Published Online June 12, 2007 Refractive surgery: what patients need to know Vikentia J. Katsanevaki, and Stephen J. Tuft * Moorfields Eye Hospital, NHS Foundation Trust, London, UK Objective: Most procedures to treat refractive error are based on laser surgery, but other techniques are available. We review the relative advantages and the risk associated with the different surgical options. Areas of agreement: Laser refractive surgery is now a safe and effective alternative to glasses or contact lenses. Areas of controversy: Because refractive surgery is an area of rapidly developing technology, the relative benefits of the different surgical options remain uncertain. Areas to develop research: Controlled trials are needed to provide better guidance as to the relative merits of the different surgical options. Better interventions are required to minimize the biological response after laser surface treatment to eliminate the need for mechanical cutting of a flap for laser in situ keratomileusis. An effective surgical treatment for presbyopia is awaited. Keywords: cornea/refractive error/refractive surgery/excimer laser Introduction Accepted: May 15, 2007 *Correspondence to: Stephen J. Tuft, Moorfields Eye Hospital, NHS Foundation Trust, 162 City Road, London EC1V 2PD, UK. E-mail: s.tuft@ucl.ac.uk There have been dramatic advances in refractive surgery over the last two decades and it is still a rapidly developing area of ophthalmology. Short sight is the most common type of refractive error in people under 45 years of age. 1 In most cases, this can be corrected by permanently changing the radius of curvature of the external surface of the cornea to adjust the focusing power of the eye. A high-energy ultraviolet excimer (excited dimer) laser can remove minute amounts of tissue (0.2 mm per pulse) from the corneal surface by a process called photoablation. Most refractive surgery is performed using a ArF gasfilled excimer laser (l ¼ 193 nm), although solid-state lasers (l ¼ 213 nm) have also been evaluated. 2 Other types of refractive error, such as long sight and astigmatism, can also be corrected with this method. 3 Intraocular lens implantation surgery is an alternative intervention that is usually reserved for higher levels of refractive error that British Medical Bulletin 2007; 83: 325 339 DOI: 10.1093/bmb/ldm015 & The Author 2007. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org
V. J. Katsanevaki and S. J. Tuft cannot safely be corrected by laser. Newer developments in refractive surgery aim to preserve or restore reading vision in older patients (Fig. 1). The purpose of this review is to describe the techniques that are available, the indications for treatment and the clinical results in terms of safety and visual outcome. Refractive errors The curved interface between air and the tear film on the external surface of the cornea contributes almost two-thirds of the 60 dioptres (D) of total refractive power of the eye. The more curved the corneal surface, the greater the focus power. The crystalline lens within the eye provides the majority of the remaining power, as well as enabling the eye to change focus to view near objects (accommodation). When a distant object is fixated, light should be brought to a focus at the fovea of the retina; this is termed emmetropia. If light is brought to a focus in front of the retina in the relaxed state, the eye is short-sighted (myopic) and distant objects are blurred while close objects are in focus. This can be corrected with a concave lens that is thinnest in the centre. When light is brought to a focus beyond the retina, the eye is long-sighted (hyperopic), and distant objects are clear or blurred but near objects are more blurred. This is corrected with a convex lens that is thickest in the centre. If the radius of curvature the cornea is different in the vertical and horizontal meridians light cannot be brought to a focus at a single point without the addition of a cylindrical lens (astigmatism). When, with age, the lens within the eye can no longer accommodate to bring a close object into focus, the eye is said to be presbyopic, a condition that is corrected by readers. Although the prevalence of refractive error varies in different ethnic groups, myopia being particularly common in some Asian groups, the most frequent error is low myopia with astigmatism. 1 This type of refractive error is usually readily amenable to treatment using laser refractive techniques. Fig. 1 Typical notation of refractive prescription provided by an optician. In the right eye, there is 2 D of myopia with one dioptre of astigmatism at axis 208. The dioptre (D) is the unit used to describe the power of a corrective lens or the refractive error of the eye. There is no requirement for a near prescription for reading. 326 British Medical Bulletin 2007;83
Refractive surgery Measurement of vision A Snellen chart viewed at 6 m (20 feet in the USA) is commonly used. A normal visual acuity is defined as 6/6 (20/20), although the majority of young people can read two lines better (6/4). The UK driving licence requirement is slightly worse than 6/9 (one line less than normal ). The Snellen chart uses high contrast images and if used to assess outcomes after laser surgery, it will underestimate any effect of glare. Laser refractive surgery Techniques Laser refractive surgery must treat the fibrous layer of the cornea (stroma) if it is to have a permanent effect. Techniques can be classified as either surface treatments, in which the epithelium is mechanically removed before the underlying stroma is treated, or laser in situ keratomileusis (LASIK), in which a hinged flap of stroma is cut and reflected before treatment is applied to the exposed stromal bed, after which the flap is repositioned. 4,5 The surface treatment techniques can be subclassified as follows according to the method used to remove the epithelium. In photorefractive keratectomy (PRK), the epithelium is abraded and discarded, whereas in laser-assisted subepithelial keratectomy (LASEK) and epilasik, the epithelium is reflected intact as a sheet following the brief application of dilute ethyl alcohol or mechanical stripping, respectively, after which the epithelial flap can be replaced or discarded. 6 In LASIK, a flap of 120 180 mm thickness (the normal minimum central corneal thickness is 520 mm) is cut either by an oscillating blade in a microkeratome or by a femtosecond laser (Nd:YLF laser, l ¼ 1053 nm). 7 Because there is minimal disturbance to the surface epithelium during LASIK, there is minimal post-operative discomfort, little stimulus for scar formation and rapid visual recovery when compared with surface treatment. However, all the treatments use the same type of laser. The patient s perspective The principal difference between surface treatment and LASIK lies in the speed of visual recovery and the discomfort associated with the procedure. Following surface treatment, if the epithelial flap is discarded, there is a large central epithelial defect that must regenerate. This takes a minimum of 3 days, during which the eye may be uncomfortable, photophobic and blurred. Symptoms are reduced if a bandage contact British Medical Bulletin 2007;83 327
V. J. Katsanevaki and S. J. Tuft lens is worn continuously until the cornea has re-epithelialized, and topical anaesthetic drops may also be used under supervision. Even if the epithelial sheet is replaced (i.e. after LASEK or epilasik), it is uncertain whether the epithelial cells survive and this may actually increase the time until the eye is comfortable, with no proven benefit for refractive outcome. After bilateral sequential surface treatments, a patient typically requires a week off work, whereas after LASIK, the epithelium is intact within hours, and the rapid visual recovery means patients can often return to work within 48 h. The convenience of LASIK has helped it become the most popular option. Prevention of scar formation Laser refractive procedures remove tissue and thin the cornea. The natural response of the body is to replace this lost tissue. Any regenerated (scar) tissue is initially hazy, which can cause light scatter, visual loss and a loss of the refractive effect. Early after the introduction of PRK, it was recognized that correcting higher refractive errors meant more tissue was removed with an increased risk of scarring. However, after LASIK, when the wound is immediately covered with an intact layer of epithelium and stroma, there is less scarring and the induced change in refraction is more stable. However, balanced against this advantage, the creation of a flap for LASIK requires expensive instrumentation and additional surgical skills when compared with surface treatment and there is a small risk associated with cutting a flap. In parallel with the development of LASIK, there have been improvements in the techniques of surface treatment, notably, the introduction of the topical antiproliferative agent mitomycin C 0.02% which is applied to the wound for 10 60 s after surface treatment to inhibit the scarring response. The range or refractive errors treatable by surface treatment or LASIK are now similar. Interestingly, because cutting a stromal flap for LASIK may actually introduce optical error, there has been a renewed interest in surface treatment. 8 The treatment process Laser refractive procedures are usually performed bilaterally at a single outpatient procedure. After instillation of a topical anaesthetic and an antiseptic (e.g. povidone iodine), a speculum is inserted to keep the eye open. The patient does not need to hold the eye open during treatment or avoid blinking. Most lasers have an infrared tracking mechanism that locks onto the pupil image and adjusts the beam position up to 328 British Medical Bulletin 2007;83
Refractive surgery 4000 times per second to follow eye movements, and if fixation is lost, the laser treatment is stopped. Integrated iris recognition software rotates the treatment to correctly align the axis of astigmatism. These developments have greatly reduced the risk of a decentred ablation. The treatment is almost painless, although a smell of burning accompanies tissue ablation. Wavefront-guided treatment Conventional refractive surgery aims to correct refractive error as defined by the spectacle prescription. However, more subtle optical errors are always present. These higher order aberrations usually only account for 2 5% of the total refractive error. The aberrations are measured by determining how a linear wavefront of light is altered as it enters or leaves the eye, typically detected with a Schack Hartmann microlens aberrometer. This information is then linked to the laser platform for treatment. In practice, despite the supposed accuracy of the information, most surgeons then incorporate fudge factors to adjust for discrepancies between the wavefront measurement and the spectacle correction. Wavefront treatment removes more tissue than conventional treatment and the benefits have been questioned. The principal reservation is that a single image is used to calculate the treatment, although higher order aberrations fluctuate rapidly over time. It is not even certain that patients can appreciate the subtle improvements in vision achieved if higher order aberrations are eliminated. Pre-operative patient selection for laser surgery General points This is an opportunity to identify patients who are at risk of complications or a poor visual outcome. Evidence (e.g. optician reports) should be provided that the spectacle refraction has been stable to within 0.5 D for the previous 3 years and most surgeons apply a lower age limit for treatment of 20 years to ensure eye growth is complete (Fig. 2). Treatment should be deferred if patients are pregnant or breast-feeding. Some systemic diseases (rheumatoid arthritis, diabetes and HIV-AIDS) are relative contraindications for treatment unless the disease is well controlled. 9 The high electronic charge produced by an excimer laser means that patients with a pacemaker cannot be treated unless the laser is shielded. British Medical Bulletin 2007;83 329
V. J. Katsanevaki and S. J. Tuft Fig. 2 Suggested algorithm for the surgical management of refractive error. The values of refractive error that determine management thresholds may vary between patients. IOL, intraocular lens; RLE, refractive lens exchange; ICL, intraocular contact lens; PRK, photorefractive keratectomy; LASEK, laser-assisted subepithelial keratectomy; LASIK, laser in situ keratomileusis. Specific occupations Patients may seek treatment to fulfil the visual requirements for entry into the armed forces, police or the fire brigade. Regulations can vary even between regions, so patients should confirm that refractive surgery is acceptable before undergoing treatment and whether there are restrictions on the type of treatment that can be performed. Patients at risk of ocular trauma, e.g. combat forces or contact sportsmen, are normally advised to have surface treatment because of the risk of traumatic flap displacement after LASIK. 10 Military aviators who develop low refractive error are also recommended to have surface treatment because of the risk after LASIK of experiencing dry eye symptoms when flying in un-pressurized aircraft at altitude. The requirements for civil pilots also vary, but the UK Civil Aviation Authority does not recommend refractive surgery to obtain certification. A certified pilot is considered temporarily unfit for 3 months after LASIK and for 12 months after surface treatment. Recertification then requires a favourable ophthalmologists report on the refractive and visual outcomes. The ocular examination Before measurements for surgery are taken, it is recommended that soft contact lenses are left out for at least 1 week and rigid contact lenses left out for at least 2 weeks. This is because a contact lens can mould the cornea and change the refraction. Measurements then include the refractive power of the eye, the shape and radius of curvature of the cornea, the pupil diameter in dim light and the thickness of the cornea. Autorefraction and wavefront sensing should corroborate these results, and any discrepancy or hyperopia re-evaluated after the focus of the 330 British Medical Bulletin 2007;83
Refractive surgery eye has been temporarily paralysed with cyclopentolate 1% drops. A careful assessment of corneal shape is required to exclude keratoconus, which is an inherited and progressive corneal thinning disorder that can be dramatically exacerbated by laser treatment. If a clinical assessment of the tear film suggests dry eye, an objective measurement (Schirmer test) should be performed. Conditions that may increase the risk of infection or inflammation (e.g. blepharitis) should also be treated before surgery. Treatment is contraindicated if there is a history of herpes simplex corneal disease because surgery may re-activate the disease. The lens and retina should be examined to detect early cataract or retinal disease that could affect visual outcome. Patients with glaucoma may be suitable, although the thinning of the cornea produces a spuriously low reading for intraocular pressure after treatment that needs to be taken into account at subsequent assessments. Patient goals and expectations Patients should have realistic expectations of laser refractive surgery. The treatment is unlikely to improve vision beyond the best acuity they can achieve with a contact lens or glasses before treatment. The goal should be functional vision, which can be defined as the ability to perform daily tasks such as driving, work or recreation without feeling visually restricted. The acuity needed to achieve this independence will vary between individuals, and requirements should be discussed before surgery. A general guideline for outcome is that 90% of patients will experience a 90% reduction in their refractive error, which, for a patient with a pre-operative myopic refraction of 27 D would result in an outcome of 20.7 D or less, which would probably give the acuity needed for driving unaided (Table 1). 11 Presbyopic patients (.45 years) must understand that they will still have to wear glasses for reading. However, by leaving the dominant eye emmetropic and the non-dominant eye slightly myopic (e.g. 20.75 D), it is possible to reduce the reliance for reading glasses (termed monovision). Reduced depth perception and blur mean that monovision is not always tolerated and this option can be evaluated as a contact lens correction before treatment is performed. Treatment limits The amount of refractive error that can be corrected by laser is determined by the curvature and the thickness of the cornea. If the cornea is steepened or flattened excessively, the image quality is degraded, and if too much tissue is removed, the cornea can be structurally weakened. British Medical Bulletin 2007;83 331
V. J. Katsanevaki and S. J. Tuft Table 1 Outcomes of laser refractive surgery using pooled data from studies reported by the US Food and Drug Administration agency and the National Institute of Clinical Excellence. Treatment method Pre-operative refraction (D) +1D (%) +0.5 D (%) Outcome measure UVA 6/12 (%) UVA 6/6 (%) Loss of acuity of 2þ lines (%) LASIK 3,11 0to27 96 81 96 72 1 27 to212 80 61 89 48 1 LASEK 3,11 Grouped data 74 94 74 PRK 11 Grouped data 71 94 61 LASIK 3,11 0toþ6 90 67 90 63 2 LASIK 13,15 Grouped data 91 77 0.6 LASEK 13,15 Grouped data 92 75 0 PRK 13,15 Grouped data 89 69 0.5 PRK, photorefractive keratectomy; LASEK, laser-assisted subepithelial keratectomy; LASIK, laser in situ keratomileusis. The higher the refractive error that is corrected, and the wider the treatment diameter, the more tissue is removed. 12 The residual thickness after LASIK should be at least 250 mm, which equates to a maximum treatment of about 210 D of myopia. Correction of more than þ6.0 D of hyperopia is associated with a loss of best-corrected visual acuity and tear film instability. Safety and outcome of laser refractive surgery The rapid evolution of laser refractive surgery makes it difficult to compare current practice with many published results. However, there are several reports that suggest that LASIK is safe and effective for the correction of low-to-moderate myopia (22 to 27 D) and for moderate astigmatism (,2D). 13,14 On the basis of a systematic review of the literature, the UK National Institute for Clinical Excellence reached similar conclusions. 15 For high myopia (greater than 27 D), the results are more variable. For low-to-moderate hyperopia (less than þ6d), LASIK is also effective and safe. 16 Similar systematic reviews of outcome and safety after surface treatment (LASEK and epilasik) are in progress. Complication of laser surgery Visual symptoms Excessive residual refractive error is the most common optical risk of refractive surgery. In most series, 2 4% of patients are dissatisfied 332 British Medical Bulletin 2007;83
Refractive surgery enough with their vision to request re-treatment (enhancement). However, because the risks of re-treatment are similar to primary treatment, but the gain is less, most surgeons will hesitate before attempting to correct less than 0.75 D of residual error. Re-treatment is usually delayed for at least 1 month after LASIK (up to 6 months after surface treatment) to ensure that the refraction is stable, and it is then only be possible if there is sufficient residual corneal thickness. Re-treatment is easy to perform after LASIK as the original LASIK flap can usually be re-lifted even after years, and there is also minimal discomfort and rapid visual recovery. Re-treatment after surface treatment is less predictable because there is a greater stimulus for subepithelial scarring, which can affect the accuracy of the visual outcome. New visual symptoms such as difficulty in driving at night have become uncommon (,5% of eyes) because modern lasers treat up to 8.5 mm diameter on the cornea. However, glare can still occur if the treatment is not centred on the cornea, if there is post-operative scar, or if the LASIK flap is displaced. 17 After LASIK for low-to-moderate myopia, 0.5% of treated eyes lose a line of corrected visual acuity, compared with 0 2% of eyes after similar treatment for hyperopia (Table 1). Physical complications Minor physical complications after laser refractive surgery include subconjunctival bleeding from the microkeratome fixation ring during LASIK, discomfort and epithelial abrasion. Microwrinkles in the repositioned flap and small foreign bodies under the LASIK flap are common, but of no measurable visual consequence. Transient dry eye is the most commonly reported symptom after LASIK occurring in 25% of patients. 18 Dry eye develops because the superficial corneal nerves are cut and hence the corneal sensation and the supply of neurogenic cytokines to the epithelium are reduced. Restoration of tear flow returns over 4 6 months after LASIK as the nerves regenerate, 19,20 with faster recovery after surface procedures. 21,22 Patients can use supplementary artificial tear drops during this period, or even have temporary occlusion of the lacrimal punctae to conserve tears. The risk of retinal detachment is increased in the presence of myopia, but this risk is not further increased by laser surgery. Flap complications after LASIK After LASIK, the flap is not sutured but it is held in position by osmotic and adhesive forces. In the first week after treatment, the flap is British Medical Bulletin 2007;83 333
V. J. Katsanevaki and S. J. Tuft susceptible to partial or complete displacement and 1% of eyes require repositioning of the flap. Occasionally, a LASIK procedure has to be abandoned if there are surgical complications, e.g. a free flap, a decentred flap or a flap that is too thin, buttonholed or otherwise damaged. It is then best practice to replace the flap or flap remnants and not proceed with laser treatment. It can then be several months until the flap as healed sufficiently before a second treatment can be attempted, although contact lens wear can be resumed after a few weeks. LASIK is also associated with two specific complications that occur in the interface beneath the flap. First, in 1% of cases, the surface epithelium grows beneath the flap. 23 This may require surgical removal if the ingrowth causes secondary surface irregularity or if it progresses towards the visual axis. Secondly, an inflammation termed diffuse lamellar keratitis (DLK) may cause haze in the interface. The cause of this inflammation is uncertain, although it can be associated with co-existing blepharitis or epithelial debris swept under the flap as it is cut. DLK is rarely severe and if recognized early it readily responds to topical steroid. Sight threatening complications Infection and corneal ectasia are the most serious complications of laser refractive surgery. 24,25 Infection usually results from bacterial or fungal contamination of the wound at the time of surgery. The incidence is thought to be approximately 1:3000 procedures, 26 which compares with the annual risk of severe infection associated with soft contact lens wear of 1:5000 eyes. If infection is suspected after LASIK the flap may have to be lifted or amputated to obtain appropriate samples for culture, and the interface irrigated with antibiotics. Even with active investigation and appropriate treatment, there is still the potential for permanent visual loss. Severe bilateral infection has the potential to stop a patient driving, reading or continue working, and this risk is one of the few arguments against bilateral simultaneous refractive surgery. Corneal ectasia can occur if there is excessive central corneal thinning following correction of high myopia or inappropriate treatment in the presence of unrecognized keratoconus. The central cornea then bows forward with a recurrence of short sight and astigmatism. Management may require a return to rigid contact lens wear to improve vision or lamellar graft surgery in severe cases. Which type of laser treatment is best? For the majority of patients, the choice of laser treatment is made after a consideration of the convenience but slightly increased risk of LASIK 334 British Medical Bulletin 2007;83
Refractive surgery when compared with the discomfort and slower recovery period after surface ablation techniques. A few patients have specific contraindications to one form of laser refractive treatment. Full refractive correction may not be possible by LASIK if the cornea is thinner (,500 mm) preoperatively than average, in which case surface treatment or lens implantation (discussed subsequently) may be alternative options. Patients at risk of developing symptomatic dry eye should be advised to have surface treatment. The relative clinical advantages of LASEK or epilasik surface treatment when compared with conventional PRK are as yet unresolved. Comparative data available from prospective case series performed for the US Food and Drug Administration 11 and a meta-analysis of six randomized controlled trials suggest that LASIK may be slightly more accurate than surface treatment for the correction of low-to-moderate myopia although the methods used to perform PRK in these series are now outdated and may not reflect current outcomes. 27,28 Wavefront treatments may have a slight advantage in terms of accuracy for the correction of low myopia when compared with conventional laser treatment, and the risk of a loss of best-corrected acuity after treatment of hyperopia is less. However, no clear advantage has been demonstrated for other refractive groups. 3,11 Conductive keratoplasty (thermo-keratoplasty) This is an alternative strategy for the treatment of low hyperopic error. An electromagnetic source is used to heat a ring of the corneal stroma in the mid-periphery. This causes the tissue to shrink, which steepens the curvature of the central cornea. There are no randomized controlled trials to compare conductive keratoplasty with hyperopic laser refractive treatment, and the long-term stability of the effect has not been demonstrated. It is an option for the correction of errors up to þ3.0 D and it is marketed for the improvement of presbyopia. Intraocular lens surgery Clinical indications Intraocular lens surgery rather than laser refractive surgery is the treatment of choice for the correction of high refractive errors because the cornea is not thinned and there is no gross change in corneal contour. 29 31 The two principal options are to exchange the natural lens within the eye for an artificial lens of a different power [refractive lens exchange (RLE)] or to implant an additional lens in front of the British Medical Bulletin 2007;83 335
V. J. Katsanevaki and S. J. Tuft natural lens. Both techniques can correct a very large amount of refractive error, and toric intraocular lenses are now available for the correction of astigmatism. The main disadvantage of RLE is loss of accommodation, which may not be acceptable in younger patients. For patients less than 45 years of age, the treatment of choice is thus the insertion of a second lens that rests either on the surface of the natural lens [implantable contact lens (ICL)] or is supported by the iris. 32 The accuracy of intraocular lens surgery is similar to laser refractive surgery, which is still an option to correct residual refractive error. There are no good controlled studies comparing lens implantation surgery and laser refractive surgery for moderate myopia, but as the risks associated with laser surgery are less, laser surgery currently remains the procedure of first choice in these cases. Finally, the cost of lens surgery is usually substantially greater than for laser surgery. Complications of intraocular lens surgery There are limited data regarding the safety and outcome of refractive lens implantation. The natural lens may be damaged at the time of ICL implantation and visually significant cataract develops in 2% of case after 2 years. Distortion of the pupil and lens dislocation can occur with iris-supported lens designs. RLE also increases the risk of a subsequent retinal detachment, with an incidence estimated to be as high as 8% after 7 years in high myopia. A continued but gradual loss of endothelial cells from the posterior surface of the cornea has been documented with lenses inserted anterior to the iris, although it is uncommon for this to progress to corneal oedema. 33 The risk of intraocular infection (endophthalmitis) is thought to be similar to uncomplicated surgery for age-related cataract (1:2400) 34 and it is not usual practice to perform bilateral surgery at the same session. Surgery for presbyopia Monovision allows improved near vision in one eye by intentionally leaving the non-dominant eye short-sighted. Multifocal IOLs and multifocal treatment of the cornea to produce pseudo-accommodation have been developed, but the increased range of focus is achieved at the expense of a loss of image contrast. Scleral expansion rings attempt to restore the normal accommodative range but have not achieved general acceptance. 35 Trials of true accommodating IOLs are in progress but the present designs have only a limited range of focus. 336 British Medical Bulletin 2007;83
Refractive surgery Cataract surgery following refractive surgery There is no technical difficulty in performing cataract extraction following laser refractive surgery. However, the change in the corneal shape produced by the laser surgery must be taken into account when calculating the power of the lens to be implanted. Patients who have laser refractive surgery should be given a permanent copy of their preoperative refraction, corneal curvature and final refraction as these data are used to correctly calculate the new intraocular lens power. After ICL surgery, visually significant cataract is treated by removing the implant and the cataract, which are then replaced with a single lens. Selecting a surgeon Laser refractive surgery is technically within the grasp of any moderately skilled eye surgeon. However, suitable training is required to be able to provide informed pre-operative counsel and appropriate postoperative management of potential complications. The United Kingdom Royal College of Ophthalmologists recommends that only a fully trained surgeon with additional training in refractive surgery can perform laser refractive surgery and that they maintain an audit of their clinical complications and outcomes. 36 Keypoints Refractive error has traditionally been managed with glasses or contact lenses. Refractive surgery is now widely available and, in appropriately selected patients, it has the potential to dramatically improve quality of life. Laser refractive surgery is the dominant treatment option and it is now considered to be safe and effective. However, careful patient assessment and explanation of the potential risks are essential, and severe complications can still occur. LASIK is still the most popular surgical option because it offers rapid recovery of vision and low associated discomfort. A technique that could provide these advantages while eliminating the small risk associated with cutting a flap would be a substantial advance. A technique that reliably restores accommodation for near vision to correct presbyopia is still under development. None of the procedures described are generally available in the National Health Service. British Medical Bulletin 2007;83 337
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