exit pupil as a function of the ray
position within the pupil. This, in turn,
would allow us to derive a spot diagram
that shows the intersection of the rays with
any chosen image plane. Alternatively, we
could compare the imaging wavefronts
with their ideal spherical counterparts.
This is normally done in the exit pupil of
the system. If the ideal image point is at
infinity, the ideal wavefront is plane (i.e., it
has an infinite radius of curvature).
We call the ‘ideal’ spherical wavefront,
centred at the Gaussian image point O⬘, the
reference sphere and take the wavefront
aberration at each point in the pupil as the
optical path distance between the reference
sphere and the aberrated wavefront (Figure
9.2a). In many applications, the radius of
curvature of the reference sphere is cho-
sen so that the wavefront aberration on
axis at the centre of the exit pupil is zero,
but this need not be the case. Clearly, what
results is a ‘contour map’ that shows the
variation in wavefront aberration across
the exit pupil (Figure 9.2b). It is usual to
specify the amount of wavefront aberra-
tion in microns (or sometimes wavelengths
of light) and the position in the pupil in
terms of either Cartesian (x, y) or polar (r,
θ) coordinates (Figure 9.2a). Not surpris-
ingly, the wavefront aberration varies with
the position of the object point in the field

a c

d
b

Figure 9.1
Rays and wavefronts. (a) Rays that diverge from the first focal point of an aberration-free, convergent lens emerge parallel (full lines). Alternatively,
we can envisage divergent spherical wavefronts that leave the object point to emerge as flat wavefronts (dashed lines), which are everywhere
perpendicular to the rays. (b) Situation with an imperfect convergent lens: the rays that emerge from the lens are not parallel and the corresponding
wavefronts are not flat. (c) General case of an aberration-free convergent lens: the rays that diverge from the object point all pass through the image
point. Alternatively, the spherical wavefronts that diverge from the object point emerge from the lens as spherical wavefronts all centred on the image
point. (d) In the case of an imperfect lens, the emergent rays do not intersect at a point and the imaging wavefronts are not spherical
 Wavefront technology ■ 67

Wavefront

Reference sphere
r x
␪
Chief ray
O⬘

Exit pupil
W
a b

Figure 9.2
(a) The wavefront aberration, W, is the distance between the actual wavefront in the pupil and the ideal spherical reference wavefront, centred on the
Gaussian image point. The position within the pupil can be specified either in terms of Cartesian (x, y) or polar (r, θ) coordinates. A positive value
of W(x, y) or W(r, θ) means that the wavefront is in advance of the reference sphere. (b) Typical contour map that shows the variation in wave
aberration across the pupil

(i.e., the field angle), but in the case of the
eye we are almost always concerned with
the aberration on the visual axis, when the
image point lies on the fovea.
Recalling that to form a diffraction-lim-
ited image all parts of the wavefront must
arrive in phase at the image point, we can
see that it is desirable for the wavefront
aberration to remain as small as possible,
so the ideal wave aberration map is com-
pletely free of contours. Rayleigh suggest-
ed that the wavefront aberration should
nowhere exceed a quarter wavelength,
otherwise the light disturbances from dif-
ferent parts of the exit pupil would start to
interfere destructively. Maréchal expressed
the same idea in terms of the root mean
square (RMS) value of the wavefront aber-
ration across the pupil and suggested that
this should not exceed one-fourteenth of
a wavelength (the variance of the wave-
front aberration is the square of the local
wavefront aberration integrated over the
pupil area, divided by the pupil area; the
RMS aberration is the square root of the
variance).
For both these criteria it can be seen that,
if aberration is to play a negligible role, the
typical wavefront aberration across the
pupil must remain small (about 0.1μm or
less). Referring this tolerance to refractive
surgery, this is only a small fraction of the
typical total depth of stromal material
removed (which is usually of the order of
tens of microns), which implies the need for
a very accurate control of ablation depth.
How can we relate these general ideas
on wavefront aberration to the measure-
ment of ocular aberration and perhaps
combine measurements of refractive or
defocus error with those of aberrations like
spherical aberration and coma? Consider
the ‘ideal’, aberration-free emmetropic eye
shown in Figure 9.3a. If, somehow, a point
source of light can be produced on the reti-
na (usually with the aid of a low-power
laser), all the light rays will emerge paral-
lel from the eye, which corresponds to the
ideal, plane reference wavefronts. Suppose,
however, that the eye suffers from myopia,
but not from aberration. The emergent rays

a c

b d

Figure 9.3
(a) Rays and wavefronts for a ‘perfect’ emmetropic eye: the emergent wavefronts are plane. (b) The myopic eye: the emergent wavefronts are
spherical and convergent. (c) The hypermetropic eye: the emergent wavefronts are spherical and divergent. (d) An eye that suffers from
undercorrected spherical aberration: the emergent wavefronts are non-spherical
68 ■ Refractive surgery: a guide to assessment and management
now converge to a far point in front of the
eye, that is the emergent wavefronts are
convergent and spherical rather than plane
(Figure 9.3b). If the eye is hypermetropic
the emergent rays diverge as though they
came from a far point behind the eye, so
that the wavefronts are spherical, but
divergent (Figure 9.3c). In such ‘ideal’ cases
of spherical refractive or defocus error, we
can see that the wavefront aberration cor-
responds to the distance between an ideal
plane reference and a spherical wavefront.
Recalling the sag formula, this implies that
the wavefront aberration shows a second-
order (r2) dependence on the distance from
the centre of the pupil. Thus, if we find that
the wavefront aberration varies as r2 in
polar coordinates, or (x2 + y2) in Cartesian
coordinates (second-order aberration), we
must have an error of focus for the eye.
Analogous effects occur if the eye is
astigmatic, the difference being that the
curvature of the emergent wavefronts
varies with the meridian under consider-
ation, although the wavefront aberration
still has a second-order, r2, dependence in
each meridian. The curvature takes its
maximum and minimum values in the two
principal meridians of the astigmatic eye.
It is, of course, also possible for the rays
that emerge from the eye to be parallel, but
tilted with respect to the expected direction
(i.e., that there is a prismatic effect). The
corresponding wavefronts are evidently
plane, but tilted with respect to the ‘ideal’
reference wavefronts, with the wavefront
aberration varying linearly across the
pupil in the tilt direction. Thus, first-order
wavefront aberration terms in r or (x2 +
y2)1/2 correspond to prismatic effects.
What about ‘real’ aberrations, like a
spherical aberration? This aberration
implies that the outer zones of the pupil
have a different power to the central zones.
Figure 9.3d shows the case for an eye that
is emmetropic at the centre of the pupil,
but myopic in the periphery. We can see
that, in this case, in comparison to a sim-
ple defocus the wavefront must be rela-
tively more steeply curved in the outer
parts of the pupil and the aberration must
be a higher-order function of r: since it is
rotationally symmetrical, it must be a
function of r4, r6, etc. In fact, in wavefront
terms, the classic Seidel aberrations, and
the irregular aberrations that occur in bio-
logical structures such as the human eye,
all need to be expressed as higher-order
functions of the pupil variables. For this
reason they are known as higher-order
wave aberrations (third-order and above).
Clearly, a conventional refractive correc-
tion with a spherocylindrical lens can only
correct the prism and defocus (first- and
second-order) terms of the wavefront aber-
ration, not the higher-order terms.
Importantly, we must be careful not to
confuse third- or fifth-order wavefront
aberration (i.e., wavefront aberration that
varies as the cube or fifth power of the radi-
al coordinate r) with classic third- or fifth-
order Seidel aberration theory,6 in which
the power refers to the angle of incidence
of the rays. It is unfortunate that this pos-
sible confusion of terminology exists.
Analysis of wavefront
aberration
Suppose that we have somehow produced
a ‘contour map’ that shows the total wave-
front aberration of a particular eye (Figure
9.4), how do we know how much of the
aberration is caused by second-order,
spherocylindrical defocus errors, how
much by spherical aberration, how much
by coma, and so on? Clearly, we need some
way to break down the overall aberrations
into the appropriate, simpler component
parts, each related to a particular sort of
wavefront distortion.
In principle, this can be done in a vari-
ety of different ways, but it is currently
usual in the field of refractive surgery to
represent the wavefront aberration across
the pupil as the sum of a series of Zernike
polynomial terms,7–9 each of which rep-
resents a particular ‘component’ of wave-
front distortion. These polynomials were
devised by Fritz Zernike, who was award-
ed a Nobel Prize for his invention of the
phase-contrast microscope. For enthusi-
asts, these polynomials have the mathe-
matical advantage that the terms are
orthogonal (i.e., independent of one
another) over a unit pupil (in practice, this
means that Zernike coefficients derived for
a particular pupil diameter must be recal-
culated if the pupil diameter is changed10).
Various notations can be used to repre-
sent the Zernike polynomials, but most
workers and manufacturers now use a stan-
dard system devised by a committee of the
Optical Society of America.9 This refers the
wave aberration to the entrance pupil of the
eye (since the exit pupil is not readily acces-
sible) and uses the line of sight as the refer-
ence axis. The latter corresponds to the chief
ray from the fixation point, which passes
through the centres of the entrance and exit
pupils to reach the fovea. Since the Zernike
polynomials are only orthogonal over a unit
circle, the normalized radial distance in the
pupil ρ = r/rmax is used as one polar coordi-
nate, where rmax is the maximum pupil
diameter for the measured wavefront aber-
ration. The azimuthal angle θ is defined in
the same conventional way as the cylinder
axis in optometry, except that it can have val-
ues between 0 and 360° (2π radians). The
wavefront aberration W(ρ, θ) is broken
down as the sum of the Zernike polynomi-
als, as in Equation (9.1),
W(ρ,θ) = ∑nmCnmZnm(ρ, θ)
= C00Z00 + C1–1Z1–1 + C11Z11 +
C2–2Z2–2 + C20Z20 + C22Z22 +
… etc. (9.1)
where Cnm is the coefficient for each of the
Zernike polynomials Znm(ρ, θ) and the
coefficients vary with the aberration of the
particular eye. The subscript n represents
the highest order (power) of the radial
parameter ρ contained in the particular
polynomial, which also contains a cosine
or sine term of a multiple, mθ, of the
azimuthal angle θ, so that m is often
termed the azimuthal frequency. Note that
when, for example, a fifth-order Zernike
term is mentioned, it is the value of n that
is being referred to (n = 5).
Each polynomial Znm(ρ, θ) is the prod-
uct of three components: a normalization
term, a polynomial in ρ of order n and an
azimuthal component of the form sinmθ
or cosmθ.
Table 9.1 lists polynomials up to the fifth-
order. Details of still higher-order polyno-
mials are given in, for example, Thibos et al.9
As noted earlier, each polynomial essentially
describes a particular type of deformation
of the wavefront, and the magnitudes of
Figure 9.4
Typical colour-coded contour map
of the wavefront aberration of an
eye that shows a mixture of
defocus errors caused by ametropia
and higher-order errors caused by
aberrations such as spherical
aberration and coma
 Wavefront technology ■ 69

Table 9.1 Listing of Zernike polynomials up to the fifth order (Optical Society of America format9)
Index j Order n Frequency m Zernike polynomial Znm(ρ, θ) Description
0 0 0 1 Piston
1 1 –1 2ρsinθ Tilt about x axis
2 1 1 2ρcosθ Tilt about y axis
3 2 –2 61/2ρ2sin2θ Astigmatism, axis 45°, 135°
4 2 0 31/2(2ρ2 – 1) Spherical defocus
5 2 2 61/2ρ2cos2θ Astigmatism, axis 0°, 90°
6 3 –3 81/2ρ3sin3θ Trefoil (base on x axis)
7 3 –1 81/2(3ρ3 – 2ρ)sinθ Primary coma along x axis
8 3 1 81/2(3ρ3 – 2ρ)cosθ Primary coma along y axis
9 3 3 81/2ρ3cos3θ Trefoil (base on y axis)
10 4 –4 101/2ρ4sin4θ
11 4 –2 101/2(4ρ4 – 3ρ2)sin2θ
12 4 0 51/2(6ρ4 – 6ρ2 +1) Primary spherical aberration
13 4 2 101/2(4ρ4 – 3ρ2)cos2θ
14 4 4 101/2ρ4cos4θ
15 5 –5 121/2ρ5sin5θ
16 5 –3 121/2(5ρ5 – 4ρ3)sin3θ
17 5 –1 121/2(10ρ5 – 12ρ3 + 3ρ)sinθ
18 5 1 121/2(10ρ5 – 12ρ3 + 3ρ)cosθ
19 5 3 121/2(5ρ5 – 4ρ3)cos3θ
20 5 5 121/2ρ5cos5θ

their coefficients Cnm give the amount of

deformation of that type present in the par-
ticular overall aberration map. Rather than
always using the double-indexing system
Znm to describe a particular Zernike poly-
nomial or mode, a single-indexing system,
Zj, is used occasionally. The relation between Z00
the j, m and n terms is given in Table 9.1,
which also gives some of the names that are
often attached to the polynomials.
If we examine the polynomials in more
detail, it may initially seem a little odd that,
for example, third-order polynomials often
Z1–1 Z11
include first-order terms, fourth-order poly-
nomials second-order and constant terms,
and so on. The role of these terms is to
reduce the RMS deviation contributed by
each polynomial. Thus, in Equation (9.2),

Z40 = 51/2(6ρ4 – 6ρ2 +1) (9.2) Z2–2 Z20 Z22

the wavefront aberration contributed by

the 6ρ4 term is balanced by that from the
–4ρ2 term, which corresponds to the ‘best
focus’ in the case of spherical aberration
that lies between the paraxial and mar- Z3–3 Z3–1 Z31 Z33
ginal foci. The constant piston term 1 is
added to make the mean wavefront error
zero. In fact, the form of all the polynomi-
als except the Z00 piston term is such that
in each case the mean wavefront error
across the pupil is 0. The normalization
term (51/2 in the case of Z40) is chosen so Z4–4 Z4–2 Z40 Z42 Z44
that the coefficient of the polynomial (e.g.,
C40 ) represents the contribution made by Figure 9.5
the corresponding type of wavefront defor- Contour maps that show the form of the wavefront deformation associated with each of the
mation to the overall RMS wavefront error. Zernike polynomials (modes)
70 ■ Refractive surgery: a guide to assessment and management
Z00
Z1–1
Z2–2 Z20
Z3–3 Z3–1
Z4–4 Z4–2 Z40
Figure 9.6
Isometric views of the wave aberrations that correspond to the first 15 orders. Note that the
mean wavefront error is zero in all cases except the Z00 piston term
Figures 9.5 and 9.6 show the wave-
front deformations associated with each
of the polynomials. It can be seen that the
polynomials can be arranged in a pyram-
idal manner, in which higher-order
Zernike modes represent increasingly com-
plex patterns of deformation. Although
there is no exact term-by-term equiva-
lence, the terms can be related broadly to
traditional concepts of refractive error and
aberration according to the order of their
radial components (see Table 9.1):
• The zero-order (piston) term is not sig-
nificant;
• first-order terms represent prismatic
effects;
• Second-order terms represent spheri-
cal and astigmatic defocus;
• Third- and fifth-order terms represent
coma-like aberrations; and
• Fourth and sixth-order terms repre-
sent spherical-like aberrations.
Although, theoretically, the Zernike terms
continue to higher and higher orders, it
is rarely of interest to go further than the
sixth-order for the eye, since the corre-
sponding coefficients are very small and
so these terms contribute little to the over-
all aberration. It is easy to see why this is
so: the very high-order terms represent a
wavefront with aberrations that change
Z11
Z22
Z31 Z33
Z42 Z44
rapidly with position in the pupil, where-
as under most circumstances the wave-
front after laser surgery (and in the natural
eye) is normally relatively smooth.
As noted earlier, one of the advantages
of using normalized Zernike polynomials
is that the absolute value of the coefficient
Cnm for each polynomial mode represents
the mode’s contribution to the overall RMS
wavefront deviation. Thus, for example, if
we want to know the combined contribu-
tion of the four third-order coma-like
terms to the overall wavefront variance σ2
(i.e., the square of the RMS deviation) for
the pupil diameter for which the Zernike
terms are valid, we can write Equation
(9.3),
σ2 = (C3–3)2 + (C3–1)2 + (C31)2 +
(C33)2 (9.3)
However, it is unfortunately not true that
equal coefficients for different modes imply
equal visual effects. Applegate et al.11 have
shown that, for equal coefficients, spheri-
cal defocus (Z20) has a relatively greater
degradative effect on visual acuity than
the astigmatism modes Z22 and Z2–2, and
that the coma terms Z31 and Z3–1 decrease
acuity more than the trefoil terms Z33 and
Z3–3. Combinations of terms may have a
less degradative effect than individual
terms. This is, of course, not surprising.
It is, for example, well known in optome-
try that the effect of a given cylindrical
refractive error (i.e., a constant magnitude
of second-order wavefront aberration) on
visual acuity varies with the orientation of
the cylinder axis.
Useful information on the distributions
of the values of the various Zernike coef-
ficients in normal (unoperated) eyes is
given by Porter et al.12 and Thibos et al.13
For most of the coefficients the values are
symmetrically balanced about zero, as
shown in Figure 9.7. This suggests a cen-
tral tendency for natural eyes to be free of
most higher-order aberrations, although
biological variability means that any indi-
vidual is equally likely to have a positive or
negative aberration. The only clear excep-
tion is the C40 coefficient, which is sys-
tematically biased towards positive values
(undercorrected spherical aberration). The
spread of values becomes smaller as the
mode order increases.
Wavefront aberration and
refractive correction
At first sight, it might appear that if we are
to use wavefront measurements as the basis
on which to choose a spherocylindrical
refractive correction, we need to consider
only the values of the second-order defocus
coefficients. However, if this approach is
used, the derived prescription is usually
found to vary with pupil size,14 even though
in practice subjective refraction seems to
change little under photopic conditions as
the pupil size changes.15,16 The reason for
the failure of the second-order coefficients
C2–2, C20 and C22 to provide a good predic-
tor of optimal refractive correction under all
circumstances is because of the presence of
second-order terms in several of the higher-
order Zernike polynomials. As discussed pre-
viously, these second-order terms help to
balance the degradative effects of spherical
and other aberrations. Obviously, the qual-
ity of the retinal image is improved by their
inclusion and hence they should be incor-
porated in the correction. Atchison et al.17
give appropriate equations that include all
the relevant Zernike coefficients in the cal-
culation of the corresponding objective
spherocylindrical prescription. They suggest
that an objective refraction should be based
on either just the second-order Zernike coef-
ficients for a small pupil (for which the effects
of higher-order aberrations are usually
small) or on both the second- and fourth-
order Zernike aberrations deduced with a
larger pupil (say 6mm).
72 ■ Refractive surgery: a guide to assessment and management

Figure 9.8 scatter of intersections, or ‘spots’, is

BS Essentials of the H-S obtained (Figure 9.9a), and the greater the
aberrometer. concentration of points in the ‘spot dia-
LB (a) Typical basic gram’, the more closely the eye corre-
design of sponds to the ideal case.
aberrometer: LB, Whereas the spot diagram relies purely
input laser beam, on geometrical optics, the point-spread
which produces a function (PSF) or image of a point includes
small spot light on the effects of diffraction (Figure 9.9b). When
HS the retina; BS, beam the amount of aberration is large, there is
splitter; HS, H-S little difference between the spot diagram
a lenslet array; CCD, and the PSF, but for eyes with very little
CCD CCD camera. (b) Spot aberration the PSF is more realistic. The PSF
images formed on a is calculated by first using the wave aberra-
plane wavefront: the tion to determine the variations in the phase
array of spots in the of the light disturbance across the pupil.
focal plane of the H-S The local phase is simply the wave aberra-
lenslet array is tion in microns, divided by the wavelength
regular. (c) Spot of the light in use and multiplied by 360°.
images formed with The amplitude across the pupil is either
an aberrated treated as being constant or can be weight-
wavefront yield an ed to allow for the Stiles–Crawford effect.
b irregular array of H- From the amplitude and phase distribution
S image spots. In across the pupil (the pupil function), the PSF
practice, many more can be calculated.7
lenslets are used A third descriptor of image quality that
is often of interest is the modulation trans-
fer function (MTF), which shows how the
contrast of sinusoidal gratings is degrad-
ed in the image as a function of spatial fre-
c quency. When the wavefront aberration,
and the associated spot diagram and PSF,
lack rotational symmetry, the MTF varies
with the orientation of the gratings (Figure
9.9c). The ocular MTF can also be calcu-
lated from the pupil function for the eye,
as the real part of its Fourier transform.
Lastly, software often generates a repre-
sentation of the retinal image of a chosen
object (e.g., a Snellen E) in the presence of
a known ocular wavefront aberration. This
may be obtained by convolution of the
object luminance distribution with the
appropriate PSF (i.e., by blurring each point
in the object so that it appears as a PSF of
appropriately weighted illuminance and
a b
then summing the combined PSFs to give
the overall image). Alternatively, the same
calculation may be carried out by Fourier
methods. Care must be exercised when
interpreting these calculated images, since
neural and other factors may mean that
they do not correspond very closely to what
the patient actually sees.

Using the wavefront

information in refractive
surgery
c d
Wavefront-guided surgery involves apply-
Figure 9.9 ing an ablation that attempts to neutral-
Examples of (a) a spot diagram, (b) a PSF, (c) a two-dimensional MTF and (d) a retinal image, ize the measured wavefront aberration of
calculated from wavefront data by current commercial aberrometer software the original eye, that is both the ametropia

and the higher-order aberrations. Success
in this balancing procedure is not easy to
achieve. Not only must the original wave-
front measurements be valid and reliable,
but also many laser beam, tissue ablation
and healing characteristics will affect the
final result. It is, for example, obvious that
laser-spot diameters of less than 1mm are
necessary if higher-order aberrations are
to be corrected. Yet this, in turn, means
that more spot pulses are required to cover
the full ablation area, so that at any given
pulse frequency the ablation takes longer
than with a larger spot and the problems
of maintaining patient alignment and
corneal hydration tend to increase. In
LASIK, the variables introduced by the
need to replace the flap offer further diffi-
culties. This may favour the development
of alternative methodologies, such as
LASEK. Calculation and control of the
number and position of the laser spots
required must be extremely accurate. Fast
eye tracking is likely to be necessary to
avoid problems caused by eye movement.
A further constraint on the degree to
which aberration can be corrected is set by
the need to preserve an adequate thickness
of undisturbed cornea (at least 250μm):
this is a particular problem for higher
refractive corrections, for which the diam-
eter of the ablation zone may have to be
limited, even though this leaves an aber-
rated eye for larger pupil diameters.
At the present time, most manufac-
turers of laser systems have begun to
offer wavefront measurement integrated
with their ablation systems, and experi-
ence in their combined use is beginning
to build up. Early results show promise,
but indicate that, although it can be
demonstrated that eyes with less post-oper-
ative aberration tend to show higher levels
of visual performance, low levels of ocular
aberration cannot be achieved routinely at
present. The main immediate value of the
technique is undoubtedly that, since pre-
and post-operative wavefront maps can be
compared, the exact effects of the particu-
lar ablation pattern can be assessed in rela-
tion to the other parameters of the
individual eye. Such comparisons should
lead to a fuller understanding of the factors
involved and to the development of
improved ablation algorithms able to pro-
duce more consistent refractive outcomes.
In the longer term, however, it is dif-
ficult to see how the various factors
involved in a single excimer laser ablation
procedure can be controlled routinely to
the degree of precision required to cor-
rect accurately not only spherical and
astigmatic errors (second-order wave-
front errors), but also the higher-order
aberrations. It seems reasonable to hope,
however, that higher-order aberrations
may be kept at or even below the levels
found in naturally emmetropic eyes,
rather than being substantially higher, as
is the case without wavefront technology.
A major routine application of wavefront
technology may be to help identify why some
post-operative eyes have poor acuity and to
help plan enhancement procedures to
reduce unusual levels of aberration.
Super vision
Let us suppose, perhaps optimistically in
the light of the previous section, that
understanding of the factors involved in
aberration correction improves to the
extent that ablation-corrected eyes can
give diffraction-limited performance in
monochromatic light for distance vision
(or, if required, for any other distance).
With such excellent optics, what improve-
ments in visual performance over those
achieved by natural emmetropes could be
expected? As normal eyes suffer from aber-
ration, which blurs the retinal image, will
the ideal aberration correction yield ‘super
vision’ with levels of acuity much better
than the values of 6/4 usually achieved by
normal, young adults.18
The key factor here is that visual per-
formance is not just limited by optics: it also
depends upon the retina and subsequent
stages of neural processing. It is clear that
the sampling limitations imposed by the
finite size of the cone photoreceptors that
form the foveal retinal mosaic would set a
limit on achievable acuity, even if there
were no optical degradation whatsoever, as
Wavefront technology ■ 73
illustrated in Figure 9.10. Although this
sampling limit varies somewhat with the
individual, the spacing of the foveal cones
is such that it typically lies at about 60
cycles per degree (c/°) for grating objects,
corresponding to about 6/3 Snellen equiv-
alent. Finer gratings may detected, but will
appear as some other form of coarser pat-
tern, typically as ‘zebra stripes’. This phe-
nomenon is known as aliasing.
We can see, then, that the limits set by
retinal neural factors mean that a reduc-
tion in the natural level of aberration in
the eye is unlikely to produce high-contrast
Snellen acuities much better than 6/3.
This is, of course, much better than the
levels typically achieved after current
refractive surgery (in which only about
80% of patients achieve uncorrected
acuities of 6/6), but not much better than
that achieved by the best of natural eyes.
What combined optical and neural
performance levels might be achieved in
practice if higher-order monochromatic
aberrations were eliminated? Since in the
natural and current post-surgical eye the
degradative effects of aberration worsen
as the pupil diameter rises, while diffrac-
tive blur reduces, the greatest improve-
ments in optical retinal image quality are
potentially obtainable when the pupil
diameter is large. However, unless the pupil
is artificially dilated, large pupils only
occur when light levels are low and the
spatial resolution achieved by the retina is
degraded because of a shift towards rod
vision and increased spatial integration.
We must remember, too, that even if the
monochromatic aberrations are correct-
ed, the retinal image will still be blurred by
longitudinal chromatic aberration.
Figure 9.10
Resolution limit set by the
sampling limit of the foveal
cone mosaic. To resolve the
bars of a Snellen ‘E’, there
must be unstimulated cones
between the stimulated cones
74 ■ Refractive surgery: a guide to assessment and management

To illustrate these effects, Figure 9.11

shows the MTF for the eye when the Diffraction only LCA Retinal threshold Experimental

Modulation transfer or contrast threshold

entrance pupil diameter is either 3.0 or 1.20
6.0mm. Three MTFs are shown for each
pupil diameter: 1.00
• A typical experimentally measured
MTF for a natural eye with normal lev- 0.80
els of aberration;
• MTF for an ideal aberration-free eye 0.60
working in monochromatic light of
wavelength 555nm; and 0.40
• The same eye working in white light
with the degradative effects of chro-
0.20
matic aberration included.
Also shown in Figure 9.11 is the photopic
0.00
contrast threshold at the retinal level. If the 0 10 20 30 40 50 60 70 80 90 100
MTF falls below this threshold level, the grat-
a Spatial frequency (c/°)
ing cannot be resolved, even at maximal
contrast. The highest spatial frequency of
Diffraction only LCA Retinal threshold Experimental
high-contrast grating that can be resolved
Modulation transfer or contrast threshold

1.20
lies at the intersection of the MTF with the
threshold curve. As discussed earlier, it can
1.00
be seen that to eliminate optical aberration
gives much more benefit at the larger pupil
0.80
diameter, but only if the retinal threshold is
unchanged (i.e., the pupil is artificially dilat-
ed). With smaller, normal photopic pupils, it 0.60
can be seen that it is likely that the main ben-
efit would be an overall improvement in 0.40
image contrast at spatial frequencies below
the cut-off, with only minor improvements 0.20
in the cut-off frequency itself.
Finally, even if the technical problems 0.00
associated with the corrective ablation and 0 10 20 30 40 50 60 70 80 90 100
possible regression effects can be overcome, b Spatial frequency (c/°)
it is likely to be impossible to correct mono-
chromatic aberration fully at all times by
Figure 9.11
surgical means.19 The natural aberrations
The ocular MTF for (a) 3mm and (b) 6mm pupil diameters. For each pupil diameter the MTFs
vary as a function of accommodation (i.e.,
shown are for an eye free of aberration and working in monochromatic light, for the same eye
object distance) and age, while in any case
working in white light and for an experimentally measured curve for a real eye. Also shown is
lags and leads of accommodation are
the photopic retinal contrast threshold. The highest spatial frequency of high-contrast grating
known to typify the accommodation sys-
that can be resolved lies at the intersection of the MTF with the threshold curve
tem, and introduce variable second-order
defocus aberrations. Further problems are
caused by the fast (0.1–2.0Hz) fluctuations
in accommodation that occur with ampli- In summary, then, the possibility of pro- situ, perhaps by ablation or by changing its
tudes of 0.1–0.2D: these demand a dynam- ducing a marked enhancement of the local index with a control beam, might
ic correction of aberration.20 There is also vision of those who already have good acu- present a possible future practical path to
evidence that aberrations may change as ity by surgical means appears limited. improved vision, since secondary non-inva-
a result of tear film changes, prolonged However, it has been suggested that the sive adjustments could be made to main-
near work or diurnal variation in corneal implantation of an intraocular lens of tain overall ocular aberration at a low level.
thickness and curvature.21,22 which the aberration could be adjusted in This lies some way in the future, however!

References
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Optical quality of the human eye. J
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2 Applegate RA, Howland HC, Sharp RP,
Cottingham AJ and Lee RW (1998).
Corneal aberrations and visual
performance after radial keratotomy. J
Refract Surg. 14, 397–407.
3 Fan-Pau NI, Li J, Miller JS and Florakis GJ
(2002). Night vision disturbances after
corneal refractive surgery. Surv
Ophthalmol. 47, 533–546.
4 Oliver KM, Hemenger RP, Corbett MC, et
al. (1997). Corneal optical aberrations
induced by photorefractive keratectomy.
J Refract Surg. 13, 246–254.
5 Macrae SM, Krueger RR and Applegate
RA (2001). Customized Corneal Ablation:
The Quest for Supervision. (Thorofare:
Slack Inc.).
6 Freeman MH (1990). Optics, p.
231–236. (London: Butterworths).
7 Born M and Wolf E (1993). Principles of
Optics, Sixth Edition, p. 464–466 and p.
965–973 (Oxford: Pergamon Press).
8 Kim C-J and Shannon RR (1987).
Catalog of Zernike polynomials. In
Applied Optics and Engineering, Vol. X, p.
193–221, Ed. Shannon RR and Wynant
JC (London: Academic Press).
9 Thibos LN, Applegate RA, Schwiegerling
JT and Webb R (2002). Standards for
reporting the optical aberrations of eyes.
J Refract Surg. 18, S652–S660.
10 Schwiegerling J (2002) Scaling Zernike
expansion coefficients to different pupil
sizes. J Opt Soc Am A 19, 1937–1945.
11 Applegate RA, Sarver EJ and Khemsara
V (2002). Are all aberrations equal? J
Refract Surg. 18, S556–S562.
12 Porter J, Guirao A, Cox IG and Williams
DA (2001). The human eye’s
monochromatic aberrations in a large
population. J Opt Soc Am A 18,
1793–1803.
13 Thibos LN, Bradley A and Hong X
(2002). A statistical model of the
aberration structure of normal, well-
corrected eyes. Ophthalmic Physiol Opt.
22, 427–433.
14 Mrochen MC, Bueeler M and Seiler T
(2002). Influence of higher-order optical
aberrations on refraction. Invest
Ophthalmol Vis Sci. 43, S82.
15 Charman WN, Jennings JAM and
Whitefoot H (1978). The refraction of
the eye in relation to spherical
aberration and pupil size. Br J Physiol
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16 Atchison DA, Smith G and Efron N
(1979). The effect of pupil size on visual
Wavefront technology ■ 75
acuity in uncorrected and corrected
myopia. Am J Optom Physiol Opt. 56,
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17 Atchison DA, Scott DH and Charman
WN (2003). Hartmann–Shack
technique and refraction across the
horizontal visual field. J Opt Soc Am A.
20, 965–973.
18 Elliott DB, Yang KC and Whitaker D
(1995). Visual acuity changes
throughout adulthood in normal,
healthy eyes: Seeing beyond 6/6. Optom
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19 Charman WN (2003). The prospects for
super acuity: Limits to visual
performance after correction of
monochromatic ocular aberration.
Ophthalmic Physiol Opt. 23, 479–493.
20 Hofer H, Artal P, Singer B, Aragon JL and
Williams DR (2001). Dynamics of the
eye’s wave aberration. J Opt Soc Am A
18, 497–506.
21 Handa T, Mukuno K, Niida T, Uozato H,
Tanaka S. and Shimizu K (2002).
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curvature in young adults. J Refract Surg.
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22 Harper CL, Boulton ME, Bennett D, et al.
(1996). Diurnal variations in human
corneal thickness. Br J Ophthalmol. 80,
1068–1072.
 10
Future trends in refractive
surgery
Shehzad A Naroo and W Neil Charman
Introduction
Instrumentation and techniques in refrac-
tive surgery are improving all the time.
This is evident when we look at the two
video clips (see Chapter 6 and the CD Rom)
of a flap being cut in a LASIK procedure.
Video clip 2 shows the Hansatome micro-
keratome from Bausch and Lomb, which
is by far the most popular microkeratome
in the UK today. It is a two-piece device
and cuts a hinge in the superior position.
If we compare this to video clip 3 of the
Amadeus microkeratome from Advanced
Medical Optics (AMO), it is clear that the
cutting of the flap seems to be simpler
with the one-piece Amadeus. The
Amadeus cuts a flap in the nasal posi-
tion, which some surgeons argue is bet-
ter than a superior hinged flap, while
others argue the opposite viewpoint.
Currently, there are a few very large
manufacturers of refractive surgery
equipment (excimer laser, microker-
atomes, aberrometry equipment, etc.)
and a handful of smaller companies. The
past few years have seen many smaller
companies being purchased by the larg-
er ones to strengthen expertise in a par-
ticular area previously lacking in the
larger company’s portfolio. This seems to
benefit both sizes of company, as the
larger players are able to support the
research and development of the small-
er ones and to merge their ideas with
those that may exist in another area in
which the larger company already has
expertise.
When discussing future developments
of refractive surgery it is possible to spec-
ulate on many things. A few of these are
outlined in this chapter but first the likely
growth in the industry is considered.
The UK market place
The past decade has seen an exponential
growth in the refractive surgery market. In
the UK the number of surgeons who per-
form a variety of techniques (laser and non-
laser) seems to be relatively steady, but an
increasing number of surgeons are becom-
ing involved with laser refractive surgery.
The number of specialist refractive surgery
clinics in the UK is interesting. These clin-
ics offer only refractive surgery, for which
some employ full-time refractive surgeons,
while others rely on session surgeons, who
may be involved in other areas of ophthal-
mology in a NHS hospital the rest of the
time. A few years ago, photorefractive ker-
atectomy (PRK) was gathering momentum
in the UK, but then many clinics closed.
More recently, we have seen an increase in
clinics that specialize in laser in situ ker-
atomileusis (LASIK), but some of these have
closed also. One high-street clinic that relied
heavily on co-management schemes with
nation-wide optometrists was taken over
recently by a high-street optical retailer.
Some of the other group optical retailers
have also chosen to become involved in
refractive surgery, while some have decided
not be involved at all. A few large-volume
refractive surgery clinics appear to meet
most of the nation’s refractive surgery needs
and these clinics seem to be able to adapt to
incorporate each new wave of popular tech-
niques and hence seem to be here for the
long term. Some of these clinics have
grouped together to form the Eye Laser
Association (ELA), which is able to promote
refractive surgery and increase awareness
of the area for interested patients and prac-
titioners.
It is often suggested that the market
place in the UK is a step behind that in the
USA. In the USA, the Food and Drugs
Administration (FDA) began to approve
excimer lasers for refractive surgery in
1996. Initially, the approval was granted
to some excimer laser manufacturers for
limited refractive errors. Gradually, further
approvals were granted and the industry
continued to grow. Meanwhile, in the UK
excimer lasers were already being used for
PRK and LASIK was beginning to emerge.
The USA surgeons did not have the same
early exposure to PRK as many of their
global counterparts, which may partly
explain some of the trends seen in the
USA. For example, in the USA radial kera-
totomy remained popular, whereas in
many other parts of the world it had a lim-
ited or short-lived popularity. Over the past
few years there has been a steady growth
in the refractive surgery industry in the
USA (Table 10.1). However, the percentage
growth year on year is declining steadily,
which might suggest that growth in the
industry is actually slowing down. Maybe
this is to be expected, as the initial large
group of patients who had waited to
undergo this type of surgery have now
explored this opportunity. There may now
remain a slower flow of patients who
reach the correct age or stability of
ametropia to have refractive surgery.
Perhaps when the next ‘big thing’ happens
in refractive surgery, we will see another
boom and then a gradual decline again.
Possible use of new types
of laser
Over the first two decades of laser refractive
surgery, the argon fluoride (ArF) excimer
laser, which emits at 193nm, reigned
supreme in terms of its ability to create

Table 10.1 Growth of the refractive surgery market in the USA
Year Number of treatments
1997 182,000
1998 409,500
1999 980,000
2000 1,550,000
2001 2,250,000
effective corneal ablations safely and with-
in an acceptable time span. Nevertheless,
such gas-based lasers have their disadvan-
tages in terms of cost, safety, beam stability
and maintenance. For this reason, the
search continues for both alternative laser
sources and different approaches to laser
refractive surgery.
Several solid-state lasers have been
developed with outputs at wavelengths
around 200nm, similar to that of the ArF
excimer laser. These include a flash-lamp
pumped laser that employs the fifth har-
monic of neodymium–yttrium aluminium
garnet (Nd:YAG) and emits at 213nm, a
diode-pumped fifth-harmonic neodymi-
um–yttrium lithium fluoride (Nd:YLF)
laser at 209nm and a fourth harmonic
titanium–sapphire crystal laser that works
at 208nm. None of these appears to have
gained widespread acceptance to date, but
undoubtedly the search for other alterna-
tives will continue.
A more radical departure from current
practice is offered by the use of pulses of
infrared laser light of ultra-short duration
to operate on the cornea.1 The Nd:YLF
picosecond laser is used, which emits at
1053nm. The cornea is highly transpar-
ent at these wavelengths. When used to
cut a corneal flap, the laser is focused at
the required depth (e.g., 160μm) and the
focused spots are moved in a spiral fashion
outwards from the centre of the cornea.
Since the pulses are of very short duration,
each achieves a photodisruption effect
mediated by plasma formation, stress
waves and cavitation bubbles at the appli-
cation site, rather than causing a thermal
burn. High repetition-rate pulsing
(1–2kHz) and the spiral movement mean
that the ‘cut’ normally achieved by a
microkeratome is created by a joining up
of the ‘sheet’ of photodisruption sites, the
flap being brought to the surface of the
cornea by additional pulses anterior to the
periphery of the spiral pattern. Once the
flap is lifted, ablation of the underlying
stroma can be undertaken with an
excimer laser, as normal. A more ambi-
tious procedure (picosecond laser ker-
atomileusis) involves placing two overlying
Growth (%)
125
140
58
45
spiral patterns at different and varying
depths, so that an intrastromal lenticule is
cut. This can be removed through a suit-
able aperture to correct the eye. As yet,
only limited trials have been carried out,
but doubtless further refinements, perhaps
that employ different lasers, will follow.
Surgical restoration of
accommodation
In normal eyes, the amplitude of accom-
modation declines steadily through the
early and middle years of adulthood to
reach zero at around the age of 50 years.
Beyond this age, there is no true change in
the power of the eye when objects at dif-
ferent distances are observed, although
ocular depth-of-focus allows objects to be
seen with reasonable clarity over a limit-
ed range of distances, which gives a sub-
jective amplitude of accommodation of
around 1D. Some form of near-vision cor-
rection is therefore normally required by
most people older than about 40 years.
The loss in amplitude of accommoda-
tion is thought to be multifactorial in ori-
gin. As the lens ages, it increases in
thickness and loses elasticity, as also does
its capsule. There are changes in the geom-
etry of the attachment of the zonule to the
lens and the gap between the ciliary ring
and the lens equator diminishes. The cil-
iary muscle is, however, thought to retain
its power until much later in life.
This situation has led to two approach-
es to try to extend the period over which
accommodation is possible into later life.
In the first of these, the natural, relative-
ly rigid lens is removed from the capsule
and is replaced by a more elastic synthet-
ic material with suitable characteris-
tics.2,3 In the second approach, it is
reasoned that the reduced gap between
the ciliary ring and lens equator limits the
possible extension of the zonular fibres
and their associated changes in tension:
hence, if the gap could be increased,
accommodation would be restored. It is
therefore suggested that the diameter of
the ciliary ring be increased via ‘scleral
Future trends in refractive surgery ■ 77
expansion’, in which a series of cuts are
made in the sclera around the cornea and
plugs are inserted to expand the sclera
and, with it, the ciliary body. At present
neither technique has demonstrated real
success, perhaps because each concen-
trates on only a single factor related to
presbyopia. Objective measurements of
patients who have undergone scleral
expansion surgery have so far shown no
evidence for restored accommodation,4,5
although claims have been made that sub-
jective amplitudes are increased. With the
development of better materials, the lens
replacement method may eventually be at
least partially effective, although it obvi-
ously cannot compensate for the loss in
capsular elasticity or for other changes in
the lens–ciliary body complex.
Accommodation is obviously also lost
after cataract or clear lens extraction and
intraocular lens (IOL) insertion. Bifocal, mul-
tifocal and varifocal IOLs can offer patients
reasonable distance and near vision, but
with the penalty of a generally reduced
image contrast at all object distances. For
some patients, ‘pseudo-accommodation’ –
actually enhanced depth-of-focus caused by
small pupil diameters, and small amounts
of astigmatism and, perhaps, higher-order
aberration – can also give a reasonable range
of clear vision. Recently, however, several
‘accommodative’ single-vision IOLs have
been produced and show considerable
promise. The concept of these is that,
although the IOL itself does not change
power, it moves forward within the eye for
near vision, so that the combined power of
the eye and cornea increases. Several
designs of lens are being evaluated cur-
rently. All are designed so that pressure on
the lens supports (haptics) flexes them in
such a way that the desired movement of
the lens optic can be achieved. Different
designs use changes related to near-vision
in the ciliary body, capsular and vitreous
pressures to produce the required move-
ment. Optical and physiological constraints
limit the achievable objective accommoda-
tion to about 1.0–1.50D, but (unlike the
multifocal IOLs) no compromise in retinal
image quality is involved. Although the
longer-term stability and performance of
these lenses have yet to be explored, the ini-
tial results are encouraging.6
Finally, it is clear that, in principle, PRK
or LASIK-type ablations could be used to
produce many of the types of ‘static’ cor-
rections for presbyopia achieved by con-
tact lenses or IOLs. Thus, for example, one
eye could be corrected for distance vision
and one for near, to give a monovision cor-
rection. With scanning-spot lasers and
suitable controlling algorithms, bifocal,
78 ■ Refractive surgery: a guide to assessment and management
multifocal or varifocal correction to an eye
should be possible. Attempts along these
lines have so far not been particularly suc-
cessful, however, possibly because the
scanning-spot sizes were too large to
achieve the desired corneal topography.
Replacement of the flap in LASIK will obvi-
ously tend to smooth out the abrupt tran-
sitions in power across the pupil required
for true bifocal or multifocal geometries.
Intraocular contact lenses
The main role of IOL implants has been to
replace the power of the crystalline lens
after cataract removal, but manipulation
of the lens parameters can offer more pos-
sibilities for refractive purposes.
Calculations of the required lens param-
eters from ocular dimensions and powers
for intraocular insertion are widely known.
There are now very useful systems for
accurate measurements of these ocular
parameters, which enable better visual out-
comes from the insertion.
An example is the IOLMaster (Carl
Zeiss, Jena, Germany), a recent non-inva-
sive device that provides a complete set of
ocular dimension measurements. It uses
partial coherence interferometry to meas-
ure anterior chamber depth and axial
length. The measurements obtained have
been proved to be as accurate as those of
ultrasound biometry,7 and are highly
repeatable.8 It has the benefits of its non-
contact character, and its corneal power
measurements, obtained using image
analysis, show a high correlation with
those obtained with conventional ker-
atometry7 and videokeratoscopy.8
The use of phakic IOLs for refractive cor-
rection, without crystalline lens removal,
is discussed in Chapter 4, but here it is worth
Figure 10.1
Bausch and Lomb Orbscan IIz
mentioning these devices when used in
conjunction with laser surgery. In cases of
high ametropia, some surgeons are begin-
ning to advocate the use of anterior or pos-
terior chamber phakic IOLs – often
referred to as implantable contact lenses9
– in conjunction with a partial correction
by excimer laser surgery. This combined
technique of a phakic IOL and laser epithe-
lial keratomileusis (LASEK), PRK or LASIK
is known as bioptics.
It can be expected that for patients with
high ametropia, future wavefront analysis
systems and lasers will allow an IOL to be
inserted to correct the majority of the
ametropia. The cornea would be reshaped
by excimer laser to yield total wavefront
aberration correction, if this could not be
achieved with the IOL itself. This may
increase the chances of creating a visual
acuity better than would be expected with
other refractive surgery procedures in some
patients (e.g., patients with over 10D of
myopia). A single laser procedure on a
patient with this degree of refractive error
may require the removal of so much
corneal tissue that the patient must have
quite a thick cornea originally: at this level
of laser correction the chances of reaching
a satisfactory post-operative refractive error
may be slim. The bioptics technique may
give the patient a better chance of reaching
emmetropia, as the laser part of the surgery
would only top up the change of refractive
error achieved with the phakic IOL. Of
course, one immediate problem that comes
to mind is that the patient would have
potential risks from both procedures: that
is, not only the complications of the laser
refractive surgery, but also the risk of com-
plications of cataract, chronic iritis or
Figure 10.2
The Pentacam. Courtesy of Birmingham
Optical Group
endothelial cell loss with the phakic lenses
commercially available at the moment.
Another implantable contact lens
device that is worth noting is the corneal
inlay. This has actually been around for
some time in various forms. In the early
days, synthetic or human corneal implants
were placed underneath corneal buttons
created in keratophakia.10,11 More recent-
ly, with the development of different syn-
thetic materials and more precise methods
to create a hinged corneal flap with a
microkeratome, this technique has appeared
again. It may prove to be useful for certain
groups of refractive errors.
Advances in measurement
devices
Equipment used in pre- and post-operative
assessment in refractive surgery has
improved greatly over the past few years.
One example of this is the corneal topog-
raphy devices. Although interest in assess-
ing corneal topography has been around
for many years, the real turning point was
probably the introduction of colour-coded
maps, initially by Klyce12 and later by
Maguire et al.13 The revolution in corneal
topography was probably aided by the
growth in other areas of ophthalmic work,
such as contact lenses, but probably the
major driving force was the commercial
nature of the growing refractive surgery
market. Nowadays, nearly all manufac-
turers of excimer lasers have a compatible
corneal topography device.
We have also seen a move from the tra-
ditional Placido devices (as described in
Chapter 2) to instruments like the Orbscan
Corneal Analysis unit from Bausch and
Lomb (Figure 10.1). Although the Orbscan
has been around for a few years it has
remained almost exclusively the only
instrument able to calculate the anterior
and posterior corneal shape, corneal
pachymetry and anterior chamber. One
version of the Orbscan incorporates a
Placido disc to enable more accurate data
to be obtained from the anterior cornea.
The most recent adaptation of the Orbscan
uses software that links directly into the
Bausch and Lomb Zyoptix custom-abla-
tion system, which includes an excimer
laser and wavefront aberrometer. Other
manufacturers have made similar systems
to create custom ablations, linking their
excimer lasers with either corneal topog-
raphers or aberrometers, or both. A recent
instrument from Oculus, the Pentacam
(Figure 10.2), uses a rotating Scheimpflug
camera and is able to show the shape of
the anterior and posterior cornea (Figures

10.3 and 10.4), the corneal thickness and
the anterior chamber depth, as well as the
shape of the crystalline lens. If the
patient’s pupil is dilated, the Pentacam can
map the anterior and posterior lens cur-
vatures. This is a very useful device for
looking at IOLs, as well as the results of
corneal surgery.
Conclusion
Although challenging problems remain to
be solved completely, some millions of
patients have already received substantial
benefits from refractive surgery. The
prospects are good for further developments
and refinements that will reduce complica-
tions from their already low level and give
standards of vision that will consistently
equal, or even surpass, those provided by
other methods of refractive correction.
Eyecare professionals will, undoubtedly,
want their patients to have full and
informed access to the new opportunities
for improved quality of life brought about
by these advances in refractive surgery.
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2 Nishi O, Nakai Y, Yamada Y and
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3 Haefliger E and Parel JM (1994).
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4 Elander R (1999). Scleral expansion
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9 Zaldivar R, Davidorf JM and Oscherow S
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Future trends in refractive surgery ■ 79
Figure 10.3
Image of the anterior eye cornea viewed by
the Oculus Pentacam. The anterior and
posterior corneal surfaces are visible, as well
as the anterior crystalline lens surface.
Early opacities can be seen in the crystalline
lens. (Courtesy of Birmingham Optical
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Figure 10.4
In this Oculus Pentacam image of the
anterior eye the brightness has been adjusted
so that the anterior and posterior corneal
surfacesare less clear, but there is a clear
image of an IOL resting in the lens capsule
after phacoemulsification cataract extraction
and IOL insertion. (Courtesy of
Birmingham Optical Group)
phakic intraocular lens and laser in situ
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 Index
Aberrometry, 15–16 Complications of surgery, 39–40 microanatomy of, 17–18
see also Wavefront aberrations, clear lens extraction, 32 non-native cells of, 18–19
Wavefront technology corneal infections, 40 refractive index, 17
Accommodation, surgical restoration of, 77–8 dry eye, 39–40 remodelling, 50
Accuracy, 63 intraocular pressure elevation, 40 resident cells of, 18
LASIK, 59 LASEK, 29 stem cell theory, 19
unilateral versus bilateral treatment, 62 visual complications, 41 ultrastructure, 18–19
Adhesion, 23 LASIK, 30, 37–9, 59 wound healing, 22–3
AK see Arcuate keratotomy corneal integrity, 38–9 adhesion, 23
American Society of Cataract and diffuse lamellar keratitis, 38 cell migration, 22
Refractive Surgery, 56 epithelial ingrowth, 37–8 cell proliferation, 22
Ametropia, 5, 12 interface debris, 38 latent phase, 22
intraocular lenses, 78 keratectasia, 39 Corneal hypoaesthesia, 21
Anisometropia microstriae, 38 Corneal infection, 40
post-PRK, 36 retinal detachment, 39 Corneal inlay lenses, 27, 78
with unilateral treatment, 62 visual complications, 41 Corneal innervation, 21
Arcuate keratotomy, 27, 33 overcorrection, 39 Corneal integrity post-LASIK, 38–9
Argon fluoride excimer laser, 76–7 presbyopic surgery, 33 Corneal oedema, 22
Astigmatism, 12 PRK Corneal pachymetry, 4–5, 59
post-surgical, 14 anisometropia, 36 Corneal profile, post-operative
Autorefractors, 41 epithelium irregularity, 36 measurement, 41–2
haze, 36 Corneal regeneration and healing, 20–1
Bailey–Lovie chart, 3, 41 visual complications, 41 Corneal sensitivity, 21–2
Bausch and Lomb keratometer, 11 regression, 39 Corneal shape, 10–11
BCVA see Best-corrected visual acuity stromal infiltrates, 40 descriptors of, 10
Best-corrected visual acuity, 3 undercorrection, 39 Corneal stroma, 19
LASIK, 59 visual, 40–1 microanatomy, 19
phakic intraocular lenses, 31 binocular vision, 43 ultrastructure, 19
Binocular vision problems, 43 contact lens fitting, 43 Corneal surface regularity index, 10
Bioptics, 78 haloes, 43 Corneal topography, 4, 9–16
Bowman’s layer, 17, 19 management of, 41 and aberrometry, 15–16
innervation, 21 non-tolerance of monovision, 43–4 classification, 9–10
microstriae post-LASIK, 38 poor-quality night vision, 42–3 corneal shape, 10–11
ultrastructure, 19 poor-quality vision, 42 history, 9
British Society for Refractive Surgery, 54, 56 starburst effects, 43 limitations of, 15
Confocal microscopy, 23–4 measurement methods, 11–14
Calcitonin gene-related protein, 21 Contact lenses cornea as projector system, 13–14
Cancer risk of refractive surgery, 44 corneal warpage, 15 cornea as reflector system, 11–12
Case reports, 49–52 factors influencing decision to cease use, 2 presentation of data, 12–13
Cataracts, risk of, 44 fitting post-surgery, 43 videophotokeratoscopy, 12
Cell migration, 22 intraocular, 78 in refractive surgery, 14–15
Cell proliferation, 22 polymegathism, 20 Corneal transparency, 22
CIL see Corneal inlay lenses Contour maps, 68 Corneal uniformity index, 10
Clear lens extraction, 27, 32 Contract sensitivity function, 6 Corneal warpage, 15
complications, 32 Contrast Acuity Assessment test, 42 Corneal wound healing, 20–1, 22–3
results, 32 Contrast sensitivity post-LASIK, 59–60 endothelium, 20–1, 23
surgical procedure, 32 Corneal anatomy, 17–22 epithelium, 22–3
Co-management, 53–6 Corneal endothelium, 20–1 adhesion, 23
general schedules for, 55–6 long-term damage, 44 cell migration, 22
GP’s role, 54–5 microanatomy, 20 cell proliferation, 22–3
insurance and legal issues, 56 replication and regeneration, 20–1 latent phase, 22
ophthalmologist’s role, 55 ultrastructure, 20 stroma, 23
optometrist’s role, 53–4, 55 wound healing, 20–1, 23 Cost issues, 61
professional relationships/ Corneal epithelium, 17–19
responsibilities, 54 basement membrane, 18 Descemet’s layer, 20
training, 54 ingrowth post-LASIK, 37–8 Diffuse interstitial keratitis, 59
irregularity post-PRK, 36 Diffuse lamellar keratitis, 38, 50–1

Diode thermokeratoplasty, 31
Directorate for Optometric Continued
Education and Training, 54
Dry eye, 39–40
Drysdale effect, 12
Elevation, 11
Emmetropia, 67, 78
European Society of Cataract and
Refractive Surgeons, 56
Excimer lasers, 28, 57–8
argon fluoride, 76–7
cost of, 61
equipment, 58
krypton fluoride, 28, 57–8
new developments, 76–7
see also LASEK; LASIK
Eye Laser Association, 76
EyeSys, 4, 12
Flap infection, 50–1
Flap melt, 51
Flap transaction, 49–50
Fleischer’s rings, 4
Fuchs’ endothelial dystrophy, 2
Fundus examination, 5
General Medical Council, 54
General Optical Council, 54
General practitioners, role in co-
management, 54–5
Glaucoma, 2
Glycosaminoglycans, 19
Haloes, 43
Hartmann–Shack, 71
Haze post-PRK, 36
Hemidesmosomes, 18, 22
Holliday diagnostic summary, 11
Holmium laser thermokeratoplasty, 31
Hypermetropia, 67
Hyperopia, LASIK for, 30, 60
Iatrogenic ectasia, 39
ICRS see Intracorneal ring segment
Indemnity insurance, 56
Infiltrates, 19
post-surgery, 40
International Council of Refractive
Surgery, 56
Intracorneal ring segments, 27, 31
advantages and disadvantages, 31
surgical procedure, 31
Intraocular lenses, 77
contact lenses, 78
see also Phakic intraocular lenses
Intraocular pressure, 2, 5
elevation post-surgery, 40, 60
IOLMaster, 78
Javal–Schiötz keratometer, 11
Keeler Tearscope, 6
Keratectasia, 39, 51–2
Index ■ 81
Keratitis, 23, 40 post-operative care, 29
Keratoconus, 2, 4, 27 post-operative follow-up, 39
diagnosis of, 12 refractive outcome, 39
Keratocytes, 19, 23 surgical procedure, 29
loss of, 24 versus LASIK and PRK, 28, 30–1, 60–1
morphology, 24 visual complications, 41
Keratoglobus, 2 visual outcome, 40
Keratometry, 11 Lasers
data presentation, 12–13 argon fluoride, 76–7
Keratomileusis see Laser in-situ broad beam, 58, 65
keratomileusis excimer, 28, 57–8
Keratophakia, 78 holmium, 31
Keratoscopy, 11 krypton fluoride, 28, 57–8
KR-7000P, 12 picosecond, 77
Krypton fluoride excimer laser, 28, 57–8 solid state, 77
LASIK see Laser in-situ keratomileusis
Lamina densa, 18 Lipofuscin, 24
Lamina lucida, 18 Long-term implications of surgery, 44
Langerhans’ cells, 18–19
LASEK see Laser subepithelial keratectomy Microkeratomes, 58–9
Laser in-situ keratomileusis, 3, 27, 29–30 cost of, 61
clinical outcome, 30 Microstriae post-LASIK, 38
complications, 30, 37–9, 59 Microvilli, 18
corneal integrity, 38–9 Mintel report, 53
diffuse lamellar keratitis, 38 Modulation transfer function, 72, 74
epithelial ingrowth, 37–8 Monovision, non-tolerance of, 43–4
interface debris, 38 Muscle balance, 5–6
keratectasia, 39 Myopia, LASIK for, 30, 60
microstriae, 38
retinal detachment, 39 National Health Service, 62–3
confocal microscopy, 23–4 Neovascularization, 4
contraindications, 29 Nidek OPD, 15
corneal hypoaesthesia, 21 Night vision, poor-quality, 42–3
damage to microvilli in, 18
development of, 57 Oculus Keratograph, 4
for hyperopia, 30 Oculus Pentacam, 14
indications, 29 Ophthalmologists, role in co-management, 55
keratocyte morphology, 24 Opticians Act (1989), 55
with LASEK in other eye, 51 Optometrists
late flap lift, 52 co-management fees, 53–4
for myopia, 30 indemnity insurance, 56
nerve fibre regeneration after, 22 role in co-management, 55
post-operative care, 30 Orbscan, 4, 13, 14, 42, 49, 78
post-operative follow-up, 36–9 Overcorrection, 39
results, 59–60
accuracy, 59 Pachymetry see Corneal pachymetry
contrast sensitivity, 59–60 Patient selection, 1–8
high myopia, 60 decision to cease contact lens use, 2
hyperopia, 60 occupational groups, 1
loss of best-corrected vision, 59 Pelli–Robson chart, 5, 42
predictability, 59 Penetrating keratoplasty, 14
stability, 59 Pentacam, 78, 79
surgical procedure, 29–30, 58–9 Phakic intraocular lenses, 27, 31–2
versus LASEK and PRK, 28, 30–1, 58 advantages and disadvantages, 32
visual complications, 41 anterior chamber lens implantation,
visual outcome, 40 31–2
Laser subepithelial keratectomy, 27, 28–9, in conjunction with laser surgery, 78
60–1 posterior chamber lens implant, 31–2
clinical outcome, 30 Photoablation, 27
complications, 29 Photorefractive keratectomy, 2, 27
contraindications, 29 complications
increased prescription after, 50 anisometropia, 36
indications, 29 epithelium irregularity, 36
with LASIK in other eye, 51 haze, 36
82 ■ Refractive surgery: a guide to assessment and management

confocal microscopy, 23–4 PRK see Photorefractive keratectomy Undercorrection, 39

corneal aesthesia, 21 Professional responsibilities, 54 Unilateral versus bilateral treatment, 61–2
keratocyte morphology, 24 Projection techniques, 13–14 accuracy, 62
nerve fibre regeneration after, 22 Proteoglycans, 19, 23 PRK, 62
post-operative follow-up, 36 PTK see Phototherapeutic keratectomy safety, 62
refractive outcome, 36 Pupil diameter, 3–4 subjective issues, 62
removal of corneal epithelium in, 18 Purkinje image, 11, 14
unilateral versus bilateral treatment, 62 United Kingdom and Ireland Society of
versus LASEK and LASIK, 28 Quad maps, 13 Cataract and Refractive Surgery,
visual complications, 41 56
visual outcome, 40 Radial keratotomy, 27, 44–5, 65 United Kingdom, refractive surgery in, 76
Phototherapeutic keratectomy, 2 ocular integrity, 44–5 United States, refractive surgery in, 77
cornea after, 15 refractive stability, 44
Placido visual performance, 45 Videokeratoscopy, 11
Antonio Placido, 9 Reflection techniques, 11–12 see also under Corneal topography
cone systems, 12 Refraction, 3 Videophotokeratoscopy, 12
disc systems, 4, 9, 12 post-operative measurement, 41 Visual acuity, 3
Polymegathism, 20 Refractive correction, 70 post-operative measurement, 41
Polymorphonuclear leukocytes, 19, 22 Regression, 39 Visual complications, 40–1
Poor-quality vision, 42 Retinal detachment post-LASIK, 39 binocular vision, 43
Post-mitotic cells, 22 RK see Radial keratotomy contact lens fitting, 43
Post-operative follow-up, 35–48 Rods, 24 haloes, 43
initial post-operative period, 35–40 Royal College of Ophthalmologists, 56 LASEK, 41
complications, 39–40 LASIK, 41
LASEK, 39 SimK see Simulated keratometry readings management of, 41
LASIK, 36–9 Simulated keratometry readings, 10–11 non-tolerance of monovision, 43–4
PRK, 36 Slit-lamp examination, 4 poor-quality night vision, 42–3
time scale for, 35 post-operative, 42 poor-quality vision, 42
Pre-operative assessment, 1–8 Snellen chart, 3 PRK, 41
contract sensitivity function, 6 Spot diagrams, 72 starburst effects, 43
corneal pachymetry, 4–5 Staphylococcus aureus, 51 Visual outcome, 40–1
corneal topography, 4 Starburst effects, 43 complications, 40–1
full refraction, 3 Stromal wound healing, 23 unaided vision, 40
fundus examination, 5 Super vision, 73–4 Visual quality, 42
intraocular pressure, 5 Surgical procedures, 14–15, 27–34 Vogt’s striae, 4
muscle balance, 5–6 decision-making, 27–8 von Hippel–Lindau syndrome, 51
pupil diameter, 3–4 excimer laser technology, 28
slit-lamp examination, 4 history, 27 Wavefront aberration, 66–8
tear secretion, 6 treatment plan, 28 analysis of, 68–70
visual acuity, 3 see also LASEK; LASIK; PRK measurement of, 71
Predicted corneal acuity, 10 and refractive correction, 70
Presbyopia, 3 TACs see Transient amplifying cells super vision, 73–4
Presbyopic surgery, 27, 32–3 Tear secretion, 6 use in refractive surgery, 72–3
complications of, 33 Topographic Modelling System, 12 Wavefront technology, 65–75
corneal, 32 Training, 54 Wound healing see Corneal wound healing
intraocular, 32–3 Transient amplifying cells, 19, 22
outcome, 33 Treatment plan, 28 Zernike polynomials, 68, 69
scleral, 32 Zonula occludentes, 18