Seeing the future: Innovations and accessibility in refractive surgery

As of 2024, approximately 2.6 billion people globally suffer from myopia, with projections suggesting that nearly half the world population will be affected by 2050.[1] Vision correction should be considered a basic human right. While spectacles are often considered the solution for the epidemic of refractive errors, should refractive surgery be regarded as a primary method for vision correction, especially in young adults? For any surgical procedure to be universally accepted, it must adhere to principles of safety, efficacy, accessibility, and cost-effectiveness. Cataract surgery, for instance, meets these criteria and is the most widely performed surgery globally. LASIK, the second most common eye surgery has proven to be safe, effective, predictable, and convenient, though cost remains a barrier for many.[2] Getting safer and getting better Over the years, laser ablation techniques have significantly advanced, from basic laser ablation to modern wavefront-guided and topography-driven ablation. Femtosecond lasers, now used for creating corneal flaps, offer increased precision and reduced complication risks. Furthermore, eye-tracking technology allows for real-time adjustments during surgery, compensating for even subtle eye movements and ensuring precise outcomes. Kerato-refractive lenticule extraction (KLEx),[3] introduced in the 2000s, is gaining global traction. However, concerns about interface-related complications, corneal biomechanics, and infection risk are still under study. Additionally, intraocular collamer lenses (ICLs) offer a suitable alternative for individuals with high refractive errors or thin corneas who are not ideal candidates for corneal procedures. Beyond the surface: Uncovering hidden risks before surgery A thorough preoperative evaluation remains critical for mitigating risks associated with refractive surgery. Advanced imaging techniques such as anterior segment optical coherence tomography (AS-OCT) and Scheimpflug imaging provide detailed corneal assessments essential for preventing complications. Recent artificial intelligence (AI) developments enhance patient evaluations, with algorithms predicting postoperative outcomes and identifying subtle abnormalities that could predispose patients to complications. Corneal biomechanics mapping and epithelial thickness profiling are also improving the safety of refractive surgery, particularly in identifying candidates at risk for post-surgical ectasia. From elite to essential: Accessible and affordable precision Despite its effectiveness, refractive surgery cannot prevent myopia progression and is typically recommended only for individuals with stable vision. Still, it remains a vital corrective tool for adult myopia. However, there is limited exposure to refractive surgery in ophthalmology residency programs, suggesting the need for comprehensive education and training to equip young ophthalmologists with the skills needed for this evolving field.[4] The economics of refractive surgery in low-income populations need rethinking. Like manual small-incision cataract surgery (MSICS), lower-cost alternatives, such as microkeratome flaps, could still play a role when femtosecond lasers are inaccessible. While lenticule extraction and femtosecond lasers are the future, going back to basics, i.e. microkeratome and PRK (which is now an ebbing trend, no more discussed in conferences or talked about academically) are what is needed if we are looking at it as an epidemic.[5] The ‘click-fee’ economic model built into the current lasers is a barrier to taking the procedure to the masses. Low-cost intraocular lenses have been India’s biggest revolution for blindness eradication; can the development of low-cost ICL be the next game changer? High ametropia is disabling, and surgical correction should be considered for reimbursement by both government schemes and private insurance. Ensuring the availability of affordable solutions is crucial to extending the benefits of refractive surgery to a broader population. Corneal refractive surgery continues to evolve, offering new possibilities for correcting vision impairments. With ongoing innovation, the future holds immense potential for expanding its accessibility and effectiveness.About the authorDr. Umang Mathur, CEO, Dr. Shroff’s Charity Eye Hospital, New Delhi, India Dr. Umang Mathur, a distinguished ophthalmologist, has been instrumental in revitalizing Dr. Shroff’s Charity Eye Hospital (SCEH) in Delhi, making it a leader in patient care, academics, research, and public health. Following his ophthalmology residency, he completed a Cornea and Anterior Segment fellowship at the LV Prasad Eye Institute, Hyderabad, and has over 25 years of practice. Dr. Mathur established SCEH’s Eye Bank, a leading institution in North India, and founded the Bodhya Eye Consortium, connecting eye care institutions. He has published extensively in peer-reviewed journals and trained over 250 fellows in ophthalmology.